The Impact of Patient Access to Their Electronic Health Record on Medication Management Safety: A Narrative Review.

Introduction: As the American's Federal Health Insurance Portability and Accountability Act (HIPAA) stated that patients should be allowed to review their medical records, and as information technology is ever more widely used by healthcare professionals and patients, providing patients with online access to their own medical records through a patient portal is becoming increasingly popular. Previous research has been done regarding the impact on the quality and safety of patients' care, rather than explicitly on medication safety, when providing those patients with access to their electronic health records (EHRs). Aim: This narrative review aims to summarise the results from previous studies on the impact on medication management safety concepts of adult patients accessing information contained in their own EHRs. Result: A total of 24 studies were included in this review. The most two commonly studied measures of safety in medication management were: (a) medication adherence and (b) patient-reported experience. Other measures, such as: discrepancies, medication errors, appropriateness and Adverse Drug Events (ADEs) were the least studied. Conclusion: The results suggest that providing patients with access to their EHRs can improve medication management safety. Patients pointed out improvements to the safety of their medications and perceived stronger medication control. The data from these studies lay the foundation for future research.

Treatment of ocular-involving monkeypox virus with topical trifluridine and oral tecovirimat in the 2022 monkeypox virus outbreak.

Purpose: To report a case of ocular involving monkeypox infection in the United States during the 2022 outbreak, and to review the literature regarding its clinical manifestations and management known to date. Observations: A 36-year-old man with well controlled HIV presented to the emergency department with anal pain, diffuse rash, right eye pain, and right eye redness after he tested positive for monkeypox one week prior. Ocular examination showed bilateral periorbital vesicular lesions, right eye conjunctival injection, and a single white plaque on his right medial bulbar conjunctiva. Macular, vesicular, and pustular lesions were noted throughout his body, including the genital and perianal region. His ocular and systemic symptoms completely resolved after treatment with a ten-day course of 1% trifluridine and moxifloxacin drops in both eyes, as well as two weeks of oral tecovirimat. Conclusion and Importance: In July of 2022, monkeypox virus was declared a global health emergency by the World Health Organization; however, there are no standard guidelines for monkeypox treatment. Data on its clinical presentation and course, especially pertaining to ocular manifestations, is limited. We highlight the importance of recognizing ophthalmic manifestations of monkeypox virus and a possible therapeutic approach to help guide the management of these patients.

Stress, anxiety, and health-related quality of life in BRCA1/2-positive women with and without cancer: A comparison of four US female samples.

Introduction: Women with BRCA1/2 mutations have a 11-72% increased risk of breast/ovarian cancers throughout their lifetime. The current study examines psychosocial differences between the current sample of BRCA1/2-positive women with and without cancer histories and three comparable United States (US) female samples without BRCA1/2 mutations. Methods: Sixty BRCA1/2-positive women (with and without cancer histories) were recruited through multiple private online support groups in the US. Participants completed an online survey outlining sociodemographic and genetic counseling information, and anxiety, stress, and health-related quality of life (HRQoL) outcomes. Outcomes were compared to three similar US female normative samples via independent samples t-test analyses. Results: State and trait anxiety (p = 0.00) and stress (p = 0.001) were significantly worse in the current sample of BRCA1/2-positive women compared comparable US female samples. All HRQoL domains were significantly better in the current sample except energy/vitality, which was significantly lower (p = 0.02) in the current sample. Results were stratified by cancer and recurrence status. Conclusions: This study provides insight into how a sample of BRCA1/2-positive women both with and without cancer fare post-genetic counseling as compared to three normative female populations. Results infer the need for additional education, patient-provider training, and mental health referrals to support this population in order to circumvent unintended consequences and to improve psychosocial health in those being tested for, and those who test positive for, BRCA1/2 genetic mutations.

Perceptions and care Recommendations from Previvors: Qualitative analysis of female BRCA1/2 mutation Carriers' experience with genetic testing and counseling.

Introduction: It is estimated that 12.5% of women will be diagnosed with breast cancer and 1.10% with ovarian cancer during their lifetime. Although less common, women with these mutations have a 11-72% increased risk of breast/ovarian cancers and are hereditary. Genetic testing/counseling presents the opportunity to identify carriers of BRCA1/2 genetic mutations before a cancer diagnosis. Methods: Thirty-four BRCA1/2-positive women (with and without histories of breast/ovarian cancers) were recruited through online national support groups to gain a better understanding of their genetic testing/counseling perceptions and experiences. After confirming eligibility, they were invited to participate in either a telephone or webcam interview. Interview transcripts were analyzed using qualitative thematic text analysis and descriptive coding techniques. Results: Six major themes emerged, capturing the perceptions and experiences of genetic testing/counseling for these women: 1) Emotional Reactions to Results and Genetic Counseling, 2) Future Recommendations, 3) Family Solidarity and Support, 4) Experiences with the Healthcare System, 5) Preventive Concerns and Decisions, and 6) Sources Affecting Perceived Risk. Two subthemes also emerged within the first theme, which are termed "Pre-vivor," and "Testing Intuition." Conclusions: Participants indicated that genetic testing/counseling improvements would be helpful for women in this population surrounding quality care, including sensitivity training for healthcare professionals involved in testing/counseling, additional educational resources, and increased emotional and financial support. Although these recommendations may be beneficial, more widespread research with greater generalizability to disparate groups may be necessary prior to implementation.

The type 2 diabetes 'modern preventable pandemic' and replicable lessons from the COVID-19 crisis.

To frame the substantial prevalence of type 2 diabetes (T2D) as a 'Modern Preventable Pandemic' (MPP) and present certain replicable policy lessons from the COVID-19 crisis to address it. A literature and policy review was performed to analyze data about the COVID-19 and T2D pandemics to establish their multi-factorial health, social, and economic impacts. With the global prevalence of T2D tripling in the last two decades, T2D has become an MPP largely due to modifiable human behaviors. Certain successful elements of the response to the COVID-19 pandemic provide important lessons that can be adapted for the growing T2D MPP. With proper education and access to resources, it is possible to mitigate the T2D MPP through focused government policies as illustrated by many of the lessons of the COVID-19 pandemic response. Without such government intervention, the T2D MPP will continue to grow at an unsustainable pace with enormous health, social and economic implications. Immediate action is necessary. The scale of the T2D pandemic warrants a robust response in health policy as outlined through eight coordinated efforts; the lessons of the COVID-19 crisis should be studied and applied to the T2D MPP.

Disparities in access for melanoma screening by region, specialty, and insurance: A cross-sectional audit study.

Background: Early detection of melanoma is critical for positive outcomes. However, access for the diagnosis of melanoma remains problematic for segments of the general population. Objective: To compare the rates of dermatology and family medicine practitioner acceptances for a public insurance (Medicaid) versus private insurance (Anthem Blue Cross) and clinic wait times for an appointment for a changing pigmented skin lesion concerning melanoma in rural and urban regions in California. Methods: Cross-sectional audit study between June 2017 and March 2019; scripted phone calls were made to dermatology and family medicine practices (FMPs). Results: Family medicine and dermatology practices in both regions had significantly decreased acceptance of Medicaid. Dermatology practices had 11.3% to 13.0% Medicaid acceptance rates that were less than FMP rates of 28% to 36%. In both regions, FMP wait times were 2.4- to 3.2-fold longer for public versus private insurance; there were little differences in wait times for the 2 insurance types in dermatology practices, in both regions. Limitations: Assessment of only 2 regions in the state of California. Conclusion: Delays at FMPs and insurance types limit access to melanoma screening in California for underserved segments of the general population, which has implications for melanoma outcomes and health policy.

Diabetes care and its predictors among persons experiencing homelessness compared with domiciled adults with diabetes in New York City; An observational study.

Background: There is a dearth of data regarding diabetes control among patients experiencing homelessness. Methods: We retrospectively collected type 2 diabetes-related measurements, sociodemographic, and clinical indicators from medical records of all incoming adults with diabetes (n = 418; homeless: 356 and domiciled: 58) seen in shelter-clinics in New York City in 2019. The outcomes were the rates of inadequately managed diabetes and associated factors. Findings: Bivariate analysis showed that patients experiencing homelessness (63% Black; 32% Hispanic) 134/304 (43⋅9%) were more likely than domiciled patients 13/57 (22·8%) to have inadequately managed diabetes (OR 2⋅67, CI 1·38-5·16, p = 0⋅003). The average HbA1c among homeless (8·4%, SD± 2·6) was higher than that of domiciled persons (7·3%, SD± 1·8, p = 0·002). In logistic regression, domiciled status (OR 0⋅ 42, CI 0·21 - 0·84, p = 0·013), older age (OR 0·97, CI 0·95 - 0·99, p = 0·004), and non-Hispanic/Latino ethnicity were associated with well-managed diabetes. Among persons experiencing homelessness, non-Hispanic/Latino (OR 0·61, CI 0·37-0·99, p = 0·047) and older age (0·96, CI 0·94-0·99, p = 0·003) were associated with well-managed diabetes. In linear regression, mental illness (-0·11, p = 0·048) and older age (-0·15, p = 0·010) were associated with lower HbA1c, suggesting better support in respective shelters. There was no statistically significant association between inadequately managed diabetes with several traditional risk factors including substance or alcohol use disorder, health insurance, or other chronic diseases. Interpretation: Interventions at shelters or shelter-clinics should target subgroups in addition to addressing traditional risk factors to improve diabetes control. mHealth strategies could be considered to improve engagement, care delivery, and medication taking. Ultimately, homelessness itself needs to be addressed. Funding: There are no funding sources to declare.

Dural lymphoma misdiagnosed as subdural hematoma following head trauma after an episode of syncope.

Primary dural lymphoma is a rare subtype of primary central nervous system lymphoma. Primary dural lymphoma may be radiologically misdiagnosed as it shares similar imaging characteristics with several pathologies, including meningiomas and subdural or epidural hematomas. We present a patient who was originally diagnosed with a subdural hematoma following a syncopal episode on computed tomography. Follow-up magnetic resonance imaging of the brain demonstrated heterogeneously enhancing dural-based mass overlying the left frontoparietal convexity associated with bidirectional dural tails, suggestive of a malignant meningioma. Neurosurgical histopathology revealed marginal zone B-cell lymphoma. This case represents the potential difficulty in diagnosing primary dural lymphoma, especially in the setting of uncertain clinical history and obscured imaging features.

Estimated Public Health Impact of the Recombinant Zoster Vaccine.

OBJECTIVE: To investigate the potential public health impact of adult herpes zoster (HZ) vaccination with the adjuvanted recombinant zoster vaccine (RZV) in the United States in the first 15 years after launch. METHODS: We used a publicly available model accounting for national population characteristics and HZ epidemiological data, vaccine characteristics from clinical studies, and anticipated vaccine coverage with RZV after launch in 2018. Two scenarios were modeled: a scenario with RZV implemented with 65% coverage after 15 years and a scenario continuing with zoster vaccine live (ZVL) with coverage increasing 10% over the same period. We estimated the numbers vaccinated, and the clinical outcomes and health care use avoided yearly, from January 1, 2018, to December 31, 2032. We varied RZV coverage and investigated the associated impact on HZ cases, complications, and health care resource use. RESULTS: With RZV adoption, the numbers of individuals affected by HZ was predicted to progressively decline with an additional 4.6 million cumulative cases avoided if 65% vaccination with RZV was reached within 15 years. In the year 2032, it was predicted that an additional 1.3 million physicians' visits and 14.4 thousand hospitalizations could be avoided, compared with continuing with ZVL alone. These numbers could be reached 2 to 5 years earlier with 15% higher RZV vaccination rates. CONCLUSION: Substantial personal and health care burden can be alleviated when vaccination with RZV is adopted. The predicted numbers of HZ cases, complications, physicians' visits, and hospitalizations avoided, compared with continued ZVL vaccination, depends upon the RZV vaccination coverage achieved.

Cutaneous mucormycosis in a chronic lymphocytic leukemia patient on ibrutinib.

BACKGROUND: Mucorales is a zygomycete fungi known to cause opportunistic infections in immunosuppressed hosts. Spores may be inhaled, causing rhinocerebral or pulmonary infections, or gastrointestinal infections if swallowed. Less often, cutaneous mucormycosis develops after inoculation via broken skin. PRESENTATION: A 72-year old male on ibrutinib and prednisone for chronic lymphocytic leukemia (CLL) presented with localized, right forearm cutaneous mucormycosis at the site of a dog-scratch sustained three weeks prior. The patient failed to respond to cephalexin as an outpatient, prompting biopsy showing ribbon-like pseudo septate hyphae and possible vascular invasion suggestive of Mucorales. Treatment course included liposomal amphotericin B 5 mg/kg IV every 24 h for ten days followed by a 90-day course of posaconazole 300 mg daily after general surgery consultation was sought. CONCLUSION: We outline the second reported case of localized cutaneous mucormycosis arising in the setting of ibrutinib use. Because the combination of immunosuppressed states, ibrutinib and skin trauma may serve as a nidus for mucormycosis, practitioners should be vigilant of thorough skin evaluations in these patients and appropriate anti-fungal treatment. Although amphotericin B has been well studied as first line therapy, oral posaconazole has been shown as an efficacious second-line treatment.

Randomized controlled trial evaluating a collaborative model of care for transitioning children with medical complexity from hospital to home healthcare: Study protocol.

This article describes the study protocol for an evaluation of an innovative model of care that supports home health nurses (HHN) who serve children with medical complexity (CMC). CMC constitute a small proportion of children, but have very high need for health services, are hospitalized frequently, and account for significant proportion of pediatric healthcare expenditures. High-quality home health nursing services are important for CMC, but models of care of home healthcare, after discharge of CMC from the hospital, have not been tested. Our project aims are to develop, implement, and test a model of care, called ICollab, to improve home healthcare delivery for CMC. The ICollab model consists of collaboration between HHN, primary-care physicians and clinicians of the complex care program of a tertiary-care children's hospital in the care of CMC. In this randomized clinical trial, we will recruit 110 CMC discharged home on home health nursing services. The intervention group (n = 55) will receive the ICollab intervention for 6 months post-discharge from the hospital, in addition to usual care. Children in the control group (n = 55) will receive only usual care. Outcome measures will include healthcare utilization metrics (hospitalization rates, emergency room visit rates, and days to readmission), caregiver burden and caregiver satisfaction with home healthcare, HHN retention, and HHN collaboration with other healthcare providers. We hypothesize that ICollab will reduce healthcare utilization and caregiver burden, and improve caregiver satisfaction with home healthcare, increase HHN retention, and increase HHN collaboration with other healthcare providers. Results of this study have the potential to provide a critically needed evidence-base for interventions to improve the quality of healthcare delivery for CMC. This study is registered on clinicaltrials.gov (NCT03978468) and is ongoing.

Migraine-preventive prescription patterns by physician specialty in ambulatory care settings in the United States.

Many adults with migraine who require preventive therapy are often not prescribed the proper medications. The most likely reason is that primary care physicians are unacquainted with preventive medications for migraine. The present study assessed the migraine-preventive prescription patterns in office visits using data from the National Ambulatory Medical Care Survey from 2006 to 2009 in the United States. Patients who were 18 years or older and diagnosed with migraine were included in the analysis. In accordance with the recommendations of the headache guidelines, we included beta-blockers, antidepressants, triptans for short-term prevention of menstrual migraine, and other triptans for acute treatment. Weighted visits of adults with migraine prescribed with preventive medication ranged from 32.8% in 2006 to 38.6% in 2009. Visits to primary care physicians accounted for 72.6% of the analyzed adult migraine visits. Anticonvulsants (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.14-0.57, p < 0.001) and triptans for menstrual migraine (OR 0.50, 95% CI 0.28-0.91, p = 0.025) were less frequently prescribed by primary care physicians compared with specialty care physicians, such as neurologists and psychiatrists. There were no significant differences in the prescription patterns of antidepressants and beta-blockers between primary and specialty care physicians. Beta-blockers were prescribed to patients with comorbidity of hypertension, and antidepressants were used by patients with comorbidity of depression. There are differences in the prescription patterns of certain type of preventive medications between primary care physicians and specialty care physicians.

High Grade Mucinous Urothelial Carcinoma of the Renal Collecting System: A Case Report.

High grade mucinous urothelial carcinoma is a rare pathological variant. There is still controversy as to its nomenclature and classification. We report the case of a 64 year old female with history of pelvic pain who was incidentally discovered to have a left upper pole renal mass. Left nephroureterectomy was performed and histopathological examination revealed high grade mucinous urothelial carcinoma. Accurate diagnosis of this distinct pathological entity will allow for better understanding of phenotypic behavior and inform best treatment strategies.

The Effect of Older Age on EMS Use for Transportation to an Emergency Department.

Introduction Previous studies have found that older adults are more likely to use Emergency Medical Services (EMS) than younger adults, but the reasons for this remain understudied. Hypothesis/Problem This study aimed to determine if older age is associated with using EMS for transportation to an emergency department (ED) after controlling for confounding variables. METHODS: A cross-sectional survey study was conducted at a large academic medical center. Data on previous medical history, chief complaint, self-perceived illness severity, demographic information, and mode of arrival to the ED were collected on all subjects. Those who arrived to the ED via EMS also were asked reasons why they opted to call an ambulance for their illness/injury. Descriptive statistics were used to quantify survey responses, and multivariable regression was used to assess the independent effect of age on mode of ED arrival. RESULTS: Data from 1,058 subjects were analyzed, 449 (42%) of whom arrived to the ED via EMS. Compared to adults<55 years, the unadjusted prevalence ratio for the association between age and EMS use was 1.18 (95% CI, 0.96-1.45) for subjects 55-79 years and 1.54 (95% CI, 1.18-2.02) for subjects ≥80 years. After adjustment for confounding variables, age remained a statistically significant risk factor for EMS use (P<.05). CONCLUSION: Older age is an independent risk factor for transportation to the ED via ambulance; however, this effect is attenuated by number of chronic medical conditions and history of depression. Additional research is needed to account for confounders unmeasured in this study and to elucidate reasons for the increased frequency of EMS use among older adults. Jones CMC , Wasserman EB , Li T , Amidon A , Abbott M , Shah MN . The effect of older age on EMS use for transportation to an emergency department. Prehosp Disaster Med. 2017;32(3):261-268.

Visceral leishmaniasis in a patient with systemic lupus erythematosus.

Visceral leishmaniasis is an infection with an insidious and disabling course caused by parasites of the genus Leishmania. In Europe, it is mostly associated with HIV infection. Systemic lupus erythematosus and its treatment are associated with increased risk of infection, neoplastic and concomitant autoimmune disorders. The association of these diseases may go unnoticed. A 60 year-old Caucasian woman with lupus presented with a one-year history of fever, malaise, weakness and weight loss. The highlights on physical examination were pallor, palpable hepatosplenomegaly and low-grade fever. Blood tests showed pancytopenia, hyperproteinemia with hypoalbuminemia and hypergammaglobulinemia; electrophoresis showed a polyclonal gamma curve. Full-body CT scan revealed massive hepatosplenomegaly. Microbiology investigation was negative for the most common pathogens, including tuberculosis. There were no signs of hematologic malignancy in the bone marrow smear. PCR for Leishmania infantum was positive both in blood and bone marrow. The patient was treated with liposomal amphotericin B, and immunosuppression was adjusted. She showed rapid clinical improvement and 6 months later had no signs of disease. The differential diagnosis in a patient with lupus presenting with fever and multisystemic manifestations includes infectious or neoplastic disorders. The patient lived in an endemic area of Leishmania, and typical clinical and analytical changes were all present, making this case highly educational. The case highlights the importance of a patient's epidemiological background and how it can lead to the diagnosis and timely treatment of a rare disease.