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: Extracranial carotid artery (CA) pseudoaneurysms are uncommon and can cause embolic stroke, compressive symptoms, or (rarely) can rupture. It is of paramount importance to treat this entity to avoid life-threatening complications. In this study, the authors described a cohort of patients that required open surgical repair.

Methods: This article reported the authors' experience with open surgical repair of extracranial CA pseudoaneurysms by presenting a retrospective review of data at their institution from 2016 to 2022.

Results: Of 8 patients that underwent open repair, 6 were male and 8 were female. The most common etiology was traumatic (penetrating trauma in 4 patients, iatrogenic injury in 2, and blunt trauma in 1) and 1 was infective. All patients presented with a neck mass, and 5 had compressive symptoms. Primary repair was performed in 4 patients, interposition graft using an autologous vein in 2, and patch repair in 2. None of the patients experienced perioperative mortality or stroke; nor did they develop any complications over a median follow-up period of 30 months.

Conclusion: This report demonstrated that large-size extracranial pseudoaneurysms, whether traumatic or infective etiology, can be safely repaired using an open surgical approach.

Pulmonary edema refers to the accumulation of excessive fluid in the alveolar walls and alveolar spaces of the lungs. It is a life-threatening condition with a high mortality rate and requires immediate assessment and management. Use of intravenous nitroglycerin has been advocated for such cases. The authors present a case series of 3 patients who presented to the emergency department with sympathetic crashing acute pulmonary edema (SCAPE) and were managed with high-dose intravenous nitroglycerin and bilevel positive airway pressure support using the SCAPE treatment protocol, leading to early correction of blood pressure, avoidance of endotracheal intubation, and no episodes of hypotension or rebound hypertension. The authors recommend emergency physicians utilize the SCAPE treatment protocol while managing patients with SCAPE.

Introduction: Hospital readmissions are recognized as a prevalent, yet potentially preventable, personal and economic burden. Length of stay, Acuity of admission, Comorbidities, and number of Emergency Department visits in the preceding 6 months can be quantified into one score, the LACE score. LACE scores have previously been identified to correlate with hospital readmissions within 30 days of discharge, but research specific to the pediatric population is scant. The objective of the present study was to investigate if LACE scores, in addition to other factors, can be utilized to create a predictive pediatric hospital readmission model that may ultimately be used to decrease readmission rates.

Methods: This study included 25,616 hospitalizations of patients under the age of 18 years. Data were extracted from a hospital network electronic medical record. Demographics included LACE scores, age, gender, race/ethnicity, median household income, and medical centers. The primary exposure variable was LACE score. The main outcome measures were readmissions within 7, 14, and 30 days. The area under the curve (AUC) was used to assess the predictive capability of the regression model on patient 30-day admission.

Results: LACE scores, age, gender, race/ethnicity, median household income, and medical centers were examined in a multivariable model to assess patient risk of a 30-day readmission. Only age and LACE score were observed to be statistically significant. The AUC for the combined model was 0.69.

Discussion: As only age and LACE score were observed to be statistically significant and the AUC for the combined model was 0.69, this model is considered to have poor predictive capability.

Conclusions: In this study, LACE scores, as well the other factors, had a poor predictive capability for pediatric readmissions.

Background: Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis (CRS) that has previously been associated with younger age and Black patients. However, the role of demographic and socioeconomic factors in AFRS severity remains to be fully elucidated.

Objective: The objective of this study was to determine whether demographic and socioeconomic factors are associated with incidence of AFRS, as well as with disease severity in Northern California.

Methods: A retrospective cohort study was conducted of adult patients with AFRS and CRS from 2010 to 2019. AFRS was determined by the Bent and Kuhn criteria, and severity was assessed by radiographic evidence of cranioorbital invasion and other clinical parameters. Chi-square and t-test were used to assess demographic and socioeconomic differences between AFRS and CRS cohorts, and multivariable logistic regression was used to assess risk factors for severe AFRS.

Results: Black patients represented 26.2% (55/210 patients) of the AFRS group and 4.9% (842/17,300 patients) of the CRS group, with pairwise comparison of race/ethnicity categories showing that the AFRS group had significantly higher proportions of Black race/ethnicity compared with other race/ethnicities (p < 0.01). AFRS and CRS groups differed significantly by age, with mean ages of 48.7 and 51.0 years, respectively (p = 0.04). There were no significant differences in gender, Medicaid status, comorbidities, and socioeconomic status measures. Multivariate logistic regression showed that Black patients had higher odds of having severe AFRS (adjusted odds ratio = 2.29; 95% confidence interval: 1.18-4.45).

Conclusion: AFRS has a unique predilection for Black patients, and severe disease is also more likely in this population.

The COVID-19 pandemic exacerbated the problem of secondary trauma and moral injury for health care workers. This reality, together with the epidemic of social isolation and loneliness, has brought the mental health of health care practitioners and patients to the forefront of the national conversation. Narrative medicine is an accessible, diversity-honoring, low-cost, underutilized pedagogical framework with potentially revolutionary benefits for enhancing patient care, supporting the underserved, mitigating clinician burnout, and improving team dynamics. Herein, the authors review the literature on these benefits and then discuss methods for integrating narrative medicine into clinical care and medical education at the undergraduate and graduate levels as well as continuing medical education.

Objective: This study aimed to evaluate misinformation surrounding infertility and the COVID-19 vaccine on X (formerly known as Twitter) by analyzing the prevalence and content of this misinformation across a sample of posts on X.

Methods: This study is a retrospective review of posts on X (formerly known as tweets) from the COVID-19-TweetIDs dataset from July 2021 and November 2021. Included posts were from crucial time points in the COVID-19 vaccine discourse and contained at least one word related to COVID-19 vaccination and fertility. Posts were analyzed and categorized based on factuality, common words, and hashtags. Descriptive statistics on total followers, account verification status, and engagement were obtained. Differences between posts on X classified as factual and misinformation were examined using analysis of variance or χ² tests. Sentiment analysis determined if post content was generally positive, neutral, or negative.

Results: A total of 17,418 relevant posts on X were reviewed: 11,436 from timeframe 1 (July 2021) and 5982 from timeframe 2 (December 2021). Misinformation posts rose from 29.9% in July 2021 to 45.1% in November 2021. In both timeframes, accounts sharing factual information had more followers (p < 0.001), and verified users were more likely to share accurate posts (p ≤ 0.001). Factual and misinformation posts had similar engagement. Sentiment analysis identified that real posts were more positive and misinformation posts were more negative (p < 0.001).

Conclusions and relevance: Misinformation about the COVID-19 vaccine and fertility is highly prevalent on X and threatens vaccine uptake in patients desiring future fertility. Accounts sharing factual information were likely to have more followers and be verified; therefore, verifying more physicians sharing accurate information is critical.

Introduction: Adapting clinical care decisions for patient-reported social risks is essential to social health integration and patient-centered care. Most research in this area focuses on awareness and assistance (social-needs-targeted care), such as screening and referral to food, financial, and other resources. Limited evidence for adjustment strategies (social risk-informed care) or adapting care for social risks made it difficult for Kaiser Permanente to implement new initiatives. This article describes a codesign process to build a novel, adjustment-focused continuing medical education course.

Methods: The authors codeveloped the online continuing medical education course with patients and clinicians using user-centered design. Transcripts from codesign activities were coded and analyzed by thematic analysis to identify major themes, including perceptions of social risk-informed care and barriers to care adjustment.

Results: Practical hurdles for implementing social risk-informed care emerged, including clinicians' concerns about the ethics of adjustment as substandard care, particularly without robust assistance activities. However, patients expressed a desire for their care to be adapted to their social circumstances, to allow for more realistic care plans.

Discussion: Implementation barriers identified from the codesign were addressed through an interactive, case-study approach. Existing evidence on contextualized care and shared decision making informed a general framework for primary care providers to engage in awareness and adjustment activities, paired with 3 interactive case studies based on real-world, clinician-supplied scenarios.

Conclusion: The authors recommend that multiple stakeholder perspectives be incorporated during the development of social health integration initiatives, particularly adjustment. Education complemented by active, nuanced, flexible implementation strategies may be necessary for the successful uptake of care-delivery-based social health integration activities.

Background: The escalating use of complementary and alternative medicine (CAM) raises concerns, particularly among geriatric patients taking multiple medications. Notably, the doubled chance of major drug interactions between prescription and over-the-counter (OTC) drugs in older adults underscores the need for further research. This study aimed to evaluate clinically significant CAM and prescription medication interactions in a geriatric clinic, emphasizing the growing importance of understanding CAM implications in health care.

Methods: A 2-year cross-sectional study, approved by the Institutional Review Board, enrolled 420 participants aged 65 and older from a geriatric primary care clinic. Participants completed a survey, and pharmacy students conducted chart reviews to evaluate potential CAM products and prescription medication interactions.

Results: Among the 420 participants-who were predominantly White females and who were taking supplements, OTC medications, or both-15.6% experienced potential drug interactions. Ginkgo biloba, garlic, and calcium were common contributors to major, moderate, and minor interactions, respectively, among supplements. Meanwhile, ibuprofen was among the contributors to major and moderate interactions among OTC medications. Most supplements and OTC medications were disclosed to health care professionals. However, there was a lack of investigation by health care professionals regarding CAM use, emphasizing a discrepancy between patient-reported and physician-inquired CAM usage.

Conclusion: This study highlighted the significant use of CAM and/or OTC medications, particularly among vulnerable older adults, revealing a concerning 15.6% rate of potential drug interactions. The findings emphasized the need for awareness among health care practitioners and standardized CAM surveys to enhance accuracy and patient safety.