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

Background: Vaccine-induced phantosmia is a rare adverse effect of vaccination and has not been previously reported related to the Johnson & Johnson (J&J) COVID-19 vaccine.

Case presentation: Three weeks after receiving the J&J COVID-19 vaccine, a 39-year-old veteran started smelling a burning odor in the absence of an identifiable source. At presentation to the clinic, his general and neurological examinations, brain magnetic resonance imaging, and electroencephalogram were all unremarkable. The episodes persisted for nearly 2 years (21 months postvaccination).

Conclusions: This is the only case of phantosmia reported after the use of the J&J COVID-19 vaccine and aligns with the literature that reports 1 case of phantosmia and 2 cases of hyposmia following the Pfizer-BioNTech COVID-19 mRNA vaccine. This information will help health care professionals understand the possible adverse effects of COVID-19 vaccination and be better equipped to counsel patients about the benign but potentially long-lasting adverse effects of the J&J COVID-19 vaccine.

Background: Radiation therapy can cause long-term dysphagia that seriously affects quality of life for survivors of head and neck cancer. This study evaluates a novel organ at risk, the contralateral pharyngeal constrictor muscles, to find out whether radiation dose to this structure predicts late swallowing function in patients with head and neck cancer.

Methods: The study included patients with head and neck cancer treated with radiation and concurrent systemic therapy at a single institution over 3 years. One-year dysphagia was defined as either the presence of a gastrostomy tube or an abnormal modified barium swallow ≥ 1 year after completion of radiation.

Results: Fifty-five patients met inclusion criteria, of which 46 were alive at 1 year. One-year dysphagia was present in 37% (n = 17) of this population. Contralateral constrictor V60 < 40% was associated with a 1-year dysphagia rate of 6%, compared with 57% in patients with V60 ≥ 40% (P < .001). An uninvolved pharynx mean dose < 45 Gy was associated with a 1-year dysphagia rate of 22%, compared with 52% in patients with an uninvolved pharynx mean dose ≥ 45 Gy (P = .03). Editing the clinical target volume off air cavities was associated with a decrease in 1-year dysphagia from 67% to 12% (P < .001), and with a reduction of contralateral constrictor V60 from 62% to 33% (P < .001). Air cavity editing was not associated with a change in locoregional recurrence or 1-year survival.

Conclusions: This is the first study to report a connection between contralateral constrictor dose and late swallowing function. The correlation between air cavity editing and contralateral constrictor V60 suggests that contralateral constrictor dose may depend partly on technique. Further studies are needed to explore whether these findings can be replicated prospectively and in other practice settings.

Background: The correlation between head and neck squamous cell carcinoma (SCC) and human papillomavirus (HPV) has been of great interest. We aimed to study immunoexpression of the p16^INK4a (p16) antigen, a surrogate marker for high-risk HPV infection, in oropharyngeal SCC among veterans to estimate HPV-related cancer and survival. Secondary aims included stratification of race and ethnicity, degree of tobacco and alcohol use, tumor location, stage, and age at diagnosis.

Methods: A retrospective electronic health record review was performed between January 1, 2000, and December 31, 2008, at a tertiary-level US Department of Veterans Affairs (VA) medical center for veterans who were treated for oropharyngeal SCC, had follow-up for a minimum of 2 years, and for whom paraffin-embedded tissue was available. Paraffin-embedded tissue was analyzed for p16 expression.

Results: We identified 66 veterans who met the inclusion criteria. p16 expression was observed in 29% of the patients. All patients were male with no difference in age at diagnosis between the groups. Among patients with p16-negative status, 60% were African American, whereas among patients with p16-postive status, 32% were African American (P = .04). Among patients with p16-postive status, 22% were tobacco-naïve, and 18% were alcohol-naïve vs 0% and 4%, respectively, of patients with p16-negative status (P = .005 and P = .12, respectively). Two-year survival was the same for both groups (P = .52).

Conclusions: We observed p16 expression in 29% of VA patients with oropharnygeal SCC, which was less than observed in non-VA populations. At presentation, both groups demonstrated a predilection for tonsil location and late stage without significant difference in age or disease-specific survival. Disparities in racial distribution and tobacco use between patients with and without p16-positive status appear like that reported in non-VA populations; however, the frequently reported younger age at presentation, lower stage, and improved prognosis were not observed.

Background: Cholangiocarcinoma is a highly aggressive cancer of the biliary tract epithelium. This form of cancer is prevalent in Asia, and recent reports show that its incidence is relatively rare but increasing in the United States. Although risk factors for cholangiocarcinoma have yet to be elucidated, a growing body of literature suggests chronic infection of genetically susceptible individuals with the food-borne zoonotic trematodes Clonorchis sinensis (C sinensis) and Opisthorchis viverrini (O viverrini) may play a role.

Observations: Although most infected people remain asymptomatic, untreated indolent infections with C sinensis and O viverrini may persist in peripheral intrahepatic bile ducts for almost 30 years. During this period, the trematodes' feeding activities and their excretory-secretory products may damage the bile duct epithelium and promote local inflammation. These pathological processes could then provoke epithelial desquamation, adenomatous hyperplasia, goblet cell metaplasia, periductal fibrosis, and granuloma formation that are conducive to the initiation and progression of cholangiocarcinoma in genetically susceptible people. The International Agency for Research on Cancer has determined that there is sufficient evidence in humans for the carcinogenicity of chronic infections with C sinensis and O viverrini.

Conclusions: Timely serodiagnosis of indolent C sinensis and O viverrini infections is important as these parasites may be a risk factor for cholangiocarcinoma in veterans who served in Vietnam. About 774,000 living Americans served in Vietnam and there is an urgent need to develop sensitive and specific serologic assays to detect both acute and indolent infections. We posit that testing and treatment of high-risk populations could lead to earlier detection and treatment of cholangiocarcinoma, leading to improved overall survival.

Background: Granulocyte colony-stimulating factor prophylaxis has been shown to reduce the risk and duration of chemotherapy-induced neutropenia and febrile neutropenia and is recommended for at-risk patients receiving chemotherapy. Within the South Texas Veterans Health Care System, daily filgrastim injections remain the preferred formulation of granulocyte colony-stimulating factor for primary prophylaxis of febrile neutropenia.

Methods: This retrospective, single-center cohort study included 59 patients who received daily filgrastim as primary prophylaxis with a curative cancer diagnosis and a chemotherapy regimen at the South Texas Veterans Health Care System from September 1, 2015 to September 24, 2020. Patients had either a high risk for febrile neutropenia or a chemotherapy regimen with an intermediate risk for febrile neutropenia and additional risk factors. The primary outcome was the incidence of neutropenia/febrile neutropenia leading to treatment delays. Secondary outcomes included chemotherapy dose decreases or discontinuations, hospitalizations, days of hospitalization, infections, extended duration of filgrastim, and transitions to pegfilgrastim due to neutropenia/febrile neutropenia.

Results: Patients received a median (IQR) of 7 (5-10) doses of filgrastim for primary prophylaxis. Overall, 10 patients (17%) experienced treatment delays due to neutropenia/febrile neutropenia. Fifteen patients (25%) were hospitalized with a median (IQR) length of stay of 5 (4-7) days, 9 patients (15%) had documented infections, and 2 patients (3%) required a chemotherapy dose reduction. Additionally, 9 patients (15%) required an additional median (IQR) of 2 (2-5) doses of filgrastim, and 9 (15%) patients were transitioned to pegfilgrastim.

Conclusions: These results suggest that additional measures such as tracking postnadir absolute neutrophil counts should be performed to ensure patients receive an appropriate number of filgrastim doses to prevent complications associated with neutropenia/febrile neutropenia.

Background: Definitions of malnutrition imperfectly reflect nutritional status or predict perioperative consequences. We sought to identify predictive nutritional trends by examining the effect of preoperative weight on postoperative outcomes in patients with colorectal cancer (CRC).

Methods: This retrospective review examined 148 patients with CRC treated with curative-intent surgery at the Veterans Affairs Ann Arbor Healthcare System in Michigan from January 1, 2015 to December 31, 2019. We evaluated weight dynamics of patients, starting 1 year before cancer diagnosis until 1 year after surgery. We evaluated the association of these weight dynamics with surgical outcomes. Primary outcomes observed were hospital readmission and length of stay (LOS), chemotherapy completion, and delayed recovery defined as abnormal clinical developments.

Results: There were 115 patients in the colon cancer (CC) cohort and 33 in the rectal cancer (RC) cohort. Low preoperative albumin (< 3.5 g/dL) was present in 25 patients with CC (22%) and 11 patients with RC (33%). Six-month preoperative weight loss of at least 3% occurred in 32 patients with CC (36%). Delayed recovery was observed in 35 patients with CC (30%) and 21 patients with RC (64%). Nutrition consultation rates for the CC and RC groups were 15% and 36%, respectively, before the operation; 95% and 100%, respectively, for postoperative inpatients; and 12% and 73%, respectively, for postoperative outpatients. Six-month preoperative weight loss of ≥ 3% was significantly associated with delayed recovery (P < .001) and 60-day readmissions (P = .015) but not increased LOS or chemotherapy noncompletion.

Conclusions: A ≥ 3% weight loss 6 months preceding curative surgery for CRC was associated with adverse outcomes. An intensive nutrition prehabilitation program initiated at the time of cancer diagnosis is needed and may reduce associated complications.

Background: Horner syndrome is a rare neurologic disorder that can arise from severe neurologic and systemic conditions, which may require immediate diagnosis with radiologic imaging and treatment with antiplatelet and anticoagulant therapy. Horner syndrome is often asymptomatic but can have distinct, easily identified characteristics seen with an ophthalmic examination.

Case presentation: A 61-year-old woman presented with periorbital pain localized around and behind the right eye that she rated as 7 on a 10-point scale with onset 3 days prior. She reported light sensitivity, syncope, dizziness, and a recent history of transient ischemic attacks of unknown etiology. The patient had acute, slight ptosis with pathologic miosis and pain in the ipsilateral eye with no reports of exposure to miotic pharmaceutical agents and no history of trauma to the globe or orbit eliminated other differentials, leading to a diagnosis of right-sided Horner syndrome. She was referred for emergency department evaluation where radiography was indicative of an internal carotid artery dissection.

Conclusions: Due to possible life-threatening complications that can arise in patients with Horner syndrome, clinicians must have a thorough understanding of the condition, appropriate treatment, and management modalities. Determining the underlying etiology of Horner syndrome can help prevent a decrease in a patient's vision or quality of life and in some cases prevent death. Magnetic resonance imaging and computed tomography should be used to rule out carotid artery dissection and other severe conditions.

Background: The sleep medicine community has struggled to identify the ideal role for adaptive servo-ventilation (ASV) therapy following a study that found increased mortality in patients with central sleep apnea (CSA) and heart failure with reduced ejection fraction who used ASV therapy. We aimed to identify characteristics of patients who benefit from ASV therapy.

Methods: We performed a record review of all patients treated with ASV therapy at the Hampton Veterans Affairs Medical Center in Virginia from January 1, 2015, to April 30, 2020. Clinical and polysomnographic characteristics of patients adherent to therapy were compared with those that were not adherent.

Results: Our cohort of 31 patients was entirely male with a mean age of 67.2 years, body mass index of 34.0, and Epworth Sleepiness Scale score of 10.9. Primary CSA was initially diagnosed in 3 patients (10%), comorbid obstructive sleep apnea (OSA) and CSA in 9 (29%), and primary OSA in 19 (61%). Seventeen patients (55%) met minimal adherence criteria with ASV therapy. The obstructive apnea-hypopnea index (AHI), as a proportion of the total pretreatment AHI, was higher in adherent patients (81.5%) vs nonadherent patients (46.7%) (P = .02). The median residual AHI was lower in the adherent group, both as absolute values (1.7 vs 4.7 events/h; P = .004) and as a percentage of the pretreatment AHI (3.1% vs 10.2%; P = .002).

Conclusions: Patients using ASV devices regularly have a larger component of obstructive sleep-disordered breathing and obtain greater objective benefit from ASV than those that do not. This understanding may help to identify patients that will most benefit from this debated form of therapy.

Background: Infectious diseases are the most common reason for rehospitalization in patients with spinal cord injury (SCI). Persons with SCI are at high risk for antibiotic over-use and hospital-acquired infection due to chronic bacteriuria, frequent health care exposure, implanted medical devices, and other factors. We aimed to record the percentage of subjects from the local SCI registry with an antibiotic allergy, the most common antibiotic classes responsible for the allergy, and allergic reactions.

Methods: We conducted a retrospective study at the James A. Haley Veterans' Hospital in Tampa, Florida, of patients in the SCI registry between October 1, 2015, and September 30, 2017. We collected patient demographics and SCI descriptors. The outcomes included antibiotic allergy and adverse drug reactions.

Results: Of 1866 patients, 1659 met inclusion criteria; 29.8% of the subjects had a recorded allergy to antibiotics. Penicillin (13.1%), sulfa drugs (9.6%), and fluoroquinolone (4.5%) were the most common allergens. However, only 11.9% of patients with a penicillin allergy had severe reactions.

Conclusions: Almost 30% of patients with SCI had a recorded allergy to an antibiotic. There are opportunities to examine whether approaches to confirm true reactions, such as skin testing, would help mitigate unnecessary avoidance of certain antibiotic classes due to mild adverse effects, rather than a true allergy, in the SCI population. Differentiating true allergy is the only clear way to deter unnecessary avoidance of first-line therapies for antibiotic treatment and avoid promotion of antibiotic resistance.

Background: Primary hepatic lymphoma is a rare, malignant lymphoma of the liver unlike the predominant lymph nodal or splenic involvement associated with other types of lymphoma. It is commonly associated with nonspecific symptoms and usually detected incidentally on imaging examination.

Case presentation: An 84-year-old man was evaluated for upper back pain. Chest computed tomography showed multiple large lesions in the liver, leading to the diagnosis of primary diffuse large B-cell lymphoma of the liver. Within 2 weeks of detecting his liver mass, the patient developed hypercalcemia and hyperuricemia that led to rapid deterioration and admission for treatment. Further diagnostic testing was performed, and he was initiated on appropriate chemotherapy.

Conclusions: Primary hepatic lymphoma, a form of diffuse large B-cell lymphoma of the liver is a rare disease without specific clinical manifestations, biochemical indicators, or radiologic features except for space-occupying liver lesions. However, patients' conditions can deteriorate rapidly at an advanced stage as demonstrated in this case, which highlights the importance of a high level of suspicion for early diagnosis and treatment.