The Role of Family Medicine in Addressing the Maternal Health Crisis in the United States.

The United States (US) is experiencing a maternal health crisis, with high rates of maternal morbidity and mortality. The US has the highest rates of pregnancy-related mortality among industrialized nations. Maternal mortality has more than quadrupled over the last decades. Rural areas and minoritized populations are disproportionately affected. Increased pregnancy-care workforce with greater participation from family medicine, greater collaborative care, and adequate postpartum care could prevent many maternal deaths. However, more than 40% of birthing people in the US receive no postpartum care. No singular solutions can address the complex contributors to the current situation, and efforts to address the crisis must address workforce shortages and improve care during and after pregnancy. This essay explores the role family medicine (FM) can play in addressing the crisis. We discuss pregnancy care training in FM residencies as well as the threats posed by financial and medico-legal climates to the maternal health workforce. We explore how collaborative care models and comprehensive postpartum care may impact the maternal health workforce. Efforts and resources devoted to high impact solutions for which FM has considerable autonomy, including collaborative and postpartum care, are likely to have greatest impact.

Cytomegalovirus and Herpes Simplex Virus Co-Infection in an HIV-Negative Patient: A Case Report.

Herpes simplex virus (HSV) and cytomegalovirus (CMV) infections are commonly seen in immunocompromised patients, particularly in patients with HIV. However, fulminant CMV infection and concurrent infection with HSV and CMV in non-HIV patients are quite rare. We present the case of a 72-year-old HIV-negative man with a history of oropharyngeal carcinoma in remission and recent treatment of immune thrombocytopenic purpura with high-dose steroids who was transferred from an outside hospital for Ear Nose and Throat (ENT) evaluation of a non-healing buccal ulcer. During initial presentation, the patient was found to be febrile with acute hypoxic respiratory failure and a chest x-ray suggestive of bacterial pneumonia, though he failed to improve with broad-spectrum antibiotic therapy. He underwent esophagogastroduodenoscopy for dysphagia, which revealed a discrete ulcer positive for CMV. Biopsy of his buccal lesion was ultimately positive for HSV-1 and HSV-2. The patient's clinical status improved significantly following the initiation of antiviral therapy.It is important to consider CMV infection in the setting of persistent fever, respiratory distress, or dysphagia in the non-HIV infected patient, especially in the setting of prolonged steroid use. CMV and HSV infection can occur simultaneously at distinct sites in the body, and CMV infection may predispose to HSV reactivation due to its long term effect on cell-mediated immunity. Early recognition of opportunistic infections and initiation of antiviral therapy in immunocompromised patients can greatly affect length of hospital stay, morbidity, and, ultimately, mortality.

A Novel Team-Based Learning Approach for an Internal Medicine Residency: Medication-Assisted Treatments for Substance Use Disorders.

Introduction: It is estimated that approximately one-tenth of the US population suffers from substance use disorders (SUD), a problem that is compounded when one considers the impact that drug addiction could have on treatment outcomes for many other chronic diseases. Thus, addiction medicine has become an important component of many successful urban primary care practices and residencies across the country. Our program sought to improve the confidence of our residents in managing SUD by instituting a team-based learning (TBL) activity that focused on the diagnosis and medication-assisted treatment of these illnesses. Methods: The class of 80 internal medicine residents were divided into groups of approximately 16 residents, and during the TBL sessions further divided into teams of three to four. Each TBL session consisted of an individual readiness assurance test, a group discussion of the correct answers, and a PowerPoint-based team application activity. Surveys were conducted for each group to assess the residents' attitudes after completing the activity. Results: Of residents, 69 of 80 completed the survey. The response to the TBL exercise was overwhelmingly positive, with most residents in agreement that the activity increased their knowledge and confidence in diagnosing and treating patients with SUD. Discussion: Overall, this TBL activity was well received by the residents and subjectively increased their competence in managing patients with SUD. In addition, our modification to the traditional TBL format suggested that the theories and spirit behind TBL can be successfully adapted to meet the challenges and intricacies of internal medicine residency education.

Effect of hospital teaching status on endoscopic retrograde cholangiopancreatography mortality and complications in the USA.

BACKGROUND: Our aim was to assess the differences in outcomes of cholecystitis, pancreatitis, gastrointestinal (GI) bleed, GI perforation, and mortality in teaching versus nonteaching hospitals nationwide among therapeutic and diagnostic ERCPs. We hypothesized that complication rates would be higher in teaching hospitals given greater patient complexity. METHODS: Inpatient diagnostic and therapeutic ERCPs were identified from the National Inpatient Sample (NIS) from 2008 to 2012. The presence of ACGME-approved residency programs is required to qualify as a teaching hospital. Nonteaching urban and rural hospitals were grouped together. We identified hospital stays complicated by pancreatitis, cholecystitis, GI hemorrhage, perforation, and mortality. Logistic regression propensity-matched analysis was performed in SPSS to compare differences in complication rates between teaching and nonteaching hospitals. RESULTS: A total of 1,466,356 weighted cases of inpatient ERCPs were included in this study: of those, 367 and188 were diagnostic, 1,099,168 were therapeutic, 766,230 were at teaching hospitals, and 700,126 were at nonteaching hospitals. Mortality rates were higher in teaching hospitals when compared to nonteaching hospitals for diagnostic (OR 1.266, p < 0.001) and therapeutic ERCPs (OR 1.157, p = 0.001). There was no significant difference in rates of post-ERCP cholecystitis, pancreatitis, or perforation between the two groups. Among diagnostic ERCPs, GI hemorrhage was higher in teaching compared to nonteaching hospitals (OR 1.181, p = 0.003). Likewise, length of stay was increased in teaching hospitals (7.9 vs 6.9 days, p < 0.001, for diagnostic and 6.5 vs 5.8 days, p < 0.001, for therapeutic ERCPs). CONCLUSIONS: In conclusion, teaching hospitals were noted to have a higher mortality rate associated with inpatient ERCPs as well as higher rates of GI hemorrhage in diagnostic ERCPs, which may be due to a higher comorbidity index in those patients admitted to teaching hospitals.

Trends in Post-Therapeutic Endoscopic Retrograde Cholangiopancreatography Gastrointestinal Hemorrhage, Perforation and Mortality from 2000 to 2012: A Nationwide Study.

BACKGROUND/AIMS: Recent trends in complications following inpatient therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) remain poorly defined. We studied trends of gastrointestinal (GI) hemorrhage, perforation, and mortality following inpatient therapeutic ERCPs from 2000 to 2012 with the hypothesis that ERCPs would have down trending complication rates. METHODS: First, we isolated therapeutic ERCPs in patients 18 years or older using the International Classification of Diseases, Ninth Edition in the 2000 to 2012 National Inpatient Sample databases. Procedures complicated by hemorrhage, perforation, and mortality were identified. Multivariate logistic regressions were used to calculate trends in complication rates and secondary variables, including hospital and patient demographics. Time series regressions were then built for each complication to assess for trends from 2000 to 2012. RESULTS: The mortality rate decreased from 1.77 to 1.24%, a trend that was confirmed by time series regression. Perforation rates increased from 0.07 to 0.10% for therapeutic ERCPs. However, time series regression did not show a significant trend. GI hemorrhage rates increased from 1.36 to 1.57% and this uptrend was confirmed by our time series regression. CONCLUSION: Therapeutic ERCPs have become safer, as demonstrated by a down trending mortality rate. Over the same time, GI hemorrhage rates trended upwards, while no change was noted in perforation rates.

The Association of leptin with severity of non-alcoholic fatty liver disease: A population-based study.

BACKGROUND/AIMS: Leptin is associated with metabolic disorders, which predispose one to non-alcoholic fatty liver disease (NAFLD). The role of leptin in NAFLD pathogenesis is not fully understood. We aim to investigate the association between serum leptin level and severity of NAFLD using U.S. nationally representative data. METHODS: Data were obtained from the United States Third National Health and Nutrition Examination Survey. NAFLD was defined by ultrasound detection and severity of hepatic steatosis in the absence of other liver diseases. The severity of hepatic fibrosis was determined by NAFLD fibrosis score (NFS). We used multivariate survey-weighted generalized logistic regression to evaluate the association between leptin level and the degree of NAFLD. We also performed subgroup analyses by body mass index (lean vs. classic NAFLD). RESULTS: Among 4,571 people, 1,610 (35%) had NAFLD. By ultrasound findings, there were 621 people with mild, 664 with moderate, and 325 with severe steatosis. There were 885 people with low NFS (<-1.455, no significant fibrosis), 596 with intermediate NFS, and 129 with high NFS (>0.676, advanced fibrosis). Leptin levels for normal, mild, moderate and severe steatosis were 10.7±0.3 ng/mL, 12.1±0.7 ng/mL, 15.6±0.8 ng/mL, 16±1.0 ng/mL, respectively (trend P-value<0.001). Leptin levels for low, intermediate, and high NFS were 11.8±0.5 ng/mL, 15.6±0.8 ng/mL, 28.5±3.5ng/mL, respectively (trend P-value<0.001). This association remained significant even after adjusting for known demographic and metabolic risk factors. In the subgroup analysis, this association was only prominent in classic NAFLD, but not in lean NAFLD. CONCLUSION: Serum leptin level is associated with the severity of NAFLD, especially in classic NAFLD patients.

Suicidal ideation among adults with cardiovascular disease: The National Health and Nutrition Examination Survey.

OBJECTIVE: Previous studies have shown a possible link between cardiovascular disease (CVD) and suicidal ideation (SI). However, limited information exists regarding the association between different subtypes of CVD and SI and the role of depression. METHODS: Data were used from the National Health and Nutrition Examination Survey for cycles 2009-2010 and 2011-2012. SI was assessed by item 9 of the Patient Health Questionnaire 9. Data regarding sociodemographic factors, and comorbid conditions were collected and examined as potential correlates. Logistic regression analyses were used to examine the relationship between CVD and subtypes and suicidal ideation. RESULTS: Among a total of 11,678 participants, suicidal ideation was significantly higher among patients with CVD compared to participants without a history of CVD (5.4% vs 3.6%, P<0.001). A subset of patients with CVD with a history of congestive heart failure (CHF) and prior myocardial infarction (MI) had the highest percentage of SI (10.6%). The association between CVD and SI remained significant after adjusting for baseline characteristics and associated comorbidities including depression (OR 1.40, 95% CI 1.10-2.09, P=0.006). CONCLUSION: CVD is an independent risk factor for SI. The identification of a subset of patients with CVD at greatest risk of SI underlines the importance of screening in this vulnerable population.

Time Trends and Predictors of Acute Gastroenteritis in the United States: Results From National Health and Nutrition Examination Survey 2005-2014.

GOALS: To investigate the time trends of the prevalence and predictors of acute gastroenteritis (AGE) in the United States from 2005 to 2014 using nationally representative data. BACKGROUND: AGE results in numerous visits to emergency departments and outpatient clinics annually in the United States with the estimated attributable cost to the US economy up to $145 billion dollars. However, time trends and predictors of AGE are not fully understood. METHODS: Data were obtained from the National Health and Nutrition Survey (NHANES) 2005 to 2014, a nationally representative health survey. AGE was defined by a medical question (Do you have a stomach or intestinal illness with vomiting or diarrhea that started during last 30 d?). Prevalence of AGE was estimated in the total population as well as by selected demographic variables. Predictors of AGE and time trends of prevalence over survey periods were also investigated. RESULTS: Overall monthly prevalence of AGE was 8.31% (95% confidence interval, 7.81-8.81), corresponding to 22.8 million people. AGE was associated with a younger age group, the highest in ages 0 to 9 years old, females, winter to early spring season, US born, divorced/separated/widowed individuals, current smokers, heavy alcohol users, and low household income. In the trends analyses, the prevalence of AGE significantly decreased over the study periods: 10.23% in 2005 to 2006, 9.89% in 2007 to 2008, 7.58% in 2009 to 2010, 6.44% in 2011 to 2012, and 7.47% in 2013 to 2014 (trend P<0.001). CONCLUSION: In the United States from 2005 to 2014, the monthly prevalence of AGE was 8.31% and has been significantly decreasing over time.

Obesity, Metabolic Syndrome, and Cardiovascular Risk in Gluten-Free Followers Without Celiac Disease in the United States: Results from the National Health and Nutrition Examination Survey 2009-2014.

BACKGROUND: Despite unclear benefits of gluten-free diets (GFD) in the general population, gluten-free followers without medical indications are driving the market. Few studies have investigated health benefits of GFD in the general population. AIMS: To estimate metabolic and cardiovascular disease (CVD) risk profiles among gluten-free followers without celiac disease (CD). METHODS: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2009-2014. There were 13,523 persons without CD who had GFD information. People with known CVD were excluded. We compared gluten-free followers without CD and the general population by selective metabolic and CVD risk profiles using survey-weighted generalized logistic regression. RESULTS: There were 155 gluten-free followers without CD and CVD, corresponding to a weighted prevalence of 1.3% (3.2 million Americans). Gluten-free followers tended to be women and have a smaller waist circumference and higher HDL cholesterol. They also had a lower BMI with a borderline p value (0.053) and significant self-reported weight loss (-1.33 kg) over one year. Moreover, gluten-free followers were more likely to consider their weight appropriate. There was no statistical difference by age, smoking, hypertension, total cholesterol, triglyceride cholesterol, HbA1c, or fasting glucose. Despite a lower probability of having metabolic syndrome (33.0 vs 38.5%) and lower 10-year CVD risk score (4.52 vs 5.70%) in gluten-free followers, there was no statistical difference. CONCLUSIONS: Although being on a GFD may be beneficial in weight management, there was no significant difference in terms of prevalence of metabolic syndrome and CVD risk score in gluten-free followers without CD.

Oral Tuberculosis: A Rare Manifestation of Disseminated Disease in a Patient with Dermatomyositis on Chronic Corticosteroids.

Tuberculosis remains one of the leading causes of death around the world despite advancements in diagnostic testing and medical therapies. It commonly affects the lungs, but isolated extra pulmonary clinical manifestations have been reported. Tuberculosis of the oral cavity is exceedingly rare. We present a case of a patient with dermatomyositis on chronic steroid therapy, who presented with tuberculosis involving the tongue as the only clinical manifestation of disseminated disease. Physicians must be aware of extra pulmonary manifestations of tuberculosis in patients at risk, in order to avoid delays in diagnosis and treatment and to prevent further contagion.

Impact of Hospital Teaching Status on Mortality, Length of Stay and Cost Among Patients With Cardiac Arrest in the United States.

Limited data exist regarding the in-hospital outcomes in patients with cardiac arrest (CA) in teaching versus nonteaching hospital settings. Using the Nationwide (National) Inpatient Sample (2008 to 2012), 731,107 cases of CA were identified using International Classification of Diseases, Ninth Edition codes. Among these patients, 348,368 (47.6%) were managed in teaching hospitals and 376,035 (51.4%) in nonteaching hospitals. Patients in teaching hospitals with CA were younger (62.42 vs 68.08 years old), had less co-morbidities (p <0.001), were less likely to be white (54.6% vs 65.5%) and more likely to be uninsured (9.1% vs 7.6%). Mortality in patients with CA was significantly lower in teaching hospitals than in nonteaching hospitals (55.3% vs 58.8%; all p <0.001). The mortality remained significantly lower after adjusting for baseline patient and hospital characteristics (odds ratio 0.917, CI 0.899 to 0.937, p <0.001). However, the survival benefit was no longer present after adjusting for in-hospital procedures (OR 0.997, CI 0.974 to 1.02, p = 0.779). In conclusion, teaching status of the hospital was associated with decreased in-hospital mortality in patients with CA. The differences in mortality disappeared after adjusting for in-hospital procedures, indicating that routine application of novel therapeutic methods in patients with CA in teaching hospitals could translate into improved survival outcomes.

Integrating a Resident-Driven Longitudinal Quality Improvement Curriculum Within an Ambulatory Block Schedule.

BACKGROUND: Quality improvement (QI) is essential in clinical practice, requiring effective teaching in residency. Barriers include lack of structure, mentorship, and time. OBJECTIVE: To develop a longitudinal QI curriculum for an internal medicine residency program with limited faculty resources and evaluate its effectiveness. METHODS: All medicine residents were provided with dedicated research time every 8 weeks during their ambulatory blocks. Groups of 3 to 5 residents across all postgraduate year levels were formed. Two faculty members and 1 chief resident advised all groups, meeting with each group every 8 weeks, with concrete expectations for each meeting. Residents were required to complete didactic modules from the Institute for Healthcare Improvement. Current residents and alumni were surveyed for feedback. RESULTS: Over 3 years, all eligible residents (92 residents per year in 2012-2014, 102 in 2014-2015) participated in the curriculum. Residents worked on 54 quality assessment and 18 QI projects, with 6 QI projects showing statistically significant indicator improvements. About 50 mentoring hours per year were contributed by 2 faculty advisors and a chief resident. No other staff or IT support was needed. A total of 69 posters/abstracts were produced, with 13 projects presented at national or regional conferences. Survey respondents found the program useful; most (75% residents, 63% alumni) reported it changed their practice, and 71% of alumni found it useful after residency. CONCLUSIONS: Our longitudinal QI curriculum requires minimal faculty time and resulted in increased QI-related publications and measurable improvements in quality indicators. Alumni reported a positive effect on practice after graduation.

Angioimmunoblastic T Cell Lymphoma Mimicking Chronic Urticaria.

Angioimmunoblastic T cell lymphoma (AITL) is a rare but distinct type of T cell lymphoma with an aggressive course and high mortality. Most patients are diagnosed late in the disease and usually present with generalized lymphadenopathy. A minority have skin lesions at the time of diagnosis, more commonly in the form of nonspecific maculopapular rash with or without pruritus. We report a rare case of AITL presenting with chronic, recurrent angioedema and urticaria-like lesions and no palpable peripheral adenopathy. Primary Care physicians, dermatologists, and allergists must maintain a high index of suspicion for cutaneous manifestations of lymphoma, especially if the skin lesions are refractory to standard treatment. Timely diagnosis is essential to improve survival.

Pancreatic tuberculosis in a human immunodeficiency virus positive patient: a case report.

Despite the increased incidence of tuberculosis related to human immunodeficiency virus (HIV) in recent decades, pancreatic tuberculosis has rarely been described. We report a case of pancreatic tuberculosis in a 39-year-old African man who presented with progressive dysphagia, vomiting, weight loss and productive cough, accompanied by localized epigastric pain and one episode of melena. HIV-1 testing was positive and lymphocyte subset profile showed CD(4) count of 9/mm(3). Abdominal computed tomography (CT) scan with contrast revealed a cystic mass in the body of the pancreas, significant portal and retroperitoneal cystic adenopathy, and multiple cystic lesions in the spleen and liver. CT guided cyst aspiration and node biopsy detected Mycobacterium tuberculosis. The patient responded well on antituberculosis and antiretroviral therapy. Tuberculosis rarely involves the pancreas, probably due to the presence of pancreatic enzymes which interfere with the seeding of Mycobacterium tuberculosis. Pancreatic tuberculosis is considered to be the result of dissemination of the infection from nearby lymphatic nodes. Endoscopic ultrasound or CT guided fine needle aspiration for cytology is the recommended diagnostic technique. Although the prognosis is good with anti-tuberculosis treatment, it could be fatal without correct diagnosis and treatment. The clinician's high index of suspicion of pancreatic tuberculosis and application of FNAB to obtain pathological evidence are extremely important to a correct diagnosis, especially in young HIV positive patients.