The Permanente journal最新文献

Wrist Mycobacterium tuberculosis (TB) complex osteomyelitis is rare, with polymicrobial TB osteomyelitis even more uncommon. The authors describe an unusual case of polymicrobial TB wrist osteomyelitis. The case patient presented with a 2.5-year history of 2 insidiously growing nodules on his wrist. He underwent debridement, and tissue cultures grew methicillin-resistant Staphylococcus aureus, Enterococcus faecalis, and, later, TB complex. He was started on vancomycin, rifampin, isoniazid, pyrazinamide, and ethambutol with improvement in symptoms. This case emphasizes the importance of a broad differential and thorough workup for atypical presentations of osteomyelitis. Diagnosis of uncommon etiologies is essential for definitive treatment.

Introduction: Intralesional collagenase Clostridium histolyticum (CCH) injection is an effective intervention for treatment of Peyronie's disease (PD). While CCH efficacy has been demonstrated in White populations, little is known about treatment efficacy in Black and Hispanic populations.

Methods: This study examined efficacy of intralesional CCH in a racially diverse population in a large integrated health care system over 15 years. Treatment efficacy was defined as percent change in penile curvature abnormality from baseline after up to 4 treatment cycles.

Results: Of the 112 patients with PD who underwent CCH therapy, 66.1% of men were White, 22.3% were Hispanic, and 9.8% were Black. Additionally, 63.4% of men had a baseline penile curvature of 30°-59°. There were no significant differences in treatment response to CCH across different racial and ethnical groups (P = .96). There was a statistically significant difference in number of cycles completed across different ethnicities (P = .022). When adjusted for completing a full 4-cycle treatment, the Hispanic subgroup had the most patients complete fewer than 4 cycles (P = .0004). Almost half of the Hispanic subgroup (48%) reported needing an interpreter for health appointments.

Discussion: This is the largest postmarket analysis of CCH treatment outcomes in a racially diverse PD population. Though there were no significant differences in treatment outcomes by race and ethnicity, Hispanic men were significantly less likely to complete 4 cycles of injection therapy. One possible explanation is a language barrier, which prevented future follow-up treatment.

Conclusion: The use of CCH treatment for PD is an effective option for racially diverse patient populations.

Introduction: The COVID-19 pandemic forced a rapid shift toward virtual modalities for the treatment of depression in primary care.

Methods: Participants were adults 18 years and older with a new episode of depression diagnosed in primary care between March 1, 2020, and May 21, 2021, and moderate-to-severe symptoms of depression at the time of diagnosis (N = 9619). Outcomes were 1) antidepressant medications prescribed and dispensed (referred to as received), as well as adherence to those medications; 2) referrals made to depression-related services and the receipt of those services; and 3) a follow-up visit completed with the diagnosing practitioner regardless of treatment actions.

Results: Patients were 42.4 ± 17.8 years old, and 77.6% had moderate-to-severe symptoms at diagnosis. Most patients were women (70.4%), 48.2% were Hispanic, and 8.4% were Black. Telephone visits were associated with 64% increased odds of having an antidepressant prescribed when compared to in-person visits. However, patients prescribed an antidepressant during a telephone visit were 52% less likely to receive this prescription when compared to patients who were prescribed an antidepressant during an in-person visit. Telephone and video visits were associated with 48% and 37% decreased odds, respectively, of having a follow-up visit with the prescribing practitioner when compared to an in-person visit.

Conclusion: Telemedicine for depression in adult primary care may result in greater antidepressant prescribing than in-person care, but these medications are less likely to be received. This study's findings suggest that health systems should adjust electronic decision support tools (such as mail-order pharmacies) to ensure virtual care decisions are implemented.

Background: Multiple studies have demonstrated associations between psychiatric conditions and Parkinson's disease (PD) development; fewer have examined psychotic-spectrum disorders and PD development.

Objective: The objective was to assess the prevalence of psychotic-spectrum disorders with and without depression and anxiety preceding a PD diagnosis.

Methods: In this retrospective, case-control study of adults > 60 years of age, cases were identified by PD diagnosis and controls were identified in a 3:1 ratio by ambulatory encounter from 2015 to 2020. Psychiatric conditions were identified by diagnosis code up to 5 years prior to the index date. Conditional logistic regression was conducted to assess associations.

Results: Among 13,998 patients, the odds of PD were 76% (95% confidence interval = 1.39-2.22) higher among those with psychotic-spectrum diagnoses. An additional anxiety diagnosis was associated with 166% (95% confidence interval = 1.35-5.25) higher odds of PD.

Conclusions: Awareness of psychiatric conditions, including psychotic-spectrum disorders with comorbid anxiety, can stratify individuals at higher risk of developing PD.

Introduction: Patient portals are increasingly becoming the primary channel for communicating health information, raising concerns about the potential worsening of health care access disparities among limited English proficient (LEP) patients. The authors studied the use of a health plan patient portal and potential barriers to use by comparing LEP Latino and Chinese Health Plan members to those with English language preference (non-LEP).

Methods: The authors used health record data for 480,833 Latino (31.8% LEP) and 137,904 Chinese (31.6% LEP) adult Kaiser Permanente Northern California members 25-85 years of age to study portal use during 2019. Clinic-collected survey data for 489 Latino and 1037 Chinese LEP patients was compared with data for 849 Latino and 426 Chinese non-LEP Kaiser Permanente Northern California 2020 Member Health Survey respondents to identify factors potentially inhibiting portal use. The authors used chi-square tests to assess differences in portal use and potential influencing factors across ethnic, language, and age subgroups.

Results: During 2019, LEP Latino and Chinese adults were less likely than non-LEP adults to have a portal account and, among those with a portal account, to have sent secure messages and viewed laboratory results online. Portal use was lower among LEP Latino than LEP Chinese adults. Patient surveys identified lower educational attainment, health literacy, and access to and use of digital tools among LEP vs non-LEP Latino and Chinese adults.

Conclusions: Patient portal use is lower among LEP than non-LEP Latino and Chinese patients. Health care systems should take action to decrease barriers to use, but they also should consider patient communication preferences.

Eosinophilic fasciitis (EF) is a rare dermatologic disease with clinical similarities to localized scleroderma and systemic sclerosis (SSc). Diagnosing EF is challenging due to overlapping clinical features among these conditions. Differentiating EF from localized scleroderma and SSc can be aided by laboratory tests, histopathological examination, and imaging studies. The diagnosis of EF specifically requires the exclusion of SSc and typically requires magnetic resonance imaging or en bloc fascial biopsy of affected areas. Here, the authors present a 75-year-old woman with a painful, violaceous rash on the legs and abdomen, leg swelling, and tightness around her upper abdomen. Review of systems revealed decreased appetite, unintentional weight loss, and shortness of breath on exertion. Physical examination showed a faint violaceous rash on the abdomen and legs as well as abdominal distention. The patient's clinical picture was complicated by worsening of the rash, development of chronic cough, continued unintentional weight loss, decreased appetite, early satiety, dry eyes, and dry mouth. An autoimmune process was considered, and the patient was seen by rheumatology, where an appropriate workup excluded localized scleroderma and SSc. EF was suspected and supported by magnetic resonance imaging findings showing fascial edema. En bloc fascial biopsy of the right thigh did not reveal classic EF findings.

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.