Journal of the National Medical Association最新文献

In the dynamic healthcare landscape, digital tools play a pivotal role in elevating medical practices. This talk delves into the integration of Remote Patient Monitoring (RPM), Telehealth, Customer Relationship Management (CRM) systems, ChatGPT and Virtual ancillary staff, therapists, and medical assistants as key components in digitally transforming healthcare operations.

Illustrating Enara health's digital strategy, the talk also highlights the impact of other leading RPM platforms like Optimize Health, Cadence Solutions, HealthSnap, Athelas, Health Recovery Solutions, Accuhealth, and TimeDoc Health in improving healthcare accessibility. These platforms allow clinics to digitally extend themselves, eliminating geographically associated costs with real-time data tracking and streamlined communication. The shift to digital platforms represents a strategic, cost-saving initiative. Leveraging these tools streamlines operations, automates tasks, and enhances productivity, resulting in substantial operational cost reductions.

Telehealth emerges as a pivotal solution, providing patients with convenient access to healthcare services from home while reducing providers' physical office space costs. Simultaneously, Virtual Assistant staffing contributes significantly to cost savings for physician business owners by eliminating the need for a physical office presence. Adding therapists to our virtual startup also means patients can receive comprehensive care in one place, minimizing the need for external consultations. Lastly, using ChatGPT can assist physicians by handling tasks suitable for AI solutions, making their workload more manageable.

The paper advocates for the strategic adoption of these digital solutions to optimize healthcare operations, improve customer satisfaction, and foster sustainable business growth in the evolving healthcare landscape.

Introduction

CVID is the most common primary immunodeficiency in adults. It is defined as poor response to vaccines and low immunoglobulins, excluding other causes. Paradoxically, one of the most common complications of CVID is autoimmunity involving many systems. However, these usually resolve or improve with immunoglobulin injection. Here, we present a rare case of a patient with inflammatory arthritis that progressively worsened despite treatments.

Method

Case report with literature review

Result

A 55-year-old male with history of hypothyroidism, granuloma annulare, common variable immunodeficiency, and osteoporosis presented with arthralgia. The pain and swelling involved most of the hand joints, bilateral wrists, elbows, and knees. He has been receiving weekly subcutaneous immunoglobulin G without complications. The treatment regimen involved hydroxychloroquine, methotrexate that was replaced with leflunomide, and chronic use of low-dose oral prednisone that led to osteoporosis. Physical exam revealed mild synovitis and tenderness at all joints of the hand and wrists. Autoimmune markers are all negative except for positive ANA. Recent hand radiogram showed mild erosion of the right fifth proximal phalanx. The patient did not show improvement with the regimen, and discussion would be made with immunologists and rheumatologists to consider additional treatments.

Discussion

Autoimmunity in CVID can involve inflammatory arthritis symptoms mostly resolved with immunoglobulin injection and treatment regimen. The case report showed a rare scenario and emphasized the unpredictable response to standard arthritis treatments. More clinical trials on the effect of medication on CVID complications are needed, and these patients require more careful monitoring with multiple specialty professionals.

Purpose

Lupus nephritis (LN) is kidney inflammation and injury that commonly results from systemic lupus erythematosus (SLE). Neutrophils contribute to LN is by releasing contents from preformed granules that damage the kidney. Neutrophils release α-1 acid glycoprotein (α-1AG) in secondary and tertiary granules. The purpose of this study was to investigate α-1AG as a candidate biomarker in proliferative lupus nephritis.

Methods

ELISAs were used to measure α-1AG in urine from patients with proliferative lupus nephritis, membranous lupus nephritis, minimal change disease (MCD), membranous glomerulonephritis (MGN), and healthy donor (HD) controls. α-1AG was also measured in neutrophil supernatants. Logistic regression was used to generate a receiver operating characteristic (ROC) curve, which provided an optimal cutoff concentration. Comparisons of all groups were analyzed using a Kruskal-Wallis test with post-hoc corrected Dunn's tests. Paired LN patient samples (active LN dates to inactive LN) were compared using a two-tailed Wilcoxon matched pairs signed rank test with Bonferroni correction for multiple comparisons.

Results

A-1AG are significantly more abundant in urine of Active proliferative LN patients’ more α-1AG than HD, patients with membranous LN, MCD, or MGN. An optimal cutoff concentration was determined using ROC curves at 89,230.77 ng/mL.

Conclusion

⍺-1AG appears to be a promising diagnostic marker for proliferative LN. Moreover, it also appears to be a marker for disease activity in proliferative LN. Neutrophils may release some of the ⍺-1AG that appears in LN patients’ urine. The role of neutrophil-derived ⍺-1AG on renal injury remains to be determined.

Purpose

Recent years have seen a dramatic increase in opioid-related overdose deaths in Black individuals. Naloxone is an opioid overdose antidote that works by blocking and displacing opioid agonists at the mu opioid receptor within seconds after administration. However, stigma has been a barrier to achieving wide-spread naloxone distribution in Black communities. We provide a case study from the HCS in which a partnership in Hamilton County, Ohio facilitated overdose education and naloxone distribution (OEND) in the Black community.

Methods

HCS researchers partnered with the African American Engagement Workgroup (AAEW) to facilitate OEND. The team focused OEND-related efforts at faith-based community events, large churches with significant Black membership, and Black-owned businesses. Stigma reduction was a significant component of the initial plan, followed by overdose education, instructions on how to administer naloxone, and why it was so important to keep kits available within businesses and in individual residences.

Results

Strong AAEW leadership with meaningful connections among the Ministers in the Cincinnati Area Baptist Association and Black business owners allowed the strategy to be implemented successfully. Church, and other community, members led efforts and provided trainings and distribution events at larger Black urban churches and community events. During services, church leadership supported stigma reduction and encouraged training attendance. Approximately 640 naloxone kits were distributed in five months. The initial OEND project grew into a larger-scale effort to provide expedited assessments, access, and linkage to medication for opioid use disorder.

Conclusion

Effective partnerships in the Black community facilitated OEND and other evidence-based practices.

Introduction

Numerous studies have examined health inequities. Inherent to the validity of these studies is accuracy of racial and/or ethnic designations. Without knowledge of the degree of misattribution, studies risk missing disparities that exist and finding some that do not. This study examined the accuracy of electronic medical record (EHR) racial/ethnic attribution across the three largest pediatric hospitals in Michigan.

Methods

For each hospital the specific options for the classification of race/ethnicity available in their EHR were identified (ranging from 6 to 47 for race and 2 to 9 for ethnicity). Parents were approached in outpatient clinics and asked to select from a list of the options at their hospital, the race and ethnicity of their child. This was used as the gold standard for comparison with the information in the EHR.

Analysis for matching occurred in three stages. 1) Exact match; 2) “Prioritizing” of non-white component of combinations (e.g., any combination with Black designated as Black); 3) “Prioritizing” plus consolidation (e.g., putting all Asian groups together).

Results

Approximately 1500 parents participated from each hospital. Across the 3 hospitals, exact matching for race ranged from approximately 50% to 78%. Lower matching occurred for hospitals using more categories. After consolidation and grouping of categories, match rates improved markedly.

Conclusions

Accuracy in race and ethnicity data is essential for valid assessment of inequities. Hospitals with expanded categories may need to consolidate/group race/ethnicity data for accurate analyses. Efforts to improve EHR accuracy and to statistically account for current error rates are urgently needed.

Objective

Stereotactic radiosurgery is an established treatment for breast cancer brain metastases. However, there is limited data regarding the clinical outcomes of SRS when delivered with targeted systemic therapies. Our aim was to assess the clinical outcomes and toxicities of patients receiving modern systemic therapy concurrently with SRS in comparison to patients undergoing traditional cytotoxic chemotherapy and SRS.

Methods

Through this IRB-approved retrospective analysis, we collected the clinical outcomes of 43 patients with brain metastases from breast cancer treated with SRS in combination with modern targeted systemic therapies (delivered within 4 weeks of SRS).

Results

A total of 235 brain metastases were treated with single fraction SRS in combination with systemic therapy. Of the 235 tumors, 49 were treated with concurrent cytotoxic systemic therapy, 60 with antibody or endocrine, 41 with immunotherapy combination, 56 were not treated with concurrent systemic therapy, and 56 received other systemic therapy. In comparison to patients receiving concurrent cytotoxic chemotherapy and SRS, those receiving antibody/endocrine therapy with SRS and those receiving no systemic therapy had significantly higher rates of local treatment failure (p=0.005). Patients receiving immunotherapy concurrently with SRS had similar rates of local treatment failure compared to those undergoing cytotoxic chemotherapy (p=0.47). We found no association between the type of systemic therapy delivered with SRS and elsewhere brain failure, or radionecrosis (all p>0.2).

Conclusion

Delivery of no therapy with SRS or the delivery of antibody/endocrine therapy concurrently with SRS were both associated with significantly higher rates of local treatment failure.

Introduction

Paragangliomas are infrequent neuroendocrine neoplasms that typically arise from autonomic ganglia, predominantly presenting in the head and neck regions, with the potential for benign or malignant progression. The transformation into a malignant state poses significant diagnostic and therapeutic dilemmas, underscoring the intricacies of intervention protocols. Given the paucity of standardized treatments for advanced metastatic presentations, this case report aims to augment the comprehension of integrated treatment modalities in the management of intricate cases.

Methods

A comprehensive literature review was undertaken to evaluate the epidemiology, demographic characteristics, functional attributes, tumor localization, and genomic correlations of malignant head and neck paragangliomas, including the incidence of gene mutations associated with metastatic progression, in contrast with the parameters of the presented case.

Results

A 32-year-old man diagnosed with a paraganglioma affecting the carotid artery and showing distant metastases underwent high-risk surgery and radionuclide therapy, with a positive outcome of no cranial nerve deficits post-treatment. A review of the literature on similar cases revealed a higher occurrence in females and a general pattern of low functional capacity associated with these tumors. The dominating primary therapy for these tumors based on the literature review was surgical excision.

Conclusions

Malignant paragangliomas of the head and neck present diagnostic and treatment challenges especially given the context of advanced and distant metastasis. A multimodal approach may be required in the management of complex cases including surgery, chemotherapy, and or/radiotherapy.

Purpose

This mixed-methods case study investigated the impacts, costs, barriers, and facilitators associated with implementing telehealth services across two private pediatric clinic systems. The research examined the effects of telehealth on provider engagement and financial performance.

Methods

Thirty-four clinicians, administrators, and staff across the pediatric and cardiology clinics were interviewed before and after enterprise-level telehealth adoption to examine change processes amid this innovation. Twelve months of pre- and post-implementation financial records underwent statistical analysis to assess revenue and cost dynamics. Quantitative outcome measures encompassed expenses, revenues, and telehealth visit utilization rates, while qualitative analysis of interviews and focus groups revealed key implementation themes through rigorous inductive coding of participant narratives.

Results

Results showed significantly increased costs (44-75%) and revenues (21-47%) at both clinics following virtual care expansion. Monthly telehealth visits per provider exponentially rose over 450% across sites. Qualitatively, 83% of providers appreciated scheduling flexibility benefits, but 68% of staff cited workflow disruptions. Interpretatively, findings demonstrated catalyzed financial and productivity transformations and nuanced perceived disruption amid pronounced appointment capacity expansions.

Conclusions

Interpretatively, findings demonstrated catalyzed financial and productivity transformations and nuanced perceived disruption amid pronounced appointment capacity expansions. Recommendations encompass updated care coordination protocols, enhanced training and support resources, incentivizing provider usage, and modulating implementation pacing responding to user feedback during large-scale organizational innovation.

Introduction

Hidradenitis Suppurativa (HS) is an inflammatory skin condition that disproportionately affects young Black adult females. Antibiotics are commonly used for disease management, making it important to consider the potential complications such as infection and death. The literature has started to examine the relationship between patients with HS and Clostridium Difficile (C.diff), but only with smaller studies, and no studies have examined the death rate. This study investigates the risk for infection of C. diff and death for patients with HS.

Methods

A retrospective cohort study was performed utilizing the global database TriNetX. Two cohorts were assembled that were compared in their development of C.diff or death. The first cohort included patients who used various antibiotics after their HS diagnosis (n = 86,251). The second cohort served as the control and included patients with HS that did not use these antibiotics (n = 60,157). For the statistical analysis, the risk ratio was calculated. The antibiotics examined included Clindamycin, Rifampin, Tetracycline, Minocycline, and Doxycycline.

Results

The risk ratio and associated 95% confidence intervals for contracting C.diff or death is 2.265 (1.971, 2.604) and 1.357 (1.284, 1.434), respectively.

Conclusion

The results show a statistically significant increased risk of developing a C.diff infection and of dying when utilizing these antibiotics. Antibiotic usage has shown to improve HS symptoms, however, clinicians must be wary about the complications that could occur when prescribing antibiotics, such as increased risk of C.diff infection and death.

Introduction

Hepatobiliary cancer is the second leading cause of cancer-related death worldwide. Prior data showed mixed results against racial impact in this population group, with limited specific results regarding clinical outcomes. We aim to utilize a large national database to provide comprehensive data on the clinical outcomes of hepatobiliary cancer about race.

Method

The 2020 National Inpatient Sample was utilized in this study. patients with hepatobiliary cancer were selected by ICD-10 CM code. Inpatient mortality and associated complications, including acute kidney injury (AKI), heart failure, and mechanical ventilation use were analyzed. Logistic regression analysis was used to assess the association between race and complications.

Results

We surveyed 20,670 hospitalizations with hepatobiliary cancer. Caucasians accounted for 60.7%, whereas African Americans accounted for 12%. The mean age was 65.38 years, with 66% being male. African Americans had a significantly higher inpatient mortality rate (aOR 1.61, 95%CI (1.10, 2.35), p <0.005) as well as higher odds of acute kidney injury (aOR 1.22; 95%CI (1.10-1.35), p<0.005) compared to Caucasians. We found increased, but not statistically significant in other clinical outcomes compared to Caucasians.

Conclusion

African Americans are at a higher risk of experiencing worsening clinical outcomes and mortality rates. Future longitudinal studies could shed light on these long-term connections.