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

Introduction: Pembrolizumab is an immune checkpoint inhibitor (ICI) used to treat many types of advanced cancer. ICIs can cause encephalopathy, a severe immune-related adverse event, which is a diagnosis of exclusion. Pembrolizumab immune-related adverse events typically develop early (within a few months) in treatment; presentation after a year is extremely rare.

Case presentation: A 70-year-old White female with metastatic endometrial cancer treated with pembrolizumab for 19 months presented with generalized weakness that rapidly progressed to confusion, delusions, and hallucinations.

Discussion: After ruling out other causes of encephalopathy via broad-based testing of blood and cerebrospinal fluid and imaging, her neurologic status improved after treatment with high-dose glucocorticoids and intravenous immunoglobulin.

Conclusions: Pembrolizumab is an ICI that can cause encephalopathy, which is challenging to diagnose. While immune-related adverse events typically emerge soon after starting treatment, pembrolizumab-induced encephalopathy can be delayed significantly.

Introduction: The Centers for Disease Control and Prevention recommends HIV screening for all patients aged 13 to 64. We sought to improve the health of our patient population by enacting universal HIV screening in our emergency departments.

Methods: Universal opt-out HIV screening was implemented in 7 southeastern Wisconsin emergency departments and included linkage to care for those diagnosed with HIV.

Results: In the first year of this initiative, 57 565 patients were screened for possible testing and 24 417 patients did not opt out (42.4%). In total, 12 406 HIV tests were performed in the first year of the program.

Discussion: Our emergency department opt-out HIV screening initiative identified 23 new cases of HIV, approximately 10% of the average number of incident HIV cases in Wisconsin. We linked 96% of persons newly diagnosed with HIV to HIV medical care.

Background: Justice-involved individuals are disproportionately affected by hepatitis C virus (HCV) infection. Wisconsin's viral hepatitis elimination plan prioritizes this population, yet little is known about jail capacity for testing and treatment.

Methods: A 10-item survey was emailed to administrators of 71 county jails and 1 Tribal detention facility to assess HCV testing and treatment practices and barriers. Responses were analyzed descriptively.

Results: Thirty facilities (41.7%) responded. Ten jails (33.3%) offered HCV testing; 15 (51.7%) provided treatment. Common barriers to testing included lack of contracted services (40%) and staffing constraints (23.3%). Barriers to treatment included financial restrictions (66.7%) and short incarceration periods (33.3%).

Discussion: Limited testing and treatment capacity persists despite Medicaid coverage and effective therapies.

Conclusions: Partnerships with local health agencies and policy changes addressing cost and contractual limitations are essential to expand HCV services in Wisconsin jails.

Introduction: By removing the intrinsic source of pain, total pancreatectomy offers patients with chronic pancreatitis a definitive surgical treatment. However, pancreatectomy results in labile diabetes. Specialized centers perform total pancreatectomy and islet autotransplantation (TP-IAT) to prevent labile diabetes and restore insulin independence after pancreatectomy.

Objective: The objective of this retrospective study was to describe current indications and outcomes of TP-IAT performed at the University of Wisconsin (UW)-Madison, the sole center in the state offering this procedure.

Methods: We reviewed the records of 19 TP-IAT procedures performed at our center from 2014 to 2023 for chronic and relapsing pancreatitis. All were nondiabetic and 89% required narcotics for pain. We report surgical outcomes as well as outcomes related to postoperative control of pain and diabetes, including narcotic usage, islet graft function (measured by detectable fasting serum C-peptide levels), and insulin independence.

Results: The UW experience with TP-IAT demonstrates durable pain alleviation in 79% of patients. One year post-procedure, 80% of patients exhibited islet graft function; 32% remained insulin-independent.

Conclusions: In selected nondiabetic patients with chronic pancreatitis, TP-IAT is associated with durable reductions in narcotic pain medication requirements, improved quality of life measures, islet function, and mitigation of insulin dependence. Despite the advantages of TP-IAT, the procedure is still underutilized in the United States. Our data indicate that nondiabetic patients with chronic pain syndromes due to pancreatitis should be referred for possible TP-IAT to specialized centers before they lose islet function, develop significant fibrosis/calcifications, or have other major pancreatic surgical procedures.

Introduction: Atraumatic splenic rupture is an extremely rare but serious complication of infectious mononucleosis.

Case presentation: We present the case of an 18-year-old female who presented with atraumatic splenic rupture in the setting of infectious mononucleosis. Her past medical history was significant for postural orthostatic tachycardia syndrome, and she has a sister who was diagnosed with Ehlers-Danlos syndrome. Given her presentation and unique background, she was followed closely by surgery and hematology. The decision was made to pursue conservative management, and she was discharged home 4 days after admission with a 6-week physical activity restriction.

Discussion/conclusions: This patient's medical and family history warranted unique clinical considerations and multidisciplinary collaboration throughout in-patient management and follow-up. The lessons learned from nonoperative management of pediatric splenic injuries may be applied successfully to medical organ rupture, working in close partnership with hematologists to understand the time course and endpoints for the underlying inflammatory condition.

Introduction: Wisconsin's influenza immunization rates are below public health goals, with only 38% of residents vaccinated during the 2022-2023 season. Rates vary by race, sex, ethnicity, and geography. The COVID-19 pandemic demonstrated that pharmacists are well-positioned to address vaccine rates and disparities. Similar efforts are needed to address influenza, another respiratory disease associated with substantial morbidity and mortality.

Methods: Influenza vaccination data for the 2022-2023 season were obtained from the Wisconsin Immunization Registry and analyzed by demographic and geographic subgroups to determine the proportion of immunizations administered at pharmacies. Three focus groups assessed factors affecting pharmacies' role in promoting influenza vaccine equity. Qualitative data were analyzed using thematic content analysis.

Results: Of the 38% of Wisconsin residents vaccinated, 30.6% received their immunization at a pharmacy. Vaccination rates were higher among females than males (44% v 34%), with similar proportions vaccinated at a pharmacy (29.5% females v 29.4% males). Residents aged 18 to 49 years and 50 to 64 years had lower vaccination rates than those aged > 65 (26.7%, 39.6%, and 81.1%, respectively) and lower proportions vaccinated at a pharmacy (7.1%, 13.2%, and 35.8%, respectively). Differences in vaccination rates and pharmacy use were observed across racial and ethnic groups, with most groups showing lower rates compared to White residents. Qualitative results identified barriers such as vaccine burnout, billing and insurance issues, red tape and staffing shortages; promotors included trusted messengers and improved access/outreach.

Conclusions: Discrepancies in influenza vaccination rates by sex, age, and race/ethnicity persist in Wisconsin. Identifying barriers and promotors at the patient and immunizer levels can inform actionable recommendations to improve vaccine rates and promote equity.