Southern Medical Journal最新文献

[This corrects the article DOI: 10.14423/SMJ.0000000000001652.].

Approximately 158,500 adults and adolescents in the United States live with undiagnosed human immunodeficiency virus (HIV). Missed or delayed diagnoses adversely affect disease management and outcomes. This is particularly salient for patients receiving immunosuppressive and immunomodulatory therapy for the management of chronic inflammatory conditions, in which additional immunosuppression may increase the risk and severity of opportunistic infections. Despite this risk, comprehensive HIV testing before the initiation of immunosuppressive therapy is not yet the norm. We describe a case series containing the narratives of three patients recently treated with immunosuppressive agents, who presented with signs concerning for HIV-associated kidney diseases and who were found to have undiagnosed HIV later in the treatment course, which, unfortunately, resulted in poor outcomes. Screening for HIV or related illnesses, such as viral hepatitis or mycobacterial co-infections including tuberculosis, is essential before initiating biologic immunosuppression.

Objectives: This study compared incidence rates, stage at presentation, and cause-specific mortality of nodular and superficial spreading melanoma along the rural-urban continuum in Kentucky. We compared resulting patterns in our data with sample demographic and other potential factors, including population by county and primary care provider rate.

Methods: Retrospective patient data were extracted from the Surveillance, Epidemiology, and End Results database from 2010 through 2017. These data were supplemented by environmental, demographic, and socioeconomic data derived from publicly accessible databases. Correlation and χ² analyses were used to test for significant differences in outcome variables by US Department of Agriculture Rural-Urban Continuum Code (RUCC) categories and other potential predictor variables.

Results: Incidence rates by Kentucky county were not associated with RUCC or population; likewise, there was no relationship between stage at presentation and RUCC category. There was, however, a highly significant association between cause-specific mortality and RUCC; patients from rural areas were significantly more likely to die from melanoma than those in urban areas. This overall difference was due to differences in mortality for superficial spreading melanoma.

Conclusions: Our results suggest that a disparity in patients' ability or tendency to access primary care and/or specialist providers postdiagnosis may be critical factors in determining the ultimate outcome of a melanoma diagnosis. Further studies should explore the availability of dermatologists and/or treatment options for melanoma in rural areas. Our data also provide additional support for inclusion of melanoma subtype in the American Joint Committee on Cancer guidelines.

Objectives: Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is considered a rare inflammatory rheumatologic disorder that is seen primarily in older adult men. Patients present with arthralgias of large joints accompanied by painful pitting edema of the hands and feet. Few studies have reported the prevalence of metabolic syndromes, including diabetes mellitus and hyperlipidemia in these patients.

Methods: This case series reviewed 25 patients who were diagnosed as having RS3PE in a private outpatient clinic.

Results: Nearly half of the patients (48%) had diabetes mellitus, predominantly type 2, and more than half of the patients (60%) had hyperlipidemia.

Conclusions: We believe that future case studies on RS3PE should include an assessment of various comorbidities that can be seen in patients with this autoinflammatory disorder. The increased availability of musculoskeletal ultrasound provides a potential area of study to differentiate this disorder from other inflammatory arthritis and improve reaching the correct diagnosis.

Objectives: Food insecurity (FI) is defined as limited or uncertain access to sufficient food for a healthy and active lifestyle. Our objective was to explore how the coronavirus disease 2019 (COVID-19) pandemic affected the FI status of pediatric patients and their families through interviewing caregivers who screen positive for FI.

Methods: Caregivers of all hospitalized patients at a tertiary children's hospital who screen positive for FI with a two-question screening tool were approached about enrolling in the study. Those who consented completed a presurvey and participated in a semistructured individual interview. Interviews were audio recorded, transcribed, and analyzed according to the guidelines of thematic analysis using NVivo 12.

Results: Interviews were conducted with 15 caregivers between July 2021 and January 2022. Caregivers were 100% female and 80% Black, 13% White, and 7% Hispanic/Latinx, with a mean age of 33 years. Seventy-three percent did not experience FI until the COVID-19 pandemic. Themes include lost wages, mothers forced out of the workforce due to childcare limitations, inflation and shortages of goods, increased stress/anxiety for caregivers and children, the centrality of extended family support, and the necessity/inadequacy of federal food programs.

Conclusions: The COVID-19 pandemic impacted unemployment and poverty and consequently exacerbated FI. Our findings point to the need to focus on proximal societal solutions, such as federal policies aimed at food assistance and childcare. Understanding the challenges related to FI that caregivers and patients experience can improve screening, support, and treatment of patients presenting for care and inform the design of necessary interventions for individuals and communities beyond COVID-19.

Objectives: Opioid use disorder (OUD) is characterized as a chronic condition that was first outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and now the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. It encompasses frequent opioid usage, cravings, the development of tolerance, withdrawal symptoms upon discontinuation, unsuccessful attempts to quit or reduce use, and recurrent use even when faced with negative consequences. Both national- and state-level data show that overdose deaths associated with prescription opioids are increasing at an alarming rate. The increasing overdose deaths from illicitly manufactured fentanyl and other synthetic opioids compound this epidemic's burden. The present study sought to determine the prevalence and potential factors associated with OUD in North Carolina.

Methods: Using the State Inpatient Database, a retrospective cross-sectional study was conducted to identify OUD-related discharges between 2000 and 2020. Descriptive statistics and rates of OUD per 1000 discharges were calculated. Simple and multivariable logistic regression models were used to identify factors associated with increased odds of having an opioid use disorder diagnosis at discharge. The deviance-Pearson goodness of fit statistic was also used. Variables were identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification, codes in the discharge records.

Results: Of 19,370,483 hospitalizations that occurred between 2000 and 2020 in North Carolina, 483,250 were associated with OUD, a prevalence rate of 24.9 cases per 1000 discharges. The highest OUD rates were seen among adults who self-paid for their hospitalization, those with Medicaid, and those with other types of payors such as Workers' Compensation and the Indian Health Service; individuals between 25 and 54 years old; tobacco and alcohol users; Native American patients; patients located in urban areas; patients with lower household income; White patients; and female patients. OUD also was associated with increased odds of having one or more comorbid psychiatric disorders when controlling for other factors.

Conclusions: Although preventive measures are crucial, including policies that discourage prescribing opioids for noncancer pain and those that target the manufacturing and distribution of synthetic opioids, providing integrated care for patients with OUD and co-occurring psychiatric and/or physical disorders is equally important. These findings suggest the need for a system-wide public health response focused on the expansion of primary prevention and treatment efforts, including crisis services, harm reduction services, and recovery programs.

Objectives: Organizations recommend providing confidential adolescent health care to reduce the consequences of high-risk health behaviors such as substance use, unhealthy eating patterns, and high-risk sexual behaviors. Family physicians are uniquely positioned to provide confidential counseling and care to this vulnerable population but must be trained to provide such care. This study describes the impact of formal and informal training on the knowledge of and comfort level in providing confidential adolescent healthcare among a sample of US Family Medicine residents.

Methods: Electronic surveys were distributed to all Family Medicine residents throughout the United States. We used descriptive statistics and χ² analysis where appropriate to determine the association between resident-reported receipt of training, confidence, and frequency in providing confidential adolescent health care.

Results: A total of 714 Family Medicine residents completed the survey. The majority reported no formal training in residency (50.3%). The receipt of formal and informal training in both medical school and residency was associated with a greater degree of comfort in providing confidential adolescent care and a higher likelihood of providing confidential time alone. Those reporting formal training were more likely to always provide confidential care (P = 0.001).

Conclusions: Training focused on confidential adolescent health care in medical school or residency was associated with a greater degree of comfort and a higher likelihood of providing confidential adolescent health care.

Androgen deprivation therapy is the cornerstone of systemic management for prostate cancer but is associated with multiple adverse effects that must be considered during treatment. These effects occur because of the profound hypogonadism that is induced from lack of testosterone or due to the medications used in the treatment or in combination with androgen receptor signaling inhibitors. This article critically reviews the associations between androgen deprivation therapy, androgen receptor signaling inhibitors, and cardiovascular complications such as prolonged QT interval, atrial fibrillation, heart failure, atherosclerosis, coronary heart disease, venous thromboembolism, and peripheral arterial occlusive disease. These unfavorable outcomes reinforce the need for regular cardiovascular screening of patients undergoing androgen deprivation for the management of prostate cancer.