One of the many challenges with treating COVID-19 is that acute respiratory distress syndrome associated with the infection is so different from what intensivists usually see. Another is that the influx of patients means that a lot of non-specialist physicians have been called on to care for these patients. In response, the Uniformed Service University of Health Sciences has created educational video series which provides critical information on ventilator usage and novel modes, such as airway pressure release ventilation, which allows for spontaneous breathing and has potential lung-protective benefits.
Clinicians treating substance use disorder patients at the VA have faced a specific dilemma during the COVID-19 pandemic: How to deal with veterans who need to receive monthly injections at clinics and VAMCs as a critical component of their therapy. Making the choices even more difficult is recent research showing that injectables significantly extend time to relapse for those patients.
VA research has found that about half of veterans with diagnosed schizophrenia or bipolar I disorder have attempted suicide. Nearly 70% of veterans with schizophrenia and more than 82% of those with bipolar disorder reported suicidal ideation or behavior. That’s why it is so critically important to maintain their medications during a crisis such as the COVID-19 pandemic. Long-acting injectable drugs has helped the VA do that.
The National Defense Authorization Act for fiscal year 2000 included a directive for the secretary of defense to establish an integrated pharmacy benefits. Since that time, the pharmacy benefit from TRICARE, the military’s healthcare program, has changed significantly, creating new benefits, strengthening the safety of the drugs it prescribes and having a direct impact on how patients manage their healthcare. Now, changes in copayments, enrollment fees, deductibles and catastrophic caps have been put into place this year in hopes of lowering pharmacy spending, which made up more than half the cost of military healthcare in 2018.
With a growing realization that post-surgical opioids might be neither the safest nor most effective way to reduce pain, VA facilities are using a variety of non-opioid painkillers to help patients manage their discomfort after undergoing surgery. In fact, opioids are no longer considered first line treatment for most types of acute pain, including that related to surgery.
MINNEAPOLIS, MN – How post-operative pain is treated has changed at the VA, as research has demonstrated that opioids and nonopioids work comparatively well when it comes to relieving pain, with nonopioids having less serious adverse effects and much lower chance of addiction.
A recent VA study found that 31% of MS patients in the VA system had suboptimal medication adherence. That can especially be an issue for relapsing forms of the disease, which affect 85% of MS patients, because there could be times of partial or complete remission when symptoms are reduced or absent.
Researchers note that recent exacerbations tended to increase adherence, although failing to regularly use disease modifying treatment has been associated with more relapses and exacerbations, a greater likelihood of disease progression and a poorer quality of life.
Most patients with mantle cell lymphoma, which is considered a presumptive condition for veterans exposed to Agent Orange, face a rapidly progressive disease and higher mortality rates. New therapies are giving VA clinicians more options to help MCL patients. For example, the availability now of three Bruton tyrosine kinase [BTK] inhibitors is allowing treatment to be better matched to the needs of the patient.
With both a movie and a documentary in recent years about television personality Fred Rogers and his neighborhood, nearly everyone knows the advice he was given by his mother. “When I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’”
More than 100,000 VA patients have been cured of hepatitis C with direct-acting antiviral treatment. Even though HCV is the leading cause of hepatocellular carcinoma in the United States, curing the infection only reduces the risk; it doesn’t entirely eliminate it. That’s why the VA has continued with research to determine who is at greatest risk of HCC and is looking at expanding screening.
Guidelines from the Institute of Safe Medication Practices have pointed out that insulin is associated with more medication errors than any other type or class of drugs. With more than 11,400 insulin-using veterans hospitalized in a recent two-year period at the VA, that is an especially critical issue for the healthcare system. Intense focus on avoiding problems with insulin, as well as new products, have improved the situation, both with subcutaneous administration – such as insulin pens – and with intravenous insulin in the critical care setting.
At one point, intensive glycemic control was seen as a magic bullet to keep Type 2 diabetes patients from developing cardiovascular disease. That approach faded, however, when VA research cautioned that any benefits of intensive therapy must be weighed against adverse effects such as hypoglycemia and weight gain. Now the focus has shifted to better medication selection, with guidelines suggesting that, for Type 2 diabetes patients who have cardiovascular disease or are at high risk for it, therapy including an SGLT-2 inhibitor or GLP-1 RA should be considered as optimal treatment.
While, in general, the U.S. military will not accept recruits diagnosed with diabetes, that is especially the case with patients who use insulin, which is seen as an automatic disqualification. The situation is different, however, in military personnel already serving. While most of those retained after diagnosis have well-controlled blood sugar, about a third have hemoglobin A1c measures greater than 7%. That’s why the ability to closely monitor those servicemembers with tools such as continuous glucose monitoring is increasingly important.
Respiratory illnesses account for a significant proportion of all noncombat diagnoses among active duty forces and veterans deployed to southwest Asia; past research estimates that more than 3% of all veterans who served in this theater had newly diagnosed asthma and a similar percentage were diagnosed with chronic obstructive pulmonary disease. How to treat those patients is even more difficult when the conditions overlap. That’s why the VA has developed recommendations for the stepwise treatment of asthma-COPD overlap syndrome.