The Permanente journal最新文献

Objective: This study aimed to evaluate associations among pretreatment hearing deficit, corticosteroid intervention, and audiologic recovery among patients presenting with sudden sensorineural hearing loss within an integrated health system.

Methods: Electronic health records within a multicenter integrated health system were queried for clinical encounters with a diagnosis of sudden sensorineural hearing loss in 2021. Patient demographics, audiometric data, and therapeutic steroid intervention were recorded. Audiologic response was defined as a decrease of 15 dB in 4-frequency (500, 1000, 2000, 4000 Hz) pure tone average (PTA). Audiologic recovery, or complete response, was defined as a follow-up PTA (PTA2) of ≤ 25 dB or within 10 dB of 1) baseline or 2) contralateral ear. Logistic regressions were performed to evaluate for predictive factors.

Results: A total of 403 patients (mean age 59.27 ± 15.80 years, 57.32% male) met inclusion criteria, of which 355 underwent corticosteroid intervention. The nonsteroid group had a less severe hearing deficit (median PTA1 49.38 dB vs 58.75 dB with steroid group; P < .05). Median PTA improvement was 6.25 dB with steroid therapy and 3.63 dB without (P < .05), but median PTA2 between steroid and nonsteroid users was not significantly different (42.5 dB and 38.13 dB, respectively; P = .821). Steroid intervention within 14 days was predictive of an audiologic response (odds ratio [OR] = 2.33) and recovery (OR = 2.46; both P < .05) compared with patients who did not undergo steroid therapy, whereas delayed steroid intervention was not, regardless of steroid regimen. Severe hearing loss had worse odds of audiologic response (OR = 0.40) or recovery (OR = 0.10; both P < .05) compared with mild hearing loss.

Conclusion: Pretreatment hearing deficit and initiation of empiric steroid therapy within 14 days were associated with audiologic prognosis, independent of the corticosteroid regimen. These findings reinforce the benefit of prompt steroid intervention, while further highlighting a need for standardized measures of audiometric outcomes.

Introduction: Restricted in-person interaction throughout the pandemic coincided with increased reliance on telehealth for patient evaluation and treatment. However, few studies have investigated telehealth efficacy and accuracy compared with in-person musculoskeletal physical examination. Importantly, this virtual platform can be challenging for practitioners whose care relies on physical examination measurements. This study evaluated the validity and accuracy of measuring hip and shoulder strength and range of motion (ROM) via telehealth examination.

Methods: In this cross-sectional study, 45 participants without hip or shoulder pain underwent an in-person physical examination and a telehealth examination. Hip and shoulder ROM were measured from in-person and telehealth examinations, using Halo goniometers (Halo Medical Devices) and virtual goniometers, respectively. Hip and shoulder strength were also assessed. Measures obtained from in-person and telehealth examinations were compared, and percent agreements were calculated.

Results: The mean age of participants was 32.0 ± 7.2 years; 67% (n = 30) were female. Hip flexion strength, right hip abduction, and right shoulder strength had the strongest percent agreement (91.1%-100.0%) across in-person and telehealth modalities. Left hip abduction, left shoulder active abduction, shoulder internal ROM, and shoulder external ROM showed moderate-to-high agreement (26.7%-77.8%). Left (2.2%) and right hip (8.9%) external ROM showed poor agreement.

Discussion: Measurements with the greatest agreement between telehealth and in-person examinations included hip flexion, shoulder strength, hip abduction, and shoulder active abduction.

Conclusion: Certain strength and ROM tests can be accurately assessed via telehealth examination. Future research is needed to expand upon these findings and to develop a reliable, standardized protocol for the telehealth musculoskeletal physical examination.

Introduction: Opportunities for otolaryngology residents to gain exposure and training in gender-affirming care (GAC) are not well-described. The authors examined the prevalence of US otolaryngology residency programs with GAC clinics, surgeons performing gender-affirming surgery (GAS), and faculty that published GAC research.

Methods: US otolaryngology residencies were identified with the AMA FREIDA, the AMA Residency & Fellowship Database®. Public program websites were used to identify facial plastic surgeons, laryngologists, and GAC clinics. Faculty were queried in PubMed for publications specific to GAC. Data were collected in January 2024.

Results: A total of 92 (70.0%) out of 131 programs had an institutional GAC clinic. Presence of GAC clinics varied between regions, and 42 (32.1%) programs encompassing 765 (41%) residents had ≥ 1 otolaryngology-trained specialist offering GAS. Within each region, programs with any faculty performing GAS were most prevalent in the midwest, with 47% of residencies (16/34 programs) publicly advertising ≥ 1 otolaryngology department faculty member working in the affiliated institutional gender clinic. The next highest region was the west (42%, 9/21 programs), followed by the northeast (29%, 10/34 programs), and lastly the south, with only 17% (7/42 programs) (P = .03). Nationally, 29.0% of programs (36/126), encompassing 652 residents (35.0% of all US trainees) had ≥ 1 otolaryngology faculty member with ≥ 1 GAC publication.

Discussion: Most otolaryngology residents in the United States train at institutions with a GAC clinic, but involvement of otolaryngology faculty is highly variable. A minority of residents have any department faculty who perform GAS or research in GAC.

Conclusion: Opportunities exist to improve otolaryngology resident exposure to both clinical and scholarly GAC, particularly in the southern region of the United States.

Background: Multiple sclerosis (MS) is a costly, chronic, complex condition, which requires customization of care at the system level to achieve better outcomes. The authors describe a cluster-randomized, coach-supported quality improvement (QI) intervention in the MS continuous QI (MS-CQI) Collaborative, which was a multicenter learning health system (LHS) study to improve MS outcomes (2018-2022).

Methods: The authors developed a coach-supported QI intervention within the MS-CQI LHS, which included aspects of standard QI approaches utilized in health care. This included a 12-step standardized QI Toolkit; team coaching twice monthly; team capability assessments; and patient-reported and clinical feedback data provided by the MS-CQI data registry. Assessments helped the coach understand clinic culture, readiness for change, QI skills and knowledge, and progress over time. The coach monitored and guided team activity and assured general adherence to the 12-step improvement process. Teams selected local QI activities within those constraints.

Results: A total of 3 out of the 4 MS-CQI centers were cluster randomized to the intervention and completed the study. Initial QI assessments revealed that teams perceived QI as important but had low initial skill and knowledge levels. Improved QI skills, knowledge, and engagement in the intervention improved, as teams realized ownership and perceived benefits.

Conclusions: The coach-supported QI intervention demonstrated basic feasibility, acceptability, QI skill advancement, and utility in the MS-CQI study. It is an example of an LHS-enabled humanistic (QI team-focused) intervention, which invests in developing capability of people involved in QI work.

Gulf War illness (GWI) is a chronic condition affecting nearly a third of Gulf War veterans and is characterized by persistent symptoms across a number of physical and neuropsychiatric domains. This case study examined a 52-year-old veteran admitted on a psychiatric hold for danger to others. The patient's symptoms, including chronic migraine, widespread musculoskeletal pain, skin sensitivities, environmental allergies, and mood and cognitive disturbances, met criteria for GWI according to 2 accepted case definitions. Initial misdiagnosis of psychosis was corrected upon evaluation, which identified severe anxiety consistent with generalized anxiety disorder. Treatment focused on providing validation of the patient's chronic symptoms and managing his anxiety through pharmacologic intervention. This case underscored the importance of recognizing GWI to ensure accurate diagnoses and targeted care for veterans.

Objectives: The purpose of this report was to summarize implementation of universal screening and treatment pathways for youth vaping in a large, community-based health care system in the United States.

Methods: Data were obtained as a part of routine clinical care and were extracted from medical records weekly for 4 years. Variables reported include number of teens screened, teens who tested positive, referrals, and quit rates, as well as gender and race or ethnicity.

Results: Of the 16,671 visits, 12,165 (73%) teens were screened, 632 (5.2%) teens screened positive, and of those who screened positive, 128 (20%) referrals were placed. For those who were referred, 40 teens (31.3%) quit vaping (abstinence for at least 3 weeks) and 21 (16%) decided to receive nicotine replacement therapy (nicotine patches, gum, or lozenges).

Conclusions: This study outlines a screening and intervening pathway that can be used in other health care systems in the United States and beyond. Teen vaping can be addressed before it becomes a serious addiction. Institutions can experience cost-saving benefits in that increasing outreach efforts and education would ultimately reduce the number of inpatient/emergency department visits/hospitalizations related to vaping.

Psychedelic and empathogenic compounds show promise for a variety of conditions. However, studying these compounds can be highly complex, be very expensive, and have substantial patient safety concerns. Here, the authors will review 8 late-phase medicinal psychedelic studies in the Food and Drug Adminisration (FDA) approval pipeline. The authors will include a review of the FDA's recent denial of the New Drug Application for 3-4-methylenedioxymethamphetamine with adjuvant psychotherapy for posttraumatic stress disorder from Lykos Therapeutics of San Jose, California (formerly the Multidisciplinary Association for Psychedelic Studies Public Benefit Corporation). Additionally, the authors will discuss the parallel legislative proposals in California to legalize psychedelic compounds for adult use. These legislative efforts reflect an alternative and less expensive pathway, but they do not make as thorough of an evaluation for drug safety. The authors will propose that the FDA remains the appropriate agency to evaluate and approve the use of this class of proposed therapeutics.