Ochsner Journal最新文献

Background: While the connection between alcohol and risky behavior is well known, a clear correlation between alcohol misuse and contracting sexually transmitted infections (STIs) has not been determined. The 4-question CAGE questionnaire-the acronym stands for attitudes and activities related to alcohol use-is often administered at primary care annual visits to screen patients for alcohol abuse. This study assessed the relationship between CAGE scores and STI results to determine if the CAGE questionnaire could help determine the need for STI screening at annual visits. Methods: All patients who received a CAGE screening from 2015 to 2022 at a Gulf South health system were included in the analysis. The primary outcome of the study was the relationship between a positive CAGE score (a score ≥2) and a positive STI result. STIs included in the primary analysis were human immunodeficiency virus (HIV), hepatitis B, syphilis, chlamydia, gonorrhea, and trichomoniasis. The correlation between a positive CAGE score and hepatitis C was examined as a secondary outcome. Results: A total of 40,022 patients received a CAGE screening during the study period, and 757 (1.9%) scored ≥2 on the CAGE questionnaire. Significant associations were found between a positive CAGE score and hepatitis B (odds ratio [OR]=2.69, 95% CI 1.91, 3.80; P<0.001), gonorrhea (OR=5.43, 95% CI 1.80, 16.39; P=0.003), and hepatitis C (OR=2.10, 95% CI 1.57, 2.80; P<0.001). No associations were found between a positive CAGE score and HIV, chlamydia, or trichomoniasis. No patients with a CAGE score ≥2 had a syphilis diagnosis; therefore, no syphilis analysis was possible. Conclusion: Based on the results of this study, patients with a CAGE score ≥2 may benefit from screening for hepatitis B, hepatitis C, and gonorrhea at their primary care annual visit. Early STI detection could lead to prompt treatment and prevent further transmission and complications.

Background: Spinal cord sarcoidosis, an uncommon manifestation of neurosarcoidosis, presents diagnostic and therapeutic challenges because the condition is rare and has diverse clinical manifestations that can mimic other conditions such as multiple sclerosis and neuromyelitis optica spectrum disorder. Case Report: A middle-aged African American female with a history of idiopathic intracranial hypertension and hydrocephalus with ventriculoperitoneal shunt presented with progressive, predominantly left-sided gait instability, weakness, and paresthesia. Cerebrospinal fluid showed lymphocytosis, red blood cells, elevated oligoclonal bands, and elevated kappa free light chains, concerning for multiple sclerosis. Neuromyelitis optica spectrum disorder testing was negative. Magnetic resonance imaging (MRI) demyelination protocol revealed normal brain imaging and a longitudinally extensive spinal cord lesion with the distinctive trident sign on contrast-enhanced axial views, consistent with spinal cord sarcoidosis. The patient was treated with intravenous methylprednisolone for 5 days, resulting in improved lower extremity strength, but ataxia and sensory deficits, especially proprioception, persisted. Follow-up imaging and examinations demonstrated continued spinal cord involvement with minimal improvement despite treatment. Conclusion: Current management guidelines for spinal cord sarcoidosis are based on limited evidence, necessitating further research to establish optimal protocols. The trident sign on MRI may distinguish spinal cord sarcoidosis from conditions such as multiple sclerosis and neuromyelitis optica spectrum disorder. Early radiologic detection could improve outcomes and reduce long-term neurologic deficits. A comprehensive multidisciplinary approach is essential for effective, patient-centered care planning.

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: 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.