Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center.

Background: Veterans suffer substantial morbidity and mortality from lung cancer. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce mortality. Guidelines recommend counseling and shared decision-making (SDM) to address the benefits and harms of screening and the importance of tobacco cessation before patients undergo screening. Observations: We implemented a centralized LCS program at the Iowa City Veterans Affairs Medical Center with a nurse program coordinator (NPC)-led telephone visit. Our multidisciplinary team ensured that veterans referred from primary care met eligibility criteria, that LDCT results were correctly coded by radiology, and that pulmonary promptly evaluated abnormal LDCT. The NPC mailed a decision aid to the veteran and scheduled a SDM telephone visit. We surveyed veterans after the visit using validated measures to assess knowledge, decisional conflict, and quality of decision making. We conducted 105 SDM visits, and 91 veterans agreed to LDCT. Overall, 84% of veterans reported no decisional conflict, and 59% reported high-quality decision making. While most veterans correctly answered questions about the harms of radiation, false-positive results, and overdiagnosis, few knew when to stop screening, and most overestimated the benefit of screening and the predictive value of an abnormal scan. Tobacco cessation interventions were offered to 72 currently smoking veterans. Conclusions: We successfully implemented an LCS program that provides SDM and tobacco cessation support using a centralized telehealth model. While veterans were confident about screening decisions, knowledge testing indicated important deficits, and many did not engage meaningfully in SDM. Clinicians should frame the decision as patient centered at the time of referral, highlight the importance of SDM, and be able to provide adequate decision support.

mtDNA Single-Nucleotide Variants Associated with Type 2 Diabetes.

Type 2 diabetes (T2D) is a chronic systemic disease with a complex etiology, characterized by insulin resistance and mitochondrial dysfunction in various cell tissues. To explore this relationship, we conducted a secondary analysis of complete mtDNA sequences from 1261 T2D patients and 1105 control individuals. Our findings revealed significant associations between certain single-nucleotide polymorphisms (SNPs) and T2D. Notably, the variants m.1438A>G (rs2001030) (controls: 32 [27.6%], T2D: 84 [72.4%]; OR: 2.46; 95%CI: 1.64-3.78; p < 0.001), m.14766C>T (rs193302980) (controls: 498 [36.9%], T2D: 853 [63.1%]; OR: 2.57, 95%CI: 2.18-3.04, p < 0.001), and m.16519T>C (rs3937033) (controls: 363 [43.4%], T2D: 474 [56.6%]; OR: 1.24, 95%CI: 1.05-1.47, p = 0.012) were significantly associated with the likelihood of developing diabetes. The variant m.16189T>C (rs28693675), which has been previously documented in several studies across diverse populations, showed no association with T2D in our analysis (controls: 148 [13.39] T2D: 171 [13.56%]; OR: 1.03; 95%CI: 0.815-1.31; p = 0.83). These results provide evidence suggesting a link between specific mtDNA polymorphisms and T2D, possibly related to association rules, topological patterns, and three-dimensional conformations associated with regions where changes occur, rather than specific point mutations in the sequence.

Combined Endoscopic Laser and Cryotherapy Management of Pediatric Central Airway Obstruction Secondary to a Histoplasmosis-Related Broncholith.

Broncholithiasis due to pulmonary histoplasmosis causing central airway obstruction and broncho-mediastinal fistula is a rare complication in the pediatric population. A 16-year-old previously healthy female was referred to a university hospital for worsening cough and shortness of breath for over a two-year period. Radiologic investigation revealed a calcified subcarinal lymph node eroding into the left mainstem bronchus causing central airway obstruction and collapse of the left lower lobe. Direct laryngoscopy and bronchoscopy showed a large obstructive lesion in the left mainstem bronchus. Debulking of the endobronchial lesion was performed with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and cryotherapy. Pathology examination was consistent with broncholith. Great clinical and radiological response to the procedure was evident with complete re-expansion of the left lung and resolution of symptoms.

Disseminated fungal infection in a patient receiving zanubrutinib.

We report a case of fatal disseminated aspergillosis in the setting of administration of zanubrutinib, a second-generation Bruton's tyrosine kinase inhibitor thought to have a lower rate of immunosuppression-related side effects.

Predictores del uso problemático del teléfono celular en adolescentes costarricenses

(analítico) Este artículo tiene por objetivo investigar los efectos del apoyo familiar y del grupo de pares, junto con la satisfacción con la vida, sobre el uso problemático de los teléfonos celulares entre los adolescentes costarricenses. Basado en datos de la encuesta nacional Global Kids Online, se desarrollaron modelos de ecuaciones estructurales para predecir el uso problemático de teléfonos celulares de adolescentes (M = 14.8, n = 530). Los resultados muestran que el apoyo entre pares correlaciona positiva y directamente con el uso problemático del teléfono celular, mientras que la percepción de la satisfacción con la vida tiene una correlación opuesta, funcionando como un factor protector. El apoyo del grupo de pares y, más aún, el apoyo familiar, ejercen efectos indirectos sobre el uso problemático del teléfono móvil.

(analytical) This study aimed to research the effects of family support and peer group support, along with the life satisfaction, on the problematic use of cell phones among costa rican adolescents. Based on data from the national survey Global Kids Online, structural equation models were developed in order to predict the problematic use of cell phones of adolescents investigated in this study (M=14.8, n = 530). The main findings indicate that peer support has a positive and direct correlation with the problematic use of the cell phone, while the perception of the life satisfaction is correlated in the opposite direction, functioning as a protective factor. Peer and family support have an indirect protective effect against the problematic use of cell phones, stronger in the case of family support.

(analítico) Este estudo teve como objetivo pesquisar os efeitos do apoio familiar e do grupo de pares, juntamente com a satisfação com a vida, no uso problemático de telefones celulares entre adolescentes costarriquenhos. Com base nos dados da pesquisa nacional Global Kids Online, foram desenvolvidos modelos de equações estruturais para prever o uso problemático de celulares dos adolescentes investigados neste estudo (13 a 17 anos; n = 530). Os principais achados indicam correlação positiva e direta do apoio dos pares com o uso problemático do celular, enquanto a perceção da satisfação com a vida está correlacionada de maneira inversa, funcionando como fator de proteção. O apoio dos pares e da família tem um efeito protetor indireto contra o uso problemático de telefones celulares, mais forte no caso do apoio familiar.

Timely Curative Treatment and Overall Mortality Among Veterans With Stage I NSCLC.

Introduction: Early stage lung cancer (LC) outcomes depend on the receipt of timely therapy. We aimed to determine the proportions of Veterans with stage I NSCLC in the age group eligible for LC screening (LCS) receiving timely curative treatment (≤12 wk after diagnosis), the factors associated with timely treatment and modality, and the factors associated with overall mortality. Methods: Retrospective cohort study in Veterans aged 55 to 80 years when diagnosed with stage I NSCLC during 2011 to 2015. We used multivariate logistic regression models to determine factors associated with receiving timely therapy and receiving surgery versus stereotactic body radiation therapy (SBRT). We used multivariate Cox proportional hazards regression analysis to determine factors associated with overall mortality. Results: We identified 4796 Veterans with stage I NSCLC; the cohort was predominantly older, White males, current or former smokers, and living in urban areas. Overall, 84% underwent surgery and 16% underwent SBRT. The median time to treatment was 63 days (61 d for surgery; 71 d for SBRT), with 30% treated more than 12 weeks. Unmarried Veterans with higher social deprivation index were less likely to receive timely therapy. Black race, female sex, and never smoking were associated with lower overall mortality. Older Veterans receiving treatment >12 wk, with higher comorbidity index, and squamous cell carcinoma had higher overall mortality. Conclusions: A total of 30% of the Veterans with stage I NSCLC in the age group eligible for LCS received curative treatment more than 12 weeks after diagnosis, which was associated with higher overall mortality. Delays in LC treatment could decrease the mortality benefits of LCS among the Veterans.

Colostomy as a definitive treatment in an ALS patient with acute colonic Pseudo-obstruction refractory to medical management, a case report.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a fatal motor neuron disease, and ALS patients may experience disturbed gastrointestinal motility often resulting in acute colonic pseudo-obstruction (ACPO). There is currently a paucity in the literature to guide the treatment of patients with both ALS and ACPO. CASE PRESENTATION: Here we describe a 39-year-old male patient with advanced ALS who developed ACPO. His condition was refractory to both medical and procedural managements including polyethylene glycol, senna, and docusate suppository, metoclopramide, linaclotide, erythromycin, prucalopride, neostigmine, and repeated colonoscopies. He ultimately underwent successful colostomy for palliation. Here we report the peri-operative multidisciplinary approach taken with this case, the surgical procedures, the potential risks, and the outcome. CONCLUSION: The patient is delighted with the result and requested publication of this case to raise awareness of constipation in ALS patients and promote the consideration of colostomy as a treatment option for patients with ileus resistant to conservative management. Ultimately, a multidisciplinary team approach is required to properly assess the risks and benefits to achieve good clinical outcomes.

A 28-Year-Old Pregnant Woman With a Lung Abscess and Complicated Pleural Effusion.

CASE PRESENTATION: A 28-year-old woman G1P0 at 22 weeks of gestation and with no significant medical history presented to the ED complaining of worsening dyspnea and right-sided pleuritic chest pain. Symptoms started 2 weeks before presentation, with minimal productive cough and dyspnea on exertion. One week after the initial symptoms, the patient started noticing right-sided chest and shoulder pain along with subjective fevers and night sweats. She denied hemoptysis, weight loss, abdominal pain, diarrhea, nausea, vomiting, arthralgia, or rash. Her pregnancy had so far been uncomplicated. The patient did not use tobacco, alcohol, or recreational drugs. She worked at a daycare center but denied any particular sick contacts. She moved to the United States 7 years ago from Sudan and denied any recent travel.

Applying a Text-Search Algorithm to Radiology Reports Can Find More Patients With Pulmonary Nodules Than Radiology Coding Alone.

INTRODUCTION: Chest imaging often incidentally finds indeterminate nodules that need to be monitored to ensure early detection of lung cancers. Health care systems need effective approaches for identifying these lung nodules. We compared the diagnostic performance of 2 approaches for identifying patients with lung nodules on imaging studies (chest/abdomen): (1) relying on radiologists to code imaging studies with lung nodules; and (2) applying a text search algorithm to identify references to lung nodules in radiology reports. METHODS: We assessed all radiology studies performed between January 1, 2016 and November 30, 2016 in a single Veterans Health Administration hospital. We first identified imaging reports with a diagnostic code for a pulmonary nodule. We then applied a text search algorithm to identify imaging reports with key words associated with lung nodules. We reviewed medical records for all patients with a suspicious radiology report based on either search strategy to confirm the presence of a lung nodule. We calculated the yield and the positive predictive value (PPV) of each search strategy for finding pulmonary nodules. RESULTS: We identified 12,983 imaging studies with a potential lung nodule. Chart review confirmed 8,516 imaging studies with lung nodules, representing 2,912 unique patients. The text search algorithm identified all the patients with lung nodules identified by the radiology coding (n = 1,251) as well as an additional 1,661 patients. The PPV of the text search was 72% (2,912/4,071) and the PPV of the radiology code was 92% (1,251/1,363). Among the patients with nodules missed by radiology coding but identified by the text search algorithm, 130 had lung nodules > 8 mm in diameter. CONCLUSIONS: The text search algorithm can identify additional patients with lung nodules compared to the radiology coding; however, this strategy requires substantial clinical review time to confirm nodules. Health care systems adopting nodule-tracking approaches should recognize that relying only on radiology coding might miss clinically important nodules.

Lung Cancer Staging at Diagnosis in the Veterans Health Administration: Is Rurality an Influencing Factor? A Cross-Sectional Study.

PURPOSE: To evaluate the association between rurality and lung cancer stage at diagnosis. METHODS: We conducted a cross-sectional study using Veterans Health Administration (VHA) data to identify veterans newly diagnosed with lung cancer between October 1, 2011 and September 30, 2015. We defined rurality, based on place of residence, using Rural-Urban Commuting Area (RUCA) codes with the subcategories of urban, large rural, small rural, and isolated. We used multivariable logistic regression models to determine associations between rurality and stage at diagnosis, adjusting for sociodemographic and clinical characteristics. We also analyzed data using the RUCA code for patients' assigned primary care sites and driving distances to primary care clinics and medical centers. FINDINGS: We identified 4,220 veterans with small cell lung cancer (SCLC) and 25,978 with non-small cell lung cancer (NSCLC). Large rural residence (compared to urban) was associated with early-stage diagnosis of NSCLC (OR = 1.12; 95% CI: 1.00-1.24) and SCLC (OR = 1.73; 95% CI: 1.18-1.55). However, the finding was significant only in the southern and western regions of the country. White race, female sex, chronic lung disease, higher comorbidity, receiving primary care, being a former tobacco user, and more recent year of diagnosis were also associated with diagnosing early-stage NSCLC. Driving distance to medical centers was inversely associated with late-stage NSCLC diagnoses, particularly for large rural areas. CONCLUSIONS: We did not find clear associations between rurality and lung cancer stage at diagnosis. These findings highlight the complex relationship between rurality and lung cancer within VHA, suggesting access to care cannot be fully captured by current rurality codes.

Genetic differentiation and diversity of the Bolivian endemic titi monkeys, Plecturocebus modestus and Plecturocebus olallae.

The genetic variability of New World primates is still poorly documented. We present the first genetic study on two threatened endemic titi monkey species in northern Bolivia (Plecturocebus modestus and Plecturocebus olallae) using six microsatellite markers to investigate genetic structure and variability of 54 individuals from two wild populations. A low level of genetic diversity was found (34 alleles in the total sampled population). Locus 1118 presented the greatest number of alleles. The mean number of alleles per locus in the total population was 5.6 and the average heterozygosity was 0.38 (range 0.12-0.88). The FIS value for the total population using all microsatellite loci shows a statistically significant heterozygote deficit. The inbreeding coefficients (FIS) were positive and significantly different from zero (0.064 for P. olallae and 0.213 for P. modestus). The genetic differentiation between populations (FST) was moderate with a pair-wise FST estimate of 0.14. Population structure analyses assigned the two populations to two differentiated clusters (K = 2). These results suggest that these two species with very close distributional ranges arose from a single population, and that they remain in a process of genetic differentiation and speciation. This study further underlines the urgent need for conservation actions for both endemic primate species.

Efficacy of a Lupinus mutabilis Sweet snack as complement to conventional type 2 diabetes mellitus treatment.

INTRODUCTION: Introduction: therapeutic lifestyles changes including frequent consumption of legumes have resulted in improved metabolic control and decreased blood pressure in type 2 diabetes-mellitus (T2DM) patients. Objective: this was a quasi-experimental-28-week crossover-study that assessed the effect of daily consumption of the legume Lupinus mutabilis (LM) on metabolic control of T2DM patients under hypoglycemic oral treatment. Material and methods: we recruited 79 adult male and female patients that were followed for 14-weeks without LM consumption and then received increasing doses of a LM-based-snack for other 14-weeks. Results: there was a significant decrease in blood pressure and a significant increase in HDL-cholesterol by the end of the study period. While patients with A1C concentrations > 8 and ≤ 10 did not significantly improve their metabolic control, patients with serum A1C concentrations ≤ 8.0% reduced significantly their A1C after the intervention and 71% achieved a target concentration of 6.5%. Conclusion: patients with T2DM could benefit with the addition of LM-snack to their conventional treatment.

INTRODUCCIÓN: Introducción: los cambios recomendados sobre los estilos de vida, incluido el consumo frecuente de leguminosas, han resultado en un mejor control metabólico y disminución de la presión arterial en pacientes con diabetes mellitus tipo 2 (DMT2). Objetivo: este fue un estudio casi experimental cruzado de 28 semanas que evaluó el efecto del consumo diario de la leguminosa Lupinus mutabilis Sweet (LM) en el control metabólico de pacientes con DMT2 con tratamiento oral hipoglucemiante. Material y métodos: inicialmente se reclutaron 79 pacientes adultos, hombres y mujeres, que fueron seguidos durante 14 semanas sin consumo de LM y luego recibieron dosis crecientes de un tentempié de LM durante otras 14 semanas. Resultados: se observó una disminución significativa en la presión arterial y un aumento significativo en el colesterol-HDL después del consumo de LM. Mientras que los pacientes con concentraciones de A1C sérica > 8 y ≤ 10 no mejoraron significativamente su control metabólico, los pacientes con concentraciones séricas de A1C ≤ 8,0% redujeron significativamente su A1C después de la intervención y el 71% de estos pacientes llegó a la meta de tratamiento ≤ 6,5%. Conclusión: los pacientes con DMT2 podrían beneficiarse con la adición de un tentempié de LM a su tratamiento convencional.

Post-imaging pulmonary nodule mathematical prediction models: are they clinically relevant?

OBJECTIVES: Post-imaging mathematical prediction models (MPMs) provide guidance for the management of solid pulmonary nodules by providing a lung cancer risk score from demographic and radiologists-indicated imaging characteristics. We hypothesized calibrating the MPM risk score threshold to a local study cohort would result in improved performance over the original recommended MPM thresholds. We compared the pre- and post-calibration performance of four MPM models and determined if improvement in MPM prediction occurs as nodules are imaged longitudinally. MATERIALS AND METHODS: A common cohort of 317 individuals with computed tomography-detected, solid nodules (80 malignant, 237 benign) were used to evaluate the MPM performance. We created a web-based application for this study that allows others to easily calibrate thresholds and analyze the performance of MPMs on their local cohort. Thirty patients with repeated imaging were tested for improved performance longitudinally. RESULTS: Using calibrated thresholds, Mayo Clinic and Brock University (BU) MPMs performed the best (AUC = 0.63, 0.61) compared to the Veteran's Affairs (0.51) and Peking University (0.55). Only BU had consensus with the original MPM threshold; the other calibrated thresholds improved MPM accuracy. No significant improvements in accuracy were found longitudinally between time points. CONCLUSIONS: Calibration to a common cohort can select the best-performing MPM for your institution. Without calibration, BU has the most stable performance in solid nodules ≥ 8 mm but has only moderate potential to refine subjects into appropriate workup. Application of MPM is recommended only at initial evaluation as no increase in accuracy was achieved over time. KEY POINTS: • Post-imaging lung cancer risk mathematical predication models (MPMs) perform poorly on local populations without calibration. • An application is provided to facilitate calibration to new study cohorts: the Mayo Clinic model, the U.S. Department of Veteran's Affairs model, the Brock University model, and the Peking University model. • No significant improvement in risk prediction occurred in nodules with repeated imaging sessions, indicating the potential value of risk prediction application is limited to the initial evaluation.

Disseminated pulmonary histoplasmosis in immunocompetent patients: a common epidemiological exposure.

We describe the initial presentation, diagnostic work-up and treatment of three adult immunocompetent men who presented within a short time frame of each other to an academic medical centre with acute respiratory distress syndrome. Their presentation was found to be secondary to a large inoculum of histoplasmosis from remodelling a building with bat droppings infestation. We discuss the pathophysiology of histoplasmosis and highlight the importance of exposure history in patients with acute respiratory failure and why patients with the occupational risk of exposure to fungal inoculum should wear protective respirator gear.

Differentiation of non-small cell lung cancer and histoplasmosis pulmonary nodules: insights from radiomics model performance compared with clinician observers.

BACKGROUND: Histoplasmosis pulmonary nodules often present in computed tomography (CT) imaging with characteristics suspicious for lung cancer. This presents a work-up decision issue for clinicians in regions where histoplasmosis is an endemic fungal infection, when a nodule suspicious for lung cancer is detected. We hypothesize the application of radiomic features extracted from pulmonary nodules and perinodular parenchyma could accurately distinguish between suspicious histoplasmosis lung nodules and non-small cell lung cancer (NSCLC). METHODS: A retrospective clinical cohort of pulmonary nodules with a confirmed diagnosis of histoplasmosis or NSCLC was collected from the University of Iowa Hospitals and Clincs. Radiomic features were extracted describing characteristics of the nodule and perinodular parenchyma regions and used to build a machine learning tool. These cases were assessed by four expert clinicians who gave a blinded risk prediction for NSCLC. Tool and observer performance were assessed by calculating the area under the curve for the receiver operating characteristic (AUC-ROC) and interclass correlation coefficient (ICC). RESULTS: A cohort of 71 subjects with confirmed histopathology (40 NSCLC, 31 histoplasmosis) were case-matched based on age, sex, and smoking history. Superior performance (AUC-ROC =0.89) was demonstrated using leave-one-subject out validation in the tool that incorporated radiomics from the nodule and perinodular parenchyma region extended to 100% nodule diameter. Observers had perfect intra-repeatability (ICC =1.0) and demonstrated fair inter-reader variability (ICC =0.52). CONCLUSIONS: Radiomics have potential utility in the challenging task of differentiation between lung cancer and histoplasmosis. Expert clinician readers have high intra-repeatability but demonstrated inter-reader variability which could provide context for a supplemental radiomics-based tool.

Large endotracheal tumour presenting as severe COPD: flow-volume loop analysis, not always a straightforward diagnostic test.

The flow-volume loop (FVL) analysis is typically helpful in establishing the diagnosis of airway obstruction caused by endobronchial lesions. In this report, we describe a patient with emphysema and tobacco abuse who presented with chronic dry cough and severe chronic obstructive pulmonary disease (COPD) refractory to standard therapy. The initial FVL showed a relatively normal forced expiratory peak flow shape followed by a smooth flattening of the expiratory curve on spirometry, a pattern consistent with distal airway obstruction as seen in severe asthma or COPD. The patient was later found to have a large endotracheal mass. This atypical presentation, along with the unusual FVL, led to a significant delay in the diagnosis of the tracheal mass. A high level of suspicion is needed to diagnose variable intrathoracic airway obstruction in patients presenting with severe asthma or COPD who fail to improve with standard therapy.

Fear of Crime and Cultivation Effect. Social and Psychological Predictors / Miedo al crimen y efecto de cultivo. Predictores sociales y psicológicos

Abstract Within the framework of the study of cultivation, the present research attempts to study the association between general TV consumption, particular TV news, and fear of crime. The analysis considers narrative transportation and system justification as psychological predictor variables; in addition, sex, level of crime in the area of residence, and social class as social covariates. Participants were 516 young (M = 20.5 years, SD = 4.7) Costa Ricans. A hierarchical regression analysis (stepwise) was conducted. Results indicated that people who experienced more narrative transportation, less system justification, women, and low social class, have higher levels of fear of crime. Results are discussed from the need to expand the cultivation hypothesis of fear of crime.

Resumen En el marco de la teoría del cultivo, la presente investigación estudia la asociación entre el consumo general de televisión, noticias televisivas y el miedo al crimen. El análisis considera el transporte narrativo y la justificación del sistema como variables predictoras psicológicas; además, el sexo, el nivel de delincuencia en el área de residencia y la clase social como covariables sociales. Los participantes fueron 516 jóvenes costarricenses (M = 20.5 años, DE = 4.7). Se realizó un análisis de regresión jerárquica (stepwise). Los resultados indican que las personas que experimentaron más transporte narrativo, menos justificación del sistema, las mujeres y la clase social baja tienen mayores niveles de miedo al crimen. Se discuten los resultados a partir de la necesidad de ampliar la hipótesis de cultivo del miedo al crimen.