A 50-year-old refugee woman with a lithopedion and a lifetime of trauma: a case report.

BACKGROUND: Lithopedion is a term that refers to a fetus that has calcified or changed to bone. The calcification may involve the fetus, membranes, placenta, or any combination of these structures. It is an extremely rare complication of pregnancy and can remain asymptomatic or present with gastrointestinal and/or genitourinary symptoms. CASE PRESENTATION: A 50-year-old Congolese refugee with a nine-year history of retained fetus after a fetal demise was resettled to the United States (U.S.). She had chronic symptoms of abdominal pain and discomfort, dyspepsia, and gurgling sensation after eating. She experienced stigmatization from healthcare professionals in Tanzania at the time of the fetal demise and subsequently avoided healthcare interaction whenever possible. Upon arrival to the U.S., evaluation of her abdominal mass included abdominopelvic imaging which confirmed the diagnosis of lithopedion. She was referred to gynecologic oncology for surgical consultation given intermittent bowel obstruction from underlying abdominal mass. However, she declined intervention due to fear of surgery and elected for symptom monitoring. Unfortunately, she passed away due to severe malnutrition in the context of recurrent bowel obstruction due to the lithopedion and continued fear of seeking medical care. CONCLUSION: This case demonstrated a rare medical phenomenon and the impact of medical distrust, poor health awareness, and limited access to healthcare among populations most likely to be affected by a lithopedion. This case highlighted the need for a community care model to bridge the gap between the healthcare team and newly resettled refugees.

Pharmacy on-site overdose protocols and prevention of overdose.

BACKGROUND: Opioid overdose is a preventable injury leading to high morbidity and premature mortality in communities across the United States. Overdoses take place where people use drugs, including commercial and public locations like community pharmacies, and necessitate swift detection and response to avoid harm and, even more seriously, death. The presence of emergency and safety protocols improves occupational health and safety for all in the workplace. The aim of this study was to assess the prevalence of experience with on-site pharmacy overdose and to explore pharmacist and site characteristics associated with having a known protocol for responding to on-site overdose emergencies.Methods: An anonymous, online survey about naloxone provision and opioid safety was delivered by email, through professional pharmacy associations and continuing education attendance lists, to 3,100 pharmacists in Massachusetts and Rhode Island between October 2017 and January 2018. Survey items gauged socio-demographics, practice site characteristics, safer opioid dispensing and naloxone provision. Summary statistics and bivariate analyses were conducted to describe characteristics associated with items pertaining to on-site overdose policy awareness.Results: Of the 357 respondents (11.5% response rate), 154 (5.0%) answered the questions of interest: 17.5% reported having at least one suspected overdose on-site at their practice location, while 42.9% reported that they were knowledgeable about and could locate at their practice location an on-site overdose protocol detailing how to respond to an overdose. Pharmacists who were knowledgeable about protocols were also more likely to offer naloxone to patients (p = 0.02) and did not practice at a chain pharmacy (p = 0.01).Conclusions: Community pharmacies that stock and distribute naloxone are key parts of community efforts to address the opioid crisis. Pharmacies and other healthcare settings should develop and implement on-site overdose response protocols and cultivate a norm of naloxone provision to patients.

Calcium Intake and Iron Status in Human Studies: A Systematic Review and Dose-Response Meta-Analysis of Randomized Trials and Crossover Studies.

BACKGROUND: The interaction between dietary (and supplementary) divalent ions has been a long-standing issue in human nutrition research. Developing an optimal calcium and iron supplementation recommendation requires detailed knowledge of the potential trade-offs between: 1) the clinical effects of concurrent intake on iron absorption and hematological indices; and 2) the potentially negative effects of separated ingestion on adherence to iron and/or calcium supplements. Human clinical studies have examined the effects of calcium intake on iron status, but there are no meta-analyses or recent reviews summarizing the findings. OBJECTIVES: To synthesize peer-reviewed, human, randomized, and cross-over studies on effects of calcium consumption on iron indices without age, gender, or any other restrictions. METHODS: Weighted mean differences for total, heme, and nonheme iron absorption (%) and serum ferritin (µg/L) were obtained from pooled analysis of the highest daily calcium intake compared to the lowest daily calcium intake. RESULTS: The negative effect of calcium intake was statistically significant in short-term iron absorption studies, but the effect magnitude was low [weighted mean difference (WMD) = -5.57%; 95% CI: -7.09 to -4.04]. The effect of calcium on the iron status was mixed. The inverse dose-response association of calcium intake with the serum ferritin concentration was significant (P value = 0.0004). There was, however, no reduction in the hemoglobin concentration (WMD = 1.22g/L;  95% CI:  0.37-2.07). CONCLUSIONS: The existing body of studies is insufficient to make recommendations with high confidence due to heterogeneity in designs, limitations of ferritin as an iron biomarker, and a lack of intake studies in pregnant women. Prescribing separation of prenatal calcium and iron supplements in free-living individuals is unlikely to affect the anemia burden. There is a need for effectiveness trials comparing the effects of prescribing separated intake to concurrent intake, with functional endpoints as primary outcomes and adherence to each supplement as intermediate outcomes.

Pharmacist attitudes toward pharmacy-based naloxone: A cross-sectional survey study.

OBJECTIVE: The aim of this study was to evaluate pharmacist attitudes regarding recommending pharmacy-based naloxone (PBN). The influence of gender, practice setting, the number of years of practice, state, and PBN involvement were explored. Barriers to, and facilitators of, provision of PBN were also assessed. DESIGN: A 71-question survey was designed to assess experience with, and attitudes toward, PBN. We employed a cross-sectional study design and utilized the online survey site Qualtrics (Qualtrics International Inc, Provo, UT). SETTING AND PARTICIPANTS: The survey was e-mailed to approximately 2900 licensed pharmacists from all practice settings in Massachusetts (approximately 1400) and Rhode Island (approximately 1500) and was open from April 5, 2016, until July 13, 2016. OUTCOME MEASURES: Attitudes toward opioid overdose prevention (12 questions) were used to develop the Opioid Overdose Prevention Attitude (OOPA) scale which consisted of 3 subscales: Opioid Overdose Prevention Attitude, Public Health Attitude, and Naloxone Dispensing Attitude. RESULTS: Of the approximately 2900 pharmacists who received the survey, 402 responded (13%), and 245 (137 from Massachusetts and 108 from Rhode Island) were included in the analyses. The majority (79%) identified as White or Caucasian, and 127 (51.8%) stated they had ever dispensed naloxone. Of those, 85 (67%) had done so in the past 30 days. We examined differences in the OOPA subscales by pharmacists' characteristics and pharmacy practice settings. Working in a pharmacy that had a standing order or collaborative practice agreement allowing pharmacists to dispense naloxone without a physician's prescription, or in a pharmacy that stocked naloxone resulted in more positive attitudes toward opioid overdose prevention and public health prevention. CONCLUSION: Respondents who practiced in a pharmacy with a standing order or collaborative practice agreement were more likely to have dispensed naloxone. Both stocking naloxone and ever having dispensed naloxone were associated with higher OOPA scores. More research is needed to better understand how pharmacist attitudes influence the distribution of naloxone.

Current trends in hospice care usage for dialysis patients in the USA.

BACKGROUND: The predictors and latest trends in hospice utilization, adequate duration of hospice care, and dialysis discontinuation without hospice enrollment among patients with end stage kidney disease are not fully known; the aim of this study was to assess them, analysing data from the United States Renal Data System. METHODS: Data from the United States Renal Data System for patients with kidney failure who died between January 1, 2012, and December 31, 2019, were analyzed. Chi-square and logistic regression were used to evaluate associations between outcomes of interest and predictors, while Joinpoint regression was used to examine trends. RESULTS: Among 803,049 patients, the median (IQR) age was 71 (17) years, 57% were male, 27% enrolled in hospice, 8% discontinued dialysis before death without hospice enrollment, and 7% remained in hospice for ≥ 15 days. Patients 65 years and older (adjusted odds ratio [aOR]: 2.75, 95% CI 2.71-2.79) and White race (aOR: 1.79, 95% CI 1.77-1.81) were more likely to enroll in hospice. White patients (aOR: 0.75, 95% CI 0.73-0.76) and those who never received a kidney transplant (aOR: 0.75, 95% CI 0.73-0.78) were less likely to have adequate duration of hospice care. Hospice enrollment and standardized duration of hospice care increased over time, with an average annual percentage change of 1.1% (95% CI 0.6-1.6) and 5% (95% CI 2.6-7.4), respectively. CONCLUSIONS: Approximately one in every four patients with kidney failure who died between 2012 and 2019 had a history of hospice enrollment, while one in every 12 discontinued dialysis before death without hospice enrollment. There was an upward trend in the duration of hospice care.

Peritoneal Dialysis and Inflammatory Demyelinating Polyneuropathy: A Correlation or Co-Incidence?

Uremic neuropathy (UN) is a sensorimotor polyneuropathy typically affecting the lower extremities due to length-dependent demyelination and axonal degeneration. Hemodialysis (HD) and peritoneal dialysis (PD) are the two widely used modalities for treating end-stage renal disease (ESRD) patients. Today, with the understanding of solute and water kinetics, PD is considered equivalent to in-center HD. Chronic inflammatory demyelinating polyneuropathy (CIDP) manifests as symmetric, motor-predominant neuropathy that results in both proximal and distal muscle weakness. It is treatable with immune modulatory therapies. Here, we present a series of three patients who developed CIDP following the initiation of PD. Patient A: 39-year-old male with ESRD secondary to renal dysplasia presented with new onset neuropathy four months after starting PD. Patient B: 30-year-old male with ESRD secondary to IgA nephropathy presented with a history of numbness in his feet gradually progressing to his legs 12 months after initiating PD. Patient C: 56-year-old female with ESRD and uncontrolled diabetes mellitus presented with progressive muscle weakness four months after initiating PD. These three patients were all on continuous cycling PD. They were followed at three different dialysis units and were initiated on CCPD at different times. All of these patients were found to have CIDP on electromyography. Patients A and B were treated with IV immunoglobulin (IVIG) and improved, while patient C received plasmapheresis and improved. It has been recognized that PD solution is not physiological and may lead to activation of the host immune system triggering an autoimmune demyelinating process. Immunologic pathogenesis is not clearly understood. Macrophage activation and cytokines may play a role in the demyelination process. With the recent initiative to increase the use of PD, more studies are warranted to understand this uncommon complication.

Health harms of non-medical prescription opioid use: A systematic review.

ISSUES: Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken. APPROACH: We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality. KEY FINDINGS: Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%). IMPLICATIONS: A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault. DISCUSSION AND CONCLUSIONS: Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.

Perceived barriers to access care, anticipated discrimination and structural vulnerability among African Americans with substance use disorders.

BACKGROUND: The application of the structural vulnerability construct in medicine addresses social structures as the source of health inequities. Evidence demonstrates structural vulnerability as the meta-problem that underlie health disparities faced by underrepresented minorities who are less likely to access care and face stigma for substance use disorders (SUDs). OBJECTIVE: The objective of this study is to assess perceived vulnerability at the structural and interpersonal levels depicted by barriers to care, treatment-related stigma and anticipated discrimination among African Americans with SUDs. METHODS: Participants were 58 consecutive African American patients receiving treatment at an acute inpatient substance use service of a teaching hospital from September to November 2019. Structural vulnerability, barriers to care and anticipated discrimination were assessed using the structural vulnerability assessment tool, Barriers to Access Care Evaluation (BACE) and the Questionnaire on Anticipated Discrimination (QUAD) surveys, respectively. RESULTS: The total mean scores for the BACE-3, BACE-3 stigma subscale and QUAD were 1.0, 1.15 and 1.51, respectively. No statistically significant differences are found in the stigma subscale based on gender and psychiatric diagnosis (p > .05). Furthermore, there were also no gender, age or differences based on psychiatric diagnosis across both the BACE and QUAD scales. CONCLUSION: Structural and interpersonal factors remain sources of vulnerability, stigma and anticipated discrimination for African Americans with SUDs and comorbid mental illness.

Dismal outcomes following damage control laparotomy in injured older adults, a cohort study.

BACKGROUND: The population of older adults is rapidly growing and more older patients are presenting with abdominal trauma. Outcomes have not been well defined for patients that require a damage control approach(DCL). METHODS: This was a retrospective study at a level one trauma center of patients age 65 years and older with abdominal trauma that required DCL. Outcomes reviewed included mortality, length of stay, discharge disposition. Presenting vital signs and laboratories were reviewed to identify predictors of mortality. RESULTS: 31 older patients(mean age 75.2 years) underwent DCL. Twenty-four of 31(77.4%) older patients died. Seven of 7 older DCL survivors were discharged to a rehabilitation center or nursing home. In comparisons of older DCL nonsurvivors and survivors there were not differences in presenting HR(90 versus 96; p = 0.56) or SBP in the emergency room(107 versus 116; p = 0.51). No differences in initial lactate or change in lactate concentration were found between nonsurvivors and survivors. Fifteen of 24 nonsurvivors died from multisystem organ failure. CONCLUSIONS/IMPLICATIONS: The mortality rate of older patients that require damage control approach for is extremely high. Presenting vital signs and laboratory markers may not be useful in older patients to predict mortality.

Prevalence of Hepatitis C Screening, Testing, and Care Experience Among Young Adults Who Use Prescription Opioids Nonmedically.

PURPOSE: Examine the prevalence of hepatitis C virus (HCV) screening, confirmatory testing, and care experiences among young adult nonmedical prescription opioid (NMPO) users. METHODS: We examined self-reported HCV screening history in a sample of 18- to 29-year-olds reporting past-month NMPO use, and we used modified Poisson regression to identify associated sociodemographic and drug use patterns. RESULTS: Among 196 participants, 154 (78.6%) reported prior HCV screening, among whom 18 (11.7%) reported positive results. Of these, 13 (72.2%) reported receiving a confirmatory test; 12 (66.7%) were referred for specialty HCV care. Screening was associated with injection drug use (adjusted prevalence ratio [APR] = 1.19; 95% confidence interval [CI] = 1.05-1.33) and history of hospitalization for psychiatric illness (APR = 1.23; 95% CI = 1.09-1.39). Younger participants (18-23 years) were less likely to have been screened (APR = .69; 95% CI = .57-.85). CONCLUSION: Among young adult NMPO users, post-HCV screening support and referral to care were inadequate.