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

{"title":"A Case Series of Rare Immune-Mediated Adverse Reactions at the New Mexico Veterans Affairs Medical Center.","authors":"Kenneth M Zabel, Lauren Tagliaferro-Epler, Coty Ho, Marissa Tafoya, Michael Reyes, Vishal Vashistha","doi":"10.12788/fp.0398","DOIUrl":"10.12788/fp.0398","url":null,"abstract":"<p><strong>Background: </strong>Immune checkpoint inhibitor (ICI) therapy has revolutionized the treatment of several solid tumors. The use of ICIs is expected to rise as a growing number of indications are approved for their use by the US Food and Drug Administration and with the increasing number of patients with cancer. Unfortunately, ICIs are associated with the development of immune-mediated adverse reactions (IMARs). About 5% to 10% of patients developing severe toxicities requiring treatment postponement or discontinuation. IMARs can affect any organ, but most frequently the skin and endocrine glands are involved.</p><p><strong>Case presentation: </strong>We present a case series of IMARs observed at the New Mexico Veterans Affairs Medical Center. First, we present a case of grade 4 myocarditis in an 84-year-old man receiving chemoimmunotherapy for lung adenocarcinoma to demonstrate the rapid progression of this rare condition. Second, we present a case of uveitis in a 70-year-old man with superficial bladder cancer undergoing treatment with pembrolizumab. Finally, we present a case of a 63-year-old man with pleuritis and organizing pneumonia secondary to dual ICI treatment (nivolumab and ipilimumab) for mesothelioma. A discussion regarding the epidemiology of these IMARs, expected course, and optimal management follows each rare toxicity described.</p><p><strong>Conclusions: </strong>Though these toxicities are uncommon, they serve as a reminder to clinicians across specialties that IMARs can drive the acute deterioration of any organ, and consideration of toxicities secondary to ICIs should be considered for any atypical presentation of unclear etiology.</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":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10681011/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74883302","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":"Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center.","authors":"Richard M Hoffman, Julie A Lang, George J Bailey, James A Merchant, Aaron S Seaman, Elizabeth A Newbury, Rolando Sanchez, Robert J Volk, Lisa M Lowenstein, Sarah L Averill","doi":"10.12788/fp.0403","DOIUrl":"10.12788/fp.0403","url":null,"abstract":"<p><strong>Background: </strong>Veterans suffer substantial morbidity and mortality from lung cancer. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce mortality. Guidelines recommend counseling and shared decision-making (SDM) to address the benefits and harms of screening and the importance of tobacco cessation before patients undergo screening.</p><p><strong>Observations: </strong>We implemented a centralized LCS program at the Iowa City Veterans Affairs Medical Center with a nurse program coordinator (NPC)-led telephone visit. Our multidisciplinary team ensured that veterans referred from primary care met eligibility criteria, that LDCT results were correctly coded by radiology, and that pulmonary promptly evaluated abnormal LDCT. The NPC mailed a decision aid to the veteran and scheduled a SDM telephone visit. We surveyed veterans after the visit using validated measures to assess knowledge, decisional conflict, and quality of decision making. We conducted 105 SDM visits, and 91 veterans agreed to LDCT. Overall, 84% of veterans reported no decisional conflict, and 59% reported high-quality decision making. While most veterans correctly answered questions about the harms of radiation, false-positive results, and overdiagnosis, few knew when to stop screening, and most overestimated the benefit of screening and the predictive value of an abnormal scan. Tobacco cessation interventions were offered to 72 currently smoking veterans.</p><p><strong>Conclusions: </strong>We successfully implemented an LCS program that provides SDM and tobacco cessation support using a centralized telehealth model. While veterans were confident about screening decisions, knowledge testing indicated important deficits, and many did not engage meaningfully in SDM. Clinicians should frame the decision as patient centered at the time of referral, highlight the importance of SDM, and be able to provide adequate decision support.</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":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10681016/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89950854","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":"What We Have Learned About Combining a Ketogenic Diet and Chemoimmunotherapy: a Case Report and Review of Literature.","authors":"Daniel Sims, Agnes K Liman, Victoria Leung, Andrew Hwang, Jeffrey Means, Andrew D Liman","doi":"10.12788/fp.0399","DOIUrl":"10.12788/fp.0399","url":null,"abstract":"<p><strong>Background: </strong>A high-fat, moderate-protein, low-carbohydrate ketogenic diet has been reported in the literature as a treatment option for patients with cancer.</p><p><strong>Case presentation: </strong>A 69-year-old veteran was initially diagnosed with stage III colorectal cancer and progressed to having liver, pancreatic, and omental lymph node involvement despite completing adjuvant FOLFOX (fluorouracil, leucovorin calcium, and oxaliplatin) after surgery. The patient was treated with FOLFIRI (fluorouracil, leucovorin calcium, and irinotecan hydrochloride) and bevacizumab, followed by encorafenib and cetuximab on progression. Subsequently, he received pembrolizumab but continued to progress. The patient was later placed on trifluridine/tipiracil and bevacizumab concurrent with a ketogenic diet. Positron emission tomography and carcinoembryonic antigen levels indicated disease stabilization for 10 months. On progression, the patient was transitioned to ipilumimab and nivolumab and continued to adhere to the ketogenic diet. The patient's disease has continued to remain stable for the past 1 year. His degree of ketosis was determined using the glucose ketone index. The patient continues to have a good quality of life during concurrent ketogenic diet and therapy.</p><p><strong>Conclusions: </strong>This case supports the tolerability of the ketogenic diet along with chemotherapy and immunotherapy and should be considered as an adjunct to standard cancer treatment. In this report, we reviewed the latest literature about cellular mechanism of the ketogenic diet and the efficacy and relationship with chemotherapy and immunotherapy. We are about to open a ketogenic diet protocol at the Veterans Affairs Central California Health Care System in Fresno.</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":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10681018/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89522355","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":"Gastrointestinal Bleeding Caused by Large Intestine Amyloidosis.","authors":"Nikhil Seth,&nbsp;Victoria A Jaeger,&nbsp;Namisha Thapa,&nbsp;James T Sing,&nbsp;Christopher R Naumann","doi":"10.12788/fp.0389","DOIUrl":"10.12788/fp.0389","url":null,"abstract":"<p><strong>Background: </strong>Amyloidosis is a rare disorder caused by abnormal folding of proteins, leading to the dysfunction of normal tissues. Amyloid deposition can affect several organs, but deposition in the large intestine is rare.</p><p><strong>Case presentation: </strong>A 79-year-old man presented with gastrointestinal bleeding and nonspecific symptoms of weight loss, dry heaves, dysphagia, and weakness. The patient underwent esophagogastroduodenoscopy and colonoscopy and a biopsy confirmed the diagnosis of intestinal amyloidosis.</p><p><strong>Conclusions: </strong>This case report highlights the importance of a strong differential when working up gastrointestinal bleeding that includes amyloidosis. Early identification and multidisciplinary involvement are crucial for management and tailored care to each patient's needs.</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":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10589003/pdf/fp-40-08-262.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49695358","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":"Alcohol-Related Hospitalizations During the Initial COVID-19 Lockdown in Massachusetts: An Interrupted Time-Series Analysis.","authors":"Matthew V Ronan,&nbsp;Kenneth J Mukamal,&nbsp;Rahul B Ganatra","doi":"10.12788/fp.0404","DOIUrl":"10.12788/fp.0404","url":null,"abstract":"<p><strong>Background: </strong>The effect of initial COVID-19 pandemic-associated lockdowns on alcohol-related hospitalizations remains uncertain. This study compares alcohol-related hospitalizations at a US Department of Veterans Affairs (VA) system in Massachusetts before, during, and after the initial COVID-19 lockdown.</p><p><strong>Methods: </strong>This study is an interrupted time-series analysis at the VA Boston Healthcare System. Participants included all patients hospitalized on the medical, psychiatry, and neurology services at VA Boston Healthcare System from January 1, 2017, to December 31, 2020, excluding those under observation status. The period January 1, 2017, to March 9, 2020, was defined as prelockdown (the reference group); March 10, 2020, to May 18, 2020, was lockdown; and May 19, 2020, to December 31, 2020, was postlockdown. Alcohol-related hospitalizations were determined using <i>International Statistical Classification of Diseases, Tenth Revision</i> primary diagnosis codes.</p><p><strong>Results: </strong>We identified 27,508 hospitalizations during the study periods. There were 72 alcohol-related hospitalizations per 100,000 patient-months during the prelockdown period, 10 per 100,000 patient-months during the lockdown, and 46 per 100,000 patient-months in the postlockdown period. Compared with the prelockdown period, the adjusted rate ratio for daily alcohol-related hospitalizations during lockdown was 0.20 (95% CI, 0.10-0.39) vs 0.72 (95% CI, 0.57-0.92) after the lockdown. A similar pattern was observed for all-cause hospitalizations.</p><p><strong>Conclusions: </strong>Our results suggest that COVID-19 pandemic lockdown measures were associated with fewer alcohol-related hospitalizations. Proactive outreach for vulnerable populations during lockdowns is needed.</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":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10589004/pdf/fp-40-08-242.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49695357","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":"Implementation of a Protocol for Management of Febrile Neutropenia in the Emergency Department at Veteran Health Indiana.","authors":"Lori Melikian, Susan Bullington, Brent Harris, Cole Smith, Justin Roberts, Chad Naville-Cook, Brooke Crawford","doi":"10.12788/fp.0371","DOIUrl":"10.12788/fp.0371","url":null,"abstract":"<p><strong>Background: </strong>Febrile neutropenia (FN) is a life-threatening oncologic emergency requiring timely evaluation and treatment. Unrecognized fever and infection can progress quickly and have been shown to increase morbidity and mortality in patients with malignancy. It is critical to identify patients with neutropenic fever on presentation to the emergency department (ED) and to initiate treatment immediately.</p><p><strong>Observations: </strong>This quality improvement initiative sought to optimize ED care of patients presenting with FN. Delays in antibiotic prescribing for patients with FN presenting to the ED were identified. A protocol was implemented to streamline clinical decision making and decrease the time from triage to the first dose of antibiotics in the ED. Key interventions included obtaining ED staff support, developing a standard empiric therapy protocol, increasing prescriber awareness of the neutropenic fever protocol and integrating it into the electronic health record. Before the protocol, the mean time from triage to the first dose of antibiotics was 3.3 hours with only 6% of patients receiving appropriate empiric therapy within 1 hour. Postimplementation, the average time to antibiotics decreased to 2.3 hours. In the postimplementation group, 17% of patients within 1 hour.</p><p><strong>Conclusions: </strong>Early identification and timely empiric antibiotic therapy are critical to improving outcomes for patients presenting to the ED with FN. Additional optimization of the order sets along with increased protocol comfort and staff education will help to further reduce the time to antibiotic administration in alignment with guideline recommendations.</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":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10681017/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78814868","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":"Naltrexone: a Novel Approach to Pruritus in Polycythemia Vera","authors":"Newsha Nikzad","doi":"10.12788/fp.0396","DOIUrl":"https://doi.org/10.12788/fp.0396","url":null,"abstract":"Background\u0000Pruritus is a characteristic and often debilitating clinical manifestation reported by about 50% of patients with polycythemia vera (PV). Interventions for PV-associated pruritus include phlebotomy, antidepressants, antihistamines, phototherapy, interferon α, myelosuppression, and signaling pathway-specific agents.\u0000\u0000\u0000Case Presentation\u0000A 40-year-old man presented with Janus kinase 2 (Jak2)-positive PV complicated by intractable pruritus that was not alleviated by multimodal therapy and lifestyle modifications. Following the initiation of naltrexone, the patient experienced immediate relief that has persisted for 2 years.\u0000\u0000\u0000Conclusions\u0000This case demonstrates a novel approach to the management of PV-associated pruritus. Notably, naltrexone is an affordable, accessible, and potentially effective option for patients with intractable PV pruritus. Future directions involve consideration of case series or randomized clinical trials investigating the efficacy and pathophysiology of naltrexone in treating PV-associated pruritus.","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":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136375577","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 Case of Duodenocaval Fistula in the Setting of Respiratory Failure Initially Confused for Transfusion-Related Acute Lung Injury.","authors":"Gaurav Suryawanshi,&nbsp;Aaron Boothby,&nbsp;Richard Dykowski","doi":"10.12788/fp.0391","DOIUrl":"10.12788/fp.0391","url":null,"abstract":"<p><strong>Background: </strong>A duodenocaval fistula is seen when a connection exists between the duodenum and the inferior vena cava. It is a rare entity that presents a diagnostic challenge due to its nonspecific presenting symptoms and often is found only during a laparotomy or autopsy.</p><p><strong>Case presentation: </strong>A 37-year-old man initially presented to the hospital for melena but went into cardiac arrest before undergoing an esophagogastroduodenoscopy. Unfortunately, a duodenocaval fistula was only found during the autopsy.</p><p><strong>Conclusions: </strong>Duodenocaval fistula is a diagnostic challenge as it may present with nonspecific findings concerning for other etiologies. We want to highlight that although rare, duodenocaval fistula should be considered for patients who present with gastrointestinal bleeding and hypoxic respiratory failure.</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":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10588995/pdf/fp-40-07-228.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49695352","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":"COVID-19 Incidence After Emergency Department Visit.","authors":"Jonathan Balakumar,&nbsp;My-Phuong Pham,&nbsp;Selene Mak,&nbsp;Kathleen Yip","doi":"10.12788/fp.0384","DOIUrl":"10.12788/fp.0384","url":null,"abstract":"<p><strong>Background: </strong>The emergency department (ED) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) saw a decrease in the number of visits during the early stages of the COVID-19 pandemic. Little is known whether risk mitigation procedures may help reduce the spread of COVID-19 infections for veterans visiting the ED. Therefore, we reviewed patient visits to the ED for diagnoses other than COVID-19 to assess whether these patients had an increased COVID-19 positivity rate within 21 days of the initial visit.</p><p><strong>Observations: </strong>Risk mitigation procedures instituted by the VAGLAHS ED included a COVID-19 outdoor testing tent, immediate isolation of persons under investigation for COVID-19, disinfection protocols between high-risk patient encounters, dedicated training in donning and doffing personal protective equipment, implementation of 2-physician airway teams for COVID-19 intubations, use of electronic tablets to communicate with COVID-19 patients, and implementation of social distancing initiatives in the waiting room to minimize COVID-19 exposures. The average positivity rate at the VAGLAHS ED during this time frame was 0% to 6.7%, compared with 6.9% to 33.3% within the wider VAGLAHS.</p><p><strong>Conclusions: </strong>Implementing risk mitigation procedures in the VAGLAHS ED helped minimize exposure and subsequent diagnosis of COVID-19 for veterans who visited the VAGLAHS ED for symptoms not associated with COVID-19 infection. Seeking acute medical care in the ED did not put patients at higher risk of contracting COVID-19.</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":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10588997/pdf/fp-40-07-224.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49695354","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":"Transition to Tenecteplase From t-PA for Acute Ischemic Stroke at Walter Reed National Military Medical Center","authors":"Cole P Denkensohn","doi":"10.12788/fp.0351","DOIUrl":"https://doi.org/10.12788/fp.0351","url":null,"abstract":"Background: Tissue plasminogen activator (t-PA) has been the standard IV thrombolytic drug used in acute ischemic stroke treatment since 1995. Tenecteplase has been available for use in acute myocardial infarction and has been endorsed by the American Heart Association stroke guidelines as an alternative to t-PA. Observations: A systematic process to safely transition from t-PA to tenecteplase for acute ischemic stroke was undertaken at Walter Reed National Military Medical Center. The process to implement tenecteplase required extensive training and education for staff physicians, nurses, pharmacists, radiologists, trainees, and the rapid response team. There are a variety of benefits and implementation challenges to consider when transitioning thrombolytic therapy for institutional use in acute ischemic stroke. Conclusions: Evidence supports the transition from t-PA to tenecteplase for acute ischemic stroke. Successful transition required months of preparation involving multidisciplinary meetings that included neurology, nursing, pharmacy, radiology, rapid response teams, critical care, and emergency medicine. Safeguards must be implemented to avoid dosing errors that can lead to life-threatening adverse events.","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":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91144935","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}