Clinical Review

BACKGROUND: Platinum-based chemotherapy is very effective in treating a variety of cancer types however, it has the potential to cause dose limiting ototoxicity that may result in permanent hearing loss. Studies have shown that hearing loss can affect quality of life by interfering with relationships and degrading communication. Early detection of hearing loss assists the oncologist in determining drug dosing and selecting the appropriate treatment regimens. It also allows the audiologist the opportunity for early intervention with rehabilitative measures. At our facility, Veterans starting cisplatin did not consistently have an audiology consult placed or a baseline audiogram completed prior to initiating treatment. A literature review was conducted, and an interdisciplinary team was formed with key stakeholders from medical oncology, audiology, pharmacy, and nursing.

RESULTS: The initial data review from January 1, 2016 to August 8, 2018 (n=85) showed only 17 Veterans (20%) had an audiology consult placed prior to initiating treatment. The target timeframe determined by the audiology department for baseline audiogram completion was eight weeks prior to or up to 24 hours post initial cisplatin administration. Following these guidelines, only seven (8%) of the 17 audiology consults were placed and completed within the recommended timeframe. Our goal was to increase the number of Veterans receiving audiograms prior to cisplatin administration from 8% to 100% by January 1, 2020.

INTERVENTIONS: enhanced provider education for early identification of Veterans starting cisplatin, creation of an email group for increased communication between nursing and audiology, trialing a portable audiometer in the outpatient infusion clinic, and adding a quick order set to the audiology consult on all cisplatin templates. A post-intervention data review from January 1, 2020 to April 30, 2020 (n=17) demonstrated all 17 (100%) Veterans had an audiology consult placed prior to the first dose of cisplatin. The data review also showed that 17 out of 17 Veterans (100%) had an audiogram completed within the target timeframe. This quality improvement project is aimed at maintaining quality of life for our Veterans throughout their cancer journey.

BACKGROUND: Platinum-based chemotherapy is very effective in treating a variety of cancer types however, it has the potential to cause dose limiting ototoxicity that may result in permanent hearing loss. Studies have shown that hearing loss can affect quality of life by interfering with relationships and degrading communication. Early detection of hearing loss assists the oncologist in determining drug dosing and selecting the appropriate treatment regimens. It also allows the audiologist the opportunity for early intervention with rehabilitative measures. At our facility, Veterans starting cisplatin did not consistently have an audiology consult placed or a baseline audiogram completed prior to initiating treatment. A literature review was conducted, and an interdisciplinary team was formed with key stakeholders from medical oncology, audiology, pharmacy, and nursing.

RESULTS: The initial data review from January 1, 2016 to August 8, 2018 (n=85) showed only 17 Veterans (20%) had an audiology consult placed prior to initiating treatment. The target timeframe determined by the audiology department for baseline audiogram completion was eight weeks prior to or up to 24 hours post initial cisplatin administration. Following these guidelines, only seven (8%) of the 17 audiology consults were placed and completed within the recommended timeframe. Our goal was to increase the number of Veterans receiving audiograms prior to cisplatin administration from 8% to 100% by January 1, 2020.

INTERVENTIONS: enhanced provider education for early identification of Veterans starting cisplatin, creation of an email group for increased communication between nursing and audiology, trialing a portable audiometer in the outpatient infusion clinic, and adding a quick order set to the audiology consult on all cisplatin templates. A post-intervention data review from January 1, 2020 to April 30, 2020 (n=17) demonstrated all 17 (100%) Veterans had an audiology consult placed prior to the first dose of cisplatin. The data review also showed that 17 out of 17 Veterans (100%) had an audiogram completed within the target timeframe. This quality improvement project is aimed at maintaining quality of life for our Veterans throughout their cancer journey.

BACKGROUND: Platinum-based chemotherapy is very effective in treating a variety of cancer types however, it has the potential to cause dose limiting ototoxicity that may result in permanent hearing loss. Studies have shown that hearing loss can affect quality of life by interfering with relationships and degrading communication. Early detection of hearing loss assists the oncologist in determining drug dosing and selecting the appropriate treatment regimens. It also allows the audiologist the opportunity for early intervention with rehabilitative measures. At our facility, Veterans starting cisplatin did not consistently have an audiology consult placed or a baseline audiogram completed prior to initiating treatment. A literature review was conducted, and an interdisciplinary team was formed with key stakeholders from medical oncology, audiology, pharmacy, and nursing.

RESULTS: The initial data review from January 1, 2016 to August 8, 2018 (n=85) showed only 17 Veterans (20%) had an audiology consult placed prior to initiating treatment. The target timeframe determined by the audiology department for baseline audiogram completion was eight weeks prior to or up to 24 hours post initial cisplatin administration. Following these guidelines, only seven (8%) of the 17 audiology consults were placed and completed within the recommended timeframe. Our goal was to increase the number of Veterans receiving audiograms prior to cisplatin administration from 8% to 100% by January 1, 2020.

INTERVENTIONS: enhanced provider education for early identification of Veterans starting cisplatin, creation of an email group for increased communication between nursing and audiology, trialing a portable audiometer in the outpatient infusion clinic, and adding a quick order set to the audiology consult on all cisplatin templates. A post-intervention data review from January 1, 2020 to April 30, 2020 (n=17) demonstrated all 17 (100%) Veterans had an audiology consult placed prior to the first dose of cisplatin. The data review also showed that 17 out of 17 Veterans (100%) had an audiogram completed within the target timeframe. This quality improvement project is aimed at maintaining quality of life for our Veterans throughout their cancer journey.

PURPOSE: To establish a program utilizing a multidisciplinary team to address health care disparities and improve outcomes. To develop a process that would streamline our navigation workflow and assist with the identification of barriers to care. Thus, enabling the Cancer Care program to focus on what really matters— - Veterans.

PROBLEM: The Cancer Care program utilized a series of spreadsheets and an Access database to follow the care of Veterans receiving care within Southeast Louisiana Veterans Health Care System (SLVHCS) and for those Veterans being care for in the community. Each navigator has distinct intervals in which they contact or educate their patients for which care must be carefully coordinated. Our team strives to provide a multidisciplinary approach, but our former workflow of 12 years not only restricted us to one user at a time, but it also restricted usage to one service at a time. Our Clinical Nurse Navigators, Cancer Care Social Worker and Registered Nutritionist were creating and utilizing customized spreadsheets via an Excel program which also restricted access within services. These technological constraints further increased potential for negative outcomes and delays in care.

METHOD: Standardize our navigation process and allow for systemic changes within the department. With over 200 patient navigation programs to choose from (Institute for Alternative Futures, 2007); we adopted OncoNav as our navigation software program. OncoNav is oncologyspecific software designed to help Patient Navigators schedule, track, organize, and report their interactions with patients. It is designed to integrate into the Navigator’s workflow, allowing Navigators to quickly view pertinent patient information, add notes, schedule appointments and run patient-specific reports seamlessly from one system. After purchasing and implementing, ONCONAV, staff participated in training and tailored the package to meet the needs unique to our cancer team.

OUTCOME: Enables staff to schedule, track, organize and report interventions. It optimizes a multidisciplinary approach in which the team can provide their respective expert recommendations and interventions in a singular location; easily accessible by all navigation team members.

IMPLICATIONS: Our goal is to promote and help establish our navigation process as best practice that will be utilized across VA networks.

PURPOSE: To establish a program utilizing a multidisciplinary team to address health care disparities and improve outcomes. To develop a process that would streamline our navigation workflow and assist with the identification of barriers to care. Thus, enabling the Cancer Care program to focus on what really matters— - Veterans.

PROBLEM: The Cancer Care program utilized a series of spreadsheets and an Access database to follow the care of Veterans receiving care within Southeast Louisiana Veterans Health Care System (SLVHCS) and for those Veterans being care for in the community. Each navigator has distinct intervals in which they contact or educate their patients for which care must be carefully coordinated. Our team strives to provide a multidisciplinary approach, but our former workflow of 12 years not only restricted us to one user at a time, but it also restricted usage to one service at a time. Our Clinical Nurse Navigators, Cancer Care Social Worker and Registered Nutritionist were creating and utilizing customized spreadsheets via an Excel program which also restricted access within services. These technological constraints further increased potential for negative outcomes and delays in care.

METHOD: Standardize our navigation process and allow for systemic changes within the department. With over 200 patient navigation programs to choose from (Institute for Alternative Futures, 2007); we adopted OncoNav as our navigation software program. OncoNav is oncologyspecific software designed to help Patient Navigators schedule, track, organize, and report their interactions with patients. It is designed to integrate into the Navigator’s workflow, allowing Navigators to quickly view pertinent patient information, add notes, schedule appointments and run patient-specific reports seamlessly from one system. After purchasing and implementing, ONCONAV, staff participated in training and tailored the package to meet the needs unique to our cancer team.

OUTCOME: Enables staff to schedule, track, organize and report interventions. It optimizes a multidisciplinary approach in which the team can provide their respective expert recommendations and interventions in a singular location; easily accessible by all navigation team members.

IMPLICATIONS: Our goal is to promote and help establish our navigation process as best practice that will be utilized across VA networks.

PURPOSE: To establish a program utilizing a multidisciplinary team to address health care disparities and improve outcomes. To develop a process that would streamline our navigation workflow and assist with the identification of barriers to care. Thus, enabling the Cancer Care program to focus on what really matters— - Veterans.

PROBLEM: The Cancer Care program utilized a series of spreadsheets and an Access database to follow the care of Veterans receiving care within Southeast Louisiana Veterans Health Care System (SLVHCS) and for those Veterans being care for in the community. Each navigator has distinct intervals in which they contact or educate their patients for which care must be carefully coordinated. Our team strives to provide a multidisciplinary approach, but our former workflow of 12 years not only restricted us to one user at a time, but it also restricted usage to one service at a time. Our Clinical Nurse Navigators, Cancer Care Social Worker and Registered Nutritionist were creating and utilizing customized spreadsheets via an Excel program which also restricted access within services. These technological constraints further increased potential for negative outcomes and delays in care.

METHOD: Standardize our navigation process and allow for systemic changes within the department. With over 200 patient navigation programs to choose from (Institute for Alternative Futures, 2007); we adopted OncoNav as our navigation software program. OncoNav is oncologyspecific software designed to help Patient Navigators schedule, track, organize, and report their interactions with patients. It is designed to integrate into the Navigator’s workflow, allowing Navigators to quickly view pertinent patient information, add notes, schedule appointments and run patient-specific reports seamlessly from one system. After purchasing and implementing, ONCONAV, staff participated in training and tailored the package to meet the needs unique to our cancer team.

OUTCOME: Enables staff to schedule, track, organize and report interventions. It optimizes a multidisciplinary approach in which the team can provide their respective expert recommendations and interventions in a singular location; easily accessible by all navigation team members.

IMPLICATIONS: Our goal is to promote and help establish our navigation process as best practice that will be utilized across VA networks.

BACKGROUND: Antineoplastic ordering is high in both complexity and risk for medication errors. Joint Commission and institutional policy recommends computerized prescriber order entry and verification by a pharmacist as a best practice for patient safety. The use of ordering templates minimizes the risk of errors and ensures appropriate supportive care is being provided. The Veterans Affairs electronic medical record does not feature an antineoplastic ordering component; historically, templates have been on paper. The oncology, pharmacy, and clinical informatics departments in our health system formed a team to create electronic antineoplastic ordering templates.

PURPOSE: To evaluate the impact of electronic antineoplastic ordering templates on pharmacy and infusion clinic efficiency and pharmacist interventions.

METHODS: Ordering templates, which included standard dosing and supportive care medications, were developed and activated for prescribers in phases over the course of two years. Immunotherapy and oral oncolytic templates were activated initially, followed by full implementation of the majority of intravenous (IV) ordering templates. Percent of electronic antineoplastic orders, pharmacy processing time, time to first drug delivery, and number of pharmacist encounters and interventions were documented daily for four weeks after initial implementation and for ten weeks after full implementation. Means were compared using unpaired t tests.

RESULTS: After initial implementation, the percentage of electronic antineoplastic orders increased from 0% to 100% for oral antineoplastics and from 0% to 39% for IV orders. After full implementation, IV orders increased to 69% in weeks 1-5 and 96% in weeks 6-10. Mean pharmacy processing time for supportive care medications was 35 minutes initially. This increased briefly after full implementation (weeks 1-5), then decreased to 17 minutes in weeks 6-10 (p<0.01). Delivery of the first medication to the infusion center decreased by 31 minutes at week ten (<0.01). Mean daily pharmacist encounters increased by 28%(<0.01) and documented interventions increased by 22% (<0.01).

IMPLICATIONS: Implementation of electronic antineoplastic ordering templates increased provider order entry, pharmacy and infusion clinic efficiency and pharmacist interventions. These outcomes may translate to improved patient safety and patient access to quality care. Templates developed can serve as a model for other health systems to implement electronic antineoplastic ordering.

BACKGROUND: Antineoplastic ordering is high in both complexity and risk for medication errors. Joint Commission and institutional policy recommends computerized prescriber order entry and verification by a pharmacist as a best practice for patient safety. The use of ordering templates minimizes the risk of errors and ensures appropriate supportive care is being provided. The Veterans Affairs electronic medical record does not feature an antineoplastic ordering component; historically, templates have been on paper. The oncology, pharmacy, and clinical informatics departments in our health system formed a team to create electronic antineoplastic ordering templates.

PURPOSE: To evaluate the impact of electronic antineoplastic ordering templates on pharmacy and infusion clinic efficiency and pharmacist interventions.

METHODS: Ordering templates, which included standard dosing and supportive care medications, were developed and activated for prescribers in phases over the course of two years. Immunotherapy and oral oncolytic templates were activated initially, followed by full implementation of the majority of intravenous (IV) ordering templates. Percent of electronic antineoplastic orders, pharmacy processing time, time to first drug delivery, and number of pharmacist encounters and interventions were documented daily for four weeks after initial implementation and for ten weeks after full implementation. Means were compared using unpaired t tests.

RESULTS: After initial implementation, the percentage of electronic antineoplastic orders increased from 0% to 100% for oral antineoplastics and from 0% to 39% for IV orders. After full implementation, IV orders increased to 69% in weeks 1-5 and 96% in weeks 6-10. Mean pharmacy processing time for supportive care medications was 35 minutes initially. This increased briefly after full implementation (weeks 1-5), then decreased to 17 minutes in weeks 6-10 (p<0.01). Delivery of the first medication to the infusion center decreased by 31 minutes at week ten (<0.01). Mean daily pharmacist encounters increased by 28%(<0.01) and documented interventions increased by 22% (<0.01).

IMPLICATIONS: Implementation of electronic antineoplastic ordering templates increased provider order entry, pharmacy and infusion clinic efficiency and pharmacist interventions. These outcomes may translate to improved patient safety and patient access to quality care. Templates developed can serve as a model for other health systems to implement electronic antineoplastic ordering.

BACKGROUND: Antineoplastic ordering is high in both complexity and risk for medication errors. Joint Commission and institutional policy recommends computerized prescriber order entry and verification by a pharmacist as a best practice for patient safety. The use of ordering templates minimizes the risk of errors and ensures appropriate supportive care is being provided. The Veterans Affairs electronic medical record does not feature an antineoplastic ordering component; historically, templates have been on paper. The oncology, pharmacy, and clinical informatics departments in our health system formed a team to create electronic antineoplastic ordering templates.

PURPOSE: To evaluate the impact of electronic antineoplastic ordering templates on pharmacy and infusion clinic efficiency and pharmacist interventions.

METHODS: Ordering templates, which included standard dosing and supportive care medications, were developed and activated for prescribers in phases over the course of two years. Immunotherapy and oral oncolytic templates were activated initially, followed by full implementation of the majority of intravenous (IV) ordering templates. Percent of electronic antineoplastic orders, pharmacy processing time, time to first drug delivery, and number of pharmacist encounters and interventions were documented daily for four weeks after initial implementation and for ten weeks after full implementation. Means were compared using unpaired t tests.

RESULTS: After initial implementation, the percentage of electronic antineoplastic orders increased from 0% to 100% for oral antineoplastics and from 0% to 39% for IV orders. After full implementation, IV orders increased to 69% in weeks 1-5 and 96% in weeks 6-10. Mean pharmacy processing time for supportive care medications was 35 minutes initially. This increased briefly after full implementation (weeks 1-5), then decreased to 17 minutes in weeks 6-10 (p<0.01). Delivery of the first medication to the infusion center decreased by 31 minutes at week ten (<0.01). Mean daily pharmacist encounters increased by 28%(<0.01) and documented interventions increased by 22% (<0.01).

IMPLICATIONS: Implementation of electronic antineoplastic ordering templates increased provider order entry, pharmacy and infusion clinic efficiency and pharmacist interventions. These outcomes may translate to improved patient safety and patient access to quality care. Templates developed can serve as a model for other health systems to implement electronic antineoplastic ordering.

BACKGROUND: Cancer treatment with immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). Incidence and onset time of irAEs vary across therapies and trials. There is lack of data regarding irAEs in veterans. The aim of this study was to evaluate irAEs in a real-world veteran population to assess the safety of ICIs.

METHODS: This is a retrospective study of United States veterans who received at least one ICI dose from 1/1/14 to 10/31/19 at VA Long Beach Healthcare System (VALBHS). The primary objectives are to describe the incidence of irAEs and time to onset after ICI therapy. The secondary objectives are to identify factors that may predict irAE occurrence and to compare the incidence and time to irAE onset at VALBHS to literature data. The irAEs evaluated were diarrhea/colitis, kidney injury, pneumonitis, thyroid disorder, and transaminitis, as defined by the National Comprehensive Cancer Network (NCCN) guidelines. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, and logistic regression where appropriate.

RESULTS: Of 140 evaluable patients, 31 experienced 1 or more irAEs, for a total of 37 irAEs. Baseline characteristics among patients with irAEs versus patients with no irAEs were not statistically significant except for thoracic cancer (19.4% vs. 45%, p=0.01) and number of ICI doses received (median 9 vs. 5 doses, =0.01), respectively. There were 5 incidences of diarrhea/colitis, 5 kidney injury, 2 pneumonitis, 17 thyroid disorder, and 8 transaminitis. Severity ranged from grade 1-3. The median time to irAE onset was 18 weeks (range, 1-78 weeks). The factors examined (age, gender, race, cancer type, ICI drug class, and number of ICI doses received) did not significantly predict irAE occurrence (B<0.436, >0.21). When compared to literature data, VALBHS had broadly similar irAE incidence rates, but patients generally had a longer time to irAE onset.

CONCLUSION: Incidence of irAEs in the veteran population at VALBHS is generally consistent with the literature. The longer time to irAE onset in the study underscores the importance of ongoing monitoring during ICI therapy, as irAEs can happen anytime and there were no patient factors that helped predict occurrence.

BACKGROUND: Cancer treatment with immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). Incidence and onset time of irAEs vary across therapies and trials. There is lack of data regarding irAEs in veterans. The aim of this study was to evaluate irAEs in a real-world veteran population to assess the safety of ICIs.

METHODS: This is a retrospective study of United States veterans who received at least one ICI dose from 1/1/14 to 10/31/19 at VA Long Beach Healthcare System (VALBHS). The primary objectives are to describe the incidence of irAEs and time to onset after ICI therapy. The secondary objectives are to identify factors that may predict irAE occurrence and to compare the incidence and time to irAE onset at VALBHS to literature data. The irAEs evaluated were diarrhea/colitis, kidney injury, pneumonitis, thyroid disorder, and transaminitis, as defined by the National Comprehensive Cancer Network (NCCN) guidelines. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, and logistic regression where appropriate.

RESULTS: Of 140 evaluable patients, 31 experienced 1 or more irAEs, for a total of 37 irAEs. Baseline characteristics among patients with irAEs versus patients with no irAEs were not statistically significant except for thoracic cancer (19.4% vs. 45%, p=0.01) and number of ICI doses received (median 9 vs. 5 doses, =0.01), respectively. There were 5 incidences of diarrhea/colitis, 5 kidney injury, 2 pneumonitis, 17 thyroid disorder, and 8 transaminitis. Severity ranged from grade 1-3. The median time to irAE onset was 18 weeks (range, 1-78 weeks). The factors examined (age, gender, race, cancer type, ICI drug class, and number of ICI doses received) did not significantly predict irAE occurrence (B<0.436, >0.21). When compared to literature data, VALBHS had broadly similar irAE incidence rates, but patients generally had a longer time to irAE onset.

CONCLUSION: Incidence of irAEs in the veteran population at VALBHS is generally consistent with the literature. The longer time to irAE onset in the study underscores the importance of ongoing monitoring during ICI therapy, as irAEs can happen anytime and there were no patient factors that helped predict occurrence.

BACKGROUND: Cancer treatment with immune checkpoint inhibitors (ICIs) can cause immune-related adverse events (irAEs). Incidence and onset time of irAEs vary across therapies and trials. There is lack of data regarding irAEs in veterans. The aim of this study was to evaluate irAEs in a real-world veteran population to assess the safety of ICIs.

METHODS: This is a retrospective study of United States veterans who received at least one ICI dose from 1/1/14 to 10/31/19 at VA Long Beach Healthcare System (VALBHS). The primary objectives are to describe the incidence of irAEs and time to onset after ICI therapy. The secondary objectives are to identify factors that may predict irAE occurrence and to compare the incidence and time to irAE onset at VALBHS to literature data. The irAEs evaluated were diarrhea/colitis, kidney injury, pneumonitis, thyroid disorder, and transaminitis, as defined by the National Comprehensive Cancer Network (NCCN) guidelines. Statistical analysis was performed using Fisher’s exact test, Mann-Whitney U test, and logistic regression where appropriate.

RESULTS: Of 140 evaluable patients, 31 experienced 1 or more irAEs, for a total of 37 irAEs. Baseline characteristics among patients with irAEs versus patients with no irAEs were not statistically significant except for thoracic cancer (19.4% vs. 45%, p=0.01) and number of ICI doses received (median 9 vs. 5 doses, =0.01), respectively. There were 5 incidences of diarrhea/colitis, 5 kidney injury, 2 pneumonitis, 17 thyroid disorder, and 8 transaminitis. Severity ranged from grade 1-3. The median time to irAE onset was 18 weeks (range, 1-78 weeks). The factors examined (age, gender, race, cancer type, ICI drug class, and number of ICI doses received) did not significantly predict irAE occurrence (B<0.436, >0.21). When compared to literature data, VALBHS had broadly similar irAE incidence rates, but patients generally had a longer time to irAE onset.

CONCLUSION: Incidence of irAEs in the veteran population at VALBHS is generally consistent with the literature. The longer time to irAE onset in the study underscores the importance of ongoing monitoring during ICI therapy, as irAEs can happen anytime and there were no patient factors that helped predict occurrence.

INTRODUCTION: Methylene blue (MB) has recently gained traction as an adjunctive therapy in the management of vasoplegia. Due to risk of inducing oxidative hemolysis its use should be avoided in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Although rare, drug induced oxidative hemolysis can still occur in patients without G6PD deficiency. In this report, we describe a case of severe oxidative hemolysis in a G6PD sufficient adult following administration of a large dose of MB.

CASE REPORT: A 78-year-old male with a history of coronary artery disease was admitted for coronary artery bypass graft surgery. Patient underwent surgery without any major complications. Post operatively however he developed severe shock refractory to multiple vasopressors and inotropes. A presumptive diagnosis of vasoplegia was made for which the patient was given multiple boluses of MB. Hemodynamics improved thus the patient was started on a MB infusion. Approximately 24 hours later the patient was noted to have an acute drop in his hemoglobin from 9.9 to 8.0 g/dl. He was transfused multiple units of blood with only transient improvements in his hemoglobin. Physical exam and imaging revealed no evidence of bleeding. Additional workup was notable for an LDH of 7222 U/L and an elevated bilirubin raising concern for hemolytic anemia.

Review of his peripheral smear was notable for the presence of numerous bite cells. A diagnosis of oxidative hemolytic anemia secondary to MB administration was made. MB infusion was discontinued and within 48 hours the patient’s LDH normalized and hemoglobin had stabilized. A quantitative G6PD test ordered during the acute hemolytic period and was reported as normal. Due to the possibility of a falsely normal result in the setting of active hemolysis, G6PD testing was repeated two months following discharge and was also normal.

CONCLUSIONS: Methylene blue can be a lifesaving medication in the setting of severe vasoplegia. However, clinicians should be aware of the possibility of inducing severe oxidative hemolytic anemia even in G6PD sufficient patients when giving this agent in large doses. Management of oxidative hemolysis secondary to MB is supportive care with prompt discontinuation resulting in resolution of hemolysis.

INTRODUCTION: Methylene blue (MB) has recently gained traction as an adjunctive therapy in the management of vasoplegia. Due to risk of inducing oxidative hemolysis its use should be avoided in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Although rare, drug induced oxidative hemolysis can still occur in patients without G6PD deficiency. In this report, we describe a case of severe oxidative hemolysis in a G6PD sufficient adult following administration of a large dose of MB.

CASE REPORT: A 78-year-old male with a history of coronary artery disease was admitted for coronary artery bypass graft surgery. Patient underwent surgery without any major complications. Post operatively however he developed severe shock refractory to multiple vasopressors and inotropes. A presumptive diagnosis of vasoplegia was made for which the patient was given multiple boluses of MB. Hemodynamics improved thus the patient was started on a MB infusion. Approximately 24 hours later the patient was noted to have an acute drop in his hemoglobin from 9.9 to 8.0 g/dl. He was transfused multiple units of blood with only transient improvements in his hemoglobin. Physical exam and imaging revealed no evidence of bleeding. Additional workup was notable for an LDH of 7222 U/L and an elevated bilirubin raising concern for hemolytic anemia.

Review of his peripheral smear was notable for the presence of numerous bite cells. A diagnosis of oxidative hemolytic anemia secondary to MB administration was made. MB infusion was discontinued and within 48 hours the patient’s LDH normalized and hemoglobin had stabilized. A quantitative G6PD test ordered during the acute hemolytic period and was reported as normal. Due to the possibility of a falsely normal result in the setting of active hemolysis, G6PD testing was repeated two months following discharge and was also normal.

CONCLUSIONS: Methylene blue can be a lifesaving medication in the setting of severe vasoplegia. However, clinicians should be aware of the possibility of inducing severe oxidative hemolytic anemia even in G6PD sufficient patients when giving this agent in large doses. Management of oxidative hemolysis secondary to MB is supportive care with prompt discontinuation resulting in resolution of hemolysis.

INTRODUCTION: Methylene blue (MB) has recently gained traction as an adjunctive therapy in the management of vasoplegia. Due to risk of inducing oxidative hemolysis its use should be avoided in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency Although rare, drug induced oxidative hemolysis can still occur in patients without G6PD deficiency. In this report, we describe a case of severe oxidative hemolysis in a G6PD sufficient adult following administration of a large dose of MB.

CASE REPORT: A 78-year-old male with a history of coronary artery disease was admitted for coronary artery bypass graft surgery. Patient underwent surgery without any major complications. Post operatively however he developed severe shock refractory to multiple vasopressors and inotropes. A presumptive diagnosis of vasoplegia was made for which the patient was given multiple boluses of MB. Hemodynamics improved thus the patient was started on a MB infusion. Approximately 24 hours later the patient was noted to have an acute drop in his hemoglobin from 9.9 to 8.0 g/dl. He was transfused multiple units of blood with only transient improvements in his hemoglobin. Physical exam and imaging revealed no evidence of bleeding. Additional workup was notable for an LDH of 7222 U/L and an elevated bilirubin raising concern for hemolytic anemia.

Review of his peripheral smear was notable for the presence of numerous bite cells. A diagnosis of oxidative hemolytic anemia secondary to MB administration was made. MB infusion was discontinued and within 48 hours the patient’s LDH normalized and hemoglobin had stabilized. A quantitative G6PD test ordered during the acute hemolytic period and was reported as normal. Due to the possibility of a falsely normal result in the setting of active hemolysis, G6PD testing was repeated two months following discharge and was also normal.

CONCLUSIONS: Methylene blue can be a lifesaving medication in the setting of severe vasoplegia. However, clinicians should be aware of the possibility of inducing severe oxidative hemolytic anemia even in G6PD sufficient patients when giving this agent in large doses. Management of oxidative hemolysis secondary to MB is supportive care with prompt discontinuation resulting in resolution of hemolysis.

BACKGROUND: Oral antineoplastic therapy (OAT) use among Veterans is rising significantly. Through the MISSION/CHOICE Act, Veterans can receive Veterans Affairs (VA)-funded hematology/oncology care from non-VA community providers. These providers can prescribe high-risk, high-cost OATs which the VA then dispenses. However, Veterans receiving hematology/ oncology treatment in rural and community settings often lack access to comprehensive medication management, increasing their risk for suboptimal care.

SYNTHESIS OF RELEVANT LITERATURE: A survey performed within VISN 19 revealed Veterans on OATs prescribed by community providers receive inadequate monitoring and follow-up. Clinical pharmacist- driven medication management programs are established in a variety of clinical settings, including for patients taking OATs for hematologic and oncologic malignancies. Additionally, the American Society of Clinical Oncology (ASCO) considers medically integrated dispensing of OATs, often through hematology/ oncology pharmacist-driven medication management programs, a quality standard.

INTERVENTION(S) PROVIDED: The VA CARES program provides a dedicated clinical pharmacy specialist (CPS) for all phases of OAT treatment prescribed by community providers. During the OAT initiation phase, the CPS ensures appropriate indication and dosing, reviews baseline laboratory results, and performs a thorough drug-drug interaction analysis. The CPS also performs baseline patient assessment and education through a telephone encounter. During the OAT maintenance phase, the CPS ensures necessary monitoring occurs (e.g., labs are drawn and results are within appropriate limits), and schedules regular follow-up encounters with the patient to assess knowledge, adherence, toxicities, and need for OAT refills.

OUTCOME OF THE INTERVENTION/SITUATION: In the first three months, VA CARES enrolled sixteen patients with a total of nineteen community care prescriptions (sixteen for OATs, three for broad-spectrum antifungals). The CPS performed thirty-eight encounters and twenty-nine interventions. The majority of interventions included detection and/or prevention of drug-drug interactions (n=15), followed by prevention of adverse events (n=5). Other interventions included drug not indicated (n=3), alternative therapy suggested (n=2), limited-quantity dispensed (n=1), and unnecessary consultation prevented (n=1). Total cost avoidance and savings in three months were estimated at $52,013.

IMPLICATIONS: A CPS-driven medication management program for Veterans receiving OATs through the MISSION/CHOICE Act is associated with clinical and economic benefits.

BACKGROUND: Oral antineoplastic therapy (OAT) use among Veterans is rising significantly. Through the MISSION/CHOICE Act, Veterans can receive Veterans Affairs (VA)-funded hematology/oncology care from non-VA community providers. These providers can prescribe high-risk, high-cost OATs which the VA then dispenses. However, Veterans receiving hematology/ oncology treatment in rural and community settings often lack access to comprehensive medication management, increasing their risk for suboptimal care.

SYNTHESIS OF RELEVANT LITERATURE: A survey performed within VISN 19 revealed Veterans on OATs prescribed by community providers receive inadequate monitoring and follow-up. Clinical pharmacist- driven medication management programs are established in a variety of clinical settings, including for patients taking OATs for hematologic and oncologic malignancies. Additionally, the American Society of Clinical Oncology (ASCO) considers medically integrated dispensing of OATs, often through hematology/ oncology pharmacist-driven medication management programs, a quality standard.

INTERVENTION(S) PROVIDED: The VA CARES program provides a dedicated clinical pharmacy specialist (CPS) for all phases of OAT treatment prescribed by community providers. During the OAT initiation phase, the CPS ensures appropriate indication and dosing, reviews baseline laboratory results, and performs a thorough drug-drug interaction analysis. The CPS also performs baseline patient assessment and education through a telephone encounter. During the OAT maintenance phase, the CPS ensures necessary monitoring occurs (e.g., labs are drawn and results are within appropriate limits), and schedules regular follow-up encounters with the patient to assess knowledge, adherence, toxicities, and need for OAT refills.

OUTCOME OF THE INTERVENTION/SITUATION: In the first three months, VA CARES enrolled sixteen patients with a total of nineteen community care prescriptions (sixteen for OATs, three for broad-spectrum antifungals). The CPS performed thirty-eight encounters and twenty-nine interventions. The majority of interventions included detection and/or prevention of drug-drug interactions (n=15), followed by prevention of adverse events (n=5). Other interventions included drug not indicated (n=3), alternative therapy suggested (n=2), limited-quantity dispensed (n=1), and unnecessary consultation prevented (n=1). Total cost avoidance and savings in three months were estimated at $52,013.

IMPLICATIONS: A CPS-driven medication management program for Veterans receiving OATs through the MISSION/CHOICE Act is associated with clinical and economic benefits.

BACKGROUND: Oral antineoplastic therapy (OAT) use among Veterans is rising significantly. Through the MISSION/CHOICE Act, Veterans can receive Veterans Affairs (VA)-funded hematology/oncology care from non-VA community providers. These providers can prescribe high-risk, high-cost OATs which the VA then dispenses. However, Veterans receiving hematology/ oncology treatment in rural and community settings often lack access to comprehensive medication management, increasing their risk for suboptimal care.

SYNTHESIS OF RELEVANT LITERATURE: A survey performed within VISN 19 revealed Veterans on OATs prescribed by community providers receive inadequate monitoring and follow-up. Clinical pharmacist- driven medication management programs are established in a variety of clinical settings, including for patients taking OATs for hematologic and oncologic malignancies. Additionally, the American Society of Clinical Oncology (ASCO) considers medically integrated dispensing of OATs, often through hematology/ oncology pharmacist-driven medication management programs, a quality standard.

INTERVENTION(S) PROVIDED: The VA CARES program provides a dedicated clinical pharmacy specialist (CPS) for all phases of OAT treatment prescribed by community providers. During the OAT initiation phase, the CPS ensures appropriate indication and dosing, reviews baseline laboratory results, and performs a thorough drug-drug interaction analysis. The CPS also performs baseline patient assessment and education through a telephone encounter. During the OAT maintenance phase, the CPS ensures necessary monitoring occurs (e.g., labs are drawn and results are within appropriate limits), and schedules regular follow-up encounters with the patient to assess knowledge, adherence, toxicities, and need for OAT refills.

OUTCOME OF THE INTERVENTION/SITUATION: In the first three months, VA CARES enrolled sixteen patients with a total of nineteen community care prescriptions (sixteen for OATs, three for broad-spectrum antifungals). The CPS performed thirty-eight encounters and twenty-nine interventions. The majority of interventions included detection and/or prevention of drug-drug interactions (n=15), followed by prevention of adverse events (n=5). Other interventions included drug not indicated (n=3), alternative therapy suggested (n=2), limited-quantity dispensed (n=1), and unnecessary consultation prevented (n=1). Total cost avoidance and savings in three months were estimated at $52,013.

IMPLICATIONS: A CPS-driven medication management program for Veterans receiving OATs through the MISSION/CHOICE Act is associated with clinical and economic benefits.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.

PURPOSE: Immune checkpoint inhibitor (ICI) therapy has become a mainstay in cancer treatment and even has first-line indications for malignancies such as melanoma, non-small cell lung cancer, and many others. Recent data has demonstrated that patients who received either antimicrobial therapy prior to or within the first 60 days of ICI initiation tend to have worse outcomes as measured by time to progression and overall survival. It has been theorized that this may be caused by the influence of the antibiotics on the intestinal microbiota. This study evaluates the effect of antimicrobial therapy on outcomes in veteran patients initiated on ICI therapy.

METHODS: A retrospective chart review was conducted on all patients initiated on ICIs from 1/1/2015 through 12/31/2017. Patients were evaluated as to whether they received any antibiotics within 30 days of ICI initiation or 60 days after ICI initiation or if they received no antibiotics during this time. Data was gathered using the Veterans Health Administration electronic health record. Primary endpoints evaluated were progression free survival (PFS) and overall survival (OS), using Wilcoxon signed-rank test. Descriptive statistics were utilized for patient demographics and antibiotic characteristic comparisons.

RESULTS: A total of 55 patients were identified as having been initiated on an ICI. Twenty-two patients (40%) had received antibiotic treatment prior to or concurrently with their ICI therapy and 33 patients (60%) did not. Median overall survival was numerically longer in patients who did not receive antibiotics at 10 months (95% confidence interval [CI], 4-17 mo.) versus 4 months in patients who received antibiotics (95% CI, 2-9 mo.). However, no significant benefit was observed in median PFS among patients who did not receive antibiotics compared to those who received antibiotics (5 mo. versus 11 mo.).

CONCLUSIONS: No association was observed between antibiotic use and ICI patient outcomes. Although this correlation has been suggested by several recent publications, the cause is not fully understood. This study has several limitations, which could explain why this association was not reproduced. Future investigation and monitoring will be helpful to elucidate any true relationship between ICI and antimicrobial therapies.

PURPOSE: Immune checkpoint inhibitor (ICI) therapy has become a mainstay in cancer treatment and even has first-line indications for malignancies such as melanoma, non-small cell lung cancer, and many others. Recent data has demonstrated that patients who received either antimicrobial therapy prior to or within the first 60 days of ICI initiation tend to have worse outcomes as measured by time to progression and overall survival. It has been theorized that this may be caused by the influence of the antibiotics on the intestinal microbiota. This study evaluates the effect of antimicrobial therapy on outcomes in veteran patients initiated on ICI therapy.

METHODS: A retrospective chart review was conducted on all patients initiated on ICIs from 1/1/2015 through 12/31/2017. Patients were evaluated as to whether they received any antibiotics within 30 days of ICI initiation or 60 days after ICI initiation or if they received no antibiotics during this time. Data was gathered using the Veterans Health Administration electronic health record. Primary endpoints evaluated were progression free survival (PFS) and overall survival (OS), using Wilcoxon signed-rank test. Descriptive statistics were utilized for patient demographics and antibiotic characteristic comparisons.

RESULTS: A total of 55 patients were identified as having been initiated on an ICI. Twenty-two patients (40%) had received antibiotic treatment prior to or concurrently with their ICI therapy and 33 patients (60%) did not. Median overall survival was numerically longer in patients who did not receive antibiotics at 10 months (95% confidence interval [CI], 4-17 mo.) versus 4 months in patients who received antibiotics (95% CI, 2-9 mo.). However, no significant benefit was observed in median PFS among patients who did not receive antibiotics compared to those who received antibiotics (5 mo. versus 11 mo.).

CONCLUSIONS: No association was observed between antibiotic use and ICI patient outcomes. Although this correlation has been suggested by several recent publications, the cause is not fully understood. This study has several limitations, which could explain why this association was not reproduced. Future investigation and monitoring will be helpful to elucidate any true relationship between ICI and antimicrobial therapies.

PURPOSE: Immune checkpoint inhibitor (ICI) therapy has become a mainstay in cancer treatment and even has first-line indications for malignancies such as melanoma, non-small cell lung cancer, and many others. Recent data has demonstrated that patients who received either antimicrobial therapy prior to or within the first 60 days of ICI initiation tend to have worse outcomes as measured by time to progression and overall survival. It has been theorized that this may be caused by the influence of the antibiotics on the intestinal microbiota. This study evaluates the effect of antimicrobial therapy on outcomes in veteran patients initiated on ICI therapy.

METHODS: A retrospective chart review was conducted on all patients initiated on ICIs from 1/1/2015 through 12/31/2017. Patients were evaluated as to whether they received any antibiotics within 30 days of ICI initiation or 60 days after ICI initiation or if they received no antibiotics during this time. Data was gathered using the Veterans Health Administration electronic health record. Primary endpoints evaluated were progression free survival (PFS) and overall survival (OS), using Wilcoxon signed-rank test. Descriptive statistics were utilized for patient demographics and antibiotic characteristic comparisons.

RESULTS: A total of 55 patients were identified as having been initiated on an ICI. Twenty-two patients (40%) had received antibiotic treatment prior to or concurrently with their ICI therapy and 33 patients (60%) did not. Median overall survival was numerically longer in patients who did not receive antibiotics at 10 months (95% confidence interval [CI], 4-17 mo.) versus 4 months in patients who received antibiotics (95% CI, 2-9 mo.). However, no significant benefit was observed in median PFS among patients who did not receive antibiotics compared to those who received antibiotics (5 mo. versus 11 mo.).

CONCLUSIONS: No association was observed between antibiotic use and ICI patient outcomes. Although this correlation has been suggested by several recent publications, the cause is not fully understood. This study has several limitations, which could explain why this association was not reproduced. Future investigation and monitoring will be helpful to elucidate any true relationship between ICI and antimicrobial therapies.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.