Proximity to Hospital-Based Obstetric Care in a Maternity Desert in the Deep South.

Objectives. To examine the accessibility of hospital facilities with maternity care services in 1 rural county in Alabama in preparation for the initiation of prenatal care services at a federally qualified health center. Methods. We analyzed driving distance (in miles) from maternal city of residence in Conecuh County, Alabama to hospital of delivery, using 2019-2021 vital statistics data and geographic information system (GIS) software. Results. A total of 370 births to mothers who have home addresses in Conecuh County were reported, and 368 of those were in hospital facilities. The majority of deliveries were less than 30 miles (median = 23 miles) from the maternal city of residence. Some women traveled more than 70 miles for obstetrical care. Conclusions. Pregnant patients in Conecuh County experience significant geographic barriers related to perinatal care access. Using GIS for this analysis is a promising approach to better understand the unique challenges of pregnant individuals in this rural population. Public health policy efforts need to be geographically tailored to address these disparities. (Am J Public Health. 2024;114(S4):S330-S333. https://doi.org/10.2105/AJPH.2024.307692).

Optimal Tai Chi forms in knee osteoarthritis: An exploration from biomechanical rationale to pain reduction.

Objectives: Tai Chi (TC) shows some beneficial effects in reducing pain in knee osteoarthritis (OA). However, the selection of criteria TC forms in previous studies were unclear and inconsistent, possibly accounting for the varying outcomes and rendering the training effects suboptimal. We have selected four optimal TC (OTC) forms based on the knee joint load and its association with pain. This pilot study sought to examine the effect of the OTC forms on reducing knee pain in individuals with knee OA. Methods: Fifteen knee OA participants were recruited. Their knee joint pain level was rated by using the Visual Analogue Scale before and after two weeks of OTC training and compared between these two assessments. Results: The two-week OTC training course was well accepted by our participants. The knee OA pain showed a significant reduction (median pain score: 5 â€‹cm before training and 1 â€‹cm post-training, Wilcoxon p â€‹< â€‹0.001) after the two-week training program. Conclusions: Our pilot results revealed that the 2-week four-form-based OTC program could significantly reduce the knee pain level in people with knee OA. Additionally, our OTC program appears to be about 50% more effective in reducing knee pain than the existing TC-based program, which uses 10 â€‹TC forms over 12 weeks (1.59 vs. 1.06 in Hedge's g). The findings in this study may inform the development of OTC-based knee pain reduction programs and the design of relevant clinical trials to establish OTC's effectiveness, safety, and dose-response relationship in easing knee OA pain.

HPV and HPV Vaccination Knowledge and Attitudes Among Medical Students in Alabama.

In addition to being the most common sexually transmitted infection, the human papillomavirus (HPV) is associated with six types of cancer in men and women. The HPV vaccine provides long-lasting, effective protection from high-risk HPV infection, thus serving as a means of cancer prevention. An effective healthcare provider recommendation is well-established as the most significant influence on HPV vaccine uptake, and, as emerging providers, it is critical that medical students receive comprehensive training in this area. However, the type and extent of such training for current medical students in the USA is unclear. An online survey assessing HPV and HPV vaccine knowledge, attitudes, and vaccine status was distributed to all medical students at an Alabama university. Scales were developed to assess composite HPV and HPV knowledge scores and HPV vaccination intentions. Of those age-eligible, 32.1% reported completion of the HPV vaccine series while 15.2% reported partial completion. Knowledge of both HPV and HPV vaccination significantly increased with program year (p < 0.0001 and p = 0.0069, respectively); however, there were knowledge gaps across all years regarding HPV-associated cancers. Attitudes and intentions showed a similar association, with more advanced students demonstrating more positive attitudes toward HPV vaccination (p = 0.0003). There is a need within the current curriculum to include more education and training on HPV, HPV vaccination, and counseling-particularly for students in the first 2 years of their program. Implementation of a classroom module or interactive workshop would likely improve knowledge and attitudes, better preparing students for their future role as potential immunizers.

Neurologic Conditions: Common Peripheral Neuropathies.

Peripheral neuropathies (PNs) are a group of conditions caused by damage to the peripheral nervous system. PN is a condition commonly seen in the family medicine setting and can lead to reduced quality of life due to pain, ulceration, and falls. More than 100 etiologies of PN have been identified; the most common are metabolic, drug-related, and systemic etiologies. Common treatable etiologies include diabetes and other medical conditions. Screening is recommended only for patients with suspected diabetic PN. The diagnosis of neuropathies is made primarily using the clinical history and physical examination results. Laboratory and electrodiagnostic tests can be used to identify the etiology of PN, and should be considered in atypical cases or if the diagnosis is uncertain. In some cases, management of the underlying cause of the neuropathy is indicated. Management includes adequate control of the blood glucose level in patients with diabetes and correction of vitamin deficiencies. Symptom control often is achieved with use of drugs.

Neurologic Conditions: Parkinson Disease.

Parkinson disease (PD) is a complex neurologic disorder that involves motor and nonmotor brain functions. PD is the second most common neurodegenerative disease after Alzheimer disease. Motor symptoms include resting tremor, cogwheel rigidity, extreme slowness of movement, shuffling gait, and impaired balance. Swallowing and speaking difficulties also are common. Nonmotor symptoms include depression, hallucinations, and sleep disturbances that seriously affect quality of life. There is no cure for PD but management of motor and nonmotor symptoms can improve quality of life. Carbidopa-levodopa is an effective initial treatment for motor symptoms of rigidity and resting tremors. Treatments for nonmotor symptoms include antidepressants, antipsychotics, and drugs for dementia. (This is an off-label use of some antidepressants, antipsychotics, and drugs for dementia.) A multidisciplinary approach to optimizing care can include physical and occupational therapy, speech therapy, and psychological therapy.

Neurologic Conditions: New-Onset Seizures in Adults.

Family physicians may be the first point of contact for adults with new-onset seizure. There are many etiologies of seizures in adults. Etiologies of provoked seizures include temporary metabolic disturbances, central nervous system infections, cerebrovascular disease, drug withdrawal, and traumatic brain injury. Stable or evolving cerebral conditions can cause unprovoked seizures. Nonorganic etiologies include nonepileptiform convulsions, such as a pseudoseizure, which are psychogenic. In the emergency department setting, computed tomography scan of the head should be considered for all patients with new-onset seizure. An electroencephalogram and magnetic resonance imaging study are recommended as further evaluation for an adult with a new-onset seizure unrelated to trauma, alcohol, or drugs. The occurrence of a single seizure does not always necessitate initiation of an antiepileptic drug. The risk of recurrent seizure should dictate the need for drug initiation. Patients should be counseled against driving until they have been seizure free for at least 3 months. Patients who are planning for pregnancy should be informed that antiepileptic drugs are potentially teratogenic.

Neurologic Conditions: Dizziness and Vertigo.

Dizziness is seen frequently in patients in the family medicine and emergency department settings. The differential diagnosis of dizziness can be expansive but with a targeted history and physical examination, a correct diagnosis often can be established and appropriate treatment offered. Common etiologies of dizziness include hypotension, benign paroxysmal positional vertigo (BPPV), and Meniere disease. Strokes and malignancies also can cause this symptom. Imaging is indicated if intracranial pathology is suspected. BPPV typically is self-limited but maneuvers such as the Epley maneuver can be used for more rapid resolution. Meniere disease can be difficult to manage. First-line treatments are lifestyle and diet modification. Avoidance of triggers is important for patients with vestibular migraine. Some vestibular-suppressive drugs and anticonvulsants may be useful in the prevention and management of vestibular migraine. (This is an off-label use of some anticonvulsants.).

Epilepsy: Treatment Options.

The occurrence of a single seizure does not always require initiation of antiepileptic drugs. Risk of recurrent seizures should guide their use. In adults, key risk factors for recurrence are two unprovoked seizures occurring more than 24 hours apart, epileptiform abnormalities on electroencephalography, abnormal brain imaging, nocturnal seizures, or an epileptic syndrome associated with seizures. In children, key risk factors are abnormal electroencephalography results, an epileptic syndrome associated with seizures, severe head trauma, and cerebral palsy. The risk of adverse effects from antiepileptic drugs is considerable and includes potential cognitive and behavioral effects. In the absence of risk factors, and because many patients do not experience recurrence of a seizure, physicians should consider delaying use of antiepileptic drugs until a second seizure occurs. Delaying therapy until a second seizure does not affect one- to two-year remission rates. Treatment should begin with monotherapy. The appropriate choice of medication varies depending on seizure type. Routine monitoring of drug levels is not correlated with reduction in adverse effects or improvement in effectiveness and is not recommended. When patients have been seizure free for two to five years, discontinuation of antiepileptic drugs may be considered. For patients with seizures that are not controlled with these agents, alternative treatments include surgical resection of the seizure focus, ketogenic diets, vagus nerve stimulators, and implantable brain neurostimulators. Patients who have had a recent seizure within the past three months or whose seizures are poorly controlled should refrain from driving and certain high-risk physical activities. Patients planning for pregnancy should know that antiepileptic drugs are possibly teratogenic.

Recreational Waterborne Illnesses: Recognition, Treatment, and Prevention.

Illness after recreational water activities can be caused by a variety of agents, including bacteria, viruses, parasites, algae, and even chlorine gas. These illnesses are more common in summer. Waterborne illnesses are underreported because most recreational activity occurs in unsupervised venues or on private property, and participants tend to disperse before illness occurs. Symptoms of waterborne illness are primarily gastrointestinal, but upper respiratory and skin manifestations also occur. Gastrointestinal symptoms are usually self-limited, and supportive treatment may be all that is necessary. However, some infections can cause significant morbidity and mortality. Cryptosporidium and Giardia intestinalis are the most common cause of gastrointestinal illness and have partial chlorine resistance. Respiratory infections are typically mild and self-limited. However, if legionnaires' disease develops and is unrecognized, mortality may be as high as 10%. Cellulitis caused by Vibrio vulnificus can result in serious illness, amputation, and death. Early and appropriate antibiotic treatment is important. Chronically ill and immunocompromised persons are at high risk of infection and should be counseled accordingly.

Primary Brain Tumors in Adults: Diagnosis and Treatment.

Primary intracranial tumors of the brain structures, including meninges, are rare with an overall five-year survival rate of 33.4%; they are collectively called primary brain tumors. Proven risk factors for these tumors include certain genetic syndromes and exposure to high-dose ionizing radiation. Primary brain tumors are classified by histopathologic criteria and immunohistochemical data. The most common symptoms of these tumors are headache and seizures. Diagnosis of a suspected brain tumor is dependent on appropriate brain imaging and histopathology. The imaging modality of choice is gadolinium-enhanced magnetic resonance imaging. There is no specific pathognomonic feature on imaging that differentiates between primary brain tumors and metastatic or nonneoplastic disease. In cases of suspected or pathologically proven metastatic disease, chest and abdomen computed tomography may be helpful, although determining the site of the primary tumor is often difficult, especially if there are no clinical clues from the history and physical examination. Using fluorodeoxyglucose positron emission tomography to search for a primary lesion is not recommended because of low specificity for differentiating a neoplasm from benign or inflammatory lesions. Treatment decisions are individualized by a multidisciplinary team based on tumor type and location, malignancy potential, and the patient's age and physical condition. Treatment often includes a combination of surgery, radiotherapy, and chemotherapy. After craniotomy, patients should be followed closely for complications, including deep venous thrombosis, pulmonary embolism, intracranial bleeding, wound infection, systemic infection, seizure, depression, worsening neurologic status, and adverse drug reaction. Hospice and palliative care should be offered when appropriate throughout treatment.

Improving our approach to preventive care.

Many components of the chronic care model can be successfully applied to preventive care, evidence shows. Here's how to do more with the resources you have.

Atypical moles: diagnosis and management.

Atypical moles are benign pigmented lesions. Although they are benign, they exhibit some of the clinical and histologic features of malignant melanoma. They are more common in fair-skinned individuals and in those with high sun exposure. Atypical moles are characterized by size of 6 mm or more at the greatest dimension, color variegation, border irregularity, and pebbled texture. They are associated with an increased risk of melanoma, warranting enhanced surveillance, especially in patients with more than 50 moles and a family history of melanoma. Because an individual lesion is unlikely to display malignant transformation, biopsy of all atypical moles is neither clinically beneficial nor cost-effective. The ABCDE (asymmetry, border irregularity, color unevenness, diameter of 6 mm or more, evolution) mnemonic is a valuable tool for clinicians and patients to identify lesions that could be melanoma. Also, according to the "ugly duckling" concept, benign moles tend to have a similar appearance, whereas an outlier with a different appearance is more likely to be undergoing malignant change. Atypical moles with changes suggestive of malignant melanoma should be biopsied, using an excisional method, if possible.

Using a lay cancer screening navigator to increase colorectal cancer screening rates.

INTRODUCTION: Preventive care is often not performed during the ambulatory office visit due to the acute nature of the visit. One possible strategy is the use of a lay cancer screening navigator using the lay health worker model. METHODS: A training program for the lay cancer screening navigator and a patient registry for colorectal cancer screening was developed. The RE-AIM framework was used to evaluate the intervention. Descriptive statistics were generated for patient demographics. RESULTS: Reach: The lay cancer screening navigator contacted 91.9% of eligible patients. Effectiveness: At baseline, 28.6% of patients were current on their colorectal cancer screening, 40.5% at 6 months, and 42.2% at 12 months. Adoption: Patients contacted all reported being receptive to the intervention. IMPLEMENTATION: Of the 368 fecal immunochemical test kits mailed, 151 were returned (41.0%), and 26 (17.2%) were positive. Maintenance: The percentage of patients who were current between 6 months and at 12 months were not significantly different. DISCUSSION: This study demonstrates that the use of a lay cancer screening navigator to increase the rate of colorectal cancer screening is a viable strategy.

Recognition and management of polymyalgia rheumatica and giant cell arteritis.

Polymyalgia rheumatica affects proximal muscles and joints, causing disability in older adults. Giant cell arteritis affects medium and large arteries and can result in blindness. These conditions overlap significantly, often occurring together. Despite the similarities, each has distinct symptoms, corticosteroid dosing requirements, and prognosis. The hallmark of both conditions is inflammation. Polymyalgia rheumatica primarily affects the shoulders, neck, and hips with prominent bilateral pain. Systemic findings such as fatigue and weight loss are common, and there is no definitive diagnostic test. Moderate-dose corticosteroid therapy with a slow taper rapidly resolves symptoms. Management of patients responding to treatment can occur in the primary care setting, if there is no concomitant giant cell arteritis. The clinical presentation of giant cell arteritis varies widely, from new-onset headache and constitutional symptoms, to jaw claudication, to less common isolated visual changes and upper extremity claudication. Treatment requires higher dosages of corticosteroids and urgent referral to a rheumatologist. Relapse is common in both diseases. Surveillance is important, as is monitoring for long-term complications of corticosteroid use. Osteoporosis management and gastrointestinal ulcer prophylaxis should be initiated. The primary care physician's coordination of care with a rheumatologist and with other subspecialists, if needed, is essential in the management of giant cell arteritis.

Attitudes toward colorectal cancer screening in the digital age: a survey of practices and attitudes among screening-eligible Alabamians.

OBJECTIVES: To ascertain barriers to colorectal cancer screening in an environment of changing recommendations, payment structures, and information access, and to develop strategies for overcoming these barriers by undertaking a population survey of colorectal cancer (CRC) screening knowledge and attitudes in Alabama. METHODS: An 80-item questionnaire focused on cancer screening, specifically CRC screening, was developed and pretested. A random sample of Alabama residents was generated using random-digit dial methods and interviews of 615 participants aged 50 and older were conducted in March 2012 and April 2012. Screened and unscreened groups were compared using χ statistics. RESULTS: Sixty-one percent of Alabamians who participated in this survey reported being screened for CRC, the majority (95%) of these by colonoscopy. Both screened and unscreened participants reported using the Internet for health information more often if they were younger than 65 years. Those screened often reported feeling well informed regarding the guidelines, often to have discussed CRC screening with their family physician, and often to have had other cancer screenings. All of the respondents, screened and unscreened, reported financial considerations to be the most significant barriers to screening. CONCLUSIONS: Although educating the general population could be helpful, a physician championing screening is key. Home stool testing is underused in Alabama in part because physicians are not fully aware of its utility. As financial barriers diminish, it is important to offer multiple effective modalities when available, and insurance reform, which includes payment for preventive care, may improve screening rates.

Colorectal cancer screening practices in Alabama: a survey of primary care physicians.

In order to inform efforts to increase screening rates for colorectal cancer (CRC), we conducted a survey of Alabama primary care physicians regarding CRC screening practices, educational preferences, and perceptions of obstacles to screening. A mail survey of 2,378 Alabama physicians in Family Medicine, Internal Medicine, and Obstetrics & Gynecology was conducted. Many physicians are not fully up-to-date with current CRC screening practices that could improve patient compliance with screening guidelines. One example is the potential use of high-sensitivity stool tests, such as the fecal immunochemical test, instead of the no longer recommended low-sensitivity guaiac fecal occult blood tests. In addition, enhanced multimedia and web-based approaches to educating physicians and patients could be more fully utilized. Further, greater use of health information technologies could increase screening rates. Enhancing primary care physicians' knowledge of screening modalities and increasing their use of electronic technology could significantly improve colorectal cancer screening outcomes.

Enhancing response rates in physician surveys: the limited utility of electronic options.

OBJECTIVE: To evaluate the utility of offering physicians electronic options as alternatives to completing mail questionnaires. DATA SOURCE: A survey of colorectal cancer screening practices of Alabama primary care physicians, conducted May-June 2010. STUDY DESIGN: In the follow-up to a mail questionnaire, physicians were offered options of completing surveys by telephone, fax, email, or online. DATA COLLECTION METHOD: Detailed records were kept on the timing and mode of completion of surveys. PRINCIPAL FINDINGS: Eighty-eight percent of surveys were returned by mail, 10 percent were returned by fax, and only 2 percent were completed online; none were completed by telephone or email. CONCLUSIONS: Offering fax options increases response rates, but providing other electronic options does not.