Southern Medical Journal最新文献

Psychiatric conditions are prevalent among adults with intellectual and developmental disabilities (IDDs), with studies estimating that 33% of this population experiences psychiatric disorders such as mood, anxiety, and behavioral issues. These rates are significantly higher than the general population, underscoring the need for proper management within primary care settings. Although the integration of mental health services into primary care is increasing, general practitioners often report a lack of training and time to treat psychiatric conditions in adults with IDDs. Collaborative care models, involving partnerships between primary care providers and mental health specialists, have emerged as a promising solution, offering tailored, patient-centered treatment. Barriers like diagnostic overshadowing, communication challenges, and stigmatization hinder access to appropriate care, however. In recent years, the inclusion of genetic testing in psychiatric care has gained traction, especially in managing IDDs associated with specific genetic conditions like fragile X syndrome and DiGeorge syndrome. Genetic testing can help identify the underlying causes of psychiatric symptoms, offering valuable insights into appropriate treatment pathways. Pharmacogenetic insights provided by genetic testing can guide more personalized medication management, reducing adverse effects and improving outcomes. Effective management of psychiatric conditions in adults with IDDs requires further research, particularly randomized controlled trials, to establish evidence-based treatment approaches. Expanding research on interventions, including psychotherapy, pharmacotherapy, and genetic testing, is essential to improve patient outcomes in this underserved population.

Objective: Incidental lesions identified clinically or on imaging are diagnostically challenging. The workup for these lesions is not well established. We investigated diagnostic modalities used at our institutions for undiagnosed lesions and the timeline from intake to biopsy and resultant diagnoses.

Methods: We retrospectively analyzed data from all 3 Mayo Clinic sites (Arizona, Florida, and Minnesota) between November 1, 2018 and July 31, 2022. We evaluated the frequency of the biopsy technique used (if any) and how often the resultant diagnosis was malignant, benign, or inconclusive. The turnaround time from intake to biopsy and final diagnosis also was evaluated.

Results: Of 93 patients with an undiagnosed lesion, 54 (58%) underwent biopsy; most patients underwent a single biopsy (n = 42, 77%), and 12 (23%) had two or more biopsies. Unbiopsied patients were diagnosed as having benign lesions according to imaging or had follow-up imaging. Of the 54 patients biopsied, 38 (70%) biopsies were obtained via fine-needle aspiration. Biopsy results were malignant for 34 patients (63%), benign for 14 (26%), and inconclusive for six (11%). Most patients were seen within 9 days of their initial contact (69/93, 74%), underwent biopsy within 20 days of seeing the physician (40/54, 74%), and had a final diagnosis within 30 days of the initial visit (72/93, 77%).

Conclusions: Our findings can help clinicians dispel the misconception that most undiagnosed lesions are malignant. Our findings also may help clinicians determine the appropriate workup for undiagnosed lesions. Further research is recommended to guide clinicians on the best sampling methodologies to obtain the highest yield of tissue for analysis. Dedicated patient workflows can help expedite diagnosis.

Objective: Extreme temperatures negatively impact pulmonary function. This study explored whether the variability in ambient temperatures across disparate geographic regions in the United States was associated with differences in hospital outcomes for patients admitted with chronic obstructive pulmonary disease (COPD).

Methods: Using the 2016-2019 National Inpatient Sample database, we compared adults hospitalized with COPD in the US Northeast with those in the US South. We conducted multivariable regression analyses to study outcomes, including mortality, resource utilization, and posthospital discharge disposition.

Results: From 2016 to 2019, 463,830 (30.1%) patients were admitted with COPD in the Northeast and 1,078,930 (69.9%) in the South. The lowest hospitalization rates for COPD were observed in both regions during the hottest months (July and August). Those in the Northeast had higher adjusted odds of in-hospital mortality (adjusted odds ratio: 1.1 [95% confidence interval {CI} 1.0-1.2]; P = 0.03) and a lower likelihood of being discharged to home after the hospitalizations (adjusted odds ratio: 0.63 [95% CI 0.61-0.65]; P < 0.01]) compared with patients hospitalized in the South. Patients in the Northeast had longer hospital stays (adjusted mean difference: +0.19 days; 95% CI 0.13-0.25; P < 0.01) and incurred greater hospital charges compared with patients in the South (adjusted mean difference: $3728; 95% CI 1840-5616; P < 0.01).

Conclusions: Patients hospitalized with COPD in the Northeast had worse clinical outcomes and greater resource utilization than in the South. These findings, coupled with the higher admission rates during colder months, raise questions about the influence of colder ambient temperatures on COPD exacerbations.

Objectives: There has been growing evidence that insurance status is a major indicator of postoperative outcomes, which has been extensively reported in orthopedic procedures such as shoulder and knee arthroplasty. Patients with Medicaid public insurance had increased complications, longer lengths of stay, and increased costs compared with patients who had private insurance when controlling for demographic characteristics. Our study compared the outcomes of patients with Medicaid insurance with those patients with private commercial insurance who have undergone anterior cruciate ligament (ACL) reconstruction. We hypothesized that patients with Medicaid insurance coverage would have worse patient-reported outcomes and complication rates in comparison with a matched cohort of patients with private insurance.

Methods: Our departmental registry was queried for all patients who underwent primary arthroscopically assisted ACL reconstruction by 10 surgeons in the practice between January 2018 and June 2022 and were at least 2 years out from their surgery. Eligible patients in the matched cohort model were contacted via telephone for consent to participate in this study and questioned about their pain level, return to sport, physical therapy compliance, and any incidence of retear rates or additional procedures in their ipsilateral or contralateral knee. Patients were then compared across insurance types based on Lysholm knee score, as well as the other patient-reported outcomes.

Results: A total of 189 ACL reconstructions were screened during the study period. Fifteen private insurance and 15 Medicaid patients responded to the telephone call and consented to the study. Comparison of the clinical outcomes within the insurance cohorts revealed that there were no significant differences in Lysholm knee scores, pain scores, revision rate, and return to sport. The only significant difference observed was that Medicaid patients had a greater physical therapy compliance rate. Multivariate linear regression analysis revealed that males had the highest odds ratio associated with higher Lysholm scores, but there was no significance observed with any factor.

Conclusions: Although Medicaid patients did have greater physical therapy attendance, this did not improve their postoperative outcomes, which may suggest that Medicaid status may affect physical therapy effectiveness and can be a confounding variable related to other health disparities. Because the multivariate linear regression analysis did not show any associated factors with poorer postoperative outcomes, this may imply that some demographic factors or insurance status may not be contraindications to ACL reconstruction. Despite the lack of significance, males had a greater likelihood of achieving acceptable Lysholm knee scores based on the multivariate analysis.

Objectives: Despite the common performance of thoracentesis, predicting risk for adverse outcomes and abnormal postprocedural findings remains difficult. Although guidelines and experts have suggested that routine postprocedure imaging has low yield, compliance with these guidelines has not been well studied. In addition, previous studies have shown that pleural effusions are associated with high short-term mortality rates, longer hospitalizations, and higher readmission rates, increasing the importance of systematic study of procedural results. We aimed to determine the rate of imaging abnormalities, the utility of routine postprocedure imaging, and health outcomes for hospitalized patients requiring thoracentesis.

Methods: An epidemiologic description including adult inpatients at one academic medical center who underwent thoracentesis outside of radiology-specialty procedural areas during a 2-year period. Charts were individually reviewed for data extraction.

Results: In total, 425 thoracentesis procedures in 329 patients were included. A chest x-ray was obtained after 80.9% of procedures. Postprocedure imaging abnormalities included pneumothorax (8.0%), hemothorax (1.6%), reexpansion pulmonary edema (7.8%), and pneumothorax ex vacuo (4.7%). The average hospital length of stay was 13 days, and 15% required mechanical ventilation during their hospitalization. Fifty-five percent of participants were discharged home, 22.8% to a medical facility, 14.4% transitioned to hospice care, and 8.1% died during hospitalization.

Conclusions: Overall, approximately 20% of patients required clinical reassessment or intervention following thoracentesis. The findings confirm a high rate of secondary morbidity, in-hospital mortality, and long length of stay for hospitalized patients undergoing thoracentesis. The requirement for inpatient thoracentesis represents an opportunity to address end-of-life issues and to identify approaches to optimize resource utilization.

Objectives: Learning communities (LCs) are on the rise in medical education. Key features of LCs include fostering student learning, wellness, and engagement. The ways in which different programs are currently using LCs are still relatively new, however, and literature on this topic is scarce. We developed and incorporated a wellness-in-action session, coined Brian's Field Day, into our LC curriculum with the aim to improve self-care, camaraderie, and socialization.

Methods: More than 180 first-year medical students and 20 LC faculty advisors participated in Brian's Field Day, a large-scale 1-hour wellness-in-action session, in academic years (AYs) 2021-2022 and 2022-2023. The session was divided into different activities, including yoga, meditation, dodgeball, kickball, coloring, pet therapy, board games, walking, improvisation, and Zumba. All students received an electronic survey assessing their perceptions of the activity.

Results: The overall response rate was 47% (86/183 students) in AY 2021-2022 and 49% (90/182 students) in AY 2022-2023. Overall, postactivity perceptions were positive with mean scores ranging from 4.00 to 4.61 (standard deviation [SD] range ± 0.69-1.30) for "enjoyment," "improved camaraderie," "should continue as part of the curriculum," and "would like more events like this." The mean was 3.96 (SD ±1.15) and 3.83 (SD ±1.38) for "improving self-care" in AY 2021-2022 and AY 2022-2023, respectively. Themed qualitative comments also indicated improved student-student and faculty-student bonding and the desire for more similar activities.

Conclusions: Academic stress among medical students is high and many schools have incorporated LCs into their curricula to help with socialization and promotion of wellness and community. As more schools adopt LCs, they should consider integrating a wellness-in-action session as a fun way to augment both peer-to-peer and student-faculty relationships.

Objectives: Concussions are one of the most frequent pediatric injuries, especially for high school athletes. Many of the psychological sequalae from concussions go unnoticed and undertreated particularly in the rural setting. There is limited research on optimizing recovery for these patients; however, newer studies are beginning to show the utilization of deep breathing exercises. In this study, we evaluated the effectiveness of self-administered relaxation techniques for postconcussive mood symptoms in an Appalachian population.

Methods: Patients' charts (N = 308) from a rural specialty concussion clinic between September 2020 and May 2023 underwent a review. Eligible patients included those who completed the Post-Concussion Symptom Scale (PCSS), Patient Health Questionnaire, and Generalized Anxiety Disorder scale (GAD-7) during their initial intake visit. Patients who suffered from at least mild to moderate depression and/or anxiety were educated on self-administered relaxation techniques, which consisted of 15 minutes of deep breathing exercises to be performed nightly. Their mood symptoms were reassessed, after monitoring patient compliance with breathing exercises, via a 4-point Likert scale at their follow-up appointment (average 13.5 days). The data were grouped based on the patient's compliance (good vs limited) with their respective score improvement and analyzed via paired t tests. Good compliance consisted of performing the breathing exercises "most of the time" and the limited compliance group performed exercises "some of the time, seldom, or rarely/none." The second part of the analysis investigated if there were any significant difference in improvements between the good and limited compliance groups using unpaired t test statistics.

Results: The good compliance group experienced a significant improvement in Patient Health Questionnaire (7.11, P < 0.01), GAD (6.33, P < 0.01), and PCSS (24.33, P < 0.01) scores at follow-up. The limited compliance group only had a significant improvement in GAD (2.14, P = 0.025) and PCSS (29.77, P < 0.01). There was a significant difference in anxiety improvement between good and limited compliance groups by 4.19 points as assessed by the GAD scale (P < 0.01).

Conclusions: Self-administered deep breathing exercises are a cost-free, practical, and safe intervention that may benefit patients with persistent mood symptoms in the concussion rehabilitation process, particularly in resource scarce areas in Appalachia.