Background: Gulf War veterans deployed to operations Desert Shield and Desert Storm returned with chronic multisystemic symptoms. This Gulf War Illness (GWI) has defied attempts to identify an underlying etiology. Pain and other symptoms attributable to autonomic nervous system (ANS) dysfunction are common, which may suggest a pathophysiologic underpinning. Small fiber neuropathy (SFN) presents with similar symptoms. Toxic exposures have been implicated in both SFN and GWI. Methods: A retrospective chart review of clinical data at the New Jersey War Related Illness and Injury Study Center addressed the following questions: (1) how common was biopsy-confirmed SFN in veterans with GWI; (2) do veterans with GWI and SFN report more symptoms attributable to ANS dysfunction as compared to veterans with GWI and no SFN; and (3) can SFN in veterans with GWI and SFN be explained by conditions commonly associated with SFN? Chart review abstracted GWI status, skin biopsy results, and ANS symptom burden. For veterans with GWI and SFN, additional chart abstraction was explored for commonly reported contributing conditions. Results: From March 1, 2015, to January 31, 2019, 51 Gulf War veterans evaluated at the War Related Illness and Injury Study center had a skin biopsy. Of these, 42 (83%) were diagnosed with GWI and 24 of 42 (57%) also had SFN. No differences were observed in ANS symptoms when compared with veterans with GWI and no SFN. A potential etiology for SFN was identified in 16 of 24 (67%) veterans with GWI and SFN, increasing to 19 (79%) when hyperlipidemia was included. Our analysis did not identify an explanation in 5 of 24 (21%) veterans with GWI and SFN. Conclusions: SFN was common in this clinical sample of veterans diagnosed with GWI. A well-established potential etiology was identified in most cases of SFN. About 20% of veterans with GWI in our clinical sample had idiopathic SFN, and it is plausible that deployment-related exposures could have contributed to this condition. Symptoms of ANS are prevalent in GWI, though SFN cannot solely account for this. Our study does not generally support SFN as etiologic for GWI, though this may still be relevant for some. Additional research is required to explore relationships between Gulf War exposures and SFN.
{"title":"Small Fiber Neuropathy in Veterans With Gulf War Illness","authors":"Edward Shadiack","doi":"10.12788/fp.0470","DOIUrl":"https://doi.org/10.12788/fp.0470","url":null,"abstract":"Background: Gulf War veterans deployed to operations Desert Shield and Desert Storm returned with chronic multisystemic symptoms. This Gulf War Illness (GWI) has defied attempts to identify an underlying etiology. Pain and other symptoms attributable to autonomic nervous system (ANS) dysfunction are common, which may suggest a pathophysiologic underpinning. Small fiber neuropathy (SFN) presents with similar symptoms. Toxic exposures have been implicated in both SFN and GWI. Methods: A retrospective chart review of clinical data at the New Jersey War Related Illness and Injury Study Center addressed the following questions: (1) how common was biopsy-confirmed SFN in veterans with GWI; (2) do veterans with GWI and SFN report more symptoms attributable to ANS dysfunction as compared to veterans with GWI and no SFN; and (3) can SFN in veterans with GWI and SFN be explained by conditions commonly associated with SFN? Chart review abstracted GWI status, skin biopsy results, and ANS symptom burden. For veterans with GWI and SFN, additional chart abstraction was explored for commonly reported contributing conditions. Results: From March 1, 2015, to January 31, 2019, 51 Gulf War veterans evaluated at the War Related Illness and Injury Study center had a skin biopsy. Of these, 42 (83%) were diagnosed with GWI and 24 of 42 (57%) also had SFN. No differences were observed in ANS symptoms when compared with veterans with GWI and no SFN. A potential etiology for SFN was identified in 16 of 24 (67%) veterans with GWI and SFN, increasing to 19 (79%) when hyperlipidemia was included. Our analysis did not identify an explanation in 5 of 24 (21%) veterans with GWI and SFN. Conclusions: SFN was common in this clinical sample of veterans diagnosed with GWI. A well-established potential etiology was identified in most cases of SFN. About 20% of veterans with GWI in our clinical sample had idiopathic SFN, and it is plausible that deployment-related exposures could have contributed to this condition. Symptoms of ANS are prevalent in GWI, though SFN cannot solely account for this. Our study does not generally support SFN as etiologic for GWI, though this may still be relevant for some. Additional research is required to explore relationships between Gulf War exposures and SFN.","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"205 S623","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141040246","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":"Persistent Flu-Like Symptoms in a Patient With Glaucoma and Osteoporosis","authors":"Timothy Bodnar","doi":"10.12788/fp.0477","DOIUrl":"https://doi.org/10.12788/fp.0477","url":null,"abstract":"","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"37 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141025637","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}
Background: Robotic pet therapy could aid in the nonpharmacologic treatment of pain, agitation, delirium, immobility, and sleep disruption (PADIS) in the intensive care unit (ICU), similar to traditional pet therapy. Observations: The North Florida/South Georgia Veterans Health System implemented a robotic pet therapy program for patients requiring ICU care. Details of this program are described in this article, including evaluating its impact on PADIS management. Conclusions: Robotic pet therapy can be successfully implemented in the ICU and could be a simple, safe, and beneficial nonpharmacologic intervention for PADIS.
{"title":"Robotic Pet Therapy in the Intensive Care Unit","authors":"Andrew Franck","doi":"10.12788/fp.0468","DOIUrl":"https://doi.org/10.12788/fp.0468","url":null,"abstract":"Background: Robotic pet therapy could aid in the nonpharmacologic treatment of pain, agitation, delirium, immobility, and sleep disruption (PADIS) in the intensive care unit (ICU), similar to traditional pet therapy. Observations: The North Florida/South Georgia Veterans Health System implemented a robotic pet therapy program for patients requiring ICU care. Details of this program are described in this article, including evaluating its impact on PADIS management. Conclusions: Robotic pet therapy can be successfully implemented in the ICU and could be a simple, safe, and beneficial nonpharmacologic intervention for PADIS.","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"4 11","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141046434","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":"Remembering the Dead in Unity and Peace","authors":"Cynthia Geppert","doi":"10.12788/fp.0482","DOIUrl":"https://doi.org/10.12788/fp.0482","url":null,"abstract":"","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"23 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141049688","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}
Background: Wolff-Parkinson-White (WPW) syndrome is characterized by the presence of accessory pathways and development of potentially malignant arrhythmias that can lead to sudden cardiac death. We aimed to determine the impact of atrial fibrillation and/or flutter (AF/AFL) on adverse cardiac outcomes and mortality in patients with WPW syndrome. Methods: This study identified a cohort of Military Health System patients with WPW syndrome from January 1, 2014, to December 31, 2019. The cohort was divided into 2 subgroups by the presence or absence of AF/AFL. Cardiac composite outcome and mortality were assessed. Kaplan-Meier curves were constructed to assess the bivariate association between exposure and these 2 study outcomes. Cox proportional models were used to estimate the hazard ratios and 95% CIs associated with the cardiac composite outcome and mortality. Results: Of 35,539 patients included in the study, 19,961 were female (56.2%), the mean (SD) age was 62.9 (18.0) years, and 5291 patients (14.9%) had AF/AFL. The cardiac composite outcome and mortality incidence rates per 100 person-years in the AF/AFL vs non-AF/AFL subgroups were 8.18 vs 4.90, and 4.09 vs 2.13, respectively ( P < .001). There were 3130 (8.8%) deaths. After adjusting for confounding variables, the AF/AFL subgroup maintained a 12% and 16% higher association with the composite outcome and mortality, respectively. Conclusions: Patients with WPW syndrome and AF/AFL have a higher association with adverse cardiac outcomes and death. Consideration for more aggressive electrophysiology screening and ablation strategies may be warranted in this population.
{"title":"Association of Atrial Fibrillation and/or Flutter With Adverse Cardiac Outcomes and Mortality in Patients With Wolff-Parkinson-White Syndrome","authors":"John Chin","doi":"10.12788/fp.0471","DOIUrl":"https://doi.org/10.12788/fp.0471","url":null,"abstract":"Background: Wolff-Parkinson-White (WPW) syndrome is characterized by the presence of accessory pathways and development of potentially malignant arrhythmias that can lead to sudden cardiac death. We aimed to determine the impact of atrial fibrillation and/or flutter (AF/AFL) on adverse cardiac outcomes and mortality in patients with WPW syndrome. Methods: This study identified a cohort of Military Health System patients with WPW syndrome from January 1, 2014, to December 31, 2019. The cohort was divided into 2 subgroups by the presence or absence of AF/AFL. Cardiac composite outcome and mortality were assessed. Kaplan-Meier curves were constructed to assess the bivariate association between exposure and these 2 study outcomes. Cox proportional models were used to estimate the hazard ratios and 95% CIs associated with the cardiac composite outcome and mortality. Results: Of 35,539 patients included in the study, 19,961 were female (56.2%), the mean (SD) age was 62.9 (18.0) years, and 5291 patients (14.9%) had AF/AFL. The cardiac composite outcome and mortality incidence rates per 100 person-years in the AF/AFL vs non-AF/AFL subgroups were 8.18 vs 4.90, and 4.09 vs 2.13, respectively ( P < .001). There were 3130 (8.8%) deaths. After adjusting for confounding variables, the AF/AFL subgroup maintained a 12% and 16% higher association with the composite outcome and mortality, respectively. Conclusions: Patients with WPW syndrome and AF/AFL have a higher association with adverse cardiac outcomes and death. Consideration for more aggressive electrophysiology screening and ablation strategies may be warranted in this population.","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"151 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140792800","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}
Background: The US Department of Veterans Affairs (VA) partners with 250 sponsors of graduate medical education (GME), annually providing $850 million for 11,000 full-time equivalent resident positions that support veteran patient care and provide educational opportunities for trainees from affiliated academic programs. Knowledge of VA GME financing is vital to maintain these partnerships. Observations: In response to increased scrutiny from several federal oversight bodies, the VA revised its GME reimbursement policy and procedures, including implementing new resident tracking and auditing mechanisms. This article describes the VA GME reimbursement policies and procedures and, to facilitate understanding, compares GME financing policies of the VA and Centers for Medicare and Medicaid Services. Similarities include counting full-time equivalent positions for reimbursable resident activities (eg, patient care and didactics) and ensuring reimbursement is limited to 1 payment per resident. Differences include funding of resident salaries and benefits, indirect funding to support education, and the calculations to determine reimbursement. Conclusions: The VA continues to refine its GME financing policies and procedures to maintain compliance with laws and regulations, and to provide accurate reimbursement to academic affiliates. This endeavor is essential to support the vital GME partnerships between the VA and its affiliate institutions.
{"title":"Graduate Medical Education Financing in the US Department of Veterans Affairs","authors":"John Byrne","doi":"10.12788/fp.0472","DOIUrl":"https://doi.org/10.12788/fp.0472","url":null,"abstract":"Background: The US Department of Veterans Affairs (VA) partners with 250 sponsors of graduate medical education (GME), annually providing $850 million for 11,000 full-time equivalent resident positions that support veteran patient care and provide educational opportunities for trainees from affiliated academic programs. Knowledge of VA GME financing is vital to maintain these partnerships. Observations: In response to increased scrutiny from several federal oversight bodies, the VA revised its GME reimbursement policy and procedures, including implementing new resident tracking and auditing mechanisms. This article describes the VA GME reimbursement policies and procedures and, to facilitate understanding, compares GME financing policies of the VA and Centers for Medicare and Medicaid Services. Similarities include counting full-time equivalent positions for reimbursable resident activities (eg, patient care and didactics) and ensuring reimbursement is limited to 1 payment per resident. Differences include funding of resident salaries and benefits, indirect funding to support education, and the calculations to determine reimbursement. Conclusions: The VA continues to refine its GME financing policies and procedures to maintain compliance with laws and regulations, and to provide accurate reimbursement to academic affiliates. This endeavor is essential to support the vital GME partnerships between the VA and its affiliate institutions.","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"60 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140786594","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}
Background: Moral injury had been discussed by health care professionals as a cause of occupational distress prior to COVID-19, but the pandemic expanded the appeal and investigation of the term. Moral injury incorporates more than the transdiagnostic symptoms of exhaustion and cynicism and goes beyond operational, demand-resource mismatches of corporatized systems. Observations: Moral injury describes the frustration, anger, and helplessness associated with existential threats to a clinician’s professional identity as business interests erode their ability to put patients’ needs ahead of corporate and health system obligations. We propose a framework that combines 2 moral injury definitions. An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. Moral injury arises when a superior’s actions or a system’s policies and practices undermine one’s professional obligations to prioritize the patient’s best interest. Perceived as inescapable, the resignation or helplessness of moral injury may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both moral injury and burnout can mediate and moderate the relationship between triggers for workplace distress and the resulting psychological, existential, and physical harm. Conclusions : Moral injury is increasingly recognized as a source of distress among health care professionals. It emerges from structural constraints on the ability of health care professionals to deliver optimal care and stand up for patients, their oaths, and their professions. A unified definition of moral injury must be integrated into the framing of clinician distress alongside burnout, recentering health care on ethical decision making rather than profit.
{"title":"Moral Injury in Health Care: A Unified Definition and its Relationship to Burnout","authors":"Wendy Dean","doi":"10.12788/fp.0467","DOIUrl":"https://doi.org/10.12788/fp.0467","url":null,"abstract":"Background: Moral injury had been discussed by health care professionals as a cause of occupational distress prior to COVID-19, but the pandemic expanded the appeal and investigation of the term. Moral injury incorporates more than the transdiagnostic symptoms of exhaustion and cynicism and goes beyond operational, demand-resource mismatches of corporatized systems. Observations: Moral injury describes the frustration, anger, and helplessness associated with existential threats to a clinician’s professional identity as business interests erode their ability to put patients’ needs ahead of corporate and health system obligations. We propose a framework that combines 2 moral injury definitions. An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. Moral injury arises when a superior’s actions or a system’s policies and practices undermine one’s professional obligations to prioritize the patient’s best interest. Perceived as inescapable, the resignation or helplessness of moral injury may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both moral injury and burnout can mediate and moderate the relationship between triggers for workplace distress and the resulting psychological, existential, and physical harm. Conclusions : Moral injury is increasingly recognized as a source of distress among health care professionals. It emerges from structural constraints on the ability of health care professionals to deliver optimal care and stand up for patients, their oaths, and their professions. A unified definition of moral injury must be integrated into the framing of clinician distress alongside burnout, recentering health care on ethical decision making rather than profit.","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"46 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140775320","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}
Background: Chronic obstructive pulmonary disease (COPD) is a respiratory disorder associated with chronic and slowly progressive systemic inflammation. The Global Initiative for Chronic Obstructive Lung Disease recommends a combination inhaler of a long-acting β -2 agonist and inhaled corticosteroid for patients with a history of frequent exacerbations. In 2021, the US Department of Veterans Affairs transitioned patients who were prescribed budesonide/formoterol inhaler to a fluticasone/ salmeterol inhaler. Methods: The primary objective of this study was to compare clinical outcomes including COPD exacerbations and hospitalizations 6 months before vs 6 months after the inhaler transition. Secondary outcomes included adverse effects, treatment failure, tobacco use, and antimicrobial/systemic corticosteroid use. A retrospective chart review was conducted on patients with a prescription for a budesonide/formoterol or fluticasone/salmeterol inhalers between February 1, 2021, and May 30, 2022, at the Hershel “Woody” Williams Veterans Affairs Medical Center, Huntington, West Virginia. Results: In a convenience sample of 100 patients who transitioned from the budesonide/formoterol inhaler to the fluticasone/salmeterol inhaler, exacerbations increased from 24 before the transition to 29 after the transition, which was not a statistically significant change ( P = .56). There were no statistically significant differences in the secondary endpoints including active tobacco use. Three patients had adverse reactions to fluticasone/ salmeterol, while 18 patients experienced a therapeutic failure to fluticasone/salmeterol. Conclusions: Patients with COPD that transitioned from budesonide/formoterol to fluticasone/salmeterol during the formulary conversion yield no clinical or statistically significant change in their clinical outcomes. Switching between these inhalers in the same therapeutic class may not impact clinical efficacy of the therapy for veterans with COPD but some intolerances and treatment failures should be expected.
背景：慢性阻塞性肺疾病（COPD）是一种与慢性、缓慢进展的全身性炎症相关的呼吸系统疾病。慢性阻塞性肺病全球倡议》建议有频繁加重病史的患者使用长效β-2受体激动剂和吸入皮质类固醇的联合吸入剂。2021 年，美国退伍军人事务部将处方布地奈德/福莫特罗吸入剂的患者转为使用氟替卡松/沙美特罗吸入剂。研究方法本研究的主要目的是比较吸入器过渡前 6 个月和过渡后 6 个月的临床结果，包括慢性阻塞性肺疾病加重和住院情况。次要结果包括不良反应、治疗失败、吸烟和抗菌药/系统性皮质类固醇的使用。该研究对西弗吉尼亚州亨廷顿市赫谢尔-威廉姆斯退伍军人事务医疗中心（Hershel "Woody" Williams Veterans Affairs Medical Center）2021年2月1日至2022年5月30日期间开具布地奈德/福莫特罗或氟替卡松/沙美特罗吸入剂处方的患者进行了回顾性病历审查。研究结果在从布地奈德/福莫特罗吸入剂过渡到氟替卡松/沙美特罗吸入剂的100名患者中，病情恶化从过渡前的24例增加到过渡后的29例，变化无统计学意义（P = .56）。包括主动吸烟在内的次要终点差异无统计学意义。3名患者对氟替卡松/沙美特罗产生了不良反应，18名患者对氟替卡松/沙美特罗治疗失败。结论在处方转换过程中，从布地奈德/福莫特罗过渡到氟替卡松/沙美特罗的慢性阻塞性肺病患者的临床结果没有发生临床或统计学意义上的显著变化。在同一治疗类别的吸入剂之间进行转换可能不会影响慢性阻塞性肺病退伍军人的临床疗效，但预计会出现一些不耐受和治疗失败的情况。
{"title":"Clinical Implications of a Formulary Conversion From Budesonide/formoterol to Fluticasone/salmeterol at a VA Medical Center","authors":"Lindsay Hoke","doi":"10.12788/fp.0459","DOIUrl":"https://doi.org/10.12788/fp.0459","url":null,"abstract":"Background: Chronic obstructive pulmonary disease (COPD) is a respiratory disorder associated with chronic and slowly progressive systemic inflammation. The Global Initiative for Chronic Obstructive Lung Disease recommends a combination inhaler of a long-acting β -2 agonist and inhaled corticosteroid for patients with a history of frequent exacerbations. In 2021, the US Department of Veterans Affairs transitioned patients who were prescribed budesonide/formoterol inhaler to a fluticasone/ salmeterol inhaler. Methods: The primary objective of this study was to compare clinical outcomes including COPD exacerbations and hospitalizations 6 months before vs 6 months after the inhaler transition. Secondary outcomes included adverse effects, treatment failure, tobacco use, and antimicrobial/systemic corticosteroid use. A retrospective chart review was conducted on patients with a prescription for a budesonide/formoterol or fluticasone/salmeterol inhalers between February 1, 2021, and May 30, 2022, at the Hershel “Woody” Williams Veterans Affairs Medical Center, Huntington, West Virginia. Results: In a convenience sample of 100 patients who transitioned from the budesonide/formoterol inhaler to the fluticasone/salmeterol inhaler, exacerbations increased from 24 before the transition to 29 after the transition, which was not a statistically significant change ( P = .56). There were no statistically significant differences in the secondary endpoints including active tobacco use. Three patients had adverse reactions to fluticasone/ salmeterol, while 18 patients experienced a therapeutic failure to fluticasone/salmeterol. Conclusions: Patients with COPD that transitioned from budesonide/formoterol to fluticasone/salmeterol during the formulary conversion yield no clinical or statistically significant change in their clinical outcomes. Switching between these inhalers in the same therapeutic class may not impact clinical efficacy of the therapy for veterans with COPD but some intolerances and treatment failures should be expected.","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"102 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140278819","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":"Fighting to Serve: Women in Military Medicine","authors":"Cynthia Geppert","doi":"10.12788/fp.0465","DOIUrl":"https://doi.org/10.12788/fp.0465","url":null,"abstract":"","PeriodicalId":513268,"journal":{"name":"Federal Practitioner","volume":"37 8","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140084525","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}
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