A Failure to Guide: Patient Experiences within a State-Run Cannabis Program in Pennsylvania, United States.

INTRODUCTION: Medical cannabis has been available for purchase in dispensaries in Pennsylvania, United States since April 2018. Patients wanting to access medical cannabis must receive certification from physicians for a limited number of physical and psychological conditions. Despite increasing numbers of patients using cannabis in the United States, little is known about the patient experience during certification and entry into state-regulated cannabis programs and how and if they are guided by health care professionals and dispensary staff. Through focus group discussions, we sought to capture patient perspectives of certification, cannabis acquisition and cannabis use. METHODS: Twenty-seven Pennsylvania participants took part in 7 virtual focus groups from June to July 2020. Participants were recruited statewide from the community, medical settings, and dispensaries. RESULTS: Focus group results indicate that while the medical cannabis program is functional, policymakers and the medical community have failed to meaningfully integrate cannabis into the health care system. Participants expressed frustration around two central themes: there was no overarching education about medical use of cannabis and there was little consistency and availability for people once they found a suitable product, resulting in inadequate symptom relief and exorbitant out of pocket costs to pursue cannabis use as an adjuvant therapeutic. Participants noted a siloed experience between the certification process, accessing dispensaries, and receiving ongoing medical care. The lack of integrated care required high levels of self-reliance and experimentation with medical cannabis for participants. CONCLUSION: We recommend that cannabis be better integrated into medical care for patients with qualifying conditions.

Beyond prophylaxis: Extended risk of venous thromboembolism following primary debulking surgery for ovarian cancer.

OBJECTIVE: To determine the incidence and risk factors for venous thromboembolism (VTE) within six months after primary debulking surgery (PDS) for epithelial ovarian cancer (EOC). METHODS: In a historical cohort, we estimated the cumulative incidence of clinically diagnosed VTE within 6 months among consecutive women who underwent PDS for EOC at a single institution from 1/1/2003 to 12/31/2011. We evaluated perioperative variables as potential risk factors of VTE within 6 months during the postoperative period using univariate and multivariable Cox proportional hazards models. RESULTS: Among 860 women without an immediate history (past 30 days) of a VTE, the cumulative incidence of VTE was 7.5% (95% CI, 5.7-9.3) by 30 days and 13.8% (95% CI, 11.4-16.2) by 6 months following surgery. Macroscopic residual disease (adjusted HR 1.99 [95% CI 1.35-2.94] vs microscopic), increasing estimated blood loss (1.25 [1.05-1.49] per doubling), longer hospital length of stay (3.00 [1.57-5.75]), and experiencing a cardiac event within 30 postoperative days (2.72 [1.55-4.80]) were independently associated with subsequent VTE within 6 months. In-hospital VTE prophylaxis included heterogeneous approaches; dual prophylaxis did not impact 30-day or 6-month VTE rates. CONCLUSIONS: VTE occurred in 1 in 7 women with EOC within 6 months of PDS-a substantial risk of VTE that extends into the adjuvant chemotherapy period. Novel prophylactic measures should be explored in these women at high risk for VTE.

Lyme Carditis Complicated by Polymorphic Ventricular Tachycardia and Cardiac Arrest: A Case Report.

Lyme disease is commonly encountered in endemic areas of the United States harboring the causal organism Borrelia burgdorferi. Lyme carditis can manifest in early disseminated infections, usually as atrioventricular nodal blockade. Timely antibiotic therapy typically suppresses myocardial inflammation and reverses cardiac conduction disturbances. We present a case of a previously healthy male who presented to the emergency department with non-prodromal syncope, multifocal annular rashes, and antecedent inflammatory knee pain and effusion, found to have positive 2-tier Lyme testing and pause-dependent polymorphic ventricular tachycardia leading to cardiac arrest. Lyme carditis occurs in early disseminated infections but rarely leads to cardiac arrest. Acute management is entrained in well-established guidelines for therapy, and together with risk stratification scoring can be considered by emergency care physicians in the workup of undifferentiated syncope with concern for Lyme disease with cardiac involvement.

Osteopathic Medical Licensing Compliance With the Americans With Disabilities Act of 1990.

CONTEXT: Physicians have an increased rate of depression and suicide compared with nonphysician peers. State medical licensure questions about mental health deter physicians from seeking mental health care. Several previous studies have examined state medical licensing board compliance with the Americans with Disabilities Act (ADA) of 1990, but none have included osteopathic licensing boards. OBJECTIVE: To evaluate compliance of state osteopathic medical licensing boards with ADA requirements regarding mental health. METHODS: State medical licensing applications for 51 states, including the District of Columbia (DC), and 16 states with osteopathic licensing entities were reviewed for ADA compliance in questions about mental health. In states where both osteopathic and allopathic applications were available, questions and compliance were compared. RESULTS: Fourteen of 51 states (including DC) were grossly out of compliance with ADA statutes. In states where osteopathic and allopathic licensing were both available, 7 of 16 asked different mental health questions of osteopathic physicians than their allopathic physician counterparts. Of those 7 states, 6 of the osteopathic boards were out of compliance with ADA, while their allopathic counterparts were either compliant or intermediately compliant. CONCLUSION: To improve physician wellbeing, corrective action must be taken to create ADA-compliant language in medical licensing so physicians can seek treatment for mental health conditions without discrimination by licensing boards. Osteopathic physicians should be aware that there is a discrepancy in state licensure compliance compared with allopathic requirements in some states.

Emergence of IgG3 alloantibody after renal transplantation associated with early graft failure.

In this small study, emergence of complement-fixing alloantibody in the early post-operative period was associated with clinical antibody-mediated rejection that required treatment. It appears that IgG3 alloantibody may be a significant determinant of poorer allograft outcome and failure to respond to PE therapy. Intuitively, it is reasonable that IgG3 may escalate the damage to an allograft over IgG1 alone due to its higher affinity for complement fixation. However, the inability to remove IgG3 by PE filtration was unexpected and may promote refractory rejection. On the other hand, the conversion of alloantibody to IgG2 among the Rescued group may be pivotal to their successful reversal of rejection. The clinical consequences of these atypical isotype presentations upon long-term renal allograft survival are unknown and warrant further study.

Comparison of two drug regimens upon clinical outcome among renal transplant recipients with positive flow cytometric crossmatches.

Renal transplant recipients with positive flow cytometric crossmatches (FCXM) face greater risk of early rejection and graft failure. It is clear that the pharmacologic needs of this high risk group have not been identified. We retrospectively compared the impact of two drug regimens upon early rejection and 5 yr actuarial survival among 324 primary cadaveric transplant recipients with positive and negative FCXM. Patients received either Regimen I (OKT3 induction, cyclosporine and steroids) or Regimen II (mycophenolate mofetil with cyclosporine or Prograf). Recipient gender, age, disease etiology, ethnic distribution and cytotoxic panel reactive antibody (PRA) were equivalent between regimens (p=ns). With Regimen I, the incidence of rejection was greater for FCXM positive vs. FCXM negative patients (51 vs. 21%, p=0.001). In contrast, with Regimen II the incidence of rejection for FCXM positive and FCXM negative patients was equivalent (18 vs. 12%, p=ns) and lower than patients treated with Regimen I (p < 0.01). Ethnic variation was only observed with Regimen I in which African Americans with positive FCXM had more rejections than Caucasians (60 vs. 45%, p < 0.05). Five-year actuarial survival was lower for FCXM positive vs. FCXM negative patients treated with Regimen I (40 vs. 75%, p=0.0006) or Regimen 2 (60 vs. 90%, p=0.001). Allograft survival was equivalent (p=ns) among FCXM positive individuals receiving Regimen I or II. However, allograft survival among FCXM negative individuals improved with Regimen II (p < 0.05). Ethnic variation in survival was not observed with either regimen (p=ns).