Assessing olaparib efficacy in U.S. Veterans with metastatic prostate cancer utilizing a time-indifferent g-rate method ideal for real-world analyses.

Background: We aimed to assess real-world efficacy of the PARP inhibitor, olaparib, in US Veterans with metastatic prostate cancer (mPC) by leveraging the national data repository and evaluate a novel approach to assess treatment efficacy in tumors considered rare or harboring rare mutations.

Methods: Included Veterans had 1) mPC with somatic or germline alterations/mutations in genes involved in homologous recombination repair (HRR), 2) received olaparib monotherapy as well as a novel hormonal therapy/androgen receptor pathway inhibitors (NHT/ARPI), and/or chemotherapy, and 3) estimable rates of tumor growth (g-rate) using PSA values obtained while receiving treatment. Previous work has shown an excellent inverse correlation of g-rate with survival.

Tumour-To-Tumour Metastasis: A Rare Case of Prostate Cancer Metastasising to Primary Lung Adenocarcinoma.

Unlabelled: Tumour-to-tumour metastasis (TTM) is a rare phenomenon that clinicians should be aware of when evaluating patients with a history of prostate cancer. We present the diagnosis and management of an 80-year-old former smoker with high-risk prostate cancer, who developed a lung nodule consistent with TTM. The patient had concurrent primary lung adenocarcinoma and metastatic prostate cancer, making this a unique case of dual primary and metastatic malignancies.

Clinician Insights into Effective Components, Delivery Characteristics and Implementation Strategies of Ambulatory Palliative Care for People with Heart Failure: A Qualitative Analysis.

Objectives: To elicit perspectives from specialist palliative care (SPC) and cardiology clinicians concerning the necessary components, delivery characteristics and implementation strategies of successful ambulatory SPC for people with heart failure (HF).

Background: Palliative care is a recommended component of guideline-directed care for people with HF. However, optimal strategies to implement SPC within ambulatory settings are unknown.

Assessment of PSA responses and changes in the rate of tumor growth (g-rate) with immune checkpoint inhibitors in US Veterans with prostate cancer.

We examined data from US Veterans with prostate cancer (PC) to assess disease response to immune checkpoint inhibitors (ICI) as monotherapy or combined with abiraterone or enzalutamide to assess ICI efficacy in the real-world. We queried the VA corporate data warehouse (CDW) to identify Veterans with a diagnosis of PC who received ICI for any malignancy and had ≥1 PSA measurement while receiving ICI. To evaluate ICI monotherapy, we restricted analysis to Veterans who had not received LHRH agonists/antagonists, PC-directed medical therapy, or radiation/extirpative surgery of the bladder/prostate within and preceding the duration of ICI administration.

Influence of Cancer on COVID-19 Incidence, Outcomes, and Vaccine Effectiveness: A Prospective Cohort Study of U.S. Veterans.

Purpose: Coronavirus disease 2019 (COVID-19) has been a constant health threat since its emergence. Amongst risk factors proposed, a diagnosis of cancer has been worrisome. We report the impact of cancer and other risk factors in US Veterans receiving care at Veterans Administration (VA) Hospitals, their adjusted odds ratio (aOR) for infection and death, and report on the impact of vaccines on the incidence and severity of COVID-19 infections in Veterans without/with cancer.

Liver Granulocytic Sarcoma With Megakaryocytic Differentiation: A Rare Extra Medullary Involvement That Warrants Liver Biopsy for Prompt Diagnosis.

Granulocytic sarcoma (GS) is an extramedullary manifestation of acute myeloid leukemia (AML), myelodysplastic syndrome (MDS) or myeloproliferative neoplasms. The diagnosis depends on morphology, immunohistochemistry and flow cytometry. An unusual location of this tumor may mask its primary source, therefore, a strategy involving immediate symptom control, and investigation is crucial in preventing clinical deterioration.

Patterns of Care and Survival of Metastatic Metaplastic Breast Cancer Patients.

Background: Metaplastic breast cancer (MBC) is a rare, aggressive variant of breast cancer, usually triple negative disease and chemotherapy refractory. Despite this, the standard of care remains the same as invasive ductal breast cancer. We sought to analyze patterns of care and outcomes among patients with metastatic MBC.

Clinical Characteristics and Outcomes of Caribbean Patients With Adult T-Cell Lymphoma/Leukemia at Two Affiliated New York City Hospitals.

Purpose: Adult T-cell lymphoma/leukemia ATL) is a rare and aggressive peripheral T-cell malignancy caused by human T-cell lymphotropic virus-1 infection, which occurs in areas of high prevalence, predominantly in Japan and the Caribbean basin. Most ATL literature is derived from Japan and little is published about Caribbean patients. We describe the clinicopathologic characteristics and treatment outcomes of our Caribbean patients who have ATL at the State University of New York Downstate Medical Center and Kings County Hospital.

Acquired factor VIII deficiency in prostate adenocarcinoma presenting as multiple hematomas and hemarthrosis.

Acquired hemophilia A or acquired factor VIII deficiency is a rare bleeding disorder due to the presence of autoantibodies to factor VIII. It has been associated with autoimmune conditions, certain medications, and malignancy. It has a high morbidity and mortality, and early diagnosis and treatment is critically important.

Doxorubicin-associated takotsubo cardiomyopathy in a patient with adult T-cell leukemia/lymphoma.

This case highlights the first reported association of doxorubicin with takotsubo cardiomyopathy (TC) presenting as cardiogenic shock during the first continuous infusion in a patient with adult T-cell leukemia/lymphoma. We aim to raise awareness to recognize and distinguish between irreversible doxorubicin-associated cardiomyopathy and reversible doxorubicin-associated TC in patients with cancer.

A National VA Palliative Care Quality Improvement Project for Improving Intensive Care Unit Family Meetings (ICU-FMs).

Background: We sought to increase intensive care unit-family meeting (ICU-FM) documentation in the electronic health record in Veterans Affairs (VA) hospitals.

Measures: Primary outcomes were proportion of VA decedents with ICU-FM and Bereaved Family Survey-Performance Measure (BFS-PM) scores of "excellent."

Intervention: Quality improvement (QI) project, clinical champion, and ICU-FM templates were implemented in nine participating VA facilities.

Top Ten Tips Palliative Care Providers Should Know About Caring for Veterans.

Many of America's Veterans have unique medical and psychosocial needs related to their military service. Since most medical care received by Veterans occurs outside of the Department of Veterans Affairs (VA) health care system, it is imperative that all medical providers have a working understanding of the unique needs of Veterans and some of the many programs and services available to Veterans through the VA. This article, created by an interdisciplinary team of palliative care and hospice providers who care for Veterans throughout the country, seeks to improve the comfort with which non-VA clinicians care for Veterans while increasing knowledge about programs for which Veterans might qualify through the VA.

Survival of a Jehovah's Witness with thrombotic thrombocytopenic purpura without using plasma: A case report and review of the literature.

Acquired thrombotic thrombocytopenic purpura (aTTP) is a serious disorder with arteriolar and capillary thrombosis for which the treatment usually requires plasma exchange with plasma as the replacement fluid. Management of patients who do not accept blood products is a serious challenge. We present the case of a Jehovah's Witness patient who achieved clinical response after treatment with plasma exchange using human albumin solution as the replacing fluid, high dose corticosteroids, and rituximab.

Purulent Pericarditis in Sickle Cell Disease Due to ; a Unique Case Report and Literature Review.

Purulent pericarditis is a localized infection with a thick, fibrinous hypercellular exudate and is historically associated with a high mortality. We describe a case of purulent pericarditis due to in a 30-year-old woman with sickle cell disease who presented with fever, dyspnea, and septicemia. Despite timely initiation of antibiotics, she developed a large purulent pericardial effusion requiring surgical pericardiocentesis followed by a pericardial window.

Incidental Discovery of Multiorgan Extramedullary Plasmacytomas in the Setting of Newly Diagnosed Multiple Myeloma and Delayed Hemolytic Transfusion Reaction.

Extramedullary plasmacytomas (EMPs) are defined by the presence of clonal plasma cell proliferation outside of the bone marrow, portending an overall poor prognosis. This case highlights extramedullary plasmacytomas as an unusual presenting manifestation of multiple myeloma. Through incidental discovery during a delayed hemolytic transfusion reaction workup, EMPs were found in the liver, spleen, and possibly the lung.

Improving Family Meetings in Intensive Care Units: A Quality Improvement Curriculum.

Background: Family meetings in the intensive care unit are associated with beneficial outcomes for patients, their families, and health care systems, yet these meetings often do not occur in a timely, effective, reliable way.

Objective: The Department of Veterans Affairs Comprehensive End-of-Life Care Implementation Center sponsored a national initiative to improve family meetings in Veterans Affairs intensive care units across the United States. Process measures of success for the initiative were identified, including development of a curriculum to support facility-based quality improvement projects to implement high-quality family meetings.

Moving upstream: a review of the evidence of the impact of outpatient palliative care.

Background: There is good evidence for the efficacy of inpatient palliative care in improving clinical care, patient and provider satisfaction, quality of life, and health care utilization. However, the evidence for the efficacy of nonhospice outpatient palliative care is less well known and has not been comprehensively reviewed.

Objective: To review and assess the evidence of the impact of outpatient palliative care.

Training nurses for interdisciplinary communication with families in the intensive care unit: an intervention.

Background: Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses.

Methods: We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients.

Implementation and evaluation of a network-based pilot program to improve palliative care in the intensive care unit.

Background: Intensive care unit (ICU) care could be improved by implementation of time-triggered evidence-based interventions including identification of a patient/family medical decision maker, the patient's advance directive status, and cardiopulmonary resuscitation preferences by Day 1; offer of social work and spiritual support by Day 3; and a family meeting establishing goals of care by Day 5. We implemented a program to improve care for ICU patients in five Department of Veterans Affairs' ICUs.

Measures: We measured the percent of ICU patients with lengths of stay of five or more days that received the care processes by the appropriate day.

Pseudohypobicarbonatemia caused by an endogenous assay interferent: a new entity.

Serum total carbon dioxide, measured using a chemistry analyzer, and gas panel-derived plasma bicarbonate, calculated from the pH and partial pressure of carbon dioxide, often are used interchangeably for clinical purposes. When they disagree, there is a tendency to accept total carbon dioxide and discredit gas panel-derived plasma bicarbonate values. We report a patient who, during a 5-month hospitalization, had persistently low total carbon dioxide levels (12.

Measuring families' perceptions of care across a health care system: preliminary experience with the Family Assessment of Treatment at End of Life Short form (FATE-S).

Context: Because the Family Evaluation of Treatment at End of Life (FATE) survey was too long for routine use in the Veterans Administration (VA) health care system to measure quality of care, a shorter instrument was developed.

Objectives: To evaluate the short version of the FATE survey for use as a nationwide quality measure in the VA health care system.

Methods: Fifty-one VA medical centers, including acute and long-term care, participated in this nationwide telephone survey.

Hospital-based palliative care consultation: effects on hospital cost.

Context: Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs.

Family meetings made simpler: a toolkit for the intensive care unit.

Although a growing body of evidence has associated the intensive care unit (ICU) family meeting with important, favorable outcomes for critically ill patients, their families, and health care systems, these meetings often fail to occur in a timely, effective, and reliable way. In this article, we describe 3 specific tools that we have developed as prototypes to promote more successful implementation of family meetings in the ICU: (1) a family meeting planner, (2) a meeting guide for families, and (3) a family meeting documentation template. We describe the essential features of these tools and ways that they might be adapted to meet the local needs of individual ICUs and to maximize acceptability and use.

End-of-life care pathways.

Purpose Of Review: To summarize recent research findings about the use and effects of integrated care pathways for end-of-life care.

Recent Findings: Integrated care pathways designed for patients at the end of life include the Liverpool Care Pathway, used widely in the UK, and Palliative Care for Advanced Disease, developed in the USA. There is general consensus in the current literature that integrated care pathways improve standardization, continuity and collaboration among the interdisciplinary team.

Use of a report card to implement a network-based palliative care program.

Objective: To report on implementation of a Veterans Affairs (VA) network-wide, standardized, high-quality palliative care (PC) program using a Web-based PC Report Card for performance monitoring and improvement.

Intervention: The PC director and coordinator and facility directors established interdisciplinary teams at five acute care and three nursing home sites. Teams were trained together and subsequently met quarterly for ongoing training.