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

Background: Idiopathic thrombocytopenic purpura and leukocytoclastic vasculitis can present in a similar fashion and can be very hard to differentiate clinically without a biopsy. This can cause diagnostic dilemma and delay in management. A thorough evaluation is recommended to determine etiology, although about half are idiopathic.

Case presentation: A patient aged 79 years with longstanding thrombocytopenia secondary to chronic idiopathic thrombocytopenic purpura presented with a rash. Although it was thought to be secondary to idiopathic thrombocytopenic purpura, a biopsy revealed presence of leukocytoclastic vasculitis.

Conclusions: Although most leukocytoclastic vasculitis cases are mild and resolve without intervention, many go undiagnosed due to biopsy delays. Health care professionals should determine and treat the underlying cause.

Background: Guidelines offer varying recommendations for preoperative long-acting basal insulin dosing, despite mounting evidence of the advantages of maintaining perioperative glucose levels between 80 and 180 mg/dL.

Observations: We iteratively adjusted health care practitioner (HCP) instructions to intensify insulin dosing on the evening before surgery for 195 consecutive patients with diabetes mellitus treated with long-acting basal insulin with an evening dosage. Baseline data was collected in phase 1. In phase 2, the preoperative insulin dose on the evening before surgery was increased for patients with hemoglobin A_1c (HbA_1c) > 8%; in phase 3, it was increased for patients with HbA_1c ≤ 8% while sustaining the phase 2 change. Increased preoperative insulin doses did not change the rates of day of surgery (DOS) hyperglycemia or hypoglycemia. Overall, HCP adherence to the modified protocols was high (89%). A decline in HCP adherence after phase 2 protocol change was associated with a transient increase in DOS hyperglycemia. Patient adherence to preoperative medication instructions was high (86%) and was not affected by protocol changes.

Conclusions: Preoperative insulin intensification the evening before surgery did not change rates of DOS hyperglycemia or hypoglycemia. HCP adherence decreased transiently, which briefly increased DOS hyperglycemia rates in some patients. Perioperative hyperglycemia, defined as blood glucose levels ≥ 180 mg/dL in the immediate pre- and postoperative period, is associated with increased postoperative morbidity, including infections, preoperative interventions, and in-hospital mortality.1-3 Despite being identified as a barrier to optimal perioperative glycemic control, limited evidence is available on patient or health care practitioner (HCP) adherence to preoperative insulin protocols.4-6.

Background: During the initial phase of the COVID-19 pandemic, facilities transformed some medical care to virtual appointments. There was a subsequent decline in chronic disease screening and management, as well as cancer screening rates.

Observations: COVID-19 vaccine events offered an opportunity to provide face-to-face preventive care to veterans, and mobile vaccine events enabled us to reach rural veterans. In this quality improvement project, we partnered with state and community organizations to reach veterans at large vaccine events, as well as in rural sites and homeless housing. The program resulted in the successful provision of preventive care to 115 veterans at these events, with high follow-up for recommended medical care. In all, 404 clinical reminders were completed and 10 new veterans were enrolled for health care. Important clinical findings included an invasive colorectal cancer, positive HIV point-of-care test, diabetic retinal disease, uncontrolled hypertension, and depression.

Conclusions: Vaccine events offer a venue for chronic disease screening, referral, and cancer screening.

Background: The prototypical patient with schizophrenia spectrum disorders (SSDs) is often thought to possess positive symptoms. However, patients with SSDs can present with predominantly negative and cognitive symptoms, which can create diagnostic and treatment challenges.

Case presentation: A 33-year-old female veteran presented to the emergency department with diminished speech output, markedly blunted affect, tangential speech, was not oriented to situation, and appeared to be responding to internal stimuli. Following inpatient admission, the veteran was diagnosed with schizoaffective disorder, which was misdiagnosed as major depressive disorder and borderline personality disorder during her military service. She was initially treated with olanzapine injections and psychotherapy but continued to experience worsening symptoms, resulting in multiple hospitalizations. After starting clozapine, she demonstrated marked improvement and continued with outpatient mental health care.

Conclusions: Predominant negative and cognitive symptom presentations of SSDs require unique considerations to accurately identify and provide optimal treatment for the patient. Clozapine is a promising treatment for addressing these symptoms. This case demonstrates how careful multidisciplinary evaluations, review of health records, collateral information from family members, and other diagnostic and treatment considerations in patients with predominant negative and cognitive symptoms of SSDs can refine and enhance the clinical care offered to such patients.

Background: Recent guidelines indicate that aspirin affords less cardiovascular protection and greater bleeding risks in adults aged > 70 years. Deprescribing potentially inappropriate medications is particularly important in older adults, as this population experiences a high risk of adverse effects and polypharmacy. Limited data are available regarding targeted aspirin deprescribing approaches by pharmacists. The objective of this study was to implement and evaluate the success and feasibility of a pharmacist-led aspirin deprescribing protocol for older adults in a primary care setting.

Observations: This prospective feasibility study in a US Department of Veterans Affairs ambulatory care pharmacy setting included patients aged ≥ 70 years with documented aspirin use. We reviewed 459 patient records and determined that 110 were eligible for deprescribing. A pharmacistinitiated telephone call was attempted for each eligible patient to discuss the risks and benefits of deprescribing aspirin. The primary outcome was the proportion of patients reached for whom aspirin was discontinued. Secondary outcomes included patient rationale for declining deprescribing and the time to complete the intervention. Of 94 patients reached, 45 (48%) agreed to aspirin deprescribing, 3 (3%) agreed to dose reduction, and 29 (31%) declined the intervention. An additional 17 (18%) had previously stopped aspirin, which led to a medication reconciliation intervention. Pharmacists spent about 2 minutes per record review and 12 minutes on each encounter, including documentation.

Conclusions: Implementing a pharmacist-driven aspirin deprescribing protocol in a primary care setting led to the discontinuation of inappropriate aspirin prescribing in nearly half of older adults contacted. The protocol was well accepted by collaborating physicians and feasible for pharmacists to implement, with potential for further dissemination across primary care settings.

Background: Choosing the best medication regimen for a patient with type 2 diabetes mellitus (T2DM) depends on glycemic control, adherence, adverse effect profile, and comorbid conditions. Two new medication classes, glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i), have demonstrated cardiovascular and renal protective properties, creating a new way to care for patients with T2DM.

Methods: This study evaluated the safety and efficacy of the combined use of GLP-1 RA and SGLT2i medications in a veteran population with T2DM. We conducted a pre-post, retrospective chart review of patients at the Veterans Affairs Ann Arbor Healthcare System in Michigan who were prescribed both a GLP-1 RA and SGLT2i medications. The primary objective was to determine the effect on hemoglobin A_1c levels (HbA_1c) at 12 weeks when using a GLP-1 RA and SGLT2i in combination.

Results: HbA_1c levels decreased by 1% after 12 weeks of combination therapy from baseline (P < .001), and this reduction was sustained through the duration of the study period. At 26 and 56 weeks of combination therapy, body weight decreased by about 5 kg (5%) from baseline (P < .001). Systolic blood pressure (BP) reduction from baseline reached statistical significance after 26 and 52 weeks of combination therapy (P < .01 and P < .05, respectively). There was no significant change in diastolic BP, serum creatinine, or estimated glomerular filtration rate during the study period.

Conclusions: The combined use of GLP-1 RA and SGLT2i resulted in statistically significant improvement in HbA_1c levels, weight, and systolic BP compared with separate use.

Background: Clinical use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is well established as add-on therapy to oral medications and basal insulin. However, there is little published data regarding the use of GLP-1 RAs for longer than 12 months in patients taking basal/bolus insulin regimens. The primary goal of our study was to assess the long-term efficacy of GLP-1 RAs as add-on therapy to basal/bolus insulin regimens.

Methods: This study was a retrospective record review of all patients on basal/bolus insulin regimens who received additional therapy with a GLP-1 RA. The primary outcome was the change in glycosylated hemoglobin A_1c (HbA_1c) at 3, 6, 12, 18, and 24 months after initiation of the GLP-1 RA. Secondary outcomes included change in weight and total daily dose (TDD) of insulin and incidence of hypoglycemia and other adverse effects (AEs).

Results: Ninety-two patient records were reviewed. Mean glycemic control changed from baseline -1.1% (95% CI, -1.3 to -0.8; P < .001) at 3 months; -1.0% (95% CI, -1.3 to -0.7; P < .001) at 6 months; -0.9% (95% CI, 1.3 to -0.6; P < .001) at 12 months; -0.9% (95% CI, -1.4 to -0.3; P = .002) at 18 months; and -0.7 (95% CI, -1.4 to 0.1; P = .07) at 24 months. A significant decrease in weight was also observed from baseline through 18 months, and a significant decrease in TDD of insulin was identified from baseline through 12 months. Hypoglycemia was documented in 29.8% of patients at any point during GLP-1 RA therapy, and gastrointestinal AEs were documented in 18.3% of patients.

Conclusions: Adding GLP-1 RAs to complex insulin regimens may help achieve glycemic control while decreasing insulin requirements and mitigating undesirable AEs, such as weight gain.

Background: Low-density lipoprotein cholesterol (LDL-C) can build up on the walls of blood vessels, leading to coronary heart disease. Medications used to lower LDL-C levels have demonstrated decreased risks of atherosclerotic cardiovascular disease, but currently, there is no consensus on how to define very low LDL-C levels. It is necessary for the body to have LDL-C to maintain proper brain function; however, the safety and effects of prolonged very low LDL-C levels are unknown. The current study sought to gather information to determine the risks of very low LDL-C levels in a veteran population.

Methods: A retrospective chart review was conducted at a US Department of Veterans Affairs medical center. Patients with hyperlipidemia/dyslipidemia treated with HMG-CoA reductase inhibitors or proprotein convertase subtilisin/kexin type 9 (PCSK9) therapy and LDL-C levels < 40 mg/dL between January 1, 2010, and September 1, 2020, were included. The primary outcome was the rate of intracranial hemorrhage that could be caused by an LDL-C level < 40 mg/dL. The secondary outcomes included actions taken by clinicians, adverse drug reactions (ADRs), duration of therapy, and medication adherence.

Results: This study included 3027 patients. Of the included patients, 8 had an intracranial hemorrhage within 1 year from a documented LDL-C level < 40 mg/dL (0.26%). Thirty-two patients with an LDL-C level < 40 mg/dL did not have a documented ADR with the studied medications. Of the 32 charts, 26 had a clinician address the LDL-C level < 40 mg/dL with either documentation and/or modification of the medication prescribed. The most common ADRs among the studied medications were muscle and joint pain, rash, and cramps. Adherence to the medications was consistently similar for all studied medications.

Conclusions: Of the patient population included in this study, 0.26% of patients had an intracranial hemorrhage within 1 year of having an LDL-C level < 40 mg/dL. The rate of ADRs related to the medications analyzed in this study shows no statistical significance (P > .05). When compared with low- and moderate-intensity statin medications, high-intensity statin medications were statistically significant in resulting in an LDL-C level < 40 mg/dL (P < .001). LDL-C levels < 40 mg/mL were not routinely documented as being addressed in the chart by the clinician.

Background: In 2001, before the Affordable Care Act (ACA), some states expanded Medicaid coverage to include an array of mental health services, changing veterans' reliance on US Department of Veterans Affairs (VA) services.

Methods: Using Medicaid and VA administrative data from 1999 to 2006, we used a difference-in-difference design to calculate shifts in veterans' reliance on the VA for depression care in New York and Arizona after the 2 states expanded Medicaid coverage to adults in 2001. Demographically matched, neighbor states Pennsylvania and New Mexico/Nevada were used as paired comparisons, respectively. Fractional logit was used to capture the distribution of inpatient and outpatient depression care utilization between the VA and Medicaid, while ordered logit and negative binomial regressions were applied to model Medicaid-VA dual users and per capita utilization of total depression care services, respectively.

Results: Medicaid expansion was associated with a 9.50 percentage point (pp) decrease (95% CI, -14.61 to -4.38) in reliance on the VA for inpatient depression care among service-connected veterans and a 13.37 pp decrease (95% CI, -21.12 to -5.61) among income-eligible veterans. For outpatient depression care, VA reliance decreased by 2.19 pp (95% CI, -3.46 to -0.93) among income-eligible veterans. Changes among service-connected veterans were nonsignificant (-0.60 pp; 95% CI, -1.40 to 0.21).

Conclusions: After Medicaid expansion, veterans shifted depression care away from the VA, with effects varying by health care setting, income- vs service-related eligibility, and state of residence. Issues of overall cost, care coordination, and clinical outcomes deserve further study in the ACA era of Medicaid expansions.