The Permanente journal最新文献

Background: As rates of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH) rise, national organizations have released new guidance for primary care-driven detection of patients with advanced fibrosis who are most likely to have clinically relevant morbidity. Yet time constraints, workflow, and practitioner awareness limit integration of risk identification into clinical care.

Materials and methods: At the authors' primary care clinic, they implemented a panel management strategy that utilized the electronic health record to identify patients older than 35 years of age at risk for MASLD fibrosis with abnormal Fibrosis-4 (Fib-4) scores. Using a proactive model, these patients were offered elastography-based screening and follow-up appointments focused on metabolic health, with referrals to subspecialty care when indicated.

Results: Of 855 patients older than 35 years of age, 384 were identified as having risk factors for MASLD/MASH. Of these, 53 had abnormal Fib-4 scores with no prior work-up; 29 patients consented to a shear wave elastography; 16 underwent shear wave elastography; and 6 had moderate or high results concerning for at-risk fibrosis. Twenty patients attended MASLD-focused appointments. Reluctance to pursue testing was driven by skepticism surrounding preventative medicine, perceived cost, and desire to focus on other medical problems, some of which were life-limiting.

Conclusion: Panel management represents a scalable strategy to quickly identify patients in primary care most likely to experience complications from MASLD/MASH and provides a targeted intervention to direct further management. Limitations include access to care, medical complexity, and patient acceptance.

The prevalence of cannabis use has been increasing among both adolescents and adults worldwide. New trends in cannabis legalization and enhanced social media marketing have led to the availability of multiple high-potency cannabis products with hundreds of new and powerful delivery systems. Over the last decade, there have been drastic changes in cannabis formulations, potency, routes of consumption, and device technology, with increased complexity and sophistication among growers, suppliers, and consumers. Patterns of cannabis use among patients can have important clinical implications, including acute neurocognitive effects, chronic multiorgan toxicity, psychiatric, behavioral, social, and economic impact. However, assessment of medical or surgical patients who use cannabis either recreationally or problematically has become challenging for the clinician due to the changing patterns of cannabis consumption. This review provides information on the clinical evaluation of patients who use cannabis in a problematic fashion, with the focus on tetrahydrocannabinol. It provides the clinician with knowledge regarding cannabis terminology, sources, pharmacology, routes of administration, formulations, dosing, and toxicities. Using these components, an assessment approach for diagnosing cannabis use disorder is synthesized at the conclusion of the article.

Immunoglobulin A nephropathy is a primary glomerulopathy, with prevalence ranking highest in the Pacific region, followed closely by Europe, but rare in Africa. Although practice patterns likely have contributed to its prevalence, there are genetic and environmental factors that contribute as well. Management has evolved over the past decade, with recent rapid advances in diagnosis, prognosis, and therapies. This review summarizes the history, pathogenesis, and diagnosis of immunoglobulin A nephropathy and also cites relevant clinical trials, latest treatment options, and unanswered questions.

Objective: Virtually anything can be ranked; the US News and World Report (USNWR or US News) ranks the top 50 hospitals specializing in cardiology, heart, and vascular surgery. Here the authors propose validating the effectiveness of rankings by comparing differences among the USNWR metrics across the top 50 hospitals.

Methods: The ranking system for the top 50 hospitals specializing in cardiology, heart, and vascular surgery was derived from 16 variant scores. Each hospital's scores were collected from the USNWR. Hospitals were categorized into quintiles consisting of 10 institutions (1-10, 11-20, etc). An analysis of variance/χ² comprehensive statistical analysis was run alongside a Wilcoxon/Kruskal-Wallis test to compare statistical outcomes. A significant threshold was deemed to be P < 0.05.

Results: Significant differences were noted between quintiles for advanced technologies (P = 0.05), US News specialty score (P < 0.001), number of patient referrals (P = 0.004), and expert opinion (P < 0.001). Non-statistically significant differences were found among patient experience, public transparency, Society of Thoracic Surgery transparency, American College of Cardiology transparency, recognition as a magnet hospital, and nursing staffing. Interestingly, a large variance was noted in the average number of referrals between the first quintile (13,371) and the last (6690).

Conclusions: Expert opinion plays a critical role in the reputation of the USNWR's top 10 hospitals in cardiology, heart, and vascular surgery. Although many have argued about the merits of USNWR hospital rankings, taken together, rankings fill a strong customer demand and are sticky.

Introduction: The integration of virtual visits has been met with skepticism by many surgical specialties, including otolaryngology, due to the lack of a complete physical exam. Analysis of differences in the workup between patients triaged virtually or in-person is warranted.

Methods: A chart review was performed for a cohort of adults undergoing septoplasty (January 2021-May 2022). Groups (telemedicine, in-person) were compared by 2-sample t-test and chi-square test to determine the difference in the number of preoperative visits and to assess the variation in patients with preoperative laboratory testing, imaging, or referrals.

Results: Of 338 patients, initial evaluation was in-person for 225 (66.5%) and via telemedicine for 113 (33.5%). The groups were similar in demographics (mean age 39.1 years for telemedicine vs 38.8 years for in-person, female 28.9% vs male 37.7%, P = 0.088). The telemedicine group had a significantly higher number of preoperative visits (3.03) compared to the in-person group (2.38, P = 0.001). There was no significant difference in patients who underwent preoperative laboratory testing, imaging, or referrals. Patients triaged via telemedicine experienced a shorter time to surgery compared to those triaged in person (434 vs 208, P = 0.003).

Discussion: In this cohort, triage by telemedicine allowed otolaryngology patients to have an expedited path to surgery despite having more visits. There is no evidence to suggest that otolaryngologists had an overreliance on diagnostic modalities when triaging by telemedicine.

Conclusion: Among patients undergoing septoplasty, those initially evaluated by telemedicine were more likely to have more preoperative visits and shorter time to surgery than those evaluated in person. Telemedicine can serve as an effective method for triaging surgical patients without excess diagnostics.

Introduction: In 2018, the US Preventive Services Task Force updated cervical cancer screening recommendations to allow for screening every 5 years with primary human papillomavirus (HPV) testing in combination with cytology (cotesting) or every 5 years with primary HPV screening alone. Despite these changes, the uptake of primary HPV screening has been lower than expected. The purpose of this study was to evaluate the patient perspective of an integrated health system transition from cotesting to primary HPV testing among a 30- to 65-year-old cohort.

Methods: Semistructured phone interviews were conducted from July to December 2023 at Kaiser Permanente Colorado with 16 members aged 30-65 years. Interviews asked about reactions to the forthcoming change in cervical cancer screening, personal concern about cervical cancer risk, feedback on patient-facing education materials, and preference on communication timing and modality.

Results: Participants reported concerns about cervical cancer screening intervals, primarily the reduction in frequency leading to underdiagnosis of sexually transmitted infections (STIs). Participants recommended defining the rationale for the change to primary HPV testing in the patient education materials. Participants preferred communication about the change in-clinic between practitioner and patient.

Discussion: The interviews identified key themes, including the differentiation between cervical cancer and STI screening methodologies, potential underdiagnosis of STI and cervical cancer, and the rationale supporting primary HPV testing and associated screening intervals.

Conclusion: These qualitative findings can inform health systems of potential patient concerns to address when considering the transition from cotesting every 3 years to primary HPV testing every 5 years for cervical cancer screening.

Introduction: Understanding the lived experience of illness is important for empowering patients and informing health care practitioners. This study investigated the impact of a book-length comic memoir, My Degeneration: A Journey Through Parkinson's, by Peter Dunlap-Shohl, on patients' mental health, knowledge, and attitudes about living with Parkinson's disease (PD). The authors further explored which patients found the book to be beneficial and why.

Methods: In this convergent mixed methods study, patients with PD were recruited from a multidisciplinary movement disorders clinic in 2019-2020 and were eligible if cognitively intact; English-speaking; had stage I, II, or III PD; and < 12 months had elapsed since diagnosis. Participants received My Degeneration to read at home, measures were obtained pre- and postintervention, and participants were interviewed within approximately 1 month.

Results: Thirty participants completed the study (13 males and 17 female; mean age = 59 years). Four qualitative themes emerged: Reading My Degeneration 1) validated the experience of living with PD, 2) reinforced practical behaviors that support well-being, 3) provided insight about the illness experience, and 4) was emotionally and physically taxing. There were no statistically significant pre-/postintervention changes in knowledge, self-efficacy, hope, or emotional distress. Book "endorsers" appreciated Dunlap-Shohl's dark humor and resonated with his experience; "detractors" found the book to be blunt and sometimes frightening.

Discussion/conclusion: Participants who liked the book-the "endorsers"-revealed that it deeply resonated with them and helped them realize they were not alone with the disease. Many commented that Dunlap-Shohl's story was in some ways their story-and that this was both practically and emotionally reassuring. My Degeneration has the potential to benefit patients who appreciate comics, enjoy dark humor, and are not overly pessimistic.