Coccidioides Serologic Screening Practices in Individuals With Rheumatic and Autoimmune Diseases.

OBJECTIVE: We aimed to estimate Coccidioides serologic screening rates before initiation of biologic disease-modifying antirheumatic drugs including tofacitinib (b/tsDMARDs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and/or noninhaled corticosteroids. METHODS: This retrospective cohort study used 2011 to 2016 US Medicare claims data and included beneficiaries with rheumatic or autoimmune disease residing in regions within Arizona, California, and Texas endemic for Coccidioides spp. with ≥1 prescription for a b/tsDMARD, csDMARD, and/or noninhaled corticosteroid. We estimated prior-year serologic screening incidence before initiating b/tsDMARDs, csDMARD, and/or noninhaled corticosteroid. RESULTS: During 2012 to 2016, 4,331 beneficiaries filled 64,049 prescriptions for b/tsDMARDs, csDMARDs, and noninhaled corticosteroids. Arizona's estimated screening rate was 20.1% (95% confidence interval [95% CI] 14.5-25.7) in the year before prescription initiation for b/tsDMARDs, 8.1% (95% CI 6.5-9.7) before csDMARDs, and 6.9% (95% CI: 5.6-8.2) before corticosteroids. Screening rates for b/tsDMARDs (2.8%, 95% CI 0.0-6.7), csDMARDs (1.0%, 95% CI 0.0-2.0), and corticosteroids (0.8%, 95% CI: 0.4-1.1) were negligible in California and undetected in Texas. Adjusted screening rate before prescription for b/tsDMARDs in Arizona increased from 14.5% (95% CI 7.5-21.5) in 2012 to 26.7% (95% CI 17.6-35.8) in 2016. Rheumatologists prescribing b/tsDMARDs in Arizona screened more than other providers (20.9% [95% CI 13.9-27.9] vs 12.9% [95% CI 5.9-20.0]). CONCLUSION: Coccidioides serologic screening rates among Medicare beneficiaries with rheumatic/autoimmune diseases on b/tsDMARDs, csDMARDs, and noninhaled corticosteroids was low in Coccidioides spp.-US endemic regions between 2012 and 2016. Alignment of screening recommendations and clinical practice is needed.

Daily self-regulation with biofeedback to improve stress and job satisfaction in a primary care clinic.

BACKGROUND: Burnout in healthcare professions is higher than other careers. An undesirable work-life balance has resulted in declining job satisfaction among primary care physicians. Biofeedback devices teach self-regulation techniques, which reduce stress and increase resilience. OBJECTIVES: We assessed whether self-regulation with biofeedback is effective at decreasing stress and improving job satisfaction among primary care clinicians and nurses. METHODS: Two naturally occurring cohorts of clinicians and nurses were followed over 12 weeks. The treatment group (N = 9) completed 12 weeks of self-regulation with optional clinic-based biofeedback and received peer support for the first half. The control group (N = 9) started a delayed intervention after 6 weeks without peer support. Descriptive and bivariate analyses were conducted. RESULTS: The treatment group averaged one biofeedback session weekly for 6 min and the control group two sessions for 11 min. Adherence differed by age. Subjects also reported using self-regulation techniques without biofeedback. Perceived stress initially increased in both groups with intervention implementation, more so in the treatment group (P = 0.03) whose stress then decreased but was not significant. Overall and extrinsic job satisfaction similarly increased but were not significance. CONCLUSION: The initial increase in perceived stress was related to daily biofeedback adherence and clinic responsibilities. Treatment group stress then decreased with self-regulation but was difficult to quantify in a small cohort. Larger studies could increase daily self-regulation adherence by improving biofeedback accessibility for leisurely use. Using self-regulation with biofeedback may be an innovative approach to reduce stress and improve job satisfaction in primary care.

Horner syndrome with transient visual impairment.

A 57-year-old female presented with headache, miosis, and ptosis diagnosed as Horner syndrome (HS). After delaying the recommended diagnostic imaging, she experienced transient, unilateral visual impairment in bright light. The patient was subsequently determined to have a spontaneous internal carotid artery dissection (ICAD) and secondary retinal ischemia with minimal cardiovascular risk factors and no history of preceding trauma. She wore dark glasses, received gabapentin for pain control, and was anticoagulated for a total of 4 months at which time the ICAD resolved despite a residual blepharoptosis and anisocoria.

Metabolic and histological implications of intrahepatic triglyceride content in nonalcoholic fatty liver disease.

The cut-off point of intrahepatic triglyceride (IHTG) content to define nonalcoholic fatty liver disease (NAFLD) by proton magnetic resonance spectroscopy (1 H-MRS) was established based on the 95th percentile in a group of healthy individuals (i.e., ≥5.56%). Whether this threshold correlates with metabolic and histological changes and whether a further accumulation of IHTG is associated with worsening of these parameters has not been properly assessed in a large cohort of patients. In this cross-sectional study, 352 subjects were carefully characterized with the following studies: liver 1 H-MRS; euglycemic insulin clamp with measurement of glucose turnover; oral glucose tolerance test; and a liver biopsy. Hepatic insulin sensitivity (suppression of endogenous glucose production by insulin) was affected early on after IHTG content was ∼1.5% and remained uniformly impaired (∼40%-45%), regardless of further IHTG accumulation. Skeletal muscle insulin sensitivity showed a gradual impairment at low degrees of IHTG accumulation, but remained unchanged after IHTG content reached the ∼6 ± 2% threshold. A similar pattern was observed for metabolic changes typically associated with NAFLD, such as hypertriglyceridemia and low high-density lipoprotein cholesterol (HDL-C). In contrast, adipose tissue insulin sensitivity (suppression of free fatty acids by insulin) showed a continuous worsening across the spectrum of IHTG accumulation in NAFLD (r = -0.38; P < 0.001). Histological severity of liver disease (inflammation, ballooning, and fibrosis) was not associated with the amount of IHTG content. CONCLUSION: IHTG accumulation is strongly associated with adipose tissue insulin resistance (IR), supporting the current theory of lipotoxicity as a driver of IHTG accumulation. Once IHTG accumulation reaches ∼6 ± 2%, skeletal muscle IR, hypertriglyceridemia, and low HDL-C become fully established. Histological activity appears to have an early threshold and is not significantly influenced by increasing amounts of IHTG accumulation. (Hepatology 2017;65:1132-1144).

Peripheral neuropathy linked to obstructive sleep apnea?

OSA may not be the first thing that comes to mind when examining a patient with peripheral neuropathy, but treating the sleep disorder can produce surprising benefits.

Institutional authorisation and accreditation of Transfusion Services and Blood Donation Sites: results of a national survey.

INTRODUCTION: The aim of the survey described in this article was to determine decisional and strategic factors useful for redefining minimum structural, technological and organisational requisites for transfusion structures, as well as for the production of guidelines for accreditation of transfusion structures by the National Blood Centre. MATERIALS AND METHODS: A structured questionnaire containing 65 questions was sent to all Transfusion Services in Italy. The questions covered: management of the quality system, accreditation, conformity with professional standards, structural and technological requisites, as well as potential to supply transfusion medicine-related health care services. All the questionnaires returned underwent statistical analysis. RESULTS: Replies were received from 64.7% of the Transfusion Services. Thirty-nine percent of these had an ISO 9001 certificate, with marked differences according to geographical location; location-related differences were also present for responses to other questions and were confirmed by multivariate statistical analysis. Over half of the Transfusion Services (53.6%) had blood donation sites run by donor associations. The statistical analysis revealed only one statistically significant difference between these donation sites: those connected to certified Transfusion Services were more likely themselves to have ISO 9001 certification than those connected to services who did not have such certification. CONCLUSIONS: The data collected in this survey are representative of the Italian national transfusion system. A re-definition of the authorisation and accreditation requisites for transfusion activities must take into account European and national legislation when determining these requisites in order to facilitate their effective applicability, promote their efficient fulfilment and enhance the development of homogeneous and transparent quality systems.