By Marsha Dangler, PharmD, BCACP

Marsha Dangler, PharmD, BCACP, is a clinical pharmacy specialist in Pharmacy Services at the James H. Quillen VAMC in Mountain Home, Tennessee.

Assessment is often the best step when trying to determine a solution to a problem. So first, assess the problem! Achieving the solution to a problem can be the more difficult task to manage, which is even truer when trying to change a culture within a medical community. In the May 2013 issue of Federal Practitioner, the article, “Assessing the Appropriate Use of Proton Pump Inhibitors in a Veteran Outpatient Population,” by Leslie Ochs, PharmD, PhD; Robyn White, PharmD, CDE; and myself was published. In this study, we found several areas for improving the appropriate prescribing of proton pump inhibitor (PPI) therapy.

By Wei Huang, MD, PhD

Wei Huang, MD, PhD, is a staff physician at the Atlanta VAMC and assistant professor of rehabilitation medicine at Emory University School of Medicine in Atlanta, Georgia.

As I have been often asked by practitioners from other VA facilities about the setup of acupuncture clinics, I decided to write an article on this topic. Coauthored with Theodore Johnson II, MD, Lesa Woodby, MD, and Laura Lee, MD, the article “Providing an Alternative Treatment Modality for Veterans: Establishing and Evaluating an Acupuncture Clinic in a VA Medical Center,” appears in the April 2013 issue of Federal Practitioner. I hope it will provide some useful information to those who are interested.

By Andrew P.J. Olson, MD

Andrew P.J. Olson, MD, is chief resident in the Department of Medicine at the University of Minnesota Medical School in Minneapolis, Minnesota.

In the January 2013 issue of Federal Practitioner, in the article “Bronchial Breathing and Resonant Percussion—An Important Combination of Signs in Pneumothorax,” written by Dr. Wang, Dr. Tierney, and myself, we described a case of pneumothorax that was unexpected and that diagnosis not considered until seen on chest radiography. We noted that perhaps, had additional physical examination been performed initially, a delay in the diagnosis could have been avoided.

by Busola Akinbote, PharmD

Busola Akinbote, PharmD, is a clinical pharmacist specialist at the Atlanta VAMC in Carrollton, Georgia.

“I do not want you treating me with that rat poison!”

If you have heard these words come out of your patient’s mouth, then you have dealt with warfarin or its brand equivalent. Warfarin is a special medication because it has a narrow therapeutic index. Warfarin therapy must be monitored closely and adjusted to balance the risk of bleeds against the benefits of protection against blood clots.

By Marcos Montagnini, MD
Marcos Montagnini, MD, is a staff physician and the director of the Palliative Care Program at the VA Ann Arbor Healthcare System, Geriatric Research, Education and Clinical Center (GRECC) in Ann Arbor, Michigan, and an associate professor of medicine in the Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, at the University of Michigan in Ann Arbor, Michigan.  

Having good communication skills is essential for health care providers. In the November 2012 issue of Federal Practitioner, the article “A Palliative Care Coordination Program for Veterans With Advanced Cancer,”  written by Judith R. Knudson, MPAS, PA-C, BSN; Stephanie Borchardt, PhD, MPH; Tracy Pedersen, BS, RHIT, CTR; and myself, was published. The article described the benefits of a palliative care coordination program for patients with advanced cancer. In this study, we demonstrated that the implementation of a program that strongly emphasized communication improved the utilization of end-of-life interventions for veterans with advanced cancer.

By Ellen T. Thatcher, GNP-C, CHPN
Ellen T. Thatcher, GNP-C, CHPN, is a certified geriatric, hospice, and palliative care nurse practitioner and community hospice care coordinator at the Bay Pines VA Healthcare System in Bay Pines, Florida.

The principle of double effect (PDE) has been around for centuries. It originated in Roman Catholic theology, as in aborting a fetus to save the mother’s life. PDE posits that, if the intention is not to do harm or kill, then it is morally ethical and allowable. This theory is now often used in hospice bioethics.  

By Muhammad Jawad Sethi, MD
Dr. Sethi is an endocrinology fellow at the University of Arizona in Tucson, Arizona.

There is no doubt that statins are revolutionary medications. But like anything else, they can cause adverse effects (AEs). Hypogonadism may be one of those AEs and is often missed. In the big picture, patients who are on statins, especially in higher doses, also have other comorbidities. These may include obesity, type 2 diabetes, and coronary artery disease. Type 2 diabetes and obesity are known risk factors for hypogonadism. So if the patient has these 2 risk factors, is on a high-dose statin, and complains of decreased libido, statins should be considered a potential contributor.

By Robin Shah, DO, MBA 

Robin Shah, DO, MBA, is an internal medicine resident at The Christ Hospital in Cincinnati, Ohio.

My article in the July 2012 issue of Federal Practitioner, Elevated Cardiac Troponins–Not Always an Acute Coronary Syndrome, explains that cardiac enzymes, such as troponins, are a very sensitive laboratory test. In the Emergency Department, most patients with chest pain, shortness of breath, and associated symptoms are tested for elevated cardiac enzymes. However, when interpreting the test, it is important to remember that these enzymes are elevated when there is myocardial cell injury, but does not determine the mechanism of injury. The article discusses that there are many common causes of a cardiac troponin leak.

By Ellen T. Thatcher, GNP-C, CHPN
Ellen T. Thatcher, GNP-C, CHPN, is a certified geriatric, hospice, and palliative care nurse practitioner and community hospice care coordinator at the Bay Pines VA Healthcare System in Bay Pines, Florida.

I love having my Pomeranian, Margaret, at work with me because I seem to have a better day when she’s with me. She’s allowed on the Hospice Unit and in our Community Living Center; the veterans absolutely love her. However, because of policy, she’s not allowed in the acute or intensive care areas.  

By Jorge Ruiz, MD; and Allen D. Andrade, MD
Jorge Ruiz, MD, is the director of the Laboratory of E-learning and Multimedia Research and the associate director for Education and Evaluation. Allen D. Andrade, MD, is the associate director of the Laboratory of E-learning and Multimedia Research and GRECC Investigator, and both are at the Geriatric Research, Education, and Clinical Center (GRECC), Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida.

Adherence to self-management behaviors is linked to better health care outcomes in patients with chronic illness. Despite the benefits, however, nonadherence remains a significant problem. Though interventions to improve adherence to self-management behaviors have shown some success, in most cases these interventions are resource intensive and may not be available to most patients. Computer-based interventions may constitute cost-effective ways to improve access to evidence-based self-management. We have seen that avatars (digital representations of people) are widely used in Internet environments to facilitate social interactions and communication. Compared with a computer program without avatars, one with an avatar could establish a relationship with a participant that is more engaging, persuasive, and long-term.