Atrial Flutter and Left Hemidiaphragmatic Paralysis in the Setting of Lyme Disease.

Lyme disease, caused by a tick-borne spirochete, Borrelia burgdorferi, is the most common vector-borne disease in the United States. Clinical manifestations can include erythema migrans, carditis, facial nerve palsy, or arthritis. A rare complication of Lyme disease is hemidiaphragmatic paralysis. The first case of this complication was documented in 1986, and since then, there have been 16 case reports associating hemidiaphragmatic paralysis with Lyme disease. This is a case of a patient found to be in atrial flutter likely resulting from left hemidiaphragmatic paralysis as a complication of Lyme disease. The patient was a 49-year-old male recently diagnosed with Lyme disease who was treated with a 10-day course of doxycycline and who presented with dyspnea and chest pain. He appeared in acute distress with tachypnea and tachycardia to 169 beats/minute but was not hypoxic. Electrocardiogram (EKG) showed atrial flutter with a rapid ventricular response (RVR). The patient was sent to the emergency department and was treated with intravenous (IV) metoprolol, followed by an IV diltiazem drip, and ultimately converted to normal sinus rhythm. Chest X-ray demonstrated an elevated left hemidiaphragm. Due to concern for Lyme carditis causing tachyarrhythmia, the patient was started on IV ceftriaxone 2 g daily. A transthoracic echocardiogram showed no valvular abnormalities and a normal ejection fraction, thus indicating a low likelihood of carditis. The patient was transitioned to oral doxycycline for an additional 17 days. During the hospital course, a fluoroscopic chest sniff test confirmed the left hemidiaphragmatic paralysis. A chest X-ray completed after two months showed persistent elevation of the left hemidiaphragm and the patient continued to have mild dyspnea. The main lesson from this case is to consider hemidiaphragmatic paralysis as a possible complication of Lyme disease.

A culturally sensitive educational intervention to improve the acceptance and sustained use of safer cooking stoves in the Guatemalan highlands.

This study introduces a culturally sensitive educational intervention to households that use open-fire cooking methods in order to improve the acceptance and sustained use of a safer cooking stove. A wood-burning stove with a closed firebox was introduced in two villages in the highlands of Guatemala. Usage rates were measured over a seven-month period after the stoves were built. Although higher initial acceptance rates were seen in the village that received the educational intervention, households in both villages showed acceptance and sustained usage rates of the stoves. This finding supports the premise that culturally sensitive educational interventions as well as community-based programmes lead to higher acceptance of initiatives, and news of these improvements spreads through culturally accepted routes.

Evaluating the Impact of the COVID-19 Pandemic on Monthly Trends in Primary Care.

Introduction As the COVID-19 pandemic progressed, multiple barriers arose for patients and providers in the primary care setting. Despite the attempt to utilize telemedicine to overcome barriers, visits remained lower than pre-pandemic levels. This raises concern for preventative medicine and chronic disease management. Methods This study aimed to evaluate the impact of the pandemic in primary care by utilizing two years of data from a family medicine clinic. Data obtained from the electronic medical record for March 2019 through February 2020 and March 2020 through February 2021 were used to evaluate monthly trends from the year before the pandemic and the first year of the pandemic in the following six categories: hypertension control, diabetes control, lipid profile screening, breast cancer screening, colorectal cancer screening, and cervical cancer screening. Results The paired t-tests found a significant difference in the averages between the two years for all categories except hypertension control. The results for chi-square demonstrated a significant difference in four months for cervical cancer screening, five months for hypertension control and colorectal cancer screening, nine months for diabetes control and lipid profile screening, and 10 months for breast cancer screening. Conclusion These results show a profound impact of the pandemic on both preventative medicine and chronic disease management. This study had a large sample size but is not generalizable to the entire population. These results can help guide quality improvement measures going forward. However, further research is necessary to better understand the full extent of COVID-19's impact on primary care.

Pharmaceutical savings after gastric bypass surgery.

BACKGROUND: Clinically severe obesity (CSO) is a surgically treated disease. The Roux-en-Y gastric bypass (RYGBP) has been used to treat patients with CSO and has resulted in an improvement in co-morbidities. We speculated that after a period of weight loss, patients would require less medication, resulting in cost-savings to both the patient and the insurance company, as well as an overall gain in health. METHOD: A retrospective study was performed which involved the first 100 patients who had undergone RYGBP at a community-teaching hospital. Analysis of the data was conducted by the Wilcoxon signed rank test. RESULTS: 64 patients met our inclusion criteria and had adequate follow-up data available. The mean BMI was 57 kg/m(2) (range 36.6- 85.4 kg/m(2)), the female to male ratio was 4:1 (51:13), and the mean age was 44 years (range 27-64). The average monthly medication expenditure was reduced from US dollars 317 (SEM 47.25, range US dollars 23.12-US dollars 1801.19) preoperatively, to US dollars 135 (SEM 35.35, range US dollars 0.00-US dollars 1122.72) postoperatively. This reduction is significant (P <0.01). CONCLUSION: Weight loss after RYGBP leads to a significant reduction in medication expenses. These medication savings offset the costs of the initial procedure and represent permanent financial savings for the patient and society.