Recurrent multinodular goitre and primary hyperparathyroidism due to adenoma arising in a parathyroid autotransplant more than 20 years after near-total thyroidectomy.

The patient is a female in her 60s with a remote history of a near-total thyroidectomy in 1997 for multinodular goitre. At the initial operation, she sustained a left recurrent laryngeal nerve injury. A devascularised parathyroid gland was autotransplanted into the right sternocleidomastoid muscle. She had been off of thyroid hormone for long periods, and her most recent levothyroxine requirement had fallen to only 25 mcg daily. The patient presented more than 20 years after her thyroidectomy with hoarseness, fatigue and dyspnoea. Laboratory studies suggested primary hyperparathyroidism. Imaging demonstrated bilateral pulmonary emboli and bulky thyroid tissue extending into her mediastinum. She underwent a completion thyroidectomy with the removal of a parathyroid adenoma arising in the autotransplanted parathyroid. This case illustrates the possibility of regrowth of benign thyroid tissue after thyroidectomy. In addition, to our knowledge, this is the first case report of a parathyroid adenoma arising from autotransplantation of a normal parathyroid.

Functional Gastrointestinal Disorders.

Functional gastrointestinal disorders (FGIDs) are an extremely common set of more than 50 disorders characterized by persistent and recurring gastrointestinal symptoms. Most of these patients can be diagnosed and managed by primary care physicians. Treatment includes patient education and reassurance, eliminating triggers, dietary modification, and pharmacologic management. Primary care physicians should consider referral to gastroenterologists when patients exhibit red flag symptoms such as blood in stool, abnormal laboratory findings, involuntary weight loss, age of presentation greater than 50 years, or certain concerning family history.

The Impact on Future Prescribing Patterns of Opioid Use Disorder (OUD) Education and Waiver Provision During Residency.

BACKGROUND: Family medicine residency programs vary in the extent of training offered on opioid use disorder (OUD) in their curricula. The purpose of this study was to determine the impact of OUD education and buprenorphine waiver provision on postresidency buprenorphine prescribing patterns. METHODS: Three North Carolina family medicine residency programs differed in the extent to which they taught OUD, including buprenorphine waiver provision. Program A required OUD education and assisted residents in obtaining a waiver; Program B offered OUD education and did not assist with obtaining a waiver; and Program C did not offer OUD education. In November 2019, graduates from these 3 programs were surveyed regarding the extent to which they engaged in treatment of OUD. Descriptive statistics were used to characterize the survey participants and their responses. RESULTS: Of the 62 graduates invited to participate, 49 (79.0%) responded. Across the 3 programs, the percentage of graduates with a waiver varied significantly (P < .0001): Program A (84.2%), Program B (33.3%), and Program C (0.0%). Of those who were not waivered, Program B had a larger percentage that desired to prescribe buprenorphine products (70.0%) as compared with Program C (9.1%) (P = .009). CONCLUSIONS: Family medicine residency graduates from programs with more integrated OUD education were more likely to obtain and use a waiver to prescribe buprenorphine-containing medications postgraduation.

Management of difficult-to-treat Clostridioides difficile in a patient with chronic osteomyelitis.

A 61-year-old male patient being treated with intravenous antibiotics for left foot osteomyelitis presented to the hospital septic, with several days of worsening abdominal pain, bloating and watery bowel movements. Investigation revealed that the patient had severe, treatment-resistant Clostridioides difficile colitis. He was initially treated with oral vancomycin and intravenous metronidazole, which was switched to oral fidaxomicin. After no improvement in the patient's symptoms, he was treated with two faecal microbiota transplants. He was offered a third faecal microbiota transplant but declined. The patient was placed back on oral fidaxomicin and saw ultimate resolution of his symptoms. This case provides an example of a treatment pathway for refractory C. difficile infection.

Media representation of vaccine side effects and its impact on utilization of vaccination services in Vietnam.

BACKGROUND: Media representation of vaccine side effects impacts the success of immunization programs globally. Exposure to the media can cause individuals to feel hesitant toward, or even refuse, vaccines. This study aimed to explore the impact of the media on beliefs and behaviors regarding vaccines and vaccine side effects in an urban clinic in Vietnam. METHODS: A cross-sectional study was conducted in an urban vaccination clinic in Hanoi, Vietnam from November 2015 to March 2016. The primary outcomes of this study were the decisions of Vietnamese subjects after hearing about adverse effects of immunizations (AEFIs) in the media. Socio-demographic characteristics as well as beliefs regarding vaccination were also investigated. Multivariate logistic regression was used to identify factors associated with subjects' behaviors regarding vaccines. RESULTS: Among 429 subjects, 68.2% of them said they would be hesitant about receiving vaccines after hearing about AEFIs, while 12.4% of subjects said they would refuse vaccines altogether after hearing about AEFIs. Wealthy individuals (OR=0.41; 95% CI=0.19-0.88), and those who displayed trust in government-distributed vaccines (OR=0.20; 95% CI=0.06-0.72) were less likely to display hesitancy regarding vaccination. Receiving information from community health workers (OR=0.44; 95% CI=0.20-0.99) and their relatives, colleagues, and friends (OR=0.47; 95% CI=0.25-0.88) was negatively associated with vaccine hesitancy, but facilitated vaccine refusal after reading about AEFIs in the media (OR=3.12; 95% CI=1.10-8.90 and OR=3.75; 95% CI=1.56-9.02, respectively). CONCLUSION: Our results reveal a significantly high rate of vaccine hesitancy and refusal among subjects living in an urban setting in Vietnam, after hearing about AEFIs in the media. Vietnam needs to develop accurate information systems in the media about immunizations, to foster increased trust between individuals, health care professionals, and the Vietnamese government.

Sexual Risk Behaviors of Patients with HIV/AIDS over the Course of Antiretroviral Treatment in Northern Vietnam.

Antiretroviral therapy (ART) improves the health and well-being of people living with the human immunodeficiency virus (HIV, PLWH), and reduces their risk of transmitting the virus to sexual partners. However, patterns of sexual risk behavior among HIV-positive patients taking ART in Vietnam remain largely unknown. In this study, we sought to examine sexual risk behaviors and their associated factors among HIV-positive patients receiving ART in northern Vietnam. The socio-demographic characteristics, ART use, health status, and sexual behaviors of 1133 patients taking ART in the Hanoi and Nam Dinh provinces were explored through face-to-face interviews. There were 63.5% of patients who had one sex partner, while 3.6% and 5.6% of patients had sexual intercourse with casual partners or sex workers, respectively, in the previous 12 months. Most participants tended to use condoms more often with commercial sex partners (90.2%) and intimate partners (79.7%), and less often with casual partners (60.9%). Higher age (odds ratio, OR = 1.0; 95% CIs = 1.0, 1.1) or suffering pain/discomfort (OR = 1.7; 95% CIs = 1.2, 2.4) were factors more likely to be associated with multiple sex partners. Patients who were self-employed were more likely to have sexual intercourse with casual partners/sex workers (OR = 2.1; 95% CIs = 1.1, 4.0). Meanwhile, a higher score on the EuroQol visual analog scale (EQ-VAS), an unknown HIV stage, and a longer duration of ART were adversely associated with not using condoms with casual partners/sex workers. Patients with longer durations of ART had a lower likelihood of not using a condom with casual partners/sex workers (OR = 0.5; 95% CIs = 0.3, 0.8). Our study underscored a relatively high rate of unsafe sexual behaviors among HIV-positive patients. Continuing to improve the physical and psychological well-being of HIV-positive patients in Vietnam is important in reducing the spread of HIV via risky sexual behaviors. In addition, safe-sex education should be provided to older people, and to those who are self-employed.

Evaluating Food Safety Knowledge and Practices of Food Processors and Sellers Working in Food Facilities in Hanoi, Vietnam.

Consumption of fast food and street food is increasingly common among Vietnamese, particularly in large cities. The high daily demand for these convenient food services, together with a poor management system, has raised concerns about food hygiene and safety (FHS). This study aimed to examine the FHS knowledge and practices of food processors and sellers in food facilities in Hanoi, Vietnam, and to identify their associated factors. A cross-sectional study was conducted with 1,760 food processors and sellers in restaurants, fast food stores, food stalls, and street vendors in Hanoi in 2015. We assessed each participant's FHS knowledge using a self-report questionnaire and their FHS practices using a checklist. Tobit regression was used to determine potential factors associated with FHS knowledge and practices, including demographics, training experience, and frequency of health examination. Overall, we observed a lack of FHS knowledge among respondents across three domains, including standard requirements for food facilities (18%), food processing procedures (29%), and food poisoning prevention (11%). Only 25.9 and 38.1% of participants used caps and masks, respectively, and 12.8% of food processors reported direct hand contact with food. After adjusting for socioeconomic characteristics, these factors significantly predicted increased FHS knowledge and practice scores: (i) working at restaurants and food stalls, (ii) having FHS training, (iii) having had a physical examination, and (iv) having taken a stool test within the last year. These findings highlight the need of continuous training to improve FHS knowledge and practices among food processors and food sellers. Moreover, regular monitoring of food facilities, combined with medical examination of their staff, should be performed to ensure food safety.

Concurrent drug use among methadone maintenance patients in mountainous areas in northern Vietnam.

OBJECTIVES: With the rise in methadone maintenance therapy (MMT) for drug users in Vietnam, there has been growing interest in understanding if and how often MMT patients engage in concurrent illicit drug use while on methadone therapy in various settings. This study examined factors associated with concurrent opioid use among patients on MMT in a mountainous area in Vietnam. SETTING: One urban and one rural MMT clinics in Tuyen Quang province. PARTICIPANTS: Survey participants consisted of patients who were taking MMT at the selected study sites. A convenience sampling approach was used to recruit the participants. PRIMARY AND SECONDARY OUTCOME MEASURES: Participants were asked a series of questions about their socioeconomic status, current alcohol and tobacco use, health problems (measured by the EuroQol-Five Dimension-Five Level instrument), psychological distress (measured by Kessler score), and factors associated with current and/or previous drug use. Regression models were used to determine factors associated with concurrent drug use among MMT patients. RESULTS: Among the 241 male MMT patients included in the study, 13.4% reported concurrent opioid use. On average, the longer patients had been enrolled in MMT, the less likely they were to concurrently use drugs. Conversely, patients with higher levels of psychological distress were more likely to engage in concurrent drug use while on MMT. CONCLUSION: Longer duration of MMT was significantly correlated with reduced illicit drug use among participants. Higher levels of psychological distress were associated with increased use of illicit drugs among MMT patients. Regardless of distance, long-term MMT is still effective and should be expanded in mountainous areas.

Providing Specialty Care for the Poor and Underserved at Student-Run Free Clinics in the San Francisco Bay Area.

This report describes the model of specialty clinics implemented at Stanford University's two student-run free clinics, Arbor Free Clinic and Pacific Free Clinic, in the San Francisco Bay Area. We describe our patient demographic characteristics and the specialty services provided. We discuss challenges in implementing specialty care at student-run free clinics.

Sexual behaviors among methadone maintenance patients in a mountainous area in northern Vietnam.

BACKGROUND: Methadone maintenance treatment (MMT) improves patients' ability to access HIV-related services and reduces needle sharing and other risky HIV-related behaviors. However, patients may continue to engage in risky sexual practices. In this study, we evaluate sexual behaviors of MMT patients in a mountainous province in Northern Vietnam. METHODS: We explored the health status, MMT and substance use history, and sexual practices of 241 male MMT patients in Tuyen Quang province. Health status was investigated using the EuroQOL-5 Dimensions-5 Levels (EQ-5D-5 L). Multivariate logistic regression was employed to assess associated factors. RESULTS: Most patients (66.4%) reported having at least one sexual partner within the previous twelve months. Most of these partners were spouses or primary partners (72.6%). About 8.3% of patients had casual partners, and 5.8% had visited sex workers; of those who engaged in casual sexual relationships, 90.9% reported using condoms. Current drug use and living in a remote area were associated with an increased odd of having two or more sexual partners, while anxiety or depression was associated with lower odds. CONCLUSION: This study highlights a low proportion of having sexual risk behaviors among MMT patients in Vietnamese mountainous settings. Integrating education about safe sexual practices into MMT services, along with providing medical care and ensuring methadone treatment adherence, is an important component in HIV risk reduction for these patients who were at risk of unsafe sexual practices.

Ability to join the workforce and work productivity among drug users under methadone maintenance treatment in a mountainous area of Northern Vietnam: a cross-sectional study.

OBJECTIVES: A major measure of treatment success for drug users undergoing rehabilitation is the ability to enter the workforce and generate income. This study examines the absenteeism and productivity among people who inject drugs (PWID) enrolled in methadone maintenance treatment (MMT) in Northern Vietnam. SETTING: We conducted a cross-sectional study in two clinics in Tuyen Quang province. PARTICIPANTS: A total of 241 patients enrolled in MMT. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients' work productivity was measured using the WPAI-GH instrument (Work Productivity and Activity Impairment Questionnaire: General Health V2.0). We also collected additional characteristics about participants' employment history, such as proficient jobs, whether they actively found a new job and be accepted by employers. RESULTS: Most of the participants (>90%) were employed at the time of the study. Rates of absenteeism (missed work), presenteeism (impairment while working) and overall loss of productivity were 15.8%, 5.6% and 11.2%, respectively, as measured by the WPAI-GH questionnaire. The most proficient job was 'freelancer' (17.5%), followed by 'blue-collar worker' (10.6%) and 'farmer' (10.2%). Only 26.8% of patients reported that they actively sought jobs in the past. About half of them had been refused by employers because of their drug use history and/or HIV status. We found no statistically significant difference between patients enrolled in MMT for <1 year and those who had been enrolled >1 year. Factors associated with higher work productivity included not endorsing problems in mobility, self-care or pain; being HIV-negative and having greater MMT treatment adherence. CONCLUSION: Our study highlights the high employment rate and work productivity among PWID in MMT programmes in remote areas of Northern Vietnam. The results can help to improve the quality and structure of MMT programmes across Vietnam and in other countries.

Barriers to accessing and using health insurance cards among methadone maintenance treatment patients in northern Vietnam.

BACKGROUND: Methadone maintenance treatment (MMT) patients face unique costs associated with their healthcare expenditures. As such, it is important that these patients have access to health insurance (HI) to help them pay for both routine and unforeseen health services. In this study, we explored factors related to health insurance enrollment and utilization among MMT patients, to move Vietnam closer to universal coverage among this patient population. METHODS: A cross-sectional study was conducted with 1003 patients enrolled in MMT in five clinics in Hanoi and Nam Dinh provinces. Patients were asked a range of questions about their health, health expenditures, and health insurance access and utilization. We used multivariate logistic regressions to determine factors associated with health insurance access among participants. RESULTS: The majority of participants (nearly 80%) were not currently enrolled in health insurance at the time of the study. Participants from rural regions were significantly more likely than urban participants to report difficulty using HI. Family members of participants from rural regions were more likely to have overall poor service quality through health insurance compared with family members of participants from urban regions. Overall, 37% of participants endorsed a lack of information about HI, nearly 22% of participants reported difficulty accessing HI, 22% reported difficulty using HI, and more than 20% stated they had trouble paying for HI. Older, more highly educated, and employed participants were more likely to have an easier time accessing HI than their younger, less well educated, and unemployed counterparts. HIV-positive participants were more likely to have sufficient information about health insurance options. CONCLUSIONS: Our study highlights the dearth of health insurance utilization among MMT patients in northern Vietnam. It also sheds light on factors associated with increased access to and utilization of health insurance among this underserved population. These results can help improve health insurance enrollment among MMT patients, a population that is at increased need of financial assistance in accessing health services.

Quality of life and healthcare service utilization among methadone maintenance patients in a mountainous area of Northern Vietnam.

BACKGROUND: The expansion of methadone maintenance treatment in mountainous areas in still limited and little is known about its health impacts on drug users. This study aimed to examine health-related quality of life (HRQOL) and health care access among patients engaging in methadone maintenance treatment (MMT) in Tuyen Quang, a mountainous province in Vietnam. METHODS: We conducted a cross-sectional survey with 241 patients conveniently recruited in two MMT clinics (Son Duong and Tuyen Quang). EuroQol-5 Dimensions - 5 levels (EQ-5D-5 L) and Visual analogue scale (VAS) were employed to measure HRQOL. Multivariate logistic and tobit regressions were used to determine the factors associated with HRQOL and health care utilization. RESULTS: The overall mean score of the EQ-5D index and EQ-VAS were 0.88 (SD = 0.20) and 81.8% (SD = 15.27%), respectively. Only 8.7% utilized inpatient services, and 14.9% used outpatient services. Being more highly educated, suffering acute diseases, and using health service within the last 12 months were associated with a decreased EQ-5D index. Individuals who were multiple substance abusers and those who recently had inpatient care were more likely to have a lower VAS. Older respondents, those taking their medications at the more impoverished clinic, substance abusers, and individuals who were struggling with anxiety/depression or their usual daily activities were more likely to use both inpatient and outpatient care. CONCLUSIONS: In summary, we observed good HRQOL, but high prevalence of anxiety/depression and low rates of service utilization among MMT patients in Tuyen Quang province. To improve the outcomes of MMT services in mountainous areas, it is necessary to introduce personalized and integrative services models with counseling and interventions on multiple substance use.

Patient-Centered Care Challenges and Surprises: Through the Clerkship Students' Eyes.

BACKGROUND AND OBJECTIVES: The patient-centered care model for health care delivery encourages medical providers to respect patients' preferences and give patients more autonomy over their health care decisions. This approach has gained importance within US medical school curricula. Yet, little is known about student perspectives on both patient-centered care and the benefits and challenges that lie therein. This manuscript explores the greatest impediments to, as well as the benefits from, student engagement in patient-centered care from the perspectives of students participating in their family medicine outpatient clerkship. METHODS: Clerkship students on their core family medicine clerkship at Stanford University School of Medicine were provided the following open-ended prompt: "Describe a patient-centered care challenge or surprise in the family medicine core clerkship." Free-text responses were collected and analyzed using content and thematic analysis. RESULTS: A total of 326 responses from 216 students were analyzed for frequency and patient-centered themes. Nine final themes emerged and were grouped into three domains: student definitions of patient-centered care, patient-centered care impact on patients, and patient-centered care impact on medical professionals. CONCLUSIONS: Our study suggests that students find the patient-centered care model for health care delivery to be challenging but worthwhile. We highlight that students find communication with patients in a patient-centered manner challenging and discuss the need for improved medical education about patient-centered care in order to better prepare students to implement the model in a variety of psychosocial and medical contexts.

"Social Crimes": Understandings of HIV/AIDS as a Disease Among Grandparents Raising Grandchildren in Vietnam.

Grandparent caregivers are vital to the survival of grandchildren who are orphaned and who have been affected by HIV/AIDS. The purpose of this qualitative study was to understand the meaning of HIV as a disease among grandparents raising grandchildren orphaned by HIV/AIDS in northern Vietnam and to gain insight into how this understanding affected grandparents' relationships and health-seeking decisions. Results indicated that grandparents had knowledge deficits about the biomedical aspects of the disease and often hid their grandchildren's HIV status or preferred not to seek testing. Effective interventions must address stigma reduction, family relationships, and access to health care to increase testing and treatment of grandchildren.

Gender inequality and HIV transmission: a global analysis.

INTRODUCTION: The HIV pandemic disproportionately impacts young women. Worldwide, young women aged 15-24 are infected with HIV at rates twice that of young men, and young women alone account for nearly a quarter of all new HIV infections. The incommensurate HIV incidence in young - often poor - women underscores how social and economic inequalities shape the HIV epidemic. Confluent social forces, including political and gender violence, poverty, racism, and sexism impede equal access to therapies and effective care, but most of all constrain the agency of women. METHODS: HIV prevalence data was compiled from the 2010 UNAIDS Global Report. Gender inequality was assessed using the 2011 United Nations Human Development Report Gender Inequality Index (GII). Logistic regression models were created with predominant mode of transmission (heterosexual vs. MSM/IDU) as the dependent variable and GII, Muslim vs. non-Muslim, Democracy Index, male circumcision rate, log gross national income (GNI) per capita at purchasing power parity (PPP), and region as independent variables. RESULTS AND DISCUSSION: There is a significant correlation between having a predominantly heterosexual epidemic and high gender inequality across all models. There is not a significant association between whether a country is predominantly Muslim, has a high/low GNI at PPP, has a high/low circumcision rate, and its primary mode of transmission. In addition, there are only three countries that have had a generalized epidemic in the past but no longer have one: Cambodia, Honduras, and Eritrea. GII data are available only for Cambodia and Honduras, and these countries showed a 37 and 34% improvement, respectively, in their Gender Inequality Indices between 1995 and 2011. During the same period, both countries reduced their HIV prevalence below the 1% threshold of a generalized epidemic. This represents limited but compelling evidence that improvements in gender inequality can lead to the abatement of generalized epidemics. CONCLUSIONS: Gender inequality is an important factor in the maintenance - and possibly in the establishment of - generalized HIV epidemics. We should view improvements in gender inequality as part of a broader public health strategy.

Working in partnership with interpreters: studies on individuals affected by HIV/AIDS in Vietnam.

This article brings together two American qualitative researchers and two Vietnamese interpreters who investigated the social impacts of HIV/AIDS in Vietnam from the standpoint of the local community. As cultural outsiders with limited Vietnamese language skills, the researchers relied on the insights and expertise of the interpreters to the extent that interpreter roles expanded to become co-researchers. We explain the guidelines we used to work in partnership in the field. We then describe how the relationship between researcher and interpreter developed into co-researching, and how we utilized this relationship to respond to challenges in the work. Despite an increasing number of international qualitative studies, little research has focused on the nuances of a working partnership between researcher and interpreter, and few studies include interpreters as co-researchers. This article contributes to an understanding of how the researcher-interpreter relationship impacts the voice of the participant and, ultimately, the final outcomes of the project.