Disparities in access to and timing of interventional therapies for pulmonary embolism across the United States.

BACKGROUND: Interventional therapies (ITs) are an emerging treatment modality for pulmonary embolism (PE); however, the degree of racial, sex-based, and sociodemographic disparities in access and timing is unknown. OBJECTIVES: To investigate barriers to access and timing of ITs for PE across the United States. METHODS: A retrospective cohort study utilizing the Nationwide Inpatient Sample from 2016-2020 included adult patients with PE. The use of ITs (mechanical thrombectomy and catheter-directed thrombolysis) was identified via International Classification of Diseases 10th revision codes. Early IT was defined as procedure performed within the first 2 days after admission. RESULTS: A total of 27 805 273 records from the 2016-2020 Nationwide Inpatient Sample database were examined. There were 387 514 (1.4%) patients with PE, with 14 249 (3.6%) of them having undergone IT procedures (11 115 catheter-directed thrombolysis, 2314 thrombectomy, and 780 both procedures). After multivariate adjustment, factors associated with less use of IT included Black race (odds ratio [OR], 0.90; 95% CI, 0.86-0.94; P < .01), Hispanic race (OR, 0.73; 95% CI, 0.68-0.79; P < .01), female sex (OR, 0.88; 95% CI, 0.85-0.91; P < .01), treatment in a rural hospital (OR, 0.49; 95% CI, 0.44-0.54; P < .01), and lack of private insurance (Medicare OR, 0.77; 95% CI, 0.73-0.80; P < .01; Medicaid OR, 0.65; 95% CI, 0.61-0.69; P < .01; no coverage OR, 0.87; 95% CI, 0.82-0.93; P < .01). Among the patients who received IT, 11 315 (79%) procedures were conducted within 2 days of admission and 2934 (21%) were delayed. Factors associated with delayed procedures included Black race (OR, 1.12; 95% CI, 1.01-1.26; P = .04), Hispanic race (OR, 1.52; 95% CI, 1.28-1.80; P < .01), weekend admission (OR, 1.37; 95% CI, 1.25-1.51; P < .01), Medicare coverage (OR, 1.24; 95% CI, 1.10-1.40; P < .01), and Medicaid coverage (OR, 1.29; 95% CI, 1.12-1.49; P < .01). CONCLUSION: Significant racial, sex-based, and geographic barriers exist in overall access to IT for PE in the United States.

Ruptured Middle Colic Artery Aneurysm Presenting with Symptoms of Acute Cholecystitis: A Case Report and Literature Review.

Background: Ruptured middle colic artery aneurysm is extremely uncommon. Diagnosis can be challenging, as symptomatology can be attributed to more common abdominal pathologies. Due to the rarity of this condition, only case reports are available to inform management. Case Presentation: We present the case of a 72-year-old woman with a ruptured middle colic artery aneurysm presenting with signs and symptoms more suggestive of acute calculous cholecystitis. Her co-existing bleed was confirmed on CT angiogram. Coil embolization was initially attempted unsuccessfully. She underwent laparotomy, a middle colic artery ligation, and extended right hemicolectomy with intra-aortic balloon placement for emergency proximal vascular control. Post-operatively, she had a re-bleed that was successfully managed with covered stent placement in the proximal superior mesenteric artery after an unsuccessful re-attempt at coil embolization. Her apparent associated cholecystitis was managed with antibiotics and resolved uneventfully. Conclusion: A middle colic artery aneurysm can be challenging to diagnose and treat. Management options include endovascular techniques, open surgery, or a combination approach. Intra-aortic balloon placement for emergency vascular control is a novel approach that could avoid hemorrhage when intra-abdominal vascular access is challenging.

Portal Vein Embolization: Correlation of Future Liver Remnant Hypertrophy to Type of Embolic Agent Used.

PURPOSE: The purpose of this study was to compare the effectiveness of portal vein embolization (PVE) with different embolic agents used at our centre. Specifically, the effectiveness of N-butyl cyanoacrylate (NBCA) glue is compared with that of polyvinyl alcohol (PVA) particles. METHODS: We performed a retrospective chart review of all patients (N = 77) who underwent PVE at our institution over a 5-year period. Pre- and postprocedural computed tomography or magnetic resonance imaging, when available, were used to measure the volume of total liver volume and future liver remnant (FLR). The absolute values obtained were used to calculate percentage of FLR. The growth in FLR was determined 4-6 weeks after PVE. Technical details of the procedure including the type and amount of embolic agent used were obtained from the chart reviews, electronic patient records, and radiology reports. Statistical analysis was performed using Kruskal-Wallis test, Wilcoxon rank sum test, and the Spearman correlation coefficient with post hoc analysis. Results are expressed as mean ± SD (P < .05 considered statistically significant). RESULTS: NBCA (n = 29) produced a mean change in FLR of 14.8% compared with 9.3% for PVA particles (n = 24; P = .007). Mean change in FLR was 10.1% in the group where a combination of NBCA and PVA particles was used (n = 24). The effect of glue volume and glue-to-lipiodol ratio on the outcome was not found to be statistically significant (P = .5 and .7, respectively). CONCLUSIONS: We conclude that NBCA glue is a better embolic agent than PVA particles in inducing liver hypertrophy.

Communicating Gastrointestinal Symptoms: The Patient's Challenge.

Gastrointestinal (GI) disorders present with signs that are objective and symptoms that are subjective, evaluable only if an individual can recognize, characterize, describe, and communicate them to a healthcare professional (HCP). The aim of this study was to quantify the extent to which healthcare seekers perceive difficulties in communicating their GI symptoms to HCPs. Interviews were conducted in two settings where individuals were expected to acknowledge experiencing GI symptoms: a tertiary-care, ambulatory GI clinic and the digestive health medication area of a large retail pharmacy. A 13-item questionnaire was designed to identify subjects' perceptions of the component stages of a symptom communication process. Surveys were completed by 100 participants, 50 from the clinic and 50 from the pharmacy. Most participants reported that it was difficult to know if their symptom descriptions had been understood (clinic: 68%; pharmacy: 86%), that difficulty in describing symptoms hampered access to healthcare (clinic: 82%; pharmacy: 76%), and that use of different descriptors (e.g., icons) would facilitate symptom reporting (clinic: 90%; pharmacy: 98%). Apart from difficulties in selecting a standard term and in providing a specific description for their symptoms, perceived barriers to communicating symptoms did not differ between the clinic and pharmacy settings. Most individuals with GI symptoms perceive difficulty in communicating their symptoms to healthcare professionals. Improved access and improved GI healthcare require new, patient-centered tools for symptom communication. These may be pictogram- or icon-based tools rather than traditional verbal descriptors.

Multimodality cardiac imaging of a ventricular septal rupture post myocardial infarction: a case report.

BACKGROUND: Ventricular septal rupture (VSR), a mechanical complication following an acute myocardial infarction (MI), is thought to result from coagulation necrosis due to lack of collateral reperfusion. Although the gold standard test to confirm left-to-right shunting between ventricular cavities remains invasive ventriculography, two-dimensional transthoracic echocardiography (TTE) with color flow Doppler and cardiac MRI (CMR) are reliable tests for the non-invasive diagnosis of VSR. CASE PRESENTATION: A 62-year-old Caucasian female presented with a late case of a VSR post inferior MI diagnosed by multimodality cardiac imaging including TTE, CMR and ventriculography. CONCLUSION: We review the presentation, diagnosis and management of VSR post MI.

Prevalence, impact and attitudes toward lower gastrointestinal dysmotility and sensory symptoms, and their treatment in Canada: A descriptive study.

OBJECTIVES: To investigate the impact of lower gastrointestinal (GI) symptoms in the general Canadian population, and to explore patient satisfaction with traditional therapies and the level of patient interest in new treatments. patients and METHODS: Stage 1: A telephone survey of a weighted sample of 1000 adults (18 years of age or older) was conducted to determine the prevalence of five GI symptoms--abdominal pain, abdominal discomfort, bloating, constipation or constipation with occasional diarrhea- that were present for 12 weeks or more (not necessarily consecutive) over the past year. Respondents with only abdominal pain were excluded. Stage 2: A telephone survey of 689 women (18 to 64 years of age), experiencing the GI symptoms described in stage 1, was conducted to assess symptom impact and treatment satisfaction. RESULTS: Overall, 5.2% of the Canadian population (2.3% men and 7.9% women) experienced one or more lower GI symptoms (excluding those reporting abdominal pain alone). In stage 2, 26.2% of respondents had previously been diagnosed with irritable bowel syndrome. Overall, 78.1% of participants experienced two or more symptoms. Bloating was the most common symptom (75.3%) and abdominal pain the most bothersome and most severe. Over the previous three months, 13.2% of respondents missed work or school and 28.8% were less productive. At least one physician (average of 2.2 physicians) was consulted for symptoms in 80.9% of respondents. Of the 63.8% women receiving treatment, most used nonprescription products. Patients receiving prescription treatments for constipation were most often dissatisfied (75%). CONCLUSIONS: Abdominal pain and discomfort, bloating and constipation are common, frequently occurring symptoms in the Canadian population and have a high burden on work performance and health care seeking. Most patients were dissatisfied with traditional therapies.

Doctor-patient interaction for irritable bowel syndrome in primary care: a systematic perspective.

BACKGROUND AND AIMS: Irritable bowel syndrome (IBS) is defined by specific validated symptom criteria and encompasses several different underlying pathophysiological mechanisms that express a common set of symptoms. However, IBS is poorly understood by patients. We aimed to explore how a diagnosis of IBS affects the interaction between patients and their physicians. METHODS: A comprehensive literature search for studies in the English language addressing this issue was conducted using Medline, PubMed, Cochrane Database, Psychinfo, Cinahl, Embase, Web of Science and manual recursive search of reference lists. Investigators reviewed and abstracted data from articles fulfilling our inclusion criteria: primary care patients, all ages, gender and ethnic groups diagnosed with IBS by a general practitioner (GP). RESULTS: Retrieval of 121 articles generated only four that met inclusion criteria. Research methods of three studies relied solely on qualitative subjective, anecdotal patient narratives, a bias in favor of patients' negative opinion, absence of objective physician diagnostic criteria, pre-testing questions for two studies, follow-up and patient verification of accounts for accuracy. The fourth study included objective physician diagnostic criteria, quantitative measures, a pre-testing questionnaire, and both patient and doctor perspectives. There was a disparity between patient and GP perception regarding the nature, severity and consequences of IBS in primary care, leading patients to perceive this interaction as one of dissatisfaction. The fourth study revealed GP management of IBS mostly meets patient's expectations areas of concern centered on etiology, diagnostic criteria and dietary advice. Disparity seems to lie with the physician, who needs to provide more trust, knowledge, and sympathy, create rapport and be forthcoming with information, while keeping information simple and understandable. Patient dissatisfaction stems from the actual information provided and how this is communicated. CONCLUSIONS: There is evidence that some IBS patients in primary care experience dissatisfaction and negative attitudes in GP interactions. Future research should take into account personality attributes and cross-situational stability in addition to methodological implications of studies. GPs may be the first avenue for IBS patients to vent their frustration, and appropriate education programs for optimal management of patients with IBS are needed in primary care.