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

{"title":"Pyogenic Hepatic Abscess in an Immunocompetent Patient With Poor Oral Health and COVID-19 Infection.","authors":"Manuel Vazquez,&nbsp;Alana Vassil,&nbsp;Igor Sirotkin","doi":"10.12788/fp.0382","DOIUrl":"10.12788/fp.0382","url":null,"abstract":"<p><strong>Background: </strong>Pyogenic hepatic abscess (PHA) is a collection of pus in the liver caused by bacterial infection of the liver parenchyma. PHA is more common in immunosuppressed individuals and those with diabetes mellitus, cancer, and liver transplant.</p><p><strong>Case presentation: </strong>We present a rare case of PHA with <i>Fusobacterium nucleatum</i> in an immunocompetent patient with poor oral health, history of diverticulitis, and recent COVID-19 infection whose only symptoms were chest pain and a 4-week history of fever and malaise. The source of infection in this patient was likely dental caries and periodontal disease, with COVID-19 infection playing a role as a red herring in this patient's disease progression, delaying diagnosis.</p><p><strong>Conclusions: </strong>Diagnosis and treatment of PHA must be prompt with drainage and empiric anaerobic coverage followed by a more tailored antibiotic regimen if indicated by culture and further drainage if indicated by computed tomography.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10584407/pdf/fp-40-06-182.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49686596","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":"Impact of Pharmacist Interventions at an Outpatient US Coast Guard Clinic.","authors":"Fengyee Zhou,&nbsp;Zachary Woodward","doi":"10.12788/fp.0383","DOIUrl":"https://doi.org/10.12788/fp.0383","url":null,"abstract":"<p><strong>Background: </strong>US Coast Guard (USCG) active-duty service members (ADSMs) are required to maintain medical readiness to maximize operational success. USCG pharmacists serve the traditional pharmacist role while maintaining oversight of regional pharmaceutical services. This study aimed to quantify the number, duty status impact, and replicability of medication interventions made by one pharmacist at the USCG Base Alameda clinic in California over 6 months.</p><p><strong>Methods: </strong>Medication interventions made at the USCG Base Alameda clinic from July 1, 2021, to December 31, 2021, were categorized as a drug therapy problem (DTP) or non-DTP. Each DTP was further evaluated in a retrospective record review by a panel of USCG pharmacists to assess 2 additional factors: duty status severity (potential to affect duty status) and replicability (potential for the same intervention to be made in the absence of access to the patient health record).</p><p><strong>Results: </strong>USCG Base Alameda pharmacy dispensed 1751 prescriptions and made 116 interventions (7%), of which 111 (96%) were accepted by the prescriber. Of the interventions, 64 (55%) were DTPs, and 14 of those (22%) had potential to change duty status, and 18 DTPs (28%) were made because the pharmacist had access to the health record.</p><p><strong>Conclusions: </strong>Pharmacists' role in USCG clinics includes collaborating with the patient care team to make medication interventions that have significant impact on ADSMs' wellness and the USCG mission.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10584406/pdf/fp-40-06-174.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49686594","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":"Pharmacist-Led Antimicrobial Stewardship and Antibiotic Use in Hospitalized Patients With COVID-19.","authors":"Selena N Pham,&nbsp;Taylor M Hori,&nbsp;Ashfaq Shafiq","doi":"10.12788/fp.0380","DOIUrl":"10.12788/fp.0380","url":null,"abstract":"<p><strong>Background: </strong>During the COVID-19 pandemic, a significant increase in the use of empiric antibiotic therapy has been observed especially in patients hospitalized with COVID-19. Improving antibiotic prescribing is one of the main goals of the antimicrobial stewardship program (ASP). The ASP pharmacists have a scope of practice that authorizes changes in anti-infective therapy.</p><p><strong>Methods: </strong>We aimed to describe antibiotic prescribing in patients hospitalized with COVID-19 at Veterans Affairs Southern Nevada Healthcare System with a pharmacist-led ASP and to determine the prevalence of bacterial coinfection in this patient population. We performed a retrospective chart review of patients admitted to the facility from November 1, 2020, to January 31, 2021.</p><p><strong>Results: </strong>A total of 199 patients were admitted to the hospital for laboratory-confirmed COVID-19 infection during the study period and 61 patients (31%) received ≥ 1 antibiotic on hospital admission and 138 (69%) did not receive antibiotics. Forty-seven patients (77%) had antibiotics discontinued by the ASP team within 72 hours of admission. Of the 199 admitted, 6 (3%) had microbiologically confirmed bacterial coinfection. <i>Pseudomonas aeruginosa</i> was the most common organism (3 sputum cultures) followed by <i>Klebsiella oxytoca</i> (2 sputum cultures). Sixteen patients (8%) developed a nosocomial infection during their hospital stay.</p><p><strong>Conclusions: </strong>Up to 31% of patients hospitalized for COVID-19 infection received empiric antibiotic treatment for concern of bacterial coinfection. Pharmacist-led ASP led to early discontinuation of antibiotics in many patients. A thorough clinical workup to determine the risk of bacterial coinfection in patients with COVID-19 is important before starting empiric antibiotic therapy. It is essential to continue promoting the ASP during the COVID-19 pandemic to ensure responsible antibiotic use and prevent antimicrobial resistance.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10584410/pdf/fp-40-06-178.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49686595","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":"Applications of ChatGPT and Large Language Models in Medicine and Health Care: Benefits and Pitfalls.","authors":"Andrew A Borkowski,&nbsp;Colleen E Jakey,&nbsp;Stephen M Mastorides,&nbsp;Ana L Kraus,&nbsp;Gitanjali Vidyarthi,&nbsp;Narayan Viswanadhan,&nbsp;Jose L Lezama","doi":"10.12788/fp.0386","DOIUrl":"https://doi.org/10.12788/fp.0386","url":null,"abstract":"<p><strong>Background: </strong>The use of large language models like ChatGPT is becoming increasingly popular in health care settings. These artificial intelligence models are trained on vast amounts of data and can be used for various tasks, such as language translation, summarization, and answering questions.</p><p><strong>Observations: </strong>Large language models have the potential to revolutionize the industry by assisting medical professionals with administrative tasks, improving diagnostic accuracy, and engaging patients. However, pitfalls exist, such as its inability to distinguish between real and fake information and the need to comply with privacy, security, and transparency principles.</p><p><strong>Conclusions: </strong>Careful consideration is needed to ensure the responsible and ethical use of large language models in medicine and health care. <i>The development of [artificial intelligence] is as fundamental as the creation of the microprocessor, the personal computer, the Internet, and the mobile phone. It will change the way people work, learn, travel, get health care, and communicate with each other.</i> Bill Gates1.</p>","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10584408/pdf/fp-40-06-170.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49686592","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":"Muscle-Related Adverse Events Associated With PCSK9 Inhibitors in a Veteran Population.","authors":"Joseph Cencetti, Callie Abramowitz, Heather Spoonhower","doi":"10.12788/fp.0357","DOIUrl":"https://doi.org/10.12788/fp.0357","url":null,"abstract":"Background\u0000Statins and PCSK9 inhibitors (PCSK9i) are used to lower low-density lipoprotein cholesterol and reduce cardiovascular events, yet some patients are unable to tolerate statin therapy due to muscle-related adverse events (AEs). The effect of PCSK9i on muscle-related AEs is not well studied, and available data show inconsistent incidence rates.\u0000\u0000\u0000Methods\u0000The primary study outcome was to determine the percentage of patients who developed muscle-related PCSK9i AEs. A secondary outcome was to analyze data based on 4 subgroups: tolerated a full PCSK9i dose; tolerated alternative PCSK9i following initial intolerance; required a PCSK9i dose reduction, or discontinued PCSK9i. In addition, the percentage of statin- and/or ezetimibe-intolerant patients in these 4 groups was determined. Another secondary outcome was the management strategies taken for patients who were on a reduced (monthly) dose of PCSK9i who did not reach their low-density lipoprotein cholesterol goal. Statin intolerance was defined as intolerable skeletal muscle AEs on at least 3 different statins. We conducted a single-center, retrospective review of patients prescribed a PCSK9i between December 1, 2017, and September 1, 2021, at a patient aligned care team clinic at the Wilkes-Barre Veterans Affairs Medical Center.\u0000\u0000\u0000Results\u0000The study included 137 veterans. Twenty-four patients (17.5%) developed a muscle-related AE while on a PCSK9i. In predefined subgroups studied, statin intolerance ranged from 68.1% to 100%, ezetimibe intolerance ranged from 41.6% to 83.3%, and both statin and ezetimibe intolerance ranged from 36.3% to 83.3%.\u0000\u0000\u0000Conclusions\u0000In this study, muscle-related PCSK9i AEs occurred at a similar incidence rate to that reported in previous clinical trials and exceeded the incidence rate reported in the prescribing information for alirocumab and evolocumab. It also appears that patients who have a prior muscle-related intolerance to a statin and/or ezetimibe have a higher likelihood of developing a muscle-related AE to a PCSK9i.","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46150109","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving Patient Access to the My HealtheVet Electronic Patient Portal for Veterans.","authors":"Corinne Roberto, Melanie Keiffer, Melanie V. Black, Carol Williams-Suich, Karen Grunewald","doi":"10.12788/fp.0331","DOIUrl":"https://doi.org/10.12788/fp.0331","url":null,"abstract":"Background\u0000The US Department of Veterans Affairs My HealtheVet (MHV) patient portal is a secure online tool that provides patients access to personal health information. Although facilitators exist to encourage veteran registration, barriers to both adoption and use among veterans persist. This quality improvement project sought to improve veteran access to MHV.\u0000\u0000\u0000Observations\u0000Using Plan-Do-Study-Act (PDSA) methodology, we identified barriers to registration, evaluated processes for enrollment, and integrated a process improvement champion into a rural primary care clinic workflow. After 3 PDSA cycles, the integration of new processes resulted in increased enrollment and engagement with MHV. Fourteen veterans registered for MHV at the point-of-care in a 3-month time frame.\u0000\u0000\u0000Conclusions\u0000Use of a connected electronic health record platform and implementation of an MHV champion in the outpatient primary care setting improved rural veteran access to personal health information. Audit and feedback on processes that provide access to health information is an important strategy to narrow the gap between veterans who access patient portals and those who do not.","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42907875","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Patient Presenting With Shortness of Breath, Fever, and Eosinophilia.","authors":"S. Varghese, M. Kouma, D. Storey, R. Arasaratnam","doi":"10.12788/fp.0336","DOIUrl":"https://doi.org/10.12788/fp.0336","url":null,"abstract":"A 70-year-old veteran with a history notable for type 2 diabetes mellitus, complicated by peripheral neuropathy and bilateral foot ulceration, and previous pulmonary tuberculosis (treated in June 2013) presented to an outside medical facility with bilateral worsening foot pain, swelling, and drainage of preexisting ulcers. He received a diagnosis of bilateral fifth toe osteomyelitis and was discharged with a 6-week course of IV daptomycin 600 mg (8 mg/kg) and ertapenem 1 g/d. At discharge, the patient was in stable condition. Follow-up was done by our outpatient parenteral antimicrobial therapy (OPAT) team, which consists of an infectious disease pharmacist and the physician director of antimicrobial stewardship who monitor veterans receiving outpatient IV antibiotic therapy.1 Three weeks later as part of the regular OPAT surveillance, the patient reported via telephone that his foot osteomyelitis was stable, but he had a 101 °F fever and a new cough. He was instructed to come to the emergency department (ED) immediately. On arrival, complete blood count (CBC) revealed leukocytosis with elevated eosinophils to 2.67 K/μL compared with 0.86 K/μL (reference range, 0 to 0.5 K/μL) 1 week earlier (eAppendix, available at doi:10.2788 /fp.0336). Renal and liver function were within normal limits. A COVID-19 test was negative. The initial examination was notable for mild respiratory distress with oxygen saturation of 90% on room air and a respiratory rate of 25 breaths/min. A lung examination showed bilateral crackles. He reported no skin rash or mucosal lesions. The patient was placed on 2 L/min of oxygen via nasal cannula. A chest radiograph showed rightsided opacities; however, further computed tomography (CT) chest imaging was significant for bilateral opacities (Figure 1).","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49654125","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Medications for Opioid Use Disorder Program in a VA Emergency Department","authors":"Jonie J Hsiao","doi":"10.12788/fp.0306","DOIUrl":"https://doi.org/10.12788/fp.0306","url":null,"abstract":"","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73471580","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Insulin Injection-Site Acanthosis Nigricans: Skin Reactions and Clinical Implications","authors":"M. Hower","doi":"10.12788/fp.0253","DOIUrl":"https://doi.org/10.12788/fp.0253","url":null,"abstract":"","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89044432","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Characterizing Opioid Response in Older Veterans in the Post-Acute Setting","authors":"Victoria D. Powell","doi":"10.12788/fp.0229","DOIUrl":"https://doi.org/10.12788/fp.0229","url":null,"abstract":"Background: Opioids often are used in post-acute care (PAC) settings, although there is a lack of evidence of sustained pain reduction and improved function. There are subgroups of individuals whose pain does not respond well to opioids yet report these agents as highly beneficial. We aimed to classify opioid responsiveness among veterans residing in a US Department of Veterans Affairs community living center PAC unit. Methods: This observational, cross-sectional study used barcode medication administration data followed by retrospective chart review. We determined opioid responsiveness along a continuum during 4 nonconsecutive days in 2016 and 2017. We defined opioid responsiveness as the mean change in pre- and postopioid pain ratings using the 0 to 10 scale over the 24-hour observation period (ie, mean ∆ score). The chart review identified correlates of opioid responsiveness adjusting for mean pre-opioid pain ratings. Results: Among the 41 residents who received opioids for at least moderate pain (≥ 4 of 10), the average response was highly variable (range, 0.5 - 6.3). Response did not correlate with demographic variables, indication for admission, or medical comorbidities, including cancer diagnosis. The presence of any psychiatric diagnosis ( P = .03), pain service consult ( P = .03), and higher opioid dosage ( P = .002) was significantly associated with poorer response. Conclusions: This pilot study classified opioid response on a continuum using a scalable administrative data source. Despite receiving higher dosages and more specialist consultations, some veterans’ pain responds poorly to opioids. Psychiatric comorbidity seems to increase this risk. Future studies in larger, more representative populations are necessary to confirm these findings to develop personalized pain management strategies that mitigate risks of opioids. its This article may discuss unlabeled or inves- tigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combina- tions—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-03-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77513052","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}