Journal of the National Medical Association最新文献

Background: Recurrent pregnancy loss (RPL) affects 2-5 % of patients trying to build their families. RPL is frequently unexplained, though hematologic, immune, uterine, or genetic factors are associated with both RPL. These same risk factors for RPL are associated with poor obstetric outcomes. However, pregnancy outcomes after RPL are poorly studied. While Black race is a known risk factor for both miscarriage and hypertensive disorders of pregnancy (HDP), it is unknown if RPL increases risk of developing HDP or other pregnancy complications in Black pregnant people. The objective of this study is to assess the maternal and fetal outcomes in low-income Black patients delivering after a history of RPL.

Methods: We performed a retrospective cohort study in exclusively low-income Black females with a delivery > 20 weeks identified based on gestational age at delivery at a single community hospital between January 1, 2018 and December 30, 2022. RPL was defined as 2 or more pregnancy losses prior to the examined pregnancy. RPL patients were compared to controls with no more than one prior miscarriage. Obstetric and neonatal outcomes were compared using a multivariate regression analysis controlling for age, chronic hypertension, aspirin use, smoking status, BMI, and diagnosis of HDP in a prior pregnancy.

Results: 2598 patients met inclusion criteria (248 patients with RPL and 2344 controls) 9.6 % of patients had a history of RPL. Overall, 14.6 % of patients were diagnosed with any HDP. Patients with a history of RPL were significantly more likely to develop any HDP in the examined pregnancy (aOR 1.57 CI[1.11, 2.22]). Additionally, patients with RPL were more likely to be diagnosed with preeclampsia with severe features (aOR1.77 CI [1.05, 2.98]) and gestational hypertension (aOR 1.75 CI [1.11, 2.275]. Patients with RPL were also more likely to deliver preterm (aOR 1.58 CI [1.32, 2.22] and deliver low birthweight infants (OR 1.44 [1.05,1.98]). There were no differences in 1- and 5-minute APGAR scores.

Conclusions: The rate of RPL was high in this cohort, at 9.6 %. Low-income Black patients with RPL were at increased risk of HDP, specifically gestational hypertension and preeclampsia with severe features, as well as preterm delivery compared to low-income Black patients without RPL. Future studies are needed to assess the underlying pathophysiology of recurrent pregnancy loss and HDP to identify opportunities for risk reduction for this high risk and understudied population.

Sarcoidosis is a systemic disease of unknown etiology, characterized by granulomatous inflammation in various organs. Elevated serum Immunoglobulin G4 (IgG4) levels are typically associated with IgG4-related disease (IgG4-RD), characterized by plasma cell infiltration and fibrosis, but their role in sarcoidosis remains unclear. Given the fibro-inflammatory nature of both conditions, this study aimed to describe a cohort of sarcoidosis patients with elevated IgG4 levels and explore the potential clinical relevance of this finding. We retrospectively analyzed biopsy-confirmed sarcoidosis cases with measured serum IgG4 levels. Clinical data were gathered, including demographics, organ involvement, pulmonary function tests (PFTs), sarcoidosis-associated pulmonary hypertension (SAPH), and markers of autoimmunity. The study cohort included ten patients with a mean age of 50 ± 15 years, comprising six males and seven Black individuals. Two patients reported a family history of sarcoidosis; the mean body mass index (BMI) was 28.5 ± 5.7. Five patients were never smokers, and four were former smokers. Eight patients had lung involvement, two with advanced Scadding stage 4, four with airflow obstruction, and two with restriction physiology on PFT. Out of seven patients with echocardiography, five had SAPH. Other organ manifestation included ocular disease in three patients, joint involvement in two, liver disease in two, and heart disease in one. Autoimmune markers were present in five patients. These findings suggest a potential overlap between IgG4-RD and sarcoidosis. Further research is needed to clarify IgG4's role in sarcoidosis and whether elevated serum IgG4 identifies a subset of patients who may benefit from B-cell depletion therapies.

Introduction: Colorectal cancer (CRC) is the second leading cause of cancer-related death in the U.S., with ∼153,000 new cases and over 52,000 deaths annually. Despite advances in screening and early detection, disparities in incidence and outcomes persist. African Americans have higher CRC incidence and mortality and lower screening rates compared to Whites. This disparity may be shaped by emotional, sociocultural, and structural factors.

Methods: We conducted a cross-sectional survey at a health fair in Washington, DC, among predominantly African American attendees. An open-ended prompt asked: "In 10 words or less, please share your perception about colorectal cancer." Responses were coded into themes (fear [with subcategories], prevention/screening, hope/self-improvement, awareness, other). Stratification was by age (<50 vs ≥50), sex, prior colonoscopy history, personal CRC history, and whether the respondent knew someone with CRC. Statistical tests included t-tests, Fisher exact, and ANOVA; significance at p < 0.05.

Results: Of 56 respondents (94.9 % of booth visitors), 96.4 % identified as Black/African American; 73 % were female, 27 % male; ages ranged 19-85 (79 % ≥50). Fear dominated responses (51.7 %), especially fear of death (26.8 %). Prevention/screening references accounted for 19.6 %. Among <50 participants, fear of screening was most common; among ≥50 participants and men, fear of death predominated (p = 0.00001, p = 0.0205, respectively).

Conclusion: Emotional perceptions of CRC among African Americans vary by age and gender: younger adults tend to fear the screening process itself, whereas older adults and men more often express fatalistic fears. Tailored, culturally sensitive interventions addressing both procedural anxiety and fatalism may enhance CRC screening uptake in this population.

Objective: This study examined the relationship between healthcare-seeking behavior and health locus of control orientations among individuals with sickle cell disease, specifically investigating whether mental health service utilization predicts internal versus external control beliefs while accounting for demographic factors.

Methods: Thirty-two African American adults with sickle cell disease were recruited from a Southeastern Comprehensive Sickle Cell center. Participants completed the Multidimensional Health Locus of Control scale (MHLC), which assesses internal control beliefs and external orientations including control by doctors, other people, powerful others, and chance factors. Hierarchical linear regression analyses examined mental health service utilization as a predictor of different locus of control dimensions while controlling age and gender.

Results: Mental health service utilization emerged as a significant predictor of internal health locus of control, accounting for 39.2% of the variance (R² = 0.392, F(3,28) = 6.015, p = 0.003). Individuals who engaged with mental health services demonstrated significantly stronger beliefs that their health outcomes were primarily determined by their own actions and behaviors (β = 0.568, p = 0.002). Mental health service utilization did not significantly predict any external locus of control dimensions, including control by doctors, other people, powerful others, or chance factors. Demographic variables (age and gender) did not emerge as significant moderators in the final models.

Conclusions: The specific association between mental health service engagement and enhanced internal control beliefs suggests that psychological interventions may serve dual functions in chronic disease care: addressing mental health symptoms while simultaneously reinforcing adaptive health cognitions that promote broader healthcare engagement. These findings support integrating mental health services into comprehensive sickle cell care programs and suggest that interventions targeting locus of control beliefs may effectively promote proactive healthcare behaviors among individuals managing chronic conditions.

Sickle cell disease (SCD) is a devastating genetic hematologic disorder affecting approximately 80,000 African Americans. Beyond the well-characterized vaso-occlusive pain crises, patients experience significant psychological morbidity, including kinesiophobia (fear of movement) and depression, which profoundly impact quality of life and functional outcomes. This comprehensive review synthesizes current evidence on the relationship between kinesiophobia and depression in SCD patients, with particular attention to gender differences, underlying pathophysiological mechanisms, and clinical implications for multidisciplinary care. We conducted a systematic examination of the literature on kinesiophobia, depression, and psychosocial factors in SCD, incorporating data from multiple cohort studies totaling 247 adult African American patients. Assessment instruments included the Tampa Scale for Kinesiophobia (TSK), Beck Depression Inventory (BDI), and Center for Epidemiologic Studies Depression Scale-Revised (CESD-r). Kinesiophobia prevalence in SCD patients (mean TSK score = 30.48) was comparable to patients with chronic back pain and fibromyalgia. Significant gender differences emerged, with women demonstrating strong positive correlations between kinesiophobia and depression (BDI r = 0.31, p = 0.045; CESD-r = 0.54, p = 0.009), while no significant relationships were observed in men (BDI r = 0.24, p > 0.05; CESD-r = 0.13, p > 0.05). The relationship appears mediated by psychomotor retardation, somatization, and pain catastrophizing behaviors. Fear of movement represents a clinically significant but underrecognized contributor to depressive symptomatology in women with SCD. These findings highlight the need for gender-specific psychological interventions and integrated care approaches that address both physical and mental health components of this complex genetic disorder.

Healthcare disparities in pain management represent one of the most persistent and pernicious manifestations of systemic bias within medicine. This comprehensive review examines the complex intersection of implicit bias, racial stigmatization, and clinical decision-making in the context of sickle cell disease, a predominantly African descent genetic disorder characterized by severe recurrent acute pain episodes and chronic pain that worsens with age. Through analysis of empirical research spanning psychosocial functioning, pain perception, healthcare utilization patterns, and provider attitudes, we demonstrate how societal-level prejudices become institutionalized within medical practice, resulting in systematic undertreatment of legitimate pain and inappropriate labeling of patients as drug-seeking. The current opioid crisis has paradoxically exacerbated these disparities, as heightened scrutiny of narcotic prescribing disproportionately affects minority patients who already face substantial barriers to adequate pain management. We argue that understanding the biopsychosocial complexity of sickle cell disease within its historical and social context is essential for dismantling discriminatory practices and achieving equitable healthcare delivery. This paper presents a framework for recognizing and addressing implicit bias in clinical settings while maintaining appropriate safeguards against prescription drug diversion. The implications extend beyond sickle cell disease to encompass broader questions about how societal inequities become embedded in medical practice and perpetuated through ostensibly objective clinical assessments.

Healthcare providers have an ethical responsibility that includes public advocacy to address social influencers of health (SIOH). The Northwestern Department of Medicine (DOM) Winter Coat Drive is an example of physician-led advocacy aimed at mitigating SIOH that contribute to health disparities. Started in 2023, the DOM Winter Coat Drive involves interdisciplinary teams (physicians, nurses, community health workers, administrators) across multiple hospital departments to provide winter clothing to people experiencing housing and financial instability in the Chicago region. In 2024, efforts were expanded to include seven regional hospitals, nine departments, and ten community organizations - yielding over 1000 coats being donated. In addition, health screenings were paired with coat distributions as a means to promote preventative care and community engagement. This initiative illustrates how structured, community-based interventions grounded in advocacy can strengthen healthcare provider participation in addressing SIOH, promote health equity, and enhance trust between healthcare institutions and marginalized communities.

Background: Nearly one in four Americans live with a disability, yet healthcare systems often fail to adequately meet the needs of this population, resulting in significant health disparities. The disparities faced by people with disabilities (PWD) can be attributed to a lack of education for medical professionals at all levels.

Objective: This exploratory study investigates medical students' exposure to disability-related content and their self-perceived preparedness to care for PWD.

Methods: Using data from the 2020 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey, we conducted a cross-sectional study analyzing responses from 107 medical students to assess medical student exposure to PWD and perceived preparedness to provide comprehensive care among an exploratory sample.

Results: Exposure to components of established health disparities curricula-including didactic instruction, clinical skills training, and interactive learning experiences-was positively associated with students' self-reported confidence in providing care for PWD. However, most students within this sample report not having these experiences during medical school.

Conclusions: The study preliminarily highlights the need for a standardized disability-focused curriculum in medical education. Incorporating structured didactic and experiential learning opportunities may improve medical student preparedness to care for PWD. Further research with larger, representative samples is needed to inform the development of standardized disability curricula.

Despite advances in treatment, the mental health challenges of individuals living with Sickle Cell Disease (SCD) remain critically overlooked. Depression, anxiety, and post-traumatic stress disorder disproportionately affect this population, yet mental health support is often inadequate or absent. This paper presents patient-driven insights into the psychological toll of SCD, emphasizing the urgent need for integrated care approaches that address both physical and mental health. By exploring barriers to mental health access, the impact of medical trauma, and strategies for resilience, we aim to shift the conversation toward a more holistic, patient-centered model of SCD care.