Southern Medical Journal最新文献

Objectives: Hypertension and diabetes mellitus (DM) are the leading causes of cardiovascular, cerebrovascular, and chronic kidney diseases. They affect an estimated 47% and 11% of Americans, respectively. In this study, we assessed whether a dedicated patient navigator embedded within a patient-centered medical home (PCMH) using a structured panel management and patient outreach strategy could improve blood pressure and glycemic control in primary care patients with uncontrolled hypertension and DM.

Methods: We performed a prospective study comparing blood pressure and glycemic control in primary care patients before and after implementation of a patient navigator executing a hypertension and DM-focused panel management plan.

Results: From January 2014 to October 2019, inclusion criteria were met 5164 times, which comprised 1958 unique patients within a PCMH. Multivariate regression analysis reveals a significant decrease in uncontrolled systolic blood pressure (SBP) over time, with an actual decrease of roughly 40% of uncontrolled episodes of SBP becoming controlled by 12 months. Multivariate regression analysis reveals a significant decrease in uncontrolled hemoglobin A1c (HbA1c) over time for each plot (P < 0.0001), with an actual decrease of roughly 30% of uncontrolled episodes of HbA1c becoming controlled by 12 months.

Conclusions: This study demonstrated the benefit of a dedicated patient navigator embedded within a PCMH on improving BP and glycemic control in primary care patients with uncontrolled hypertension and DM. Glycemic control was achieved, with 30% of episodes reaching an HbA1c of <8% and BP control achieved for 40% of episodes with SBP <140 mm Hg at 12 months. There were no differences by the social determinants of race and poverty.

Objectives: Socioeconomic characteristics may be associated with cesarean section (CS) rates. We probe the relationship between socioeconomic variables and primary cesarean section (PCS) by studying indicators of socioeconomic status (SES) in a population-based study in New York City.

Methods: This was a retrospective study of all 80,506 women in New York City who gave birth to a live child during 2018, and who met inclusion and exclusion criteria. Data were drawn from the New York City Department of Health and Mental Hygiene and the US Census. The main outcome measure was performance of PCS as compared with vaginal birth.

Results: Approximately 21% of neonates were delivered by PCS. Multivariate multilevel mixed-effects logistic regression analysis showed higher odds for PCS for women with an upper-middle class median household income of US$108,500 to $380,499 (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.07-1.76, P = 0.001), and the percentage enrolled in the Supplemental Nutrition Assistance Program (OR 1.01, 95% CI 1.001-1.012, P = 0.02). Lower odds for PCS occurred for all middle-class categories of per capita income: US$32,500 to $54,499 (OR 0.91, 95% CI 0.84-0.99, P = 0.02), US$54,500 to $108,499 (OR 0.76, 95% CI 0.66-0.88, P < 0.001), and US$108,500 to $380,499 (OR 0.80, 95% CI 0.66-0.96, P = 0.02). No significant association occurred for women receiving public assistance.

Conclusions: Patient preferences in favor or against CS may be related to SES. There may be conflicts between obstetric care that is maximally beneficial and a patient's desire for delivery mode. Clinicians should be aware of the potential implications of this dilemma.

Coins occasionally cause health problems. These problems have a wide range of presentations and can affect multiple organ systems. This article updates a 2009 review of the medical literature addressing health problems caused by coins in several ways. The spectrum of clinical findings is expanded by describing new entities associated with coin ingestion, including laryngeal impaction in adults, gastric perforation, and pancreatic disease. Guidelines for differentiating swallowed coins from the potentially life-threatening mimic of swallowed button batteries are summarized. Multiple new case series better define outcomes and management approaches in coin ingestion. Metal toxicity from coins remains rarely reported. The evidence that systemic allergic reactions can result from ingested coins is strengthened by new case reports. Maintaining the perspective that coin ingestion can cause obscure symptoms may lead to both a diagnosis of the cause of such symptoms and the description of clinical findings not yet reported.

Objectives: In response to worldwide shortages of N95 masks during the severe acute respiratory syndrome-coronavirus-2 pandemic, various strategies have been used. The Centers for Disease Control and Prevention recommend several strategies, including simple isolation to reprocessing methods using vaporized hydrogen peroxide to guide reuse of masks up to five times. National Institute for Occupational Safety and Health (NIOSH) quantitative fit testing was performed after five trials of donning and doffing in one cohort of new masks and two cohorts of repeatedly sterilized "duckbill"-type N95 masks.

Methods: One cohort of new masks and two cohorts of sterilized masks were repeatedly subjected to 35% vaporized hydrogen peroxide for either five or 10 cycles. Then, they were subjected to five trials of donning and doffing, with NIOSH quantitative fit testing performed after each wear cycle to assess for any degradation on fit performance caused by sterilization and/or repeated donning and doffing up to the recommended Centers for Disease Control and Prevention limit of five times. All of the fit testing was performed on a single volunteer.

Results: The means and 95% confidence intervals for each cohort and the individual results for each mask within each cohort were reported. A χ² analysis showed significant differences in percentages of masks that pass fit testing in both recycled mask cohorts.

Conclusions: These data show the variability of NIOSH fit testing results of both new and sterilized masks. The mask recycling program of our partner health systems thus discarded these types of masks due to the variable failure rate. Health systems should consider individual evaluation to inform their overall policies on mask reuse and recycling.

Objectives: Physicians other than dermatologists evaluate nearly 60% of all skin diseases, and 22% of these physicians are family physicians. Dermatology education is therefore an important aspect of Family Medicine training. Dermatologic procedural training in Family Medicine residency is not standardized, however, so family physicians graduate with highly variable skills. This study describes the scope and diagnostic outcomes of skin biopsies performed by residents at a multisite Family Medicine residency network in comparison with those performed by attendings at a Family Medicine faculty community practice.

Methods: We performed a retrospective chart review of patients evaluated at eight Family Medicine residency training sites and one Family Medicine faculty community practice within a regional academic health system between January 2020 and October 2022. Patients with a skin finding who underwent at least one skin biopsy during their visit were included in the study.

Results: Among all of the skin findings, the incidence of skin biopsy was 3.6% (258/7104) for residents and 1.8% (175/9917) for attendings (P < 0.001). Family Medicine residents performed fewer shave biopsies (57.8% vs 77.7%, P < 0.001) and more punch biopsies (25.6% vs 11.4%, P < 0.001) compared with attendings. Most biopsies performed by residents and attendings were benign, although residents biopsied significantly more benign (79.1% vs 64.6%, P < 0.001) and malignant lesions (11.2% vs 5.7%, P = 0.049). Attendings biopsied significantly more low-to-moderate-grade dysplastic (22.3% vs 5.0%, P < 0.001) and high-grade atypical lesions (4.0% vs 0.8%, P = 0.034).

Conclusions: Family Medicine residents at this residency network receive training in a variety of skin biopsy types. Distinct skin biopsy practices and outcomes between residents and attendings may reflect differences in patient populations, clinical expertise, and dermatology referral patterns.

Objectives: This study aimed to compare endometrial cavity length measurements obtained by preoperative three-dimensional (3D) reconstruction of coronal images on pelvic ultrasound with intraoperative endometrial cavity measurements obtained in advance of Minerva endometrial ablation.

Methods: This was a retrospective cohort study of 41 individuals who underwent a Minerva endometrial ablation between August 1, 2018 and March 15, 2022 at a single academic medical center. Patients were excluded if they had an in-clinic ablation or no ultrasound with 3D uterine volume within 180 days before surgery. Physician sonologists measured the endometrial cavity length using 3D coronal reconstruction of the cavity. Two measurements were obtained by separate physicians who were blinded to intraoperative values. Intraoperative endometrial cavity lengths were obtained from operative reports. A Bland-Altman plot was used to evaluate the agreement of intraoperative and ultrasound measurements.

Results: The mean intraoperative endometrial cavity length (50.7 ± 7.8 mm) was greater than the mean endometrial cavity length by 3D coronal reconstruction of pelvic ultrasound (36.1 ± 6.2 mm, P < 0.0001). The average difference between intraoperative and ultrasound measurements of cavity length was 14.6 ± 9.0 mm. The agreement between measurements was poor (Lin's concordance correlation coefficient 0.06). Using a Bland-Altman plot, the limits of agreement (-3.1 to 32 mm) exceeded the a priori acceptable limits of agreement (-10 to 10 mm).

Conclusions: Our findings suggest that preoperative coronal endometrial cavity length measurements by ultrasound are not a valid substitute for intraoperative measurements before Minerva ablation.

Objectives: Atopic dermatitis (AD) is one of the most common chronic childhood conditions. Disparities in treatment and access to care can result in poor disease control and decreased quality of life. The aim of this study was to determine whether race and ethnicity affect treatment and healthcare utilization for pediatric atopic dermatitis in central Florida.

Methods: This study of 4008 children with AD compared healthcare utilization and management using the numbers of AD-related healthcare visits, prescriptions, testing, and subspecialty referrals. Multivariable models were used to compare racial and ethnic groups (Black, Hispanic, Asian, and Other) with the reference group of non-Hispanic White, while adjusting for common confounders.

Results: The mean number of urgent care visits for the Hispanic group was 1.61 times that of the non-Hispanic White group, and the mean number of emergency department visits was 3.71 (P < 0.001) times the reference group. Black or African American patients had a mean number of emergency department visits that was 1.52 times that of non-Hispanic White patients (P = 0.021). The mean count of primary care visits was lower among Hispanic patients and higher among Asian patients (P = 0.012). Visits to subspecialty clinics and hospitalizations did not differ significantly. There were no consistent patterns in differences of AD-related prescriptions, testing, or subspecialty referrals.

Conclusions: This study indicates that racial and ethnic disparities exist in healthcare utilization in pediatric AD. The underlying factors contributing to these disparities need to be further studied and addressed to reach health equity within pediatric AD.

Objectives: Addressing structural barriers to care for people living with human immunodeficiency virus (HIV) in the southern United States is critical to increase rates of viral suppression and to reduce existing HIV disparities. This qualitative study aimed to describe transportation-related barriers experienced by people living with HIV in South Carolina, understand perceived effects of transportation vulnerability on HIV care, and explore strategies used by individuals to overcome transportation-related challenges.

Methods: We conducted semistructured interviews with 20 people living with HIV from South Carolina who were either reengaging in HIV care after a prolonged absence (>9 months) or in care but with a detectable viral load (ie, >200 copies/mL). All people living with HIV reported transportation vulnerability. A deductive/inductive approach was used to identify transportation-related barriers perceived to negatively affect HIV care. We also identified strategies and resources described by people living with HIV as helpful in addressing transportation challenges.

Results: Participants described a range of transportation-related barriers to HIV care, including lack of access to reliable, safe, and affordable transportation, as well as stigma due to HIV and socioeconomic statuses. These barriers were reported to negatively affect engagement in care and worsen both physical and mental health. Participants indicated flexible clinic policies and instrumental support from family and friends were useful in overcoming barriers.

Conclusions: This study offers insight for the development of transportation interventions to improve equitable access to HIV care for people living with HIV in South Carolina. It also calls attention to the ways in which transportation vulnerability, HIV-related stigma, and disability status intersect to create unique challenges for some people living with HIV.

Objectives: Teledermatology is a cost-effective and efficient approach to delivering care and is particularly beneficial for patients with limited access to specialized services. Considering the rapid expansion of telehealth, it is crucial to focus on optimization. The purpose of our study was to evaluate the triaging of dermatologic care in an electronic consultation (e-consultation) service in a safety-net hospital.

Methods: This was a 2-year retrospective review of a dermatology asynchronous store-and-forward e-consultation service.

Results: A total of 1425 patients completed 1502 e-consultation. Of these e-consultations, 46% of the patients had Medicaid and 44% were Black or African American. The top three diagnoses were dermatitis unspecified, neoplasm of uncertain behavior, and acne/rosacea. Most (68%) were managed via e-consultation and did not require an in-person appointment. Children and adolescents were more likely to require an in-person appointment (74%) compared with adults (30%, P < 0.0001). Patients with a chief complaint of hair loss or skin lesion were more likely to require in-person evaluation (58% and 41%, respectively) compared with rash (24%) and acne (18%) (P < 0.0001). There was no difference found in recommendations for in-person evaluation based on race, non-English-language preference, or insurance status.

Conclusions: E-consultation services seem well suited for certain concerns, and underserved populations can be evaluated by teledermatology.