The Permanente journal最新文献

Background: Peyronie's disease (PD) is a progressive fibrotic disorder of the penis that can induce pain and erectile dysfunction and has various treatment modalities, including surgical, pharmaceutical, and Clostridium histolyticum injection therapies.

Methods: The authors used electronic medical records from Kaiser Permanente Southern California, an integrated health care system that consists of 15 medical centers, and identified patients diagnosed with stable PD without concomitant erectile dysfunction from January 1, 2004, to December 31, 2020. Baseline characteristics between surgical and injection groups were compared using Chi-squared and Kruskal-Wallis tests. Multivariable logistic regression with adjustment of confounders was implemented to identify which variables may influence whether patients received injection or surgical therapy.

Results: A total of 11,706 patients with PD were identified. The rate of new PD diagnosis per 100,000 patients increased by 0.37 every year, P < .05. The incident rate (per 1000 eligible patients) of surgical management declined on average by 0.40 each year (P < .001), although there was an increase rate of 1.19 for injection therapy (P < .001). On multivariable modeling, patients 45-54 years of age were more likely to receive injection therapy as the primary treatment for PD (adjusted odds ratio = 2.77; P = .002; confidence interval = 1.34-5.73).

Conclusion: This study illustrates that pentoxifylline is now more frequently used than colchicine and vitamin E as oral treatments for PD, while collagenase C. histolyticum injection therapy is now more prevalently employed than surgical intervention as the therapeutic approach for PD.

Introduction: Hip hemiarthroplasty is a surgical procedure that requires the adhesion of the prosthetic implant by utilizing a fixation technique, either cemented or noncemented. The current literature does not provide a clear recommendation on a superior technique, although many countries outside the US have guidelines recommending cemented over noncemented procedures. Further, surgeon perceptions and beliefs related to the cemented and noncemented techniques in hip arthroplasty fractures are generally unknown.

Methods: Orthopedic surgeon leaders adopted a quality assurance initiative to increase the rate of cemented cases within their practice. A survey was developed to capture the surgeons' perceptions related to fixation technique, affordability, and potential barriers and facilitators. Likert scale data were analyzed with descriptive statistics and chi-square tests.

Results: Sixty-one total joint surgeons throughout 13 locations were invited to participate in the study via email. A total of 38 of the 61 total joint surgeons completed the survey, representing a 62% response rate. Most responses were neutral or disagreed with the use of cement for femoral fixation in hemiarthroplasty.

Conclusion: Although some questions elicited strong opinions, many surgeons expressed hesitancy to change their current fixation technique and their desire for autonomy within their clinical practices. However, the large number of neutral responses suggests the potential to engage, educate, and shift the surgeons' perception to adopt the quality assurance initiative and increase the rate of cemented cases.

Introduction: As airway management becomes more complex with the adoption of new technologies and strategies, it is important to ensure that emergency medicine residents, the future of the specialty, receive extensive training. This study was designed to understand the prevailing airway management practices and training within emergency medicine residency programs.

Methods: A survey consisting of 19 multiple-choice questions was sent to program directors of 258 emergency medicine residency programs in the United States.

Results: A total of 63 emergency medicine residency programs completed the airway survey, a response rate of 24%. Programs from all regions of the country are represented, most of them from university-based teaching hospitals (40%) and 3-year programs (78%). The majority of programs provide their residents with 50-100 intubations (50.8%) during their training. Pediatric intubations remain scarce with 54.1% of programs having only 5-10 pediatric intubations per resident. The emergency medicine team manages 93.6% of all trauma intubations, and residents complete 81% to 100% of all the department's intubations 88.9% of the time. Video laryngoscopy is on the rise, with GlideScope^® (93.7%) and C-Mac^® (55.6%) being the most common devices available. Overall, programs use both succinylcholine and rocuronium equally, but there is a trend toward using rocuronium more frequently than succinylcholine. By employing different teaching modalities, multiple times a year, residency programs expose residents to a variety of backup tools and surgical airway techniques.

Conclusions: Emergency medicine residents are exposed to multiple advanced airway adjuncts and comprehensive airway curriculums as emergency airway management practices evolve and become more complex.

Introduction: Transgender and gender-diverse (TGD) individuals frequently encounter discrimination in health care settings. The Veterans Health Administration (VA) is committed to addressing the health disparities experienced by TGD veterans. The purpose of this study was to explore the experiences of TGD veterans with LGBTQ+ veteran care coordinators.

Methods: The authors conducted semi-structured interviews with TGD veterans with depression between January and March 2022. Participants were recruited with assistance from the VA's network of LGBTQ+ veteran care coordinators. Interviews were recorded, transcribed, and analyzed.

Results: Twenty-six TGD veterans participated in the study, with a range of experiences, both positive and negative, with LGBTQ+ veteran care coordinators. Veterans spoke of the role of coordinators in educating both patients and clinicians about TGD health care needs. Participants who expressed dissatisfaction with their coordinators highlighted the need for a clearer definition and communication of coordinator duties.

Conclusions: This study highlights the important roles played by the VA LGBTQ+ care coordinators in addressing the needs of TGD veterans. The study also points to an immense need for clinician education in TGD care. Further training and education are recommended to improve equitable care for TGD veterans.

Introduction: Lymphoma is the most common neck mass malignancy in adults but can present diagnostic challenges due to controversy surrounding the best initial biopsy approach. In this study, the authors characterize the diagnostic pathway in adults with lymphoma (or leukemia) presenting initially as a neck mass and examine the biopsy procedures required for diagnosis in a large community-based practice setting.

Methods: Using data from a retrospective cohort of 4103 adults referred to otolaryngology with a neck mass (5% found to be malignant), the authors identified the subset with lymphoma (or leukemia) and examined the time to diagnosis and the number and type of biopsies required for diagnosis.

Results: Among 73 adults with lymphoma or leukemia that initially presented with a neck mass (25% diffuse large B-cell lymphoma, 32% Hodgkin lymphoma, 18% follicular lymphoma, and 25% other lymphoma/leukemia), 70% required repeated biopsies for diagnosis. Overall, 93% required a core-needle biopsy (CNB) or an excisional biopsy for diagnosis, although 64% of patients underwent fine-needle aspiration (FNA) for their first biopsy. Patients undergoing initial FNA were diagnosed a median of 19 days after presentation (95% required additional biopsy), whereas those undergoing initial CNB were diagnosed a median of 5 days after presentation (only 25% required additional biopsy).

Discussion: These data highlight the limited diagnostic utility of FNA for lymphoma presenting as a neck mass and support consideration of CNB when lymphoma is suspected in a neck mass to minimize repeat biopsy and time to diagnosis.

Conclusion: Lymphoma represents a diagnostic challenge. CNB represents an opportunity to improve diagnostic efficiency, although additional research is needed to ascertain impacts on cost and side effects in various health care environments.

Introduction: The authors evaluated factors associated with neonatal hepatitis B vaccination (HepB), including prenatal vaccinations, race, ethnicity, neonatal disposition, parity, and maternal age to identify potential areas of engagement to improve maternal and child health.

Methods: The authors conducted a retrospective cohort study of patients who received prenatal care and delivered at an academic tertiary care hospital in central Pennsylvania from 2015-2020. A multiple logistic regression model was used to assess factors associated with newborn receipt of HepB.

Results: Prenatal vaccination was significantly (P < .0001) associated with subsequent neonatal HepB vaccination in the hospital following birth. Race, Hispanic ethnicity, age at delivery, neonatal disposition, and parity were not shown to be associated with HepB vaccine uptake.

Conclusion: Prenatal vaccination was significantly associated with neonatal in-hospital HepB vaccine uptake.

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.