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AIMS: End-stage renal disease (ESRD) is associated with high morbidity and mortality. A prior study showed that many Canadian patients regretted their decision to start dialysis. We sought to determine if US patients also regretted dialysis. MATERIALS AND METHODS: We surveyed hemodialysis patients within 55 miles of Rochester, MN, with a 25-question survey about their perceptions of their health, preparedness for dialysis, advance care planning, and regrets about starting dialysis. Surveys were administered in person at the patients' usual dialysis session from July 1 through December 1, 2014; responses were captured electronically. RESULTS: Of the 198 eligible patients, 128 participated (70% men); 80% received dialysis for more than 1 year; 38% reported their health and 58% described their quality of life as "good" or "very good"; 51% had started dialysis in the hospital; and 68% agreed they were prepared for what to expect. Only 35% of patients reported being offered supportive care without dialysis. Most patients (82%) recalled a discussion about prognosis. Only 43% completed an advance directive, but 72% thought it was at least "very important" to plan for the end of life. Nine (7%) reported regretting the decision to start dialysis. CONCLUSIONS: Most of our patients were optimistic about their health and prognosis. Few regretted the decision to start dialysis.â©.
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Emociones , Fallo Renal Crónico/terapia , Satisfacción del Paciente , Calidad de Vida , Diálisis Renal/psicología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Encuestas Epidemiológicas , Humanos , Fallo Renal Crónico/psicología , Masculino , Persona de Mediana Edad , PronósticoRESUMEN
BACKGROUND: Over 30% of patients with COVID-19 have persistent symptoms that last beyond 30 days and referred to as Long COVID. Long COVID has been associated with a persistent elevation in peripheral cytokines including interleukin-6, interleukin-1ß, and tumor necrosis factor-α. This study reports cytokine profiles of patients in our clinic across SARS-COV-2 variant epochs. METHODS: The clinical cytokine panel was analyzed in patients with Long COVID during periods that were stratified according to variant epoch. The 4 variant epochs were defined as: (1) wild-type through alpha, (2) alpha/beta/gamma, (3) delta, and (4) omicron variants. RESULTS: A total of 390 patients had the clinical cytokine panel performed; the median age was 48 years (IQR 38-59) and 62% were female. Distribution by variant was wild-type and alpha, 50% (n = 196); alpha/beta/gamma, 7.9% (n = 31); delta, 18% (n = 72); and omicron, 23% (n = 91). Time to cytokine panel testing was significantly longer for the earlier epochs. Tumor necrosis factor-α (P < .001) and interleukin 1ß (P < .001) were significantly more elevated in the earlier epochs (median of 558 days in wild-type through Alpha epoch vs 263 days in omicron epoch, P < .001)). Nucleocapsid antibodies were consistently detected across epochs. DISCUSSION: When stratified by variant epoch, patients with early epoch Long COVID had persistently elevated peripheral pro-inflammatory cytokine levels when compared to later epoch Long COVID. Patients with Long COVID have similar clusters of symptoms across epochs, suggesting that the underlying pathology is independent of the peripheral cytokine signature.
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COVID-19 , Citocinas , SARS-CoV-2 , Humanos , Femenino , Persona de Mediana Edad , Masculino , Citocinas/sangre , COVID-19/inmunología , COVID-19/sangre , Adulto , SARS-CoV-2/inmunología , Síndrome Post Agudo de COVID-19 , Interleucina-1beta/sangre , Factor de Necrosis Tumoral alfa/sangre , Interleucina-6/sangreRESUMEN
BACKGROUND: In addition to the morbidity and mortality associated with acute infection, COVID-19 has been associated with persistent symptoms (>30 days), often referred to as Long COVID (LC). LC symptoms often cluster into phenotypes, resembling conditions such as fibromyalgia, postural orthostatic tachycardiac syndrome (POTS), and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). LC clinics have been established to best address the needs of LC patients and continuity of care. We developed a cross-sectional survey to assess treatment response through our LC Clinic (LCC). METHODS: A 25-question survey (1-10 Likert scale) was expert- and content-validated by LCC clinicians, patients, and patient advocates. The survey assessed LC symptoms and the helpfulness of different interventions, including medications and supplements. A total of 852 LCC patients were asked to complete the survey, with 536 (62.9%) responding. RESULTS: The mean time from associated COVID-19 infection to survey completion was 23.2 ± 6.4 months. The mean age of responders was 52.3 ± 14.1 (63% females). Self-reported symptoms were all significantly improved (P < .001) from the initial visit to the LCC (baseline) to the time of the follow-up survey. However, only 4.5% (24/536) of patients rated all symptoms low (1-2) at the time of the survey, indicating low levels of full recovery in our cohort. The patients rated numerous interventions as being helpful, including low-dose naltrexone (45/77; 58%), vagal nerve stimulation (18/34; 53%), and fisetin (28/44; 64%). CONCLUSIONS: Patients report general improvements in symptoms following the initial LCC visit, but complete recovery rates remain low at 23.2 ± 6.4 months.
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COVID-19 , Síndrome Post Agudo de COVID-19 , Humanos , Estudios Transversales , COVID-19/terapia , Persona de Mediana Edad , Femenino , Masculino , Adulto , Encuestas y Cuestionarios , Estudios Longitudinales , Progresión de la Enfermedad , SARS-CoV-2 , AncianoRESUMEN
BACKGROUND Some patients who have recovered from acute infection with SARS-CoV-2 develop persistent symptoms that have been termed post-COVID syndrome (PoCoS). PoCoS can affect the musculoskeletal system, with arthralgia and myalgia being common. Preliminary evidence suggests that PoCoS is an immune-mediated condition that not only predisposes but also precipitates pre-existing inflammatory joint diseases such as rheumatoid arthritis and reactive arthritis. Here, we describe a series of patients who presented to our Post-COVID Clinic and were found to have inflammatory arthritis (reactive and rheumatoid arthritis). CASE REPORT We present 5 patients who developed joint pain several weeks after recovery from acute SARS-CoV-2 infection. These patients were seen in our Post-COVID Clinic and came from locations across the United States. All 5 patients were women, with age of diagnosis of COVID-19 disease between 19 and 61 years (mean 37.8 years). All patients presented with joint pain as the primary concern to the Post-COVID Clinic. Abnormal joint imaging was present in all patients. Treatments varied and included non-steroidal anti-inflammatory drugs, acetaminophen, corticosteroids, immunomodulators (golimumab), methotrexate, leflunomide, and hydroxychloroquine. CONCLUSIONS COVID-19 disease is a potential cause of inflammatory arthritis, with both rheumatoid arthritis and reactive arthritis demonstrated in our PoCoS population. Care must be taken to identify these conditions, as there are treatment ramifications.
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Artritis Reactiva , Artritis Reumatoide , COVID-19 , Humanos , Femenino , Adulto Joven , Adulto , Masculino , SARS-CoV-2 , Artritis Reumatoide/complicaciones , Artritis Reumatoide/tratamiento farmacológico , ArtralgiaRESUMEN
Objective: To decrease the electronic health record (EHR) clerical burden and improve patient/clinician satisfaction, allied health staff were trained as visit facilitators (VFs) to assist the physician in clinical and administrative tasks. Patients and Methods: From December 7, 2020, to October 11, 2021, patients with complex medical conditions were evaluated by an internal medicine physician in an outpatient general internal medicine (GIM) consultative practice at a tertiary care institution. A VF assisted with specific tasks before, during, and after the clinical visit. Presurvey and postsurvey assessments were performed to understand the effect of the VF on clinical tasks as perceived by the physician. Results: A total of 57 GIM physicians used a VF, and 41 (82%) physicians and 39 (79%) physicians completed the pre-VF and post-VF surveys, respectively. Physicians reported a significant reduction in time reviewing outside materials, updating pertinent information, and creating/modifying EHR orders (P<.05). Clinicians reported improved interactions with patients and on-time completion of clinical documentation. In the pre-VF survey, "too much time spent" was the most common response for reviewing outside material, placing/modifying orders, completing documentation/clinical notes, resolving in-baskets, completing dismissal letters, and completing tasks outside of work hours. In the post-VF survey, "too much time spent" was not the most common answer to any question. Satisfaction improved in all areas (P<.05). Conclusion: VFs significantly reduced the EHR clinical burden and improved GIM physician practice satisfaction. This model can potentially be used in a wide range of medical practices.
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OBJECTIVE: To design and evaluate, through a human-centered design approach, a multispeciality clinic for patients with central sensitization syndromes that combined virtual previsit consultations, traditional face-to-face appointments, and technology-enabled educational programming. PATIENTS AND METHODS: Patients with suspected fibromyalgia and chronic abdominal pain were seen in a multispecialty practice, and the performance of the clinic was evaluated against a contemporary cohort. Quantitative and qualitative evaluation measures included team estimates of time spent on care-related tasks, physician rank of alignment of patient need with clinic design, major appointment changes, and nonvisit care tasks. Members of the care team also evaluated strengths, weaknesses, opportunities, and threats to the success of the clinic. RESULTS: The pilot clinic was operated from April 1, 2020, to April 30, 2021, and included 34 patients with suspected fibromyalgia/chronic abdominal pain. During the pilot period, physicians ranked the value of the virtual previsit consultations in providing care as 7.5 on a scale of 0 to 10 and reported an average of 50 minutes in preparation for the appointment, execution of the appointment, and postvisit documentation. We did not observe substantial differences in the number of added appointments or messages received within the patient portal when compared with a comparison cohort. Patients who participated in the combination nurse educator-led and digital education program provided positive feedback about their experience. CONCLUSION: Our clinic model provides a framework for the treatment of patients with debilitating centrally sensitized conditions and future expansion of virtual care delivery models to better meet patient care and educational needs.
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Breast cancer remains the most common cancer in women in the United States. For certain women at high risk for breast cancer, endocrine therapy (ET) can greatly decrease the risk. Tools such as the Breast Cancer Risk Assessment Tool (or Gail Model) and the International Breast Cancer Intervention Study risk calculator are available to help identify women at increased risk for breast cancer. Physician awareness of family history, reproductive and lifestyle factors, dense breast tissue, and history of benign proliferative breast disease are important when identifying high-risk women. The updated US Preventive Services Task Force and American Society of Clinical Oncology guidelines encourage primary care providers to identify at-risk women and offer risk-reducing medications. Among the various ETs, which include tamoxifen, raloxifene, anastrozole, and exemestane, tamoxifen is the only one available for premenopausal women aged 35 years and older. A shared decision-making process should be used to increase the usage of ET and must be individualized. This individualized approach must account for each woman's medical history and weigh the benefits and risks of ET in combination with the personal values of the patient.
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Anastrozol/administración & dosificación , Neoplasias de la Mama/prevención & control , Antagonistas de Estrógenos/administración & dosificación , Personal de Salud/educación , Medicina Preventiva/educación , Clorhidrato de Raloxifeno/administración & dosificación , Moduladores Selectivos de los Receptores de Estrógeno/administración & dosificación , Tamoxifeno/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/epidemiología , Curriculum , Toma de Decisiones Conjunta , Educación Médica Continua , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medicina Preventiva/métodos , Medición de Riesgo , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: Central sensitization syndromes (CSS) comprise an overlapping group of clinical conditions with the core feature of "pain arising as a direct consequence of a lesion or disease affecting the somatosensory system." Patients with CSS are known to have challenging interactions with healthcare providers contributing to psychological distress and increased healthcare utilization. CSS symptom severity has been associated with psychologic comorbidities, but little is known about how symptom severity relates to provider interactions. METHODS: We performed a cross-sectional survey among patients with CSS in our primary care practices to examine the relationship between CSS symptom severity and experiences with doctors. RESULTS: A total of 775 respondents completed the survey (775/5000; 15.5%) with 72% reporting high CSS symptom severity. About 44% of respondents had a prior diagnosis of fibromyalgia, 72% had migraines, and 28% had IBS. Patients with high CSS symptom severity were more likely to report that doctor(s) had often/always told them that they don't need treatment when they feel like they do (OR = 3.6, 95% CI 1.9-7.5), that doctor(s) often/always don't understand them (OR = 3.1, 95% CI 1.9-5.4), and that doctor(s) often/always seem annoyed with them when compared with respondents with low-moderate CSS symptom severity (OR = 4.8, 95% CI 2.2-12.5). Patients with high CSS symptom severity were at greater than 5 times odds of reporting being told that their symptoms were "all in their head" when compared to patients with low-moderate symptom severity (OR = 5.4, 95% CI 3.3-9.0). CONCLUSION: Patients with CSS spectrum disorders experience frequent pain and decreased quality of life. A high degree of CSS symptom severity is associated with negative experiences with healthcare providers, which deters the establishment of a positive provider-patient relationship. Further research is needed to help understand symptom severity in CSS and harness the power of the therapeutic alliance as a treatment modality.
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Sensibilización del Sistema Nervioso Central , Fibromialgia , Estudios Transversales , Humanos , Relaciones Profesional-Paciente , Calidad de VidaRESUMEN
OBJECTIVE: To describe the collaborative efforts of a large healthcare institution and its local blood center in reducing preoperative autologous blood donation (PABD). METHODS: Through an educational letter-based campaign, we contacted physicians who historically had ordered PABD units. Follow-up educational efforts occurred at departmental and individual meetings. RESULTS: Our educational campaign to reduce PABD achieved complete elimination of PABD orders and the resultant waste of PABD units within 3 years of the start of the program. These changes were sustained for at least 2 subsequent years without the need for additional educational efforts. CONCLUSION: Targeted educational efforts directed at practitioners of PABD were successful in significantly decreasing the use and waste of PABD at the health care institution we studied and may yield the same results in comparable institutions.
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Donantes de Sangre , Conducta Cooperativa , Educación Médica , Médicos/psicología , Transfusión de Sangre Autóloga/estadística & datos numéricos , Hospitales , Humanos , Estudios Longitudinales , Cuidados PreoperatoriosRESUMEN
Transthoracic fine needle aspiration (TFNA)/core needle biopsy (CNB) under computed tomography (CT) guidance has proved useful in the assessment of pulmonary nodules. We sought to determine the TFNA false-negative (FN) rate at our institution and identify potential causes of FN diagnoses. Medical records were reviewed from 1,043 consecutive patients who underwent CT-guided TFNA with or without CNB of lung nodules over a 5-year time period (2003-2007). Thirty-seven FN cases of "negative" TFNA/CNB with malignant outcome were identified with 36 cases available for review, of which 35 had a corresponding CNB. Cases were reviewed independently (blinded to original diagnosis) by three pathologists with 15 age- and sex-matched positive and negative controls. Diagnosis (i.e., nondiagnostic, negative or positive for malignancy, atypical or suspicious) and qualitative assessments were recorded. Consensus diagnosis was suspicious or positive in 10 (28%) of 36 TFNA cases and suspicious in 1 (3%) of 35 CNB cases, indicating potential interpretive errors. Of the 11 interpretive errors (including both suspicious and positive cases), 8 were adenocarcinomas, 1 squamous cell carcinoma, 1 metastatic renal cell carcinoma, and 1 lymphoma. The remaining 25 FN cases (69.4%) were considered sampling errors and consisted of 7 adenocarcinomas, 3 nonsmall cell carcinomas, 3 lymphomas, 2 squamous cell carcinomas, and 2 renal cell carcinomas. Interpretive and sampling error cases were more likely to abut the pleura, while histopathologically, they tended to be necrotic and air-dried. The overall FN rate in this patient cohort is 3.5% (1.1% interpretive and 2.4% sampling errors).
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Neoplasias de la Tiroides/patología , Nódulo Tiroideo/patología , Adulto , Anciano , Biopsia con Aguja Fina/métodos , Biopsia con Aguja Gruesa , Reacciones Falso Negativas , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: To compare thromboelastography (TEG) tracings obtained from fresh and citrated whole-blood samples in patients on extracorporeal membrane oxygenation (ECMO) or after cardiopulmonary bypass and in healthy volunteers. METHODS: Samples of fresh and citrated whole blood were analyzed for 25 patients and 4 healthy volunteers. Thromboelastography analysis was performed in both plain and heparinase cups. RESULTS: In 5 of 6 patients on ECMO, use of citrated samples resulted in apparent partial or complete heparin reversal. In TEG tracings from patients following cardiopulmonary bypass, there was a slight hypercoagulable appearance in the citrated sample. No differences were noted between fresh and citrated samples from healthy volunteers whose blood was spiked with heparin. CONCLUSIONS: In some patients on ECMO, use of samples collected in sodium citrate tubes for TEG analysis results in significant artifacts, which could lead to heparin overdosing in these patients.