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

Introduction: Implicit bias in patient care and outcomes is well documented. However, the presence of bias in hospital security interactions is a relatively new area of research. Flags placed on the electronic medical record identify patients considered high risk for negative outcomes, including those with security interactions.

Objective: We sought to explore the types of flags and their frequency, differences among patients with flags, and their pattern over time.

Methods: We conducted a retrospective chart review of flags placed on electronic medical records over 13 years of adults 18 years or older who were patients at a Midwest, tertiary, academic medical center. Descriptive statistics were used to explore patient demographic data. Chi-square tests were executed to compare patients with different flag types.

Results: Three flag types were investigated: "communication alert," "vulnerable/unsafe, behavior" and "risk management." The communication alert flag was most common, although Black male patients were more likely to receive a vulnerable/unsafe behavior flag than a communication alert flag (P = 0.001). Patients who were prescribed anti-anxiety medications, antidepressants, antipsychotics, and psychotherapeutics also were more likely to receive a vulnerable/unsafe behavior flag than a communication alert flag (P = 0.001). The highest number of flags was placed during quarter 3 - the months of July, August, and September.

Conclusions: Records of patients with certain demographics and on certain medications were more likely to be labeled with vulnerable/unsafe behavior flags. There is no clear protocol to determine what behaviors elicit which flag. Standardized procedures could help provide transparency to this issue.

Background: Burnout among health care providers has reached epidemic levels, raising concerns about clinician wellness and the quality of care delivered. Based on years of collaboration with primary care providers through various models-including the Collaborative Care Model (CoCM)-the authors observed that such partnerships may enhance provider well-being. This study aimed to assess provider perceptions of CoCM and its impact of provider wellness.

Methods: In March 2023 a brief, anonymous, 9-question survey was distributed via email to 51 physicians, advanced practice nurse prescribers, and physician assistants working in 4 primary care clinics, each of which had implemented CoCM for at least 1 year. For this study, we examined 3 questions that specifically addressed provider wellness.

Results: Twenty-six (51%) primary care providers completed the survey. Among the responses to wellness-related questions, 84.6% indicated reduced stress level, 80.8% reported improved job satisfaction, and 57.7% noted increased comfort with prescribing psychotropic medications. All respondents recommended CoCM to their colleagues.

Conclusions: Primary care providers strongly endorsed CoCM as beneficial to provider wellness. Further research is needed to confirm these findings and to explore whether improvements in clinician well-being translate to enhanced patient care.

Introduction: Health care professionals can protect children by identifying and reporting injuries concerning for child physical abuse, such as sentinel injuries (bruising and intra-oral injuries in precruising infants). Citing knowledge and collaboration barriers, health care professionals sometimes fail to recognize sentinel injuries as concerning for abuse. Interprofessional education may be an ideal format to improve health care professional's responses to sentinel injuries. However, it is traditionally limited to health care professions, while responding to suspected child physical abuse requires collaboration between health care professionals and non-health care professionals. This study's purpose was to understand if an interprofessional education framework could support the need and development of interprofessional education for child physical abuse beyond health care professions.

Methods: Data were collected through semistructured interviews and analyzed using a qualitative descriptive methodology. Participants included 27 professionals who had engaged in child physical abuse responses in a US midwestern urban county. Participant professions included health care, child protective services, law enforcement, courts, victim advocates, and child advocacy center employees.

Results: Six themes were identified: 4 themes aligned with competencies of the interprofessional education framework, 1 described engaging with families, and 1 described features unique to sentinel injury investigations.

Conclusions: This study supports the need for child physical abuse interprofessional education beyond health care professions. Legal thresholds for responding to suspected abuse differ by profession, and there is no shared interprofessional language around child physical abuse. This contributes to a steep learning curve for new professionals. This study also supports that an existing interprofessional education framework can provide the foundational framework for development of such education.

Introduction: Spontaneous splenic hemorrhage is a rare initial presentation of malignancy. The objective of this case report is to elucidate the complexities of early diagnosis of splenic metastases and the complications associated with advanced malignancies of the spleen. It is also a reminder to consider splenic metastases and hemorrhage in the differential diagnosis for nonspecific presentations, such as acute abdomen, in adults.

Case presentation: A 58-year-old female with 1 month of vague, worsening systemic symptoms and computed tomography findings suspicious for a subcapsular splenic hematoma was found to have splenic rupture. After undergoing emergency laparotomy with splenectomy, pathological samples revealed metastatic poorly differentiated adenocarcinoma of unknown origin. During a subsequent admission, she was found to be hemodynamically unstable, deemed a poor candidate for inpatient chemotherapy, and elected to proceed with comfort measures after which she died from multiorgan failure 3 weeks after initial presentation.

Discussion: Spontaneous (nontraumatic) splenic hemorrhage secondary to metastasis should remain a differential diagnosis for patients with acute abdomen and associated risk factors for primary malignancies.

Introduction: Electronic cigarette (e-cigarette) use is prevalent among young adults, yet cessation treatment options are limited and underutilized.

Methods: Wisconsin residents aged 18 to 24 who had vaped nicotine in the past month (N = 480) completed an online survey assessing vaping initiation, past quit experiences, future quit intentions, and treatment knowledge and preferences. The survey also assessed perceived physical and mental health harms of vaping nicotine and other products (eg, cannabis, cannabidiol).

Results: Most young adults had made a prior e-cigarette quit attempt, commonly motivated by concerns about addiction, cost, and health problems. Though 80% want support to quit, preferred methods of support were highly variable. The same methods (eg, medication, friends/family, health care provider, therapist) that were most endorsed as the form of support young adults were most likely to use were also among the most endorsed forms of support that young adults would not want to use. Nearly 40% of participants reported vaping cannabis and perceived vaping cannabis as significantly less harmful than vaping nicotine or tobacco for physical and mental health.

Conclusions: Vaping cessation resources that are responsive to young adults' needs and preferences are needed. The high variability in treatment preferences suggests that multiple strategies need to be offered; there is no one-size-fits-all approach. Cannabis vaping is prevalent, and an important area for future research is to examine the impact of cannabis vaping on nicotine vaping dependence, cessation, and treatment use. Strategies to reach, motivate, and engage young adults in e-cigarette cessation and cessation treatment should highlight their concerns about addiction, costs, health harms, and desired treatment options.

Introduction: Crusted scabies (Norwegian scabies) is a rare and severe presentation of skin infestation caused by the mite Sarcoptes scabiei in patients with compromised cellular immunity. Kidney transplant patients are maintained on immunosuppressive agents, which induce impaired T cell immune response that can lead to increased risk of crusted scabies.

Case presentation: We report a case of crusted scabies in a kidney transplant patient who presented with a diffuse skin rash. Diagnosis was delayed and misdiagnosed initially, with subsequent skin biopsy leading to an accurate diagnosis and complete recovery with definitive treatment.

Discussion: Unlike classical scabies, crusted scabies can occur in an atypical pattern that can be misdiagnosed as common skin lesions, and a skin biopsy is crucial to obtain an accurate diagnosis to receive definitive treatment.

Conclusions: Transplant recipients are at an increased risk of severe parasitic infections such as crusted scabies due to drug-induced impairment of their cell-mediated immune response, thus maintaining a high index of suspicion for crusted scabies as a differential diagnosis in transplant kidney patients is extremely important. Early histological diagnosis of crusted scabies is essential to prevent delayed or missed diagnosis and avoid unnecessary serious complications. The combination of an oral ivermectin and topical permethrin regimen resulted in excellent clinical outcomes in our case and is recommended as the standard treatment.

Background: Health care agent (HCA) documentation as part of advance care planning (ACP) helps clinicians understand patient care wishes. This project aimed to habituate these conversations and increase documentation rates.

Methods: Workflow redesign and novel educational interventions were implemented. Patients aged 50 and older received an HCA education "blue sheet" at check-in as a discussion prompt.

Results: Of 968 visits, patients in 44% received the intervention and 4% added HCA documentation. Chart audits found that 69% of patients had outdated (older than 5 years) ACP/HCA documentation. Clinician and staff found the process helpful, important to patients, and sustainable.

Discussion: This inexpensive intervention increased HCA documentation and highlighted the need to update old ACP documents.

Introduction: More availability of HIV pre-exposure prophylaxis (PrEP) is needed to end the HIV epidemic, but this means more clinicians will encounter false positive HIV test results. These cases highlight such occurrences and the steps a clinician may take to determine the significance of such results.

Case presentation: We present the case of a 68-year-old male who presented for routine follow-up for HIV PrEP and a 41-year-old transgender male who presented to establish care with a primary care clinician. On labs, both had repeatedly positive HIV antigen/antibody tests with undetectable viral loads.

Discussion: With increasing prescription of HIV PrEP comes a need for accurate interpretation of HIV serologies. HIV PrEP users may have altered stages of seroconversion. Additionally, heterophile antibody interference can lead to false positive or negative results.

Conclusions: The reader should gain an understanding of HIV testing, potential pitfalls, and next steps amidst unclear results.

Introduction: Rhabdomyolysis is a common but complex medical condition that typically presents with asymptomatic muscle enzyme elevation and follows a benign course. Cases of rhabdomyolysis associated with mononeuropathy, mononeuropathy multiplex, and peripheral neuropathy are uncommon.

Case presentation: We present the case of a 28-year-old man with focal weakness of the left leg that developed after he fell to the floor and was immobilized on his left side for a prolonged length of time (ie, 6-8 hours). Further evaluation revealed rhabdomyolysis associated with unilateral sciatic neuropathy but no evidence of compartment syndrome.

Discussion: Severe cases of rhabdomyolysis, with or without compartment syndrome, can result in compressive neuropathies. We provide a detailed anatomic description of the sciatic nerve and review its associated clinical syndromes.

Conclusions: In cases of rhabdomyolysis associated with focal limb weakness that follows a myotomal distribution, compressive mononeuropathy should be considered in the differential diagnosis.