Necrotizing mesenteric vasculitis in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder which may affect the gastrointestinal system. Half of the patients with SLE experience gastrointestinal symptoms, with the most common being nausea, vomiting, anorexia, and abdominal pain. Mesenteric vasculitis is a severe and rare complication of SLE and one of the most frequent causes of severe acute abdominal pain. The authors present a case of a 57-year-old woman with SLE who was diagnosed with necrotizing mesenteric vasculitis following a urinary septic shock. The patient was treated with high-dose corticosteroid therapy and cyclophosphamide, with resolution of the clinical picture.

Challenges and Facilitators in Implementing Remote Patient Monitoring Programs in Primary Care.

BACKGROUND: The COVID-19 pandemic resulted in greater use of remote patient monitoring (RPM). However, the use of RPM has been modest compared to other forms of telehealth. OBJECTIVE: To identify and describe barriers to the implementation of RPM among primary care physicians (PCPs) that may be constraining its growth. DESIGN: We conducted 20 semi-structured interviews with PCPs across the USA who adopted RPM. Interview questions focused on implementation facilitators and barriers and RPM's impact on quality. We conducted thematic analysis of semi-structured interviews using both inductive and deductive approaches. The analysis was informed by the NASSS (non-adoption and abandonment and challenges to scale-up, spread, and sustainability) framework. PARTICIPANTS: PCPs who practiced at least 10 h per week in an outpatient setting, served adults, and monitored blood pressure and/or blood glucose levels with automatic transmission of data with at least 3 patients. KEY RESULTS: While PCPs generally agreed that RPM improved quality of care for their patients, many identified barriers to adoption and maintenance of RPM programs. Challenges included difficulties handling the influx of data and establishing a manageable workflow, along with digital and health literacy barriers. In addition to these barriers, many PCPs did not believe RPM was profitable. CONCLUSIONS: To encourage ongoing growth of RPM, it will be necessary to address implementation barriers through changes in payment policy, training and education in digital and health literacy, improvements in staff roles and workflows, and new strategies to ensure equitable access.

Incidental Adrenal Masses: A Case Report of an Adrenal Oncocytoma.

A 59-year-old woman underwent an abdominal and pelvic computed tomography (CT) scan to rule out non-obstructive urolithiasis. The patient was asymptomatic, with the exception of occasional bilateral low back pain. A physical examination did not reveal any notable findings. The CT scan revealed the presence of an incidental solid left adrenal lesion, which displaced the body of the pancreas and the left kidney. The lesion measured 7 cm × 6.5 cm and exhibited a rounded morphology with well-defined margins. It showed progressive and heterogeneous contrast uptake. Additionally, magnetic resonance imaging (MRI) was performed, confirming the presence of an adrenal lesion with intense and heterogeneous hypersignal on T2. The lesion also demonstrated heterogeneous and persistent enhancement in a dynamic study. Furthermore, there were some indistinct and non-specific hypointense areas identified on both T1 and T2 sequences. The lesion exhibited moderately restricted diffusion. Although the imaging features were non-specific, there were no indications of invasion or distant metastasis, which made a benign large adrenal mass the most likely diagnosis. Non-functioning pheochromocytoma, lipid-poor adrenal adenoma, as well as metastasis or primary adrenal carcinoma, were considered differential diagnoses. The patient underwent an elective adrenalectomy, during which the identified lesion was completely resected. The patient's postoperative recovery was uneventful, and she was discharged three days after the procedure. Subsequent histopathological evaluation revealed an oncocytic neoplasm of the adrenal cortex - specifically, an oncocytoma.

Choosing Or Losing In Behavioral Health: A Study Of Patients' Experiences Selecting Telehealth Versus In-Person Care.

It is not known how the growth of telehealth has affected patients' choice of visit modalities (telehealth versus in person). In 2023 we conducted a mixed-methods study that paired a nationally representative survey of 2,071 adults (including 571 who used behavioral health services) and semistructured interviews with twenty-six people with depression or bipolar disorder. We explored patients' experiences with visit modality selection and their agency in the decision. Approximately one-third of patients receiving therapy or medication visits reported that their clinicians did not offer both modalities. Thirty-two percent reported that they did not typically receive their preferred modality, and 45 percent did not believe that their clinician considered their modality preferences. Qualitative findings revealed that some clinicians did not elicit patients' modality preferences. Perceived lack of choice affected satisfaction and rapport with clinicians and encouraged some people to seek care elsewhere. These findings highlight trade-offs in policies to preserve patient choice and approaches that clinicians can take to identify and accommodate patients' preferences.

Hidradenocarcinoma of the Female Breast: A Surgical Approach to a Rare Skin Tumor.

Clear-cell hidradenocarcinomas are extremely uncommon sweat gland tumors with a predilection for the head and neck. In the limited number of articles reporting breast involvement, the primary focus concerns this entity's histological and immunohistochemical characteristics. Since hidradenocarcinomas of the breast have the potential to resemble a primary breast carcinoma closely, diagnosis may be challenging. Therefore, the authors report the first case of hidradenocarcinoma of the breast, which features its macroscopic morphology. In addition, to increase physicians' awareness of this rare neoplasm, the article also aims to detail its surgical approach.

Blunt Trauma and Right Diaphragmatic Rupture: Unveiling the Impact.

Traumatic diaphragmatic ruptures are rare, yet blunt injuries tend to be more easily overlooked compared to penetrating trauma. The minimal evidence of external injuries makes a high index of suspicion key for diagnosis. We report the case of a right-sided thoracoabdominal blunt trauma that resulted in a diaphragmatic rupture and fractured rib. Although often approached through a midline laparotomy, a definitive right thoracotomy repair was exceptionally performed since the adjacent peritoneum remained uninjured.

Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making.

PURPOSE: Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care. METHODS: We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior. RESULTS: Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD. CONCLUSIONS: There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.

Assessing Equitable Recruitment in a Digital Health Trial for Asthma.

OBJECTIVE: This study aimed to assess a multipronged strategy using primarily digital methods to equitably recruit asthma patients into a clinical trial of a digital health intervention. METHODS: We approached eligible patients using at least one of eight recruitment strategies. We recorded approach dates and the strategy that led to completion of a web-based eligibility questionnaire that was reported during the verbal consent phone call. Study team members conducted monthly sessions using a structured guide to identify recruitment barriers and facilitators. The proportion of participants who reported being recruited by a portal or nonportal strategy was measured as our outcomes. We used Fisher's exact test to compare outcomes by equity variable, and multivariable logistic regression to control for each covariate and adjust effect size estimates. Using grounded theory, we coded and extracted themes regarding recruitment barriers and facilitators. RESULTS: The majority (84.4%) of patients who met study inclusion criteria were patient portal enrollees. Of 6,366 eligible patients who were approached, 627 completed the eligibility questionnaire and were less frequently Hispanic, less frequently Spanish-speaking, and more frequently patient portal enrollees. Of 445 patients who consented to participate, 241 (54.2%) reported completing the eligibility questionnaire after being contacted by a patient portal message. In adjusted analysis, only race (odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.28-0.77, p = 0.003) and college education (OR: 0.60, 95% CI: 0.39-0.91, p = 0.016) remained significant. Key recruitment barriers included technology issues (e.g., lack of email access) and facilitators included bilingual study staff, Spanish-language recruitment materials, targeted phone calls, and clinician-initiated "1-click" referrals. CONCLUSION: A primarily digital strategy to recruit patients into a digital health trial is unlikely to achieve equitable participation, even in a population overrepresented by patient portal enrollees. Nondigital recruitment methods that address racial and educational disparities and less active portal enrollees are necessary to ensure equity in clinical trial enrollment.

Primary Petit Hernia: From Diagnosis to Open Surgical Approach.

Lumbar hernias are quite rare, even more so when primary or of spontaneous nature. These defects in the lumbar region demand a comprehensive knowledge of the anatomy of the lateral abdominal wall and paraspinal muscles. Given the proximity of bone structures, they can pose a surgical challenge when trying to achieve an ideal dissection and appropriate mesh overlap. The authors report the case of a primary Petit's hernia that underwent an open anterior surgical approach with the use of a preperitoneal mesh. In addition to the described surgical technique, the article also aims to detail the diagnosis and anatomic classification of this rare pathology.

Changes in In-Person, Audio-Only, and Video Visits in California's Federally Qualified Health Centers, 2019-2022.

This study assesses telehealth visit trends among California federally qualified health centers from 2019 to 2022.

NUT carcinoma - An aggressive thoracic tumor.

Nuclear protein in testis (NUT) carcinoma is an extremely rare and undifferentiated malignancy characterized by the rearrangement of NUT gene (NUTM1, Nuclear Protein in Testis). NUT carcinoma is a challenging disease which is difficult to diagnose and treat. Due to its rarity, lack of experience and need of specific molecular study it can be un/misdiagnosed. Therefore, NUT carcinoma should be included in differential diagnosis of poorly differentiated/undifferentiated and rapidly progressive malignancy in children and young adults, occurring in the head, neck or thorax. We report a case of NUT carcinoma presented with pleural effusion in adulthood.

Anterior Penetrating Neck Injury: A Path to the Cervical Spine.

While rare in incidence, penetrating neck injuries are often life-threatening. When a patient's physiological status is appropriate, the first step in treatment should be a detailed preoperative imaging assessment. Formulating a treatment plan that includes computed tomography (CT) imaging and discussing the surgical approach with a multidisciplinary team before operating allows for a successful selective surgical approach. The authors report the case of a Zone II penetrating injury with a right laterocervical entry wound in which an impaled blade with an inferomedial oblique path pierced deeply into the cervical spine. The blade missed multiple vital structures in the neck, such as the common carotid artery, jugular vein, trachea, and esophagus. The patient underwent a formal neck exploration, and controlled extraction of the blade under direct vision was achieved. Therefore, the author's recommendation for implementing any management algorithm for penetrating neck injuries should rely primarily on a multidisciplinary selective approach.

Solving urban water microplastics with bacterial cellulose hydrogels: Leveraging predictive computational models.

The prevalence of microplastics (MPs) in both urban and aquatic ecosystems is concerning, with wastewater treatment plants being considered one of the major sources of the issue. As the focus on developing sustainable solutions increases, unused remnants from bacterial cellulose (BC) membranes were ground to form BC hydrogels as potential bioflocculants of MPs. The influence of operational parameters such as BC:MPs ratio, hydrogel grinding, immersion and mixing time, temperature, pH, ionic strength, and metal cations on MPs flocculation and dispersion were evaluated. A response surface methodology based on experimental data sets was computed to understand how these parameters influence the flocculation process. Further, both the BC hydrogel and the hetero-aggregation of MPs were characterised by UV-Vis, ATR-FTIR, IGC, water uptake assays, fluorescence, and scanning electron microscopy. These highlights that the BC hydrogel would be fully effective at hetero-aggregating MPs in naturally-occurring concentrations, thereby not constituting a limiting performance factor for MPs' optimal flocculation and aggregation. Even considering exceptionally high concentrations of MPs (2 g/L) that far exceed naturally-occurring concentrations, the BC hydrogel was shown to have elevated MPs flocculation activity (reaching 88.6%: 1.77 g/L). The computation of bioflocculation activity showed high reliability in predicting flocculation performance, unveiling that the BC:MPs ratio and grinding times were the most critical variables modulating flocculation rates. Also, short exposure times (5 min) were sufficient to drive robust particle aggregation. The microporous nature of the hydrogel revealed by electron microscopy is the likely driver of strong MPs bioflocculant activity, far outperforming dispersive commercial bioflocculants like xanthan gum and alginate. This pilot study provides convincing evidence that even BC remainings can be used to produce highly potent and circular bioflocculators of MPs, with prospective application in the wastewater treatment industry.

Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use.

OBJECTIVE: To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties. METHODS: In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use. RESULTS: In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth. CONCLUSIONS: Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.

Atuação do agente comunitário de saúde em municípios rurais remotos do Semiárido: um olhar a partir dos atributos da Atenção Primária à Saúde / Performance of the community agent and health in remote rural municipalities of the Semiarid region: a look from the attributes of Primary Health Care

Resumo O objetivo do artigo é mapear e analisar as práticas desenvolvidas por agentes comunitários de saúde (ACS) em municípios rurais remotos (MRR) à luz dos atributos essenciais e derivados da Atenção Primária à Saúde (APS). Foi realizado estudo de caso em quatro MRR do semiárido nordestino por meio de entrevistas com ACS e usuários da Estratégia Saúde da Família (ESF). Os resultados mostram forte atuação dos ACS em ações vinculadas à porta de entrada e integralidade, com escopo ampliado, sobretudo nas áreas rurais dos MRR. A intermediação e a facilitação do acesso ocorrem por meio do forte vínculo dos ACS com os territórios e famílias e na ausência de outros recursos assistenciais. As ações individuais, mediante visitas domiciliares, foram mais prevalentes em detrimento de ações coletivas relacionadas aos atributos derivados. Identificou-se a realização de procedimentos como aferição de pressão arterial e curativos.

Abstract The article aims to map and analyze the practices developed by community health agents (CHA) in remote rural municipalities (RRM) in light of the essential and derived attributes of Primary Health Care (PHC). A case study was carried out in four RRM in the Northeastern Semi-arid Region through interviews with CHA and users of the Family Health Strategy (ESF). The results show a strong performance of the CHA in actions linked to the gateway and comprehensiveness, with an expanded scope, especially in the rural areas of the RRM. Intermediation and facilitation of access occur through the CHA's strong bond with territories and families and in the absence of other assistance resources. Individual actions, through home visits, were more prevalent to the detriment of collective actions related to derived attributes. Procedures such as blood pressure measurement and dressings were identified.

Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change.

Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.

Virtual Behavioral Health for Army Soldiers: Soldier Perspectives and Patterns of Treatment.

Delivery of high-quality behavioral health (BH) care is essential to supporting the readiness of the U.S. armed forces and their families. The coronavirus disease 2019 (COVID-19) pandemic led to a dramatic expansion of virtual behavioral health (VBH) care: remote patient access to BH care using technology such as a computer or cellular phone. The U.S. Army asked RAND Arroyo Center to examine the use of VBH to inform recommendations on the role of VBH care in the future of BH care in the Military Health System. The authors analyzed administrative data on VBH and in-person BH care from prior to the pandemic through March 2022 and surveyed soldiers who received BH care to assess their perceptions of VBH care. Administrative data analyses showed that direct care providers were less likely to deliver VBH care than private-sector providers and relied heavily on audio rather than video VBH. In addition, soldiers who received VBH care typically received a mix of VBH and in-person visits. Survey respondents who used VBH care had similar perceptions of the quality of their care and more-positive views of VBH than respondents who did not use VBH care. Few respondents had declined VBH care in favor of in-person care. Using these findings, the authors make recommendations on the role of VBH care in overall BH delivered by the military.

Financial impact of telehealth: rural chief financial officer perspectives.

OBJECTIVES: To explore the perceived impacts of a variety of telehealth services on hospital finances and assess how hospital administrators make decisions about adopting telehealth programs. STUDY DESIGN: From October 2021 to January 2022, we conducted semistructured interviews with chief financial officers (CFOs) of rural hospitals. METHODS: Recruitment occurred in collaboration with 6 rural health collaboratives and hospital associations that facilitated CFO peer-learning groups. We used inductive and deductive approaches informed by a health care innovation adoption model to identify themes in the qualitative data. RESULTS: Twenty rural hospital CFOs and other hospital administrators from 10 states participated in interviews. Seventeen (85%) represented critical access hospitals and 3 (15%) represented short-term acute care hospitals. Although CFOs believed telehealth has some financial advantages (eg, can help to avoid patient transfers), they did not believe that telehealth improved their hospitals' financial situations. CFOs, rather, seem motivated to implement telehealth services to improve quality of care and address patients' needs. CFOs reported that limited reimbursement, low volumes, preference for in-person care, and insufficient broadband were key challenges to telehealth's financial viability. CONCLUSIONS: Understanding how CFOs think about the return on investment of telehealth can inform efforts to promote telehealth utilization in rural communities and to develop policy solutions to make telehealth more sustainable. CFOs may benefit from guidance on promising practices and cost-effective implementation strategies. Policy makers could take steps to improve telehealth's financial attractiveness (eg, through payment parity, subsidies to improve technology infrastructure).

The Impact of Mindfulness Meditation Programs on Performance-Related Outcomes: Implications for the U.S. Army.

Although studies have suggested that mindfulness-based interventions might be effective in enhancing military readiness and resilience, this has not been rigorously evaluated. This study presents results from a systematic review and meta-analyses of research examining how mindfulness meditation affects 13 performance-related outcomes of interest to the U.S. Army and broader military. The authors supplemented the systematic review by examining how mindfulness meditation could support stress management and exploring characteristics of selected mindfulness programs. The goal was to develop recommendations for mindfulness meditation programs for soldiers, should the Army choose to implement such programs in the future. Findings suggest that mindfulness may improve some aspects of attention and emotion regulation, impulsivity, and work-related morale and social support. The available evidence does not suggest that mindfulness improves other outcomes of interest to the Army. Notably, mindfulness meditation programs reduce stress and may reduce parental stress, which could benefit Army families. Yet more research is needed to identify best practices for implementing mindfulness programs in the military. The authors recommend conducting high-quality evaluations of mindfulness meditation with soldiers and assessing the effect of mindfulness meditation on military families.

Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative.

In early 2020, as the coronavirus disease 2019 (COVID-19) pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering telehealth visits in high volume in March 2020 to help maintain access to care. This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make changes to technology, workflows, and staffing to accommodate telehealth visits. To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative that was launched in July 2020. RAND researchers evaluated the progress of FQHCs that participated in the CCA initiative by investigating changes in telehealth utilization and health center staff experiences with implementation. In this research, researchers review recent literature on telehealth implementation in safety net settings. They also present new information on the experiences of the 45 CCA health centers, drawing from data on visit trends, interviews with health center leaders, and surveys of health center providers and staff. Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth is implemented in a way that ensures high-quality care and health equity.