Eye Movement Desensitization and Reprocessing in a Primary Care Setting: Assessing Utility and Comparing Efficacy of Virtual Versus In-Person Methods.

Introduction: Eye movement desensitization and reprocessing (EMDR) is an evidence-based psychotherapy method designed to treat distress associated with traumatic memories. The COVID-19 pandemic has challenged providers to shift EMDR to telehealth platforms. Objectives: This research had to aims. (1) To compare EMDR in conjunction with cognitive behavioral therapy (CBT) with CBT alone for treatment of a patient population with prevalent anxiety and (2) to compare the efficacy of virtual EMDR with that of in-person EMDR in the primary care setting. Methods: Retrospective chart review of all adult patients seen by a single therapist at a primary care center was conducted from January 2018 to December 2020. Charts were reviewed for demographics, psychiatric diagnoses, number of visits, number and type of EMDR treatments, and patient health questionnaire (PHQ)-9 and general anxiety disorder (GAD-7) scores pre- and post-treatment. Results: Patients who underwent EMDR with CBT demonstrated greater decreases in PHQ-9 and GAD-7 scores than patients who had only CBT (2.4, 2.5 vs. 0.9, 1.1). However, after adjusting for total number of sessions, post-traumatic stress disorder, grief, and pain, the adjusted mean differences of change in PHQ-9 and GAD-7 scores between those who underwent EMDR with CBT and CBT-exclusive patients were not statistically significant. Similarly, the adjusted mean differences of change in PHQ-9 and GAD-7 scores between those who underwent virtual EMDR and those who had in-person EMDR were not statistically significant. Conclusions: To our knowledge, this is the first study describing the use of virtual EMDR in a primary care setting. Although our data did not provide evidence for the superiority of EMDR with CBT over CBT alone, we demonstrate that both in-person and virtual EMDR led to significantly improved GAD-7 scores.

Who Is Most Burdened in Health Care? An Analysis of Responses to the ICAN Discussion Aid.

OBJECTIVE: To create a model based on patients' characteristics that can predict the number of burdens reported using the ICAN Discussion Aid, to target use of this tool to patients likeliest to benefit. PATIENTS AND METHODS: Six hundred thirty-five patients (aged ≥18 years) completed the ICAN Discussion Aid at a Scottsdale, Arizona, family medicine clinic. Patient characteristics were gathered from their health records. Regression trees with Poisson splitting criteria were used to model the data. RESULTS: Our model suggests the patients with the most burdens had major depressive disorder, with twice as many overall burdens (personal plus health care burdens) than patients without depression. Patients with depression who were younger than 38 years had the highest number of personal burdens. A body mass index (BMI) of 26 or greater was associated with increased health care burden versus a BMI below 26. CONCLUSION: The number of burdens a patient will report on the ICAN Discussion Aid can be approximated based on certain patient characteristics. Adults with major depression, a BMI of 26 or greater, and younger age may have greater reported burdens on ICAN, but this finding needs to be validated in independent samples.

Potential for sodium-glucose cotransporter-2 inhibitors in the management of metabolic syndrome: A systematic review and meta-analysis.

BACKGROUND: Landmark trials have established the benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) in cardiovascular disease including heart failure with reduced and preserved ejection fraction and renal diseases regardless of the presence of diabetes mellitus. However, studies evaluating the role of SGLT2-Is in metabolic syndrome (MetS) are limited. AIM: This study primarily aimed to evaluate the impact of SGLT2-Is on the components of MetS. METHODS: Two independent reviewers and an experienced librarian searched Medline, Scopus and the Cochrane central from inception to December 9, 2021 to identify placebo controlled randomized controlled trials that evaluated the impact of SGLT2-Is on the components of MetS as an endpoint. Pre- and post-treatment data of each component were obtained. A meta-analysis was performed using the RevMan (version 5.3; Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration). RESULTS: Treatment with SGLT2-Is resulted in a decrease in fasting plasma glucose (-18.07 mg/dL; 95%CI: -25.32 to -10.82), systolic blood pressure (-1.37 mmHg; 95%CI: -2.08 to -0.65), and waist circumference (-1.28 cm; 95%CI: -1.39 to -1.18) compared to placebo. The impact on high-density lipoprotein cholesterol was similar to placebo (0.01 mg/dL; 95%CI: -0.05 to 0.07). CONCLUSION: SGLT2-Is have a promising role in the management of MetS.

Examining the Utility of a Novel Neurologic Test in Patients With Obstructive Sleep Apnea: A Pilot Study.

Purpose: To test the association between participant King-Devick Test (KDT) times and obstructive sleep apnea (OSA) severity and evaluate for improvement after continuous positive airway pressure (CPAP) treatment. Methods: Study dates January 30 to July 31, 2018. Patients were referred for initial evaluation of sleep disordered breathing concerns. OSA severities were defined by Apnea Hypopnea Index (AHI) results, with ≥15 considered at least moderate OSA. The KDT is an objective physical measure of brain function. We estimated correlation between KDT time and AHI and compared mean KDT time between patients with and without moderate OSA. For the OSA subgroup, we evaluated for potential improvement in KDT after CPAP. Results: We enrolled 60 participants, of whom 35 (58.3%) had OSA with an AHI ≥15. Initial analyses noted no significant KDT time differences between patients based on OSA severity. However, after excluding 3 participants who had baseline neurologic illness, adjusted analyses demonstrated that mean KDT time was significantly prolonged for patients with moderate or greater OSA (AHI ≥15) as compared to those with mild or no sleep apnea (AHI <15); 63.4 seconds (95% CI 58.9-67.8) versus 55.7 seconds (95% CI 50.2-61.1), P = .03. CPAP-treated subjects demonstrated significantly improved KDT test times; 63.5 seconds mean pretreatment versus 55.6 posttreatment; -6.6 seconds mean difference, 95%CI (-12.0, -1.13), P = .02. Conclusion: Neurologic abnormalities in patients with OSA are potentially demonstrable utilizing this objective physical measure. Significant improvement is achieved in patients after CPAP treatment.

The metabolic syndrome and cardiovascular disease: Part I.

The metabolic syndrome is a constellation of metabolic risk factors and physical conditions that are accompanied by an enhanced propensity toward the development of type 2 diabetes, atherosclerosis, and cardiovascular disease. It presents a combination of atherosclerosis risk including atherogenic dyslipidemia, hypertension, elevated plasma glucose, hypercoagulability, and a proinflammatory state. The 2 major underlying risk factors for the metabolic syndrome are obesity and insulin resistance. Exacerbating factors are physical inactivity, advancing age, and endocrine and genetic factors. Associated hyperinsulinemia, hyperglycemia, and elevated adipokine levels (adipose cytokines) lead to vascular endothelial dysfunction, an abnormal lipid profile, hypertension, and vascular inflammation, all of which promote the development of atherosclerotic cardiovascular disease. In this 2-part series, the authors present an up-to-date and detailed systematic review of the literature on this important topic.

Obstructive sleep apnea: A better Dx model for primary care.

This study identified a method that provides a truer assessment of disease probability than has been achieved with history and physical exam evaluation.

Greater Occipital Nerve Block for Acute Treatment of Migraine Headache: A Large Retrospective Cohort Study.

INTRODUCTION: Greater occipital nerve (GON) blocks are frequently used to treat migraine headaches, although a paucity of supporting clinical evidence exists. The objective of this study was to assess the efficacy of GON block in acute treatment of migraine headache, with a focus on pain relief. METHODS: This retrospective cohort study was undertaken between January 2009 and August 2014 and included patients who underwent at least 1 GON block and attended at least 1 follow-up appointment. Change in the 11-point numeric pain rating scale (NPRS) was used to assess the response to GON block. Response was defined as "minimal" (<30% NPRS point reduction), "moderate" (31-50% NPRS point reduction), or "significant" (>50% NPRS point reduction). RESULTS: A total of 562 patients met inclusion criteria; 423 were women (75%). Mean age was 58.6 ± 16.7 years. Of these 562, 459 patients (82%) rated their response to GON block as moderate or significant. No statistically significant relationship existed between previous treatment regimens and response to GON block. GON block was equally effective across the different age and sex groups. CONCLUSIONS: Greater occipital block seems to be an effective option for acute management of migraine headache, with promising reductions in pain scores.

Primary cardiac plasmablastic (diffuse large B-cell) lymphoma mimicking left ventricular aneurysm with mural thrombus.

Primary cardiac lymphoma is rare and is usually of the non-Hodgkin type. By definition, it involves only the heart and the pericardium, with no evidence of extracardiac disease. Primary cardiac lymphoma accounts for 1% of primary cardiac tumors and 0.5% of extranodal lymphomas [Gowda RM, Kahn RA. Clinical perspectives of primary cardiac lymphoma. Angiology 2003;54(5):599-604]. On the other hand, secondary cardiac involvement can occur in approximately 20% of patients with disseminated extracardiac lymphoma [Gowda RM, Kahn RA. Clinical perspectives of primary cardiac lymphoma. Angiology 2003;54(5):599-604]. The majority of primary cardiac lymphomas are diffuse large B-cell lymphomas with centroblastic or immunoblastic cytologic features. Herein, we describe an exceptional case of a primary cardiac plasmablastic variant of diffuse large B-cell lymphoma (Epstein-Barr virus-positive) presenting in an immunocompetent host with chest pain that mimicked a left ventricular apical thrombus.

An uncommon cause of epistaxis: cartoid cavernous fistula.

We report on an uncommon cause of epistaxis presenting to the emergency room. Epistaxis is not an uncommon presentation to emergency rooms across the world. The majority are easily controlled and have low mortality. We present a case of a carotid-cavernous fistula presenting with massive epistaxis culmination in cardiovascular collapse and death. Awareness of this entity will reduce the frequency of this condition resulting in major morbidity and mortality.

Evaluating the clinical and demographic features of extrafacial granuloma faciale.

Granuloma faciale (GF) is an uncommon cutaneous disease of uncertain etiology that predominantly affects the face. Extrafacial lesions are rare. The purpose of this study was to describe the clinical and demographic features of a series of patients with extrafacial manifestations of GF who were diagnosed and treated at a single center over more than 5 decades. We performed a retrospective medical record analysis for all patients diagnosed with extrafacial GF who were treated at Mayo Clinic (Rochester, Minnesota) from 1959 through 2013. During the study period, extrafacial GF was diagnosed in 10 patients (6 men, 4 women), all of whom were white. The mean age was 58.7 years (range, 26-87 years). Seven patients presented with both facial and extrafacial lesions. Although extrafacial lesions are rare in GF, this condition should be included in the differential diagnosis of well-demarcated plaques and nodules found on the arms and legs.

The efficacy of continuous positive airway pressure therapy in reducing cardiovascular events in obstructive sleep apnea: a systematic review.

Prospective studies show an association between obstructive sleep apnea and cardiovascular disease. Continuous positive airway pressure (CPAP) is the treatment of choice and effectively reduces subjective sleepiness and apneic and hypopneic events. However, randomized trials have not shown a reduction in cardiovascular outcomes with CPAP therapy. We review the past 10 years of randomized trial evidence regarding the therapeutic efficacy of CPAP on cardiovascular outcomes and mortality in adults with obstructive sleep apnea. The majority of studies found no significant improvement in cardiovascular outcomes with CPAP, although many noted nonsignificant benefits. Adjusted analysis in several trials showed significant cardiovascular benefit in those patients with higher CPAP compliance. Existing trials may lack sufficient follow-up and CPAP compliance, among other limitations.

Surgical treatment of the cardiac manifestations of relapsing polychondritis: overview of 33 patients identified through literature review and the Mayo Clinic records.

OBJECTIVES: To analyze the cardiac findings that necessitate surgery in patients with relapsing polychondritis (RP) and to compare our results to cases in the literature. MATERIAL AND METHODS: A systematic overview of the literature was completed with the addition of cases of RP from the Mayo patient population that necessitated cardiac surgery. RESULTS: Thirty-three patients were identified (25 from the literature and 8 from the Mayo patient population). Nine patients (27%) were female, 22 (67%) were male, and sex was not stated for 2 patients (6%). The patient age ranged from 17 to 69 years (mean +/- SD, 42.5 +/- 15.7 years). At operation, 30 patients (91%) had aortic regurgitation, 21 (64%) had aortic root disease, and 13 (39%) had mitral regurgitation. The most common surgical procedure performed was aortic valve replacement in 12 patients (36%). The most common complications were death in 12 patients (36%) and prosthetic valve dehiscence in 4 patients (12%). CONCLUSIONS: Cardiac involvement is more prominent in the male population and requires more invasive procedures. Aortic valve replacement with composite graft replacement of the ascending aorta along with coronary artery ostial reimplantation should be considered in these patients. Postsurgical valvular complications include prosthetic dehiscence, paravalvular leakage, mediastinitis, and heart failure, and these complications are associated with postoperative corticosteroid therapy. Initiation of second-line immunosuppressive therapy should be substituted for corticosteroids after cardiac surgery.

A systematic overview of anomalous coronary anatomy and an examination of the association with sudden cardiac death.

Coronary artery anomalies are a frequently neglected topic in cardiology. However, they are an important cause of cardiac ischemia and sudden death. Anomalous pulmonary artery and anomalous aortic origins of the coronaries are 2 major types of coronary artery anomalies. This article will examine the occurrence of these anomalies in the absence of associated congenital defects. A review of the literature reveals that the anomaly most commonly associated with sudden death is a left main coronary artery arising from the right aortic sinus of Valsalva with an interarterial course. The increased risk of sudden death with this anomaly has been associated with any of 4 high-risk features: slit-like ostium, acute-angle take-off, intramural aortic segment, and interarterial course.

The relationship of retinal VEGF and retinal IGF-1 mRNA with neovascularization in an acidosis-induced model of retinopathy of prematurity.

PURPOSE: Acidosis-induced retinopathy (AIR) in the neonatal rat provides an alternative model for retinopathy of prematurity (ROP). We studied the relationship of vascular endothelial growth factor (VEGF) retinal mRNA and insulin-like growth factor-1 (IGF-1) retinal mRNA expression with the emergence of neovascularization (NV) in AIR. METHODS: Two hundred seventy-five newborn Sprague-Dawley rats were raised in 11 expanded litters of 25. Using our established AIR model, acidosis was induced by twice-daily gavage with NH4Cl from day 2 to day 8 of life (n=175). Rats were sacrificed at days 5, 8, and 10. Nongavaged rats were used as age-matched controls (n=100). Retinae from left eyes were dissected, flatmounts were ADPase-stained, and the presence and severity of NV was scored in a masked manner. Individual right retinae were processed for analysis of retinal VEGF and IGF-1 mRNA using quantitative real-time reverse-transcriptase PCR (qRT-PCR). RESULTS: Retinal VEGF mRNA was increased 1.4-fold at day 10 in AIR, when compared with age-matched controls (p=0.03). This correlated with maximal NV at day 10 in AIR. Retinal IGF-1 mRNA was decreased to 82% of its normal expression on day 8 (p=0.006), prior to maximal NV, before returning to normal expression at day 10, when compared with nonacidotic controls. CONCLUSIONS: In AIR, preretinal neovascularization is associated with decreased retinal IGF-1 mRNA prior to maximal NV and increased retinal VEGF mRNA at the time of maximal NV. These growth factor changes in AIR are similar to those seen with hypercarbic oxygen-induced retinopathy. The retinal IGF-1 pathway may provide an alternative target for therapeutic intervention in abnormal retinal angiogenesis.

The current literature regarding the cardiovascular effects of electronic cigarettes.

Smoking is the leading cause of preventable morbidity and mortality globally. Electronic cigarettes are marketed both as nicotine substitutes and recreational devices. The popularity of electronic cigarettes has superseded other forms of nicotine replacement therapy. They are also popular in 'never smokers'. This review summarizes the available data regarding the cardiovascular effects of electronic cigarettes. The existing literature is limited and short term with a lack of high-quality studies and adequate follow-up. The available literature suggests that electronic cigarettes have sympathomimetic effects related to nicotine exposure, however, electronic cigarettes also contain other chemicals that require further investigation. Sparse data suggest vascular injury may be another concern. Further research is needed before broad recommendations can be made.

Validating the Diagnostic Accuracy of the Sleep Apnea Clinical Score for Use in Primary Care Populations.

OBJECTIVE: To provide external validation of the diagnostic accuracy of the Sleep Apnea Clinical Score (SACS) tool in a new setting and patient population. PATIENTS AND METHODS: We conducted a prospective cohort study. Potential participants were adult family medicine patients. We excluded patients with a SACS of 0, known obstructive sleep apnea (OSA), negative results of previous testing, or life-limiting conditions. After SACS determination, participants completed overnight oximetry, sleep medicine consultation, and polysomnography. Those interpreting tests were blind to the participant's SACS. We determined likelihood ratios (LRs) for OSA diagnosis and posttest probabilities (PTPs). We calculated OSA prevalence (pretest probability), sensitivity, specificity, and positive and negative predictive values. RESULTS: One hundred ninety-one of 312 participants (61%) completed all steps. The prevalence of OSA was similar to that found in the derivation cohort (40% vs 45%; P=.31). With OSA defined as Apnea Hypopnea Index greater than 10, a SACS greater than 15 was 40% sensitive and 90% specific, with a positive predictive value of 73% and a negative predictive value of 69%. A SACS greater than 15 in our cohort produced an LR of 4.03 (95% CI, 3.12-5.22) with 73% PTP for OSA as compared with an LR of 5.17 (95% CI, 2.54-10.51) with 78% PTP found in the derivation cohort. CONCLUSION: The present study provides external validation of the SACS tool. It reliably predicted OSA for patients in our family medicine practice. Broader implementation in primary care practice is recommended. Further study will examine SACS uptake by clinicians and the resulting impact on utilization and clinical efficiency in primary care practices.

Simple Interventions Improve the Quality of a Missed Lab Appointment Process.

Simple interventions resolve the problem of missed lab appointments. It is essential that patients complete ordered laboratory studies. This maintains clinical quality and, potentially, keeps patients safe from harm. In our academic family medicine practice, baseline data demonstrated patients completed 94.7% of labs as ordered (26850/28348 patients per year) while 1498 (5.3%) did not. Our baseline patient reminder process, a mail or portal based generic letter, resulted in only 449 (30%) of patients ultimately completing them (1049 [70%] did not). Our baseline system was 96.3 % reliable. This process did not allow for provider review or input, and was not personalized for patients. We designed a quality improvement project involving three PDSA (Plan, Do, Study, and Act) cycles of about two months each. Desk staff created weekly reports of unresolved lab orders. A message in the electronic medical record (EMR) solicited provider input. Providers could elect to cancel studies (if already completed, reordered, or no longer clinically indicated) or have the patient receive a personalized reminder, including provider name and associated diagnoses. This reminder was sent by patient portal secure messaging (if an account existed) or with a mailed letter. These interventions resulted in 98.8 % process reliability. The frequency of unresolved lab orders decreased from 70% at baseline to 25%. In the second PDSA cycle, we contacted patients by the portal only if there was evidence of an active account. Otherwise, they were contacted by telephone. Patients without a portal account continued to receive a letter by mail. These modified processes resulted in an overall reliability rate of 99.2%. The frequency of unresolved lab orders decreased to 17%. A final PDSA cycle utilized only telephone contact with patients with unresolved lab orders. Schedulers offered patients a choice of appointment dates if they spoke personally. Otherwise, they were left messages with a future lab appointment date two weeks later.Overall process reliability now increased to 100%. The frequency of unresolved lab orders decreased to 0%. Our interventions resulted in increased system reliability.Provider input was not perceived as burdensome. Desk staff work effort was not increased.Telephone patient contact resulted in more frequent lab order completion than other methods.

Effect of exercise training on sleep apnea: A systematic review and meta-analysis.

INTRODUCTION: Obstructive sleep apnea (OSA) is difficult to manage for those who are intolerant or noncompliant with standard facial mask treatment options. Current treatment options do not address the underlying cause of OSA. Exercise as a treatment option has been found to improve OSA indices. STUDY OBJECTIVES: To assess the efficacy of exercise on apnea/hypopnea index (AHI) in adult patients with OSA via a systematic review and meta-analysis. Additional objectives included evaluation of other indices of OSA and well-being in patients after completing an exercise regimen. MEASUREMENTS AND RESULTS: Web of Science, MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials were searched based on a priori criteria of all studies evaluating the effect of an exercise program on various sleep apnea indices. Both PRISMA statement and MOOSE consensus statement were adhered to. Eight Articles (182 participants) were included: a meta-analysis using a random effects model showed, a decrease in AHI (unstandardized mean difference [USMD], -0.536, 95% confidence interval [CI], -0.865 to -0.206, I(2), 20%), reduced Epworth sleepiness scale (ESS) (USMD, -1.246, 95% CI, -2.397 to -0.0953, I(2), 0%), and lower body mass index (BMI) (USMD, -0.0473, 95% CI, -0.0375 to 0.280, I(2), 0%), in patients receiving exercise as treatment. Relative risks (RR) and odds ratios (OR) showed decreases in AHI (OR: 72.33, 95% CI, 27.906 to 187.491, RR: 7.294, 95% CI, 4.072 to 13.065) in patients receiving exercise as treatment. CONCLUSION: Among adult patients with OSA, exercise as the sole intervention was associated with improved clinical outcomes.