Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health.

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Reductions in nonfinancial barriers to care and improvements in social determinants of health are also necessary. This ACP position paper calls for ending discrimination based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. The ACP calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems in order to achieve ACP's vision for a better U.S. health care system.

Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care.

This paper is part of the American College of Physicians' policy framework to achieve a vision for a better health care system, where everyone has coverage for and access to the care they need, at a cost they and the country can afford. Currently, the United States is the only wealthy industrialized country that has not achieved universal health coverage. The nation's existing health care system is inefficient, unaffordable, unsustainable, and inaccessible to many. Part 1 of this paper discusses why the United States needs to do better in addressing coverage and cost. Part 2 presents 2 potential approaches, a single-payer model and a public choice model, to achieve universal coverage. Part 3 describes how an emphasis on value-based care can reduce costs.

Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians.

For more than 20 years, the American College of Physicians (ACP) has advocated for the need to address firearm-related injuries and deaths in the United States. Yet, firearm violence continues to be a public health crisis that requires the nation's immediate attention. The policy recommendations in this paper build on, strengthen, and expand current ACP policies approved by the Board of Regents in April 2014, based on analysis of approaches that the evidence suggests will be effective in reducing deaths and injuries from firearm-related violence.

Hemophagocytic lymphohistiocytosis in an HIV-positive patient with concomitant disseminated histoplasmosis.

A 46-year-old Dominican man, known to have HIV, presented with constitutional symptoms of two week's duration. The patient was found to have cytopenias, significantly elevated ferritin level and lymphadenopathy. Biopsies and laboratory studies met the criteria for hemophagocytic lymphohistiocytosis (HLH). A concomitant diagnosis of histoplasmosis was confirmed as the trigger for HLH and treatment resulted in clinical improvement and resolution of symptoms.

Abstracts from the 2016 Annual Louisiana American College of Physicians Associates Meeting.

Each year medical students in Louisiana and residents from the eight Internal Medicine training programs in Louisiana are invited to submit abstracts for the Annual Louisiana American College of Physicians (ACP) Associates Meeting. The content of these abstracts includes clinical case vignettes or research activities. The abstracts have all identifying features removed (i.e., names, institutional affiliations, etc.) before being sent to physician judges. Each judge scores each abstract independently and then the scores from all judges are averaged and ranked. This year we are excited to be able to publish most highly ranked abstracts presented at this year's competition. These abstracts (17 oral; 14 poster) were presented at the Associates Meeting held at LSU Health Sciences Center in Baton Rouge on January 19, 2016. We would like to thank the Journal of the Louisiana State Medical Society and appreciate its efforts to publicize the hard work of these trainees.

Clinical Case of the Month: PERSISTENT HYPERTENSION IN A YOUNG WOMAN: A CLASSIC PRESENTATION OF CONN'S SYNDROME.

Primary aldosteronism PA is a secondary cause of hypertension that is often missed due to inadequate clinical evaluation and the lack of classically described laboratory abnormalities. Based on guidelines from the Endocrine Society, primary aldosteronism should be suspected in young patients with moderate to severe hypertension, patients with hypertension and coexisting hypokalemia, any patient with hypertension and an incidental adrenal adenoma, and hypertension in the setting of a significant family history of early onset hypertension or cerebral vascular accident in a first degree relative less than 40 years of age.1 In previous years, primary aldosteronism was attributed to less than one percent of all causes of secondary hypertension. However, recent research and increased utilization of aldosterone plasma renin ratio ARR as a method for screening has led to the understanding that majority of patients with PA are not hypokalemic, and the current literature now places the incidence of PA between 5-13 percent. Additionally, a growing body of evidence has demonstrated inflammatory, fibrotic, and remodeling effects on the cardiovascular and renal tissue that appear to be independent of PA- induced hypertension. Therefore a high suspicion for PA must be incorporated into evaluation of hypertensive patients, as diagnosis and subsequent treatment not only improves blood pressure control, but also acts to diminish cardiovascular morbidity and mortality. Here we present a case of a young woman with a seven-year history of hypertension prior to receiving a diagnosis of Conn's Syndrome.

Distended bladder presenting with altered mental status and venous obstruction.

BACKGROUND: New onset or acute worsening of bilateral lower extremity swelling is commonly caused by venous congestion from decompensated heart failure, pulmonary disease, liver dysfunction, or kidney insufficiency. A thromboembolic event, lymphatic obstruction, or even external compression of venous flow can also be the culprit. CASE REPORT: We report the case of an 83-year-old male with a history of myelodysplastic syndrome that progressed to acute myeloid leukemia, bipolar disorder, and benign prostatic hypertrophy. He presented with altered mental status and new onset lower extremity edema caused by acute bladder outflow obstruction. Computed tomography of the abdomen and pelvis showed the patient's distended bladder compressing bilateral external iliac veins. CONCLUSION: Insertion of a Foley catheter resulted in several liters of urine output and marked improvement in his lower extremity edema and mental status a few hours later. Our extensive workup failed to reveal a cause of the patient's acute change in mental status, and we attributed it to a concept known as cystocerebral syndrome.

Abstracts From The Annual Louisiana American College Of Physicians Associates Meeting.

Each year medical students in Louisiana and residents from the eight Internal Medicine training programs in Louisiana are invited to submit abstracts for the Annual Louisiana American College of Physicians (ACP) Associates Meeting. The content of these abstracts includes clinical case vignettes or research activities. The abstracts have all identifying features removed (i.e., names, institutional affiliations, etc.) before being sent to physician judges. Each judge scores each abstract independently and then the scores from all judges are averaged and ranked. This year we are excited to be able to publish the 26 most highly ranked abstracts presented at this year's competition. These abstracts (15 oral; 12 poster) were presented at the Associates Meeting held at Tulane University Health Sciences Center in New Orleans on January 27, 2015. We would like to thank the Journal of the Louisiana State Medical Society and appreciate its efforts to publicize the hard work of these trainees.

Primary clear cell adenocarcinoma of the colon: a case report and review.

A case of primary clear cell adenocarcinoma of the colon, a rare oncologic variant, was diagnosed in a 25-year-old man who presented with partial bowel obstruction. To understand better the pathology of this neoplasm, a retrospective review of Entrez PubMed entries describing primary clear cell adenocarcinoma of the colon and/or rectum was performed. Only 13 previous cases of primary clear cell adenocarcinoma of the colon and/or rectum have been reported, with an average presentation age of 57 years and generally afflicting the descending colon of men. Herein we present a case occurring in the distal ascending colon of the youngest patient in the literature to date. Our patient's diagnosis is rare in occurrence, location, and age of onset.

CLINICAL CASE OF THE MONTH. A 63-Year-Old Woman With Rash and Proximal Muscle Weakness.

A 63-year-old woman with a history of infiltrating ductal breast cancer, status post-mastectomy and chemotherapy, was in remission for 18 months prior to being admitted to the hospital with complaints of a pruritic erythematous macular rash involving her head, chest, and bilateral upper and lower extremities. Along with the dermatologic manifestations, physical exam revealed proximal symmetrical muscle weakness and bilateral axillary lymphadenopathy. Initial workup for muscle weakness revealed a creatine kinase of 2,200 IU/L (normal 20-180 IU/L). After administration of intravenous fluids for renal protection, serum sodium dropped to 121 mEQ/L (normal 135-145 mEQ/L). Computed tomography of the chest showed axillary and supraclavicular lymphadenopathy. Biopsy of a supraclavicular node revealed infiltrating ductal cancer with histologic and morphologic characteristics similar to her previous breast cancer. Following an extensive laboratory workup, we concluded that our patient's myositis and hyponatremia were paraneoplastic syndromes secondary to her recurrent breast cancer.

Clinical case of the month. A rare case of Budd Chiari syndrome.

Budd Chiari syndrome is a rare disorder resulting from hepatic venous outflow tract obstruction anywhere from the small hepatic veins to the suprahepatic inferior vena cava. This patient has a hypercoagulable state secondary to heterozygous mutation of factor V and the JAK2 mutation and is being anticoagulated. We hypothesize that the low protein C and low antithrombin III levels seen in this patient resulted from decreased synthetic function of the liver and were not indicative of actual deficiencies. Indeed, reports of coexisting protein C and antithrombin III deficiencies are not existent in the literature and likely are not compatible with life. All patients with BCS warrant a hypercoagulable work up and JAK2 mutation is increasingly recognized as a contributing factor, even in those patients without obvious signs of polycythemia vera.

The dilemma of multidrug-resistant gram-negative bacteria.

Antimicrobial resistance is one of the world's most pressing public health problems. The worldwide use and misuse of antimicrobials in medicine and agriculture have resulted in the selection of bacteria resistant to the microbiologic activity of these agents. These resistant bacteria fail to respond to treatment, resulting in prolonged hospitalizations, increased cost and greater risk of death. This article will review the emergence of multidrug-resistant Gram-negative bacteria, with a focus on risk factors, consequences, treatment and prevention for healthcare-associated infections.

Pseudomonas aeruginosa protease IV: a corneal virulence factor of low immunogenicity.

PURPOSE: To study antibody production to Pseudomonas aeruginosa protease IV (PIV) for immunoassay development and to assess the possible role of antibody in arresting corneal damage. METHODS: Rabbits were immunized with PIV, urea-soluble recombinant PIV (rPIV), or precipitated rPIV. Antibody was analyzed by ELISA and Western blotting. Antibody-mediated inhibition of PIV activity was tested by colorimetric assay and during keratitis by slit-lamp examination of infected eyes. RESULTS: Antibody was not produced after PIV immunization but was induced by rPIV. Rabbits immunized first with soluble and then precipitated rPIV produced high titers (log(10)) to rPIV (4.28 +/- 0.09) and significantly higher titers to PIV (3.90 +/- 0.06) compared to the other immunized groups. Antibody to rPIV reacted with PIV, but neither neutralized enzyme activity in vitro nor protected infected rabbits in vivo. CONCLUSIONS: The present study demonstrates that PIV is a virulence factor which can escape a protective immune response.

Effect of Sodium Chloride, pH and Temperature on Growth of Shigella flexneri.

A systematic study of the effect of sodium chloride (0.5, 2.0, 3.5, 5.0%), pH (7.5, 6.5, 5.5), and temperature (37, 28, 19, 10°C) on growth of Shigella flexneri is reported for the first time, using a factorial design. Experiments were done using Brain-Heart Infusion media inoculated to contain 1 × 103 cfu/ml and incubated on rotary shakers (150 rpm). Growth curves were plotted from the experimental data by means of the Gompertz equation, and growth rates, lag times, generation times, and maximum populations were derived for all variable combinations. Results indicated that the three variables interact to affect the growth of S. flexneri , and combinations of low temperature, low pH, and high sodium chloride contents are strongly inhibitory.