Comparison of Patient and Provider Practices between Bone Marrow and Solid Organ Transplantation Programs for Patient Education on Increased Risk of Skin Cancer.

Patients receiving immunosuppressive therapy following transplantation are at risk for skin cancer owing to dampened tumor surveillance. As long-term immunotherapy is necessary to prevent graft rejection, transplantation providers and recipients are expected to perform regular surveillance for the development of suspicious lesions, and recipients are encouraged to practice preventative sun safe behaviors. No consensus exists regarding the timing of full body skin exams, and despite the well-established risk, patient education is not always prioritized. We investigated whether differences exist between bone marrow transplant (BMT) and organ transplant (OT) recipients and their providers regarding prevention and screening. We distributed surveys to adult and pediatric BMT and OT recipients, as well as their providers, at a single academic institution. Results were evaluated using the chi-square test. The survey results show that most BMT recipients (69%) and OT recipients (77%) were aware of their increased risk for skin cancer, but despite this knowledge, only 13% of patients overall reported using sunscreen, 29% reported reapplying sunscreen, and 48% reported wearing sun protective clothing. Most OT recipients (63%) reported never having a total body skin exam, whereas only 34% BMT recipients reported having a total body skin exam every 6 months (P = .006). BMT providers recommended a total body skin exam every 6 or 12 months (44.4% each), and OT providers recommended a total body skin exam every 12 months (58.3%). Only 11.1% of BMT providers and 8.3% of OT providers reported performing a total body skin exam at each visit. Despite results indicating widespread patient knowledge of skin cancer risk, most patients do not practice adequate prevention. Inclusion of a transplantation dermatologist in the care team or use of risk stratification tools by providers may help streamline timely referrals to Dermatology.

An Unusual Presentation of Pituitary Gland Apoplexy With Noninfectious Meningitis.

Pituitary adenomas make up 10% of intracranial tumors, but because of their location, they may go undetected for long periods. In this article, we report the case of a 68-year-old white man found deceased in his residence, who died of acute pituitary tumor apoplexy. He was known to have severe symptoms including acute headache, vision loss, and altered behavior. When found, his home was in extreme disarray, mimicking a possible assault. At autopsy, the decedent had multiple superficial abrasions about the upper and lower extremities, as well as a 2.5 × 3-cm pituitary adenoma compressing the carotid arteries and optic nerves. Initial coroner and police investigators were strongly considering homicide with robbery as a motive, given the disarray present at the scene. This case highlights the importance of postmortem examination of the pituitary gland in all cases where neurological symptoms are reported prior to death.

Rationing access to care to the medically uninsured: the role of bureaucratic front-line discretion at large healthcare institutions.

BACKGROUND: Medically uninsured patients seeking nonemergency care are not guaranteed access to services at most healthcare institutions. They must first register with a clerk who could require a deposit and/or payment on an outstanding debt. OBJECTIVES: This study examines the factors that influence whether nonmedical bureaucratic staff sign in or turn away uninsured patients who cannot meet prepayment requirements. RESEARCH DESIGN: The study was conducted at a for-profit, a not-for-profit, and a public healthcare institution in a metropolitan area. The authors explored the relevant policy environment through interviews with senior administrators and a review of documents pertaining to the management of self-pay patients. Then they examined how policies affecting access were implemented through in-depth, semistructured, audiotaped interviews with 55 front-line clerical personnel. RESULTS: At all 3 institutions, policies were ambiguous about what to do when uninsured patients cannot afford required prepayments. Seventy-one percent of staff reported they do not turn patients away; the remainder stated that on occasion they do. A variety of rationales were provided for how decisions are made. Those with the lowest-level positions were significantly more likely to be sympathetic to indigent patients and less likely to report turning patients away. CONCLUSIONS: Consistent with other studies of front-line bureaucracies indicating that low-level personnel who interface with clients make discretionary decisions, particularly when organizations pursue potentially conflicting priorities, this preliminary investigation found that nonmedical personnel play a significant role in decisions affecting access to care for medically indigent patients.