Journal of the National Medical Association最新文献

Purpose

AMD degrades reading vision in aged persons worldwide. Hyper-transmission defects (HTDs) on optical coherence tomography (OCT), a structural clinical imaging biomarker for AMD progression, represents loss of shadowing by degenerating retinal pigment epithelium (RPE). We sought HTDs in individuals with normal eyes, early AMD (eAMD), and intermediate AMD (iAMD).

Methods

One eye of each participant in the baseline visit of the Alabama Study on Early Age-Related Macular Degeneration 2 (ALSTAR2) was analyzed. AMD presence and severity was determined using standardized color fundus photography. Participants underwent volume OCT angiography imaging. HTDs were defined in en face scans by hyper-intensity of signal in the choroid, confirmed on B-scans by the presence of RPE disruption, and measured by fitting circles.

Results

In 460 eyes of 460 participants (normal N=236, eAMD N=134, iAMD N=90), HTDs were detected in 134. Prevalence of any HTD (minimum diameter ≥62 μm) was higher in eyes with iAMD (86.7%, N=78) and eAMD (35.1%, N=47) compared to normal eyes (3.8%, N=9). Prevalence of HTD ≥250 μm was higher in eyes with iAMD (13.3%, N=12) and eAMD (5.2%, N=7) compared to normal eyes (0.4%, N=1).

Conclusions

More and larger HTDs are found in later stages of AMD. Degeneration of the RPE layer leads to HTDs and can be quickly identified on face OCTA scans. Persistent HTDs are markers for geography atrophy, an AMD end-stage (PMID 36958537). The prognostic significance of HTD identified at early stages of AMD will be clarified by imaging of the same participants at 3-year follow-up.

Introduction

DENGUE is one of the most frequent communicable diseases in rainy season. Along with enteric fever this year patients frequently affected by this disease which was worsen in some cases. Though DENGUE associated enteric fever is not so much common, it's management by Tab AZITHROMYCIN bring an effective outcome with reduced hospital admission.

Methods

68(age interval 24-59(+-2years) patients with history of fever who came in emergency & OPD (outdoor patient department)participated in this cross sectional study. 39 of them diagnosed DENGUE associated enteric fever based on relevant investigations like blood culture sensitivity, DENGUE NS1 and DENGUE IgM & IgG. 2

Results

6 patients comparatively feel better who refused hospital admission and seek for oral medications although having high WBC (White blood cells) counts in their CBC reports.3 of them (11.53%) were excluded for irrational drugs abuse .Rest of 23 patients (88.46%) had history of maintaining rational antibiotics . 15 patients came for follow up within 3 weeks specially for further CBC reviewing although they are mostly asymptomatic comparing with previous state. CBC reports of 12 patients indicate decrease WBC count(ranging 7000-9500 / mm^3) whose previous WBC range 11,000- 14000/mm^3 of blood. 3 patients have found constant leukocytosis though it is overlooked(p<0.05).

Conclusion

DENGUE associated enteric fever can be managed under home observation by rational AZITHROMYCIN uses which can bring a new era in clinical field of Bangladesh. But it should be monitored with rational antibiotic use.

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.