Ochsner Journal最新文献

Background: Whether remote blood pressure (BP) monitoring can decrease racial disparities in BP measurement during pregnancy and the postpartum period remains unclear. This study evaluated whether Black and White patients enrolled in the Connected Maternity Online Monitoring (CMOM) program showed improvements in BP ascertainment and interval. Methods: A retrospective cohort of 3,976 pregnant patients enrolled in CMOM were compared to matched usual care patients between January 2016 and September 2022 using electronic health record data. The primary outcomes were BP ascertainment (number of BP measurements) and BP interval (time between BP measurements) during pregnancy and the postpartum period. The proportion of patients with a hypertensive disorder of pregnancy who checked their BP within 7 days of discharge following delivery was also assessed. Results: Enrollment in CMOM was lower among Black patients than White patients (42.1% vs 54.7%, P<0.0001). Patients in the CMOM group had more BP measurements than patients in the usual care group during pregnancy (rate ratio=1.78, 95% CI 1.74-1.82) and the postpartum period (rate ratio=1.30, 95% CI 1.23-1.37), with significant improvements for both Black and White patients enrolled in CMOM compared to patients in usual care. The CMOM intervention did not result in an improvement in 7-day postpartum adherence to checking BP for Black patients (risk ratio=1.03, 95% CI 0.94-1.11) as it did for White patients (risk ratio=1.09, 95% CI 1.01-1.17). Conclusion: Remote BP monitoring programs are a helpful tool to improve the frequency of BP measurements and shorten intervals between measurements during the prenatal and postpartum periods for all patients. Future evaluation is needed to determine the barriers to offering the program to and enrolling Black patients.

Background: The objective of this study was to determine the human papillomavirus (HPV) genotypes of high-risk-other HPV Papanicolaou (Pap) tests and of biopsy tissues from patients with high-grade squamous intraepithelial lesion (HGSIL) or cervical cancer. High-risk-other HPV status was determined with the cobas HPV Test (Roche Diagnostics, North America) that identifies 12 high-risk, non-16/18 HPV genotypes. We hypothesized that we would find genotypes of HPV in our population that are not covered by the 9-valent HPV vaccine. Methods: For this retrospective cohort study, we randomly selected 50 high-risk-other HPV Pap test samples from 2018 from our pathology department registries for HPV genotype determination by Roche Linear Array (Roche Diagnostics, North America). Then we randomly selected 76 cervical biopsy samples of HGSIL or cervical cancer with high-risk-other HPV or HPV unknown status from 2016 to 2022 for HPV genotype determination by next-generation sequencing. Results are reported as counts and frequencies. Results: In the 50 high-risk-other HPV Pap test samples, 21 genotypes of HPV were noted; the most common were 53 (n=6), 51 (n=6), and 59 (n=5). In the samples with HGSIL or cervical cancer, 16 HPV genotypes were detected; the most common were 16 (n=26), 58 (n=12), and 33 (n=8). Among the patients with HGSIL or cervical cancer, the 9-valent HPV vaccine provided coverage for all the HPV variants found in 88% of patients, partial coverage in 8% of patients, and no coverage in 4% of patients. Conclusion: The 3 most common HPV genotypes seen in our high-risk-other HPV Pap test samples are not covered by the 9-valent HPV vaccine. For the HGSIL and cancer samples, 88% of the samples had full HPV genotype coverage with the 9-valent HPV vaccine. This study highlights a presence of HPV that will not be protected by vaccination in a high-risk population.

Background: Despite the substantial expenditures on health care in the United States, persistent underperformance in health system metrics necessitates innovative approaches to address complex patient needs. The MedVantage Clinic in New Orleans, Louisiana, offers a regionally tailored, value-based primary care model targeting patients with high social and medical needs. This study provides an evaluation of the efficacy of the MedVantage Clinic in improving the cost of care and service utilization for this population. Methods: We conducted a retrospective case-control study using data from electronic health records and claims data from 2017 to 2018. The case group was composed of patients with high social and medical needs who were enrolled in the MedVantage Clinic, and the control group consisted of propensity-matched non-MedVantage Clinic patients. Cost and utilization metrics-including per-member, per-month costs and inpatient length of stay-were analyzed using independent sample t tests and difference-in-difference calculations. Results: The MedVantage Clinic group demonstrated a significant decrease in mean inpatient per-member, per-month cost ($4.20) compared to an increase in the control group ($280.20, P=0.017). Inpatient length of stay decreased by 1.7 days for MedVantage Clinic patients and increased by 8 days for control group patients (P=0.019). Although other metrics showed nonsignificant improvements, the MedVantage Clinic generated a total cost of care mean resource benefit of $305.44 per member, per month compared to the control group (P=0.112), with an estimated annual total benefit of $1,224,648 for 189 patients. Conclusion: Our findings highlight the potential of the MedVantage Clinic to improve health care costs and utilization for patients with high social and medical needs. Despite the limitations of the study, including study duration and patient selection biases, the MedVantage Clinic demonstrated promise as a scalable model for addressing complex patient needs. Further research is warranted to explore long-term outcomes and implementation strategies for similar models nationwide.

Background: Knee osteoarthritis is a chronic degenerative disease associated with pain and decreased mobility that affects advanced-age individuals, thus causing further debilitation. Radiofrequency ablation can benefit patients who are not ideal candidates for surgical intervention and for whom conservative management has been unsatisfactory. Currently, radiofrequency ablation is performed using either ultrasonography or fluoroscopy. In this technique review, we propose a method of performing cooled radiofrequency ablation of the genicular nerves that uses both ultrasonography and fluoroscopy and that could be helpful for novice pain practitioners. Case Series: We report the experience of 2 patients with grade 4 osteoarthritis knee joints who underwent our cooled radiofrequency ablation technique. Each patient received a diagnostic block using ultrasonography, with ≥70% pain relief the prerequisite for performing cooled radiofrequency ablation. Our radiofrequency ablation technique involves using ultrasonography to identify and mark the superomedial, superolateral, and inferomedial genicular arteries. The marking done with ultrasonography is used during needle insertion with fluoroscopy guidance to reach the target points, and the final position of the needle is confirmed using sensory and motor stimulation before the cooled radiofrequency ablation procedure is performed. The cooled radiofrequency ablation resulted in pain reduction as measured on the visual analog scale and the Western Ontario and McMaster Universities Osteoarthritis Index scores at both patients' 3- and 6-month follow-ups. Conclusion: Using this technique for cooled radiofrequency ablation of the genicular nerves might help to reduce radiation exposure, specifically when the procedure is being performed by novice practitioners with limited experience.

Background: Undifferentiated pleomorphic sarcoma, an exceedingly rare and aggressive primary cardiac tumor arising from mesenchymal stem cells, is associated with poor prognosis and high mortality despite adequate treatment. Case Report: A 52-year-old female presented with a 2-month history of angina and dyspnea on exertion. Her clinical history included severe acute respiratory syndrome coronavirus 2 myocarditis and iron deficiency anemia. Elevated troponin 1 and D-dimer prompted further investigation, and diagnostic imaging revealed multiple hypodensities in the left atrium and a right-sided pleural effusion that were causing severe mitral stenosis and pulmonary hypertension. Full body positron emission tomography scan suggested metastatic disease, prompting surgical resection of the atrial masses. Pathology confirmed high-grade undifferentiated pleomorphic sarcoma. Treatment with chemotherapy resulted in clinical stability without radiographic evidence of recurrence at 9 months. At follow-up >2 years after the initial diagnosis, echocardiogram demonstrated normal left ventricular systolic function with ejection fraction of 55% to 60%, no mitral gradient, and resolution of pulmonary hypertension. Conclusion: Left atrial masses are a diagnostic challenge because of the location and the technical difficulty of biopsy. Undifferentiated pleomorphic sarcoma has a 5-year survival rate of approximately 60%, so the condition necessitates prompt diagnosis and treatment.

Background: Allergists perform a range of procedures with inherent risks of anaphylaxis. This study developed risk assessments for various procedures performed at our specialized referral center based on the frequency of epinephrine use during these procedures. Methods: During a 5.5-year period, 5 allergists referred patients to a monthly high-risk procedure clinic (total of 66 clinic days). We conducted a retrospective medical records review from 2016 to 2021 to assess the types of procedures performed, instances of procedure termination, and use of epinephrine. Results: A total of 596 procedures were performed: 305 food challenges, 103 aeroallergen immunotherapy rush inductions, 75 drug challenges, 66 ultrarush inductions of venom immunotherapy, 12 drug desensitizations, 14 vaccine challenges (11 COVID-19 [coronavirus disease 2019], 2 influenza, 1 Tdap [tetanus, diphtheria, and pertussis]), and 21 miscellaneous nonvaccine challenges. Most procedures (n=551, 92.4%) were completed; 45 procedures (7.6%) were aborted early because of patient, parent, or physician requests. Reasons included the child not wanting to eat the food, the patient developing a headache, and other factors. Fifty-one of the 596 procedures (8.6%) required epinephrine administration: 32/305 (10.5%) for food challenges, 12/103 (11.7%) for aeroallergen immunotherapy rush inductions, 2/75 (2.7%) for drug challenges, 2/66 (3.0%) for ultrarush inductions of venom immunotherapy, 3/12 (25.0%) for drug desensitizations, and 0/35 (0%) for other challenges. Two patients required emergency department transfers, with no instances resulting in hospitalization or patient mortality. Conclusion: These data identify risks associated with diverse procedures conducted in allergy clinics. While 8.6% of cases required epinephrine, the majority of reactions were manageable within the clinic setting. These findings underscore the allergist's role in performing procedures with potential anaphylactic outcomes and managing anaphylaxis when it occurs in the clinic setting. Additionally, the procedure clinic model is an effective educational tool that provides fellows-in-training with exposure to the identification and management of acute anaphylaxis.

Background: Heterotaxy syndrome, a condition in which the internal organs are abnormally arranged in the thorax or abdomen, is generally diagnosed early in life, often during the neonatal period. Case Report: We present the case of a 42-year-old male who was incidentally diagnosed with polysplenia syndrome and subsequently diagnosed with heterotaxy syndrome. Upon further investigation, he was determined to have a sinus venosus type atrial septal defect. Furthermore, the patient's inferior vena cava was interrupted in the infrarenal region and continued as the azygos vein with a coincidental retroaortic left renal vein, an anatomic variation unrelated to heterotaxy syndrome. Because of his minimal cardiac anomalies, the patient remained undiagnosed until adulthood. Conclusion: According to our research, this case is the first report of a patient with heterotaxy syndrome and a sinus venosus type atrial septal defect. This case augments the available information about the variations of this rare syndrome.