WMJ : official publication of the State Medical Society of Wisconsin最新文献

Introduction: Though there has been much discussion about post-acute sequelae of SARS-CoV-2 infection, there has been limited study on symptoms following infection with other respiratory viruses.

Methods: In this retrospective chart review, we reviewed the medical records of 92 patients admitted to the hospital with a diagnosis of human metapneumovirus for 17 of the common symptoms associated with post-acute sequalae of SARS-CoV-2 that were either new or worse than baseline in the time frame of 90 to 270 days after diagnosis.

Results: Of those patients hospitalized with human metapneumovirus, 55.4% had at least 1 new or worsening symptom more than 3 months after diagnosis. The most common symptoms noted were shortness of breath (29.3%) followed by fatigue and cough (17.3% each).

Conclusions: Our data suggest that other respiratory viruses - not just SARS-CoV-2 - may carry a significant burden of post-infection sequelae.

Introduction: To help combat a shortage of child and adolescent psychiatrists and assist primary care providers in managing pediatric mental health care cases, the Medical College of Wisconsin established the Wisconsin Child Psychiatry Consultation Program. The program provides educational support to primary care providers with mild to moderate pediatric mental health concerns via phone or email consultation with board-certified child and adolescent psychiatrists, as well as offering on-demand didactic training sessions and assistance locating therapeutic resources.

Objective: We sought to assess participating primary care clinicians' satisfaction with consultations and their perceptions of program services, specifically its impact on self-reported diagnostic decision-making and patient outcomes.

Methods: Primary care providers' responses to both post-consultation and annual surveys were analyzed to determine the program's impact. Five survey questions used a 5-point Likert scale, and 1 "select-all-that-apply" question was included on the post-consultation survey.

Results: Overall, 99.2% of respondents were satisfied with their most recent consultation. Additionally, mean Likert scale scores assessing provider confidence after program enrollment in the areas of diagnosing (mean 3.7, SD 0.8), prescribing medications (mean 3.6, SD 0.9), and managing child mental health problems (mean 3.5, SD 0.9) were all significantly greater than provider confidence before enrollment (P < 0.0001 for all).

Conclusions: Our study revealed that most primary care providers utilizing the Wisconsin Child Psychiatry Consultation Program find it a valuable resource for diagnostic decision-making and improving patient outcomes. This suggests that expanded utilization of the program should be encouraged.

Introduction: Emergency department (ED) visits have increased steadily since 2021, affecting patients, families, health care workers, and insurance companies through burnout and rising costs. Thus, limiting unnecessary visits is imperative. The first step is to gain better understanding of the patients presenting to the ED for nonemergent services and the reasons behind their visits. The Area Deprivation Index (ADI) is a useful tool to gauge the impact of social determinants of health play on health care decision-making. It measures factors including income, education, employment, and housing quality and uses these data to rank neighborhoods by socioeconomic disadvantage (1 = least disadvantaged, 100 = most disadvantaged). This study reviews the demographics and diagnoses of patients presenting to the ED for nonemergent concerns.

Methods: Data were collected and analyzed in a retrospective cohort study of adults aged 18 and older from a single ED for a week in June and a week in November 2022. Data were filtered to include only unnecessary visits. Each visit was analyzed by 1 reviewer and deemed "unnecessary" based on procedures performed and medications administered. Data were analyzed for patient demographics and top diagnoses and were compared with necessary ED visits during the same time frame.

Results: The most common diagnoses for unnecessary ED visits were generalized pain, abdominal pain, and cold or flu-like symptoms. The average patient age was 39 years (SD, 15.73); most were single, employed full time, and lived in areas with a high ADI. Most patients had a primary care physician on file and were insured through Medicare or Medicaid. A majority of patients were Black and non-Hispanic. Compared with necessary ED visits, there were statistically significant differences in age, race, and employment status. All demographic data were self-reported and entered into patient chart by registration staff. The study site is located next to a children's hospital; therefore, no pediatric patients were seen in this ED.

Conclusions: This study identified common chief complaints and demographic factors associated with ED encounters that did not require ED-specific resources. Understanding these patterns is the first step in designing education and resources to help patients and outpatient providers reduce unnecessary ED utilization.

Introduction: Sturge-Weber syndrome and encephalocraniocutaneous lipomatosis (ECCL) are neurocutaneous syndromes with unique presentations.

Case presentation: A 15-month-old male presented with focal seizures that progressed to medically refractory focal epilepsy. He had no ocular or cutaneous findings. Imaging demonstrated complex, transdural leptomeningeal enhancement suspicious for pial angiomatosis. Electroencephalogram showed focal seizures from the right posterior region. Sturge-Weber syndrome without cutaneous manifestations was suspected. Following right posterior disconnection surgery, next generation sequencing of affected brain tissue confirmed a mosaic FGFR1 variant, confirming the diagnosis of ECCL.

Discussion: ECCL may have variable expression and should be considered in children with refractory epilepsy and an anatomical brain abnormality.

Conclusions: Leptomeningeal enhancement is commonly found in Sturge-Weber syndrome but may be seen in other neurocutaneous syndromes, such as ECCL. Hemispheric dysplasia should raise suspicion for a neurocutaneous syndrome, even without oculocutaneous stigmata. Genotype-guided diagnostics for patients with atypical findings may facilitate targeted postsurgical management and lifetime surveillance.

Heart failure is a growing global health concern, characterized by high morbidity, frequent hospitalizations, and significant mortality. The classification of heart failure based on left ventricular ejection fraction plays a critical role in diagnosis and management, encompassing heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with improved ejection fraction (HFimpEF). While advancements in therapy have transformed HFrEF management, challenges persist in optimizing treatment for HFmrEF and HFimpEF due to their heterogeneous nature. Emerging strategies emphasize the early and simultaneous initiation of key pharmacologic therapies across these subtypes to maximize clinical benefits. Individual approaches, guided by patient characteristics and evolving evidence, are essential for improving outcomes. This narrative review provides a comprehensive overview of current treatment strategies for the different classifications of HF, highlighting the role of rapid therapy initiation.

Introduction: Opioid-induced hyperalgesia (OIH) is a paradoxical increase in pain sensitivity in patients receiving chronic opioid therapy. Many patients with OIH may be labeled incorrectly as drug-seeking or addicted. Common management strategies include opioid rotation, dose reduction, and use of N-methyl-D-aspartate receptor antagonists and/or nonsteroidal anti-inflammatory drug. However, evidence supporting these interventions is limited.

Case presentation: We report the case of a 57-year-old woman with metastatic endometrial cancer, previously treated with hysterectomy, chemotherapy, and pelvic radiation, who was receiving hospice care. Despite escalating opioid doses (240 morphine milligram equivalents daily), her pain worsened. She was discharged from hospice for opioid overuse and referred to our addiction clinic. OIH, rather than opioid use disorder, was suspected as the primary barrier to pain relief. Using a microdosing strategy, we transitioned her to buprenorphine, resulting in significant pain reduction and improved quality of life.

Discussion: Buprenorphine is an opioid widely used for the treatment of opioid use disorder, and emerging evidence supports its role in chronic pain management. However, its ability to treat OIH has not been well described. This case suggests that buprenorphine may be effective for patients with opioid tolerance and hyperalgesia and underscores the importance of considering alternative diagnoses in those who are diagnosed with opioid use disorder.

Conclusions: Buprenorphine may offer a safe and effective option for managing OIH in patients with chronic pain and high-dose opioid exposure. Further research is needed to clarify its role in treating OIH and to guide clinical practice.

Introduction: We aimed to assess the effectiveness of interprofessional teaching sessions focused on the care of patients with diabetic foot ulcers.

Methods: We conducted a pre-/post-intervention, quasi-experimental study with repeat evaluations on either side of the teaching sessions (n = 28). Surveys and chart reviews were used to assess changes in attitude, knowledge, practice, and patient outcomes.

Results: All 5 infectious disease fellows favorably reviewed the sessions. Positive baseline attitudes towards interprofessional care further improved with respect to shared learning and teamwork (5-point Likert scale scores pre- and post-session: 4.13 vs 4.44, respectively, P < 0.01). No other significant changes were observed.

Discussion: Our sessions were associated with improved attitudes toward interprofessional care but likely need to be augmented with experiential learning to achieve practice and outcome improvements.

Introduction: Chronic kidney disease (CKD) and hypertension are heritable traits. The source of this heritability remains largely unknown, and exploration has been limited principally to common genetic variants, with few studies having examined rare variants.

Methods: In this cross-sectional observational study, we evaluate whole exome sequencing data using the UK Biobank to identify the ability of rare variants in 58 kidney developmental genes to predict CKD or elevated blood pressure using logistic regression models with subgroup analysis performed by ancestry.

Results: Significant predictors of CKD included rare variants in CLCN5 (OR 1.59; 99% CI, 1.02-2.47; P = 0.007). Predictors of blood pressure included rare variants in SIX1 (OR 0.57; 99% CI, 0.35-0.94; P = 0.004) and NPHS1 (OR 0.84; 99% CI, 0.72-0.99; P = 0.005), which were protective against blood pressure elevation, and WT1 (OR 1.58; 99% CI, 1.02-2.45; P = 0.007), which was associated with elevated blood pressure. In individuals of White British ancestry, rare variants in SIX1 protected against elevated blood pressure (OR 0.58; 99% CI, 0.34-0.99; P = 0.009). Among individuals of non-White British ancestry, predictors of CKD included rare variants in SLC12A3 (OR 2.02; 99% CI, 1.08-3.78; P = 0.004) and CALB1 (OR 3.12; 99% CI, 1.15-8.47; P = 0.003). Presence of rare variants in WT1 significantly predicted elevated blood pressure (OR 2.49; 99% CI, 1.08-5.78; P = 0.005).

Conclusions: From this study, we conclude that rare variants in kidney developmental genes contribute to the risk of developing CKD and elevated blood pressure. These associations vary by ancestry.