Ocular Paraneoplastic Syndromes: A Critical Review of Diffuse Uveal Melanocytic Proliferation and Autoimmune Retinopathy.

Background: Dozens of paraneoplastic syndromes affect the visual system ranging from conjunctival pemphigoid to encephalopathy of the occipital cortex. The most profiled ocular syndromes are bilateral diffuse uveal melanocytic proliferation (BDUMP) and the autoimmune retinopathies.Purpose: To review the critical features of these 2 entities then concentrate on advancements in treatment made within the last 10 years.Study Design: Literature review with structured data abstraction.Results: Major insights into pathogenesis have been wanting. Plasmapheresis appears to improve vision in a substantial proportion of patients with BDUMP. The number of clinical variables that influence visual outcome in paraneoplastic retinopathies combined with the variety of local and systemic treatment options makes interpretation of clinical effectiveness difficult.Conclusions: The rarity of these disorders makes randomized clinical trials unlikely. It may be time for a clinical professional organization to use a modified Delphi method to establish a consensus algorithm for the diagnosis and management of retinal paraneoplastic syndromes to augment clinical communications and clinical trials.

Prevent and Protect: A Vaccination Initiative for Uninsured Patients at a Student-Run Free Clinic.

Lower vaccination rates in uninsured adults may be related to prohibitive costs of and limited access to vaccines. To compare Tdap and pneumococcal vaccination rates of a student-run free clinic to national averages. A retrospective chart review of 236 adult patients from 05/2017 to 06/2019 was conducted. Vaccine eligibility was determined according to CDC guidelines at the time of the patient visit and according vaccination history by review of medical records. Percent up-to-date was determined by dividing the number of up-to-date individuals by the total number of patients eligible for the vaccine. BRIDGE Healthcare Clinic vaccination rates were near or surpassed national averages. The percent of up-to-date individuals was 63.1% for Tdap, 90% for pneumococcal vaccines in adults 65 or older, and 86.5% for pneumococcal vaccines in high-risk adults 18-64 years. This compares with 2017 national averages of 63.4%, 69%, and 24.5%, respectively (Center for Disease Control and Prevention (CDC) Vaccination coverage among adults in the United States, National Health Interview Survey. Retrieved February 8, 2018 from https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2017.html#pneumo , 2017). Of the 197 vaccines provided during the course of this study, 184 were provided by the BRIDGE Healthcare Clinic. In conclusion, with the appropriate funding and stewardship, student-run free clinics play a resourceful role in increasing access to preventative health care for uninsured patients.

Addressing Breast Cancer Screening Disparities Among Uninsured and Insured Patients: A Student-Run Free Clinic Initiative.

Mammography rates among the uninsured are less than half of those among insured patients as reported by American Cancer Society (Breast cancer facts & figures 2017-2018, American Cancer Society, Inc., Atlanta, 2017). This may stem from high costs of and limited access to a usual place for health care, which may portend delayed breast cancer diagnoses and poorer outcomes among uninsured women. Student-run free clinics provide opportunities for uninsured patients to establish a medical home, thereby increasing access to preventative health care. The purpose of this study is to determine the rates of breast cancer screening at a student-run free clinic and compare them to national averages. A retrospective chart review was conducted using patients of BRIDGE Healthcare Clinic who were women ages 40-75 years between January 2012 and March 2018. Medical records were reviewed for demographics, date of mammogram, and screening results. A total of 194 women 40 years or older were included in the review. Overall, of the 157 women who were 45 years or older at their most recent visit, 75.5% were up-to-date according to guidelines set forth by the American Cancer Society. These values are well above the reported national rates in insured and uninsured women (21%, 53%, respectively) as reported by American Cancer Society (Breast cancer facts & figures 2017-2018, American Cancer Society, Inc., Atlanta, 2017). Of the patients who obtained screening mammograms, 84.5% utilized BRIDGE Healthcare Clinic's program. Volunteer providers are often the sole source of health care for a substantial portion of uninsured patients, who may have unmet preventative health needs. As such, the findings of this study suggest that student-run free clinics play an important role in increasing uninsured patients' access to mammograms. The breast cancer screening program described herein may serve as an example for implementation by other student-run free clinics.

Enhancing Adherence to Cervical Cancer Screening Guidelines at a Student-Run Free Clinic.

Women who lack health insurance have much lower rates of cervical cancer screening and higher rates of cervical cancer than insured women. The current screening rate for insured patients is 86.9%, while the rate for uninsured women is 68.2%. Student-run free clinics may help increase the rates of cervical cancer screening in uninsured women. As screening rates in this setting are uncertain, this study was performed to determine rates of cervical cancer screening at a student-run free clinic, and therefore determine its effectiveness in increasing screening rates in uninsured women. A retrospective chart review was conducted among female patients ages 21-64 at a student-run free clinic to determine how many patients were up-to-date with cervical cancer screening per American Cancer Society (ACS) guidelines. A total of 239 women were included in the retrospective chart review. At their most recent visit, 87.9% of clinic patients were up-to-date on cervical cancer screening. This screening rate is higher than both the reported uninsured (68.2%) and insured (86.9%) national screening rates in the United States. Although there are multiple barriers that prevent uninsured patients from undergoing cervical cancer screenings, screening rates at our student-run free clinic are higher than national screening rates. This higher screening rate can be attributed to a standardized screening system, access to resources including Pap tests provided by community partners, and the clinic's ability to longitudinally follow patients. However, there remain areas for improvement, such as reducing no-show rates and ensuring that staff screen for cervical cancer at each visit.

Validation of the Khorana score in acute myeloid leukemia patients: a single-institution experience.

BACKGROUND: Although patients with acute myeloid leukemia (AML) were shown to have an increased risk of thrombosis, no thrombosis risk assessment scoring system has been developed for AML patients. The Khorana Risk Score (KRS), which has been widely used for thrombosis risk assessment in the clinical setting, was developed on the basis of solid tumor data and has not been validated among AML patients. This study aims to validate the use of the KRS as a thrombosis risk-scoring system among patients with AML. METHODS: Using data from H. Lee Moffitt Cancer Center and Research Institution's Total Cancer Care Research Study, we retrospectively identified patients who were histologically confirmed with AML from 2000 to 2018. Clinical and laboratory variables at the time of AML diagnosis were characterized and analyzed. The thrombotic event rate was estimated with the Kaplan-Meier method and compared using the log-rank test. RESULTS: A total of 867 AML patients were included in the analysis. The median age at AML diagnosis was 75 years (range, 51-96), and the majority were male (65%, n = 565). A total of 22% (n = 191), 51% (n = 445), 24% (n = 207), and 3% (n = 24) of patients had a KRS of 0, 1, 2, and 3, respectively. A total of 42 thrombotic events (3% [n = 6/191] with a KRS of 1; 5% [n = 23/445] with a KRS of 2; 6.3% [n = 13/207] with a KRS of 3) were observed, with a median follow-up of 3 months (range, 0.1-307). There was no statistical difference in the risk of thrombosis between these groups (P = .1949). CONCLUSIONS: Although there was an increased risk of thrombosis associated with a higher KRS among AML patients with a KRS of 1 to 3, the difference was not statistically significant. Furthermore, only a few patients were found to have a KRS > 3, and this was largely due to pancytopenia, which is commonly associated with AML. These results indicate the need for a better thrombotic risk-scoring system for AML patients.

Agreement between self-reported psychoactive substance use and urine toxicology results for adults with opioid use disorder admitted to hospital.

Hospitals often perform urine drug screens (UDS) upon inpatient admission to confirm self-reported psychoactive substance use for patients with opioid use disorder (OUD). We sought to evaluate the agreement between UDS and patient self-report for psychoactive substances detected with UDS for adults with OUD admitted to hospital. For 11 substance categories, we evaluated agreement between the UDS and the documented history over a 5-year period for consecutive adults admitted to one academic center with a history of OUD. Among the 153 patients, overall agreement across the 1683 different history/UDS pairs (i.e. either history+/UDS + or history-/UDS-) was high (81.3%) but varied (from lowest to highest) by substance [opiates (56.9%), benzodiazepines (66.0%), 6-acetylmorphine (67.3%), cocaine (81.0%), cannabinoids (81.0%), methadone (83.7%), buprenorphine (85.0%), amphetamine (94.8%), barbiturates (95.4%), and phencyclidine (98.7%)]. History+/UDS- pair mismatches were most frequent for 6-acetylmorphine (32.7%), methadone (14.3%) and oxycodone (12.4%); history-/UDS + pair mismatches were most frequent for opiates (43.1%), benzodiazepines (24.8%) and cannabinoids (18.3%). The change in agreement over time of self-reported heroin use may reflect an increasing number of patients unknowingly using illicit fentanyl products. Among hospitalized patients with OUD, agreement between reported psychoactive substance use history and UDS results is strong with the exception of opiates, heroin, and benzodiazepines.

Comparação de Custo da enoxaparina e dos novos anticoagulantes orais dabigatran e rivaroxaban na profilaxia do tromboembolismo venoso / Cost comparison between enoxaparin and new oral anticoagulants dabigatran and rivaroxaban in venous thromboembolism prophylaxis

Venous thromboembolism, an important complication that is easily prevented during surgery, is among the few clinicai entities wherein the use of prophylaxis has been found to be effective, such as in the case of antibiotic prophylaxis for the prevention of surgical site infections. The objectives of prophylaxis are to reduce the incidence of deep vein thrombosis, minimize the risk of long-term complications such as chronic venous insufficiency and pulmonary hypertension, and prevent death caused by pulmonary embolism. In this study, we aimed to provide current information to plastic surgeons on the therapeutic options for prophylaxis of venous thromboembolism as well as to compare treatment costs of the drugs enoxaparin, dabigatran, and rivaroxaban. Method: For comparison, the prophylaxis regimen was started 6 hours after the surgery and continued for 10 days. The end user price was obtained from an internet search that included leading pharmacy chains. Results: The patient costs of the new oral anticoagulants dabigatran and rivaroxaban were lower than that of enoxaparin. Conclusions: The cost of venous thromboembolism prophylaxis consisting of the new oral anticoagulants dabigatran and rivaroxaban is lower than that of low molecular weight heparin.

O tromboembolismo venoso é uma complicação importante altamente evitável em cirurgia, sendo uma das poucas entidades clínica em medicina passíveis de profilaxia comprovadamente eficiente, assim como ocorre na profilaxia antibiótica da infecções cirúrgicas. A profilaxia tem por objetivo diminuir a incidência de trombose venosa profunda minimizar os riscos das complicações a longo prazo da insuficiência venosa crônica e hipertensão pulmonar, bem como prevenir a morte consequente de embolia pulmonar. Este estudo tem por objetivo atualizar os cirurgiões plásticos quanto às medicações que podem ser adotadas na profilaxia do tromboembolismo venoso bem como comparar o custo dessas medicações (enoxaparina dabigatran e rivaroxaban). Método: Para efeito de comparação foi adotado um esquema de profilaxia iniciado 6 horas após o fim da cirurgia e mantido por 1O dias. A pequisa foi realizada na internet entre as principais redes farmacêuticas, levando em conta custo para o consumidor. Resultados: Os novos anticoagulantes orais dabigatran e rivaroxaban apresentaram custo menor para o paciente. Conclusões: Os novos anticoagulantes orais dabigatran e rivaroxaban possuem custo menor na profilaxia do tromboembolismo venoso em comparação à heparina de baixo peso molecular.

Fasceíte necrotizante em dependente químico: etiologia e tratamento da fase aguda e seqüela / Necrotizing fasciitis in chemically dependent: etiology and treatment of acute and sequel

É o relato do caso de uma paciente adulta, dependente química de drogas injetáveis com quadro de infecção grave, caracterizada por necrose extensa e rapidamente progressiva do tecido celular subcutâneo e da fáscia muscular. Submetida a desbridamento cirúrgico amplo, combinado à antibioticoterapia apresentou evolução favorável do quadro infeccioso, evoluindo com seqüela em membro superior. Esta exposição serve para demonstrar a necessidade do diagnóstico clínico precoce e abordagem cirúrgica imediata, essenciais ao tratamento desta grave infecção e a contribuição do tratamento cirúrgico das seqüelas tardias (AU)

Fasceíte necrotizante em dependente químico: etiologia e tratamento da fase aguda e seqüela

É o relato do caso de uma paciente adulta, dependente química de drogas injetáveis com quadro de infecção grave, caracterizada por necrose extensa e rapidamente progressiva do tecido celular subcutâneo e da fáscia muscular. Submetida a desbridamento cirúrgico amplo, combinado à antibioticoterapia apresentou evolução favorável do quadro infeccioso, evoluindo com seqüela em membro superior. Esta exposição serve para demonstrar a necessidade do diagnóstico clínico precoce e abordagem cirúrgica imediata, essenciais ao tratamento desta grave infecção e a contribuição do tratamento cirúrgico das seqüelas tardias