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

Background: Shrapnel injuries are commonly encountered in war zones. The severity of these injuries depends on the initial damage and both the anatomical and immune response at the time of injury or at more remote times in the case of reactivation.

Case presentation: A veteran sustained a shrapnel injury to his left lower abdomen while serving in the Vietnam War. Nearly 50 years later, the patient presented with a recurrent retroperitoneal abscess associated with a residual fragment. In cooperation between interventional radiology and surgery, traditional endovascular techniques and devices were used to relocate an extravascular, secondarily infected fragment to an area more suitable for a minor surgical approach in the left inguinal region. Subsequent surgical excision and removal required only a superficial incision as opposed to a large retroperitoneal dissection, minimizing recovery time and allowing quick and full healing of the patient.

Conclusions: This case demonstrates a multidisciplinary approach to transforming an otherwise large retroperitoneal dissection to a minimally invasive and technically efficient abscess drainage and foreign body retrieval.

Background: In patients with multiple myeloma, thrombotic microangiopathy is a rare adverse event associated with proteasome inhibitors, such as bortezomib, carfilzomib, and ixazomib.

Case presentation: Two patients with multiple myeloma who presented with carfilzomib-induced thrombotic microangiopathy received eculizumab with subsequent stabilization of renal function.

Conclusions: Given the overall rarity of this adverse event, the simultaneous presentation of these 2 cases was unexpected. These cases underscores the need for heightened awareness in clinical practice of thrombotic microangiopathy. The potential role of eculizumab as a therapeutic treatment in the setting of thrombotic microangiopathy requires further investigation.

Background: Drug-induced hypersensitivity syndrome (DIHS), also called drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, is a potentially fatal drug-induced hypersensitivity reaction that is characterized by a cutaneous eruption, multiorgan involvement, viral reactivation, and hematologic abnormalities.

Case presentation: We present a case of lamotrigine-associated DIHS/DRESS complicated by an unusually prolonged course requiring oral corticosteroids and narrow-band ultraviolet B treatment and with development of extensive alopecia areata and autoimmune thyroiditis.

Conclusions: DIHS/DRESS is a severe cutaneous adverse reaction that may require prolonged treatment until symptoms resolve. Oral corticosteroids are the mainstay of treatment, but long-term use is associated with significant adverse effects. Alternative therapies, such as cyclosporine, look promising, but further studies are needed to determine safety profile and efficacy. DIHS/DRESS patients also should be educated and followed for potential autoimmune sequelae.

Background: The use of artificial intelligence (AI) in health care is increasing and has shown utility in many medical specialties, especially pathology, radiology, and oncology.

Observations: Many barriers exist to successfully implement AI programs in the clinical setting. To address these barriers, a formal governing body, the hospital AI Committee, was created at James A. Haley Veterans' Hospital in Tampa, Florida. The AI committee reviews and assesses AI products based on their success at protecting human autonomy; promoting human well-being and safety and the public interest; ensuring transparency, explainability, and intelligibility; fostering responsibility and accountability; ensuring inclusiveness and equity; and promoting AI that is responsive and sustainable.

Conclusions: Through the hospital AI Committee, we may overcome many obstacles to successfully implementing AI applications in the clinical setting.

Background: Multiple myeloma (MM) accounts for 1% to 2% of all cancers. Exposure to the pesticide Agent Orange (AO) has been established as a potential risk factor for the development of monoclonal gammopathy of undetermined significance (MGUS) and, subsequently, MM in Vietnam War veterans.

Methods: This study explored variation in survival related to AO exposure, transformation from MGUS to MM, and covariates. Vietnam War veterans with MM or MGUS were identified in Veterans Health Administration (VHA) health records data. Cox proportional hazards models analyzed survival as a function of AO, race, ethnicity, body mass index, nicotine dependence, alcohol use disorder, Charlson Comorbidity Index, and treatment. Autologous hematopoietic cell transplantation for MM was defined by procedure codes.

Results: In the VHA 16,366 patients were identified: 11,112 patients diagnosed with MGUS and 7261 with MM during fiscal years 2010 to 2015 were identified; 12% (n = 2007) had both diagnoses. No statistically significant difference in the rate of transformation from MGUS to MM in the AO exposed and AO not exposed groups was found. In survival models, AO exposure was associated with slightly lower mortality. Alcohol use disorder, nicotine dependence, older age, and greater comorbidity burden increased mortality risk. Black race, female sex, obesity/overweight, and hematopoietic cell transplantation for patients with MM were protective factors. AO exposure was associated with decreased mortality for both MM/MGUS groups. Transformation increased mortality risk for patients with MGUS and decreased mortality risk for patients with MM.

Conclusions: Because AO exposure is a nonmodifiable risk factor, focus should be placed on modifiable risk factors (eg, nicotine dependence, alcohol and drug use disorders, underlying comorbid conditions) as these were associated with worse outcomes. Future studies should examine the correlation of AO exposure, cytogenetics, and clinical outcomes in these veterans to best identify their disease course and optimize their care in the latter part of their life.

Background: Black patients have a higher incidence and mortality associated with hepatocellular carcinoma (HCC) compared with that of White patients in many retrospective analyses. This study sought to determine whether veterans treated for HCC at the Memphis Veterans Affairs Medical Center (VAMC) in Tennessee showed similar disparities in terms of stage at diagnosis, type of therapy received, and overall survival (OS).

Methods: A retrospective review evaluated 132 White and 95 Black patients treated for HCC between 2009 and 2021. We evaluated the impact on OS of age, sex, comorbidities, tumor stage, α-fetoprotein level, method of diagnosis, first-line treatment, systemic treatment, and surgical options offered. Kaplan-Meier analysis was used to investigate differences in OS and cumulative hazard ratio for death. Cox regression multivariate analysis evaluated discrepancies among investigated variables.

Results: The study found no significant difference in OS between Black and White veterans with HCC. Significant differences were found in who received surgical treatment and systemic therapy. More White veterans received any form of treatment compared with Black veterans (P < .001), and White veterans were more likely to undergo surgical resection and transplant (P = .052). There was no significant difference between age or stage at diagnosis, receipt of systemic therapy, alcohol, tobacco or drug use, HIV coinfection, or cirrhosis.

Conclusions: Black veterans with HCC at the Memphis VAMC were less likely to receive any form of treatment, surgical resection, or transplant compared with White veterans, but this did not have a statistically significant effect on OS.

Background: Many veterans are eligible to receive prescriptions from community-based pharmacies. Swift and accurate review of prior authorization drug requests by the US Department of Veterans Affairs (VA) pharmacy is necessary to mitigate treatment delays, medication misuse, adverse drug events, medication errors, and unnecessary cost to the health care system.

Methods: We performed a retrospective review of community care prior authorization drug requests to assess the direct cost savings achieved through a centralized process and to characterize submitted requests.

Results: The centralized community care pharmacy team demonstrated a cost savings of $515,872.31 over 6 months and increased patient safety. Community care prior authorization drug requests had a 46.2% approval rate. Coordination of care took an average of 8 days.

Conclusions: Use of a centralized community care pharmacy team could result in significant annual cost savings for the VA. Considering the approval rate seen in this study, VA could allocate resources to educate community-based prescribers about its formulary to increase the approval rate and reduce administrative burden for VA pharmacies and prescribers.

Background: Moderately hypofractionated radiotherapy (MHRT) is an accepted treatment for localized prostate cancer; however, limited MHRT data address high-risk prostate cancer (HRPC) and/or African American patients. We report clinical outcomes and toxicity profiles for individuals with HRPC treated in an equal access system.

Methods: We identified patients with HRPC treated with MHRT at a US Department of Veterans Affairs referral center. Exclusion criteria included < 12 months follow-up and elective nodal irradiation. MHRT included 70 Gy over 28 fractions or 60 Gy over 20 fractions. Acute and late gastrointestinal (GI) and genitourinary (GU) toxicities were graded using Common Terminology Criteria for Adverse Events, version 5.0. Clinical endpoints, including biochemical recurrence-free survival (BRFS), distant metastases-free survival (DMFS), overall survival (OS), and prostate cancer-specific survival (PCSS) were estimated using Kaplan-Meier methods. Clinical outcomes, acute toxicity, and late toxicity-free survival were compared between African American and White patients with logistic regression and log-rank testing.

Results: Between November 2008 and August 2018, 143 patients with HRPC were treated with MHRT and followed for a median of 38.5 months; 82 (57%) were African American and 61 were White patients. Concurrent androgen deprivation therapy (ADT) was provided for 138 (97%) patients for a median duration of 24 months. No significant differences between African American and White patients were observed for 5-year OS (73% [95% CI, 58%-83%] vs 77% [95% CI, 60%-97%]; P = .55), PCSS (90% [95% CI, 79%-95%] vs 87% [95 % CI, 70%-95%]; P = .57), DMFS (91% [95% CI, 80%-96%] vs 81% [95% CI, 62%-91%]; P = .55), or BRFS (83% [95% CI, 70%-91%] vs 71% [95% CI, 53%-82%]; P = .57), respectively. Rates of acute grade 3+ GU and GI were low overall (4% and 1%, respectively). Late toxicities were similarly favorable with no significant differences by race.

Conclusions: Individuals with HRPC treated with MHRT in an equal access setting demonstrated favorable clinical outcomes that did not differ by race, alongside acceptable rates of acute and late toxicities.

Background: Following deployment to the Southwest Asia theater of operations and Afghanistan, many service members and veterans report respiratory symptoms and concerns about their military and environmental exposures. The US Department of Veterans Affairs (VA) established the national Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 to help better understand long-term health conditions that may be related to these exposures.

Observations: The AHOBPR provides an online questionnaire and optional health evaluation performed by a primary care or environmental health clinician. The clinical evaluation provides an opportunity for the service member or veteran to talk with a health care professional about their symptoms, exposures, and potential treatment. Data derived from questionnaire responses and health evaluations facilitate medical surveillance and research. The VA also established a network of specialists, referred to as the Post-Deployment Cardiopulmonary Evaluation Network (PDCEN). The PDCEN identifies veterans within the AHOBPR who self-report certain conditions or have unexplained dyspnea and conducts comprehensive diagnostic evaluations. Primary objectives of PDCEN evaluations are to define respiratory and related conditions that are present, determine whether conditions are related to deployment, and work with the veteran's clinician to identify treatments and/or follow-up care to improve their health. We utilize a case example to illustrate the role of the primary care practitioner in connecting veterans to PDCEN clinical evaluations.

Conclusions: AHOBPR clinical evaluations represent an initial step to better understand postdeployment health conditions. The PDCEN clinical evaluation extends the AHOBPR evaluation by providing specialty care for certain veterans requiring more comprehensive evaluation while systematically collecting and analyzing clinical data to advance the field.

Background: Despite the use of platinum-based chemotherapy, lung cancer continues to be the leading cause of cancer-related death in the world. To overcome the rate of lung cancer-related death, scientists discovered advanced therapies, including mutant epidermal growth factor receptor-tyrosine kinase (EGFR-TK) inhibitors.

Observations: We conducted a meta-analysis to determine the safety profile of mutant EGFR-TK inhibitors in the management of advanced non-small cell lung cancer (NSCLC). Included in this study are 9 phase 3 randomized controlled trials designed to study the safety profile of mutant EGFR-TK inhibitors in patients with advanced NSCLC. The study showed that mutant EGFR-TK inhibitors have an incidence of adverse effects that is less reported when compared with platinum-based chemotherapy.

Conclusions: We recommend continuing using mutant EGFR-TK inhibitors in patients with advanced NSCLC especially in patients having mutant EGFR receptors. Adverse effects caused by mutant EGFR-TK inhibitors are significant but are usually tolerable and can be avoided by reducing the dosage of it with each cycle or by skipping or delaying the dose until patient is symptomatic.