Federal practitioner : for the health care professionals of the VA, DoD, and PHS最新文献

{"title":"Evaluation of Pharmacist-Driven Inhaled Corticosteroid De-escalation in Veterans.","authors":"Regan Dean, Maria Shin, Leah Michael, William Reesor","doi":"10.12788/fp.0663","DOIUrl":"10.12788/fp.0663","url":null,"abstract":"<p><strong>Background: </strong>The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend inhaled corticosteroids (ICSs) for patients with elevated eosinophil counts who experience chronic obstructive pulmonary disease (COPD) exacerbations while receiving non-ICS inhaler therapy. The guidelines also encourage de-escalation based on eosinophil counts and adverse events (AEs) associated with ICS use. This quality improvement project sought to determine the impact of pharmacist-driven de-escalation on ICS use in veterans with COPD.</p><p><strong>Methods: </strong>Candidates for ICS de-escalation were identified using a population health database and screened for inclusion. A Computerized Patient Record System progress note was entered recommending ICS de-escalation, initiation of non-ICS alternatives, and/or referral to a pharmacist for management. Patient charts were reviewed at baseline, 3 months, and 6 months after progress note entry. The primary endpoint was the number of patients with de-escalated ICSs. Secondary endpoints included the number of COPD exacerbations and the number of documented ICS AEs.</p><p><strong>Results: </strong>One hundred and six patients received an ICS de-escalation recommendation. At 3 months, 50 patients (47.2%) had their ICS therapy de-escalated; at 6 months, 62 patients (58.5%) de-escalated. More cases of pneumonia occurred in patients using an ICS than in patients not using an ICS. A similar number of COPD exacerbations occurred in patients using an ICS vs those who had been de-escalated.</p><p><strong>Conclusions: </strong>The results of this study suggest that pharmacist-driven ICS de-escalation may be an effective way to reduce ICS use in veterans. Controlled studies are needed to evaluate the efficacy and safety of pharmacist-driven ICS de-escalation.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 12","pages":"452-457"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13524175/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148852181","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Thoracic Intramedullary Mass Causing Neurologic Weakness.","authors":"Jonathan B Wallach, Sarah P Mattessich, David L Schwartz, Parinda N Shah","doi":"10.12788/fp.0657","DOIUrl":"10.12788/fp.0657","url":null,"abstract":"","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 12","pages":"477-480"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13524187/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148852145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Heart Failure Diagnostic Alerts to Prompt Pharmacist Evaluation and Medication Optimization.","authors":"Nicasia A D'Allesandro, Augustus Hough, Brandon Cave","doi":"10.12788/fp.0643","DOIUrl":"10.12788/fp.0643","url":null,"abstract":"<p><strong>Background: </strong>The development of heart failure (HF) decompensation may precede clear and actionable symptoms. Cardiac implantable devices use sensor data to create an index score predictive of HF admission risk.</p><p><strong>Methods: </strong>Patients at the West Palm Beach Veterans Affairs Healthcare System using the HeartLogic implantable device were monitored for 7 months by a cardiology clinical pharmacist practitioner (CPP). Interventions and metrics were tracked up to 42 days after an alert. The primary outcome was the number of CPP interventions to optimize guideline-directed medical therapy (GDMT).</p><p><strong>Results: </strong>There were 39 patients with a HeartLogic-capable device. Twenty-one alert encounters were analyzed in 16 unique patients who were contacted a mean of 5 days after the alert. Patients were on a mean 2.6 GDMT agents at baseline vs 3.0 agents at 42 days. There were 30 total medication interventions, with 27 successfully tolerated. The most common medication initiated was a sodium-glucose cotransporter type 2 inhibitor (SGLT2i) (41%), with 1 adverse effect leading to discontinuation. Optimization of SGLT2i therapy led to positive impacts on overall HeartLogic, S1, S3, impedance, respiratory rate, and activity scores. The median HeartLogic score decreased from 18 at baseline to 5 at 42 days (<i>P</i> < .001). Of patients with reported symptoms at the time of the alert, 77% experienced subjective improvement.</p><p><strong>Conclusions: </strong>CPP-led HF interventions triggered by HeartLogic alerts led to effective patient identification, reductions in HeartLogic scores, symptom improvement, and optimization of HF care.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 12","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13524186/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148852159","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gadolinium Intermediate Elimination and Persistent Symptoms After Magnetic Resonance Imaging Contrast Agent Exposure.","authors":"Brent Wagner, Olivia X Jastrzemski, Sasha R Vigil, Lien Tang, Shreeti Patel, Amy Cunningham, Joshua DeAguero, Karol Dokladny, G Patricia Escobar, Jing Yang, Frederick Gentry, Ian Henderson, Rachel Coyte, Martin L Kirk, James H Degnan, Bevan T Choate","doi":"10.12788/fp.0631","DOIUrl":"10.12788/fp.0631","url":null,"abstract":"<p><strong>Background: </strong>Gadolinium is the most widely used diagnostic heavy metal contrast agent in the Military Health System and Veterans Health Administration (VHA). Used for enhancing magnetic resonance imaging (MRI), gadolinium can also have toxic effects. From 1999 to 2025 use of contrast-enhanced MRI in VHA facilities has risen to a mean (SD) 2.6 (2.8) MRIs with gadolinium each for 939,928 patients.</p><p><strong>Case presentation: </strong>A 65-year-old Air Force veteran and retired mechanical technician sought nephrology consultation. His medical history included posttraumatic stress disorder, cervical spondylosis, ulnar nerve injury, bilateral sensorineural hearing loss, dyslipidemia, and hypertension. Twenty-five days before consultation, the patient started a contrast-enhanced MRI for elevated prostate-specific antigens. During the MRI, he experienced claustrophobia, sweating, shortness of breath, a metallic taste, and hot sensations in the groin, chest, \"kidneys,\" and lower back, and the MRI was halted. Some symptoms reappeared days later, resulting in a 4-day hospitalization. Serum gadolinium measured 0.1 ng/mL, and 24-hour urine gadolinium was 0.3 mcg. Back-extrapolation of gadolinium elimination rates suggested exposure to 0.5% to 8.0% of a standard contrast dose. At 107 days post-MRI, serum and urine gadolinium were undetectable, but the metallic taste persisted.</p><p><strong>Conclusions: </strong>Our findings suggest that detectable gadolinium in serum and urine may reflect subclinical exposure, even at doses below standard prescriptions. Clinicians must consider gadolinium as a potential cause of pleiotropic symptoms even when, as in this case, symptoms persist despite undetectable levels of gadolinium.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 11","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13012431/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147517678","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Staff Perspectives on the VISN 20 Tele-Neuropsychology Program.","authors":"Ana C Messler, David D Hargrave, Christine E Gould, Chalise Carlson, Jeffrey A Sordahl","doi":"10.12788/fp.0652","DOIUrl":"10.12788/fp.0652","url":null,"abstract":"<p><strong>Background: </strong>The use of tele-neuropsychology (teleNP) is increasing within Veterans Integrated Service Network (VISN) 20. A quality improvement survey was conducted to better understand VISN 20 staff opinions of teleNP, how to improve the services, and whether it is preferred over face-to-face (F2F) neuropsychology evaluations in community-based settings.</p><p><strong>Methods: </strong>The authors surveyed US Department of Veterans Affairs (VA) VISN 20 staff from February 7, 2024, to June 15, 2024. Eighteen of 33 respondents had referred patients for neuropsychology services during the previous year.</p><p><strong>Results: </strong>The mean (SD) rating of teleNP usefulness was 1.5 (0.8) (between very much so and mostly useful on the scale) and the rating of non-VA F2F neuropsychology evaluation usefulness was 1.7 (0.9). A Wilcoxon signed rank-test of related samples indicated no differences between the pairs of ratings (<i>Z</i> = 1.50; <i>P</i> = .41). Respondents serving rural veterans were more likely to refer patients for teleNP services compared with those serving nonrural veterans (χ² = 5.7; <i>P =</i> .02). However, ratings of teleNP usefulness did not significantly differ for those serving rural compared with nonrural veterans (χ² = 1.4; <i>P =</i> .49).</p><p><strong>Conclusions: </strong>While response rate was low, the survey provides initial support for the acceptability and utility of teleNP among VA staff who responded to the survey, with favorable comparisons of teleNP to existing F2F neuropsychology resources.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 11","pages":"1-6"},"PeriodicalIF":0.0,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13012429/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147517720","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preoperative Diabetes Management for Patients Undergoing Elective Surgeries at a Veterans Affairs Medical Center.","authors":"Chelsea A Huppert, Emily A Moore, Deanna S Kania, Kayla Cann, Christopher A Knefelkamp","doi":"10.12788/fp.0645","DOIUrl":"10.12788/fp.0645","url":null,"abstract":"<p><strong>Background: </strong>Preoperative hyperglycemia or hypoglycemia can result in surgical delays, cancellations, and/or postoperative complications, which can lead to increased costs and worsened patient outcomes. This retrospective study conducted at Veteran Health Indiana (VHI) assessed the level of preoperative glycemic control in patients undergoing major elective surgical procedures to determine what, if any, standardization exists for perioperative diabetes mellitus (DM) management and its impact on patient outcomes.</p><p><strong>Methods: </strong>A retrospective chart review of 394 elective surgeries involving patients with DM from January 1, 2018, to December 31, 2021, at VHI was conducted. The primary end point was the incidence of patients with preoperative blood glucose > 180 mg/dL or < 70 mg/dL who had surgical procedures delayed or canceled due to hyperglycemia or hypoglycemia. Postoperative complications were examined for safety outcomes.</p><p><strong>Results: </strong>A randomized sample of 131 surgeries was reviewed and included. The mean preoperative blood glucose level was 146 mg/dL; no surgical procedures delayed or canceled due to hyperglycemia or hypoglycemia. All communication for preoperative DM medication management came from surgical service letters. This identified 122 cases (93.1%). Only 30 patients (24.6%) received instructions specifically tailored to their regimen. The most frequently observed postoperative complication was acute kidney injury (8.4%).</p><p><strong>Conclusions: </strong>Based on this randomized sample, the current VHI practice of providing a presurgery clinic visit and perioperative DM medication instructions is effective for preventing delays or cancellations in elective surgeries.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 Suppl6","pages":"S18-S21"},"PeriodicalIF":0.0,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13524177/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148852205","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing Sex Disparities in Statin Therapy Among Female Veterans With Type 2 Diabetes and/or Cardiovascular Disease.","authors":"Schylar Cheyenne Hathaway, Lindsey Pearsall, Paul Hansen, Nathaniel Swanson, Marci Swanson, Deborah Hobbs","doi":"10.12788/fp.0624","DOIUrl":"10.12788/fp.0624","url":null,"abstract":"<p><strong>Background: </strong>Female veterans have higher rates of cardiovascular disease (CVD) compared with the civilian population. Medical management with statins (3-hydroxy-3-methyl-glutaryl-coenzmye A reductase inhibitors) is the cornerstone of lipid-lowering therapy and cardiovascular risk reduction. Despite eligibility, female veterans are less likely to receive statin therapy than their male counterparts. This project aimed to increase statin prescribing for female veterans with type 2 diabetes mellitus (T2DM) and CVD to reduce sex disparities.</p><p><strong>Methods: </strong>The primary objective of this project was to increase statin prescribing among female veterans with T2DM and/or CVD to reduce cardiovascular risk. Secondary outcomes included increased pharmacogenomic testing and the assessment of pharmacogenomic results related to statin therapy. The Primary Care Equity Dashboard (PCED) was used to identify female veterans without a statin prescription. A clinical pharmacist practitioner (CPP) contacted those identified to offer statin therapy and pharmacogenomic testing.</p><p><strong>Results: </strong>Of the 129 contacted veterans, 31 (24.0%) had a non-US Department of Veterans Affairs (VA) statin prescription, 13 (10.1%) had an active VA statin prescription and 85 (65.9%) did not have a statin prescription despite their eligibility. Of the 85 veterans with no active statin therapy, 37 (43.5%) were initiated on a statin. The percentage of female veterans with an active statin prescription increased from 77.8% to 79.0% for those with T2DM and from 82.2% to 90.2% for those with CVD. Seventy-one veterans agreed to pharmacogenomic testing, and 47 completed testing. Five patients had abnormal results that may impact statin tolerability.</p><p><strong>Conclusions: </strong>The percentage of female veterans with T2DM and/or CVD with a statin prescription increased following CPP outreach. Pharmacogenomic testing should be used for statin prescribing and adherence.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 Suppl6","pages":"S1-S5d"},"PeriodicalIF":0.0,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13524178/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148852194","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Case Report of Unanticipated Difficult Intubation Due to Posterior Tracheal Angulation.","authors":"Teresa H Jiang, Vivek Arora","doi":"10.12788/fp.0633","DOIUrl":"10.12788/fp.0633","url":null,"abstract":"<p><strong>Background: </strong>Lateral tracheal deviation from mechanical compression is well-known, but anterior-posterior (A-P) deviation has been rarely reported.</p><p><strong>Case presentation: </strong>A 50-year-old male with a history of chronic cerebral venous sinus thrombosis and taking enoxaparin presented to the emergency department for recurrent headaches. The patient experienced cardiac arrest and endotracheal tube (ETT) advancement was difficult secondary to unexpected posterior tracheal deviation encountered during cardiopulmonary resuscitation. Flexible fiber-optic bronchoscopy was performed to traverse the acute angulation and advance the ETT.</p><p><strong>Conclusions: </strong>Tracheal deviation in the A-P direction should be considered as a cause of difficult ETT advancement, and fiber-optic bronchoscopy should be performed early to diagnose such lesions.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 10","pages":"382-384"},"PeriodicalIF":0.0,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13012448/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147517640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comprehensive Obesity Management Part 1: Assessment and Initiation of Treatment.","authors":"Robert F Kushner, Ethan Lazarus, Eden M Miller","doi":"10.12788/fp.0636","DOIUrl":"10.12788/fp.0636","url":null,"abstract":"","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 Suppl5","pages":"S13-S18"},"PeriodicalIF":0.0,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13521297/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148842661","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying and Addressing the Hidden Risks of Mild Asthma.","authors":"Nathan Falk, Wendy L Wright","doi":"10.12788/fp.0638","DOIUrl":"10.12788/fp.0638","url":null,"abstract":"","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":"42 Suppl5","pages":"S25-S30"},"PeriodicalIF":0.0,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13521287/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148842692","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}