Proactive Recruitment Strategy for Patient Identification for Lung Cancer Screening.

PURPOSE: We assessed low-dose computed tomography (LDCT) screening for lung cancer using a proactive patient education/recruitment program. METHODS: We identified patients aged 55-80 years from a family medicine group. In the retrospective phase (March-August, 2019), patients were categorized as current/former/never smokers, and screening eligibility was determined. Patients who underwent LDCT in the past year, along with outcomes, were documented. In the prospective phase (2020), patients in the same cohort who did not undergo LDCT were proactively contacted by a nurse navigator to discuss eligibility and prescreening. Eligible and willing patients were referred to their primary care physician. RESULTS: In the retrospective phase, of 451 current/former smokers, 184 (40.8%) were eligible for LDCT, 104 (23.1%) were ineligible, and 163 (36.1%) had an incomplete smoking history. Of those eligible, 34 (18.5%) had LDCT ordered. In the prospective phase, 189 (41.9%) were eligible for LDCT (150 [79.4%] of whom had no prior LDCT or diagnostic CT), 106 (23.5%) were ineligible, and 156 (34.6%) had an incomplete smoking history. The nurse navigator identified an additional 56/451 (12.4%) patients as eligible after contacting patients with incomplete smoking history. In total, 206 patients (45.7%) were eligible, an increase of 37.3% compared with the retrospective phase (150). Of these, 122 (59.2%) verbally agreed to screening, 94 (45.6%) met with their physician, and 42 (20.4%) were prescribed LDCT. CONCLUSIONS: A proactive education/recruitment model increased eligible patients for LDCT by 37.3%. Proactive identification/education of patients desiring to pursue LDCT was 59.2%. It is essential to identify strategies that will increase and deliver LDCT screening among eligible and willing patients.

Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study.

BACKGROUND: Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association. METHODS: We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors. RESULTS: Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01). CONCLUSION: We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.

Costs-effectiveness and cost components of pharmaceutical and non-pharmaceutical interventions affecting antibiotic resistance outcomes in hospital patients: a systematic literature review.

INTRODUCTION: Limited information on costs and the cost-effectiveness of hospital interventions to reduce antibiotic resistance (ABR) hinder efficient resource allocation. METHODS: We conducted a systematic literature review for studies evaluating the costs and cost-effectiveness of pharmaceutical and non-pharmaceutical interventions aimed at reducing, monitoring and controlling ABR in patients. Articles published until 12 December 2023 were explored using EconLit, EMBASE and PubMed. We focused on critical or high-priority bacteria, as defined by the WHO, and intervention costs and incremental cost-effectiveness ratio (ICER). Following Preferred Reporting Items for Systematic review and Meta-Analysis guidelines, we extracted unit costs, ICERs and essential study information including country, intervention, bacteria-drug combination, discount rates, type of model and outcomes. Costs were reported in 2022 US dollars ($), adopting the healthcare system perspective. Country willingness-to-pay (WTP) thresholds from Woods et al 2016 guided cost-effectiveness assessments. We assessed the studies reporting checklist using Drummond's method. RESULTS: Among 20 958 articles, 59 (32 pharmaceutical and 27 non-pharmaceutical interventions) met the inclusion criteria. Non-pharmaceutical interventions, such as hygiene measures, had unit costs as low as $1 per patient, contrasting with generally higher pharmaceutical intervention costs. Several studies found that linezolid-based treatments for methicillin-resistant Staphylococcus aureus were cost-effective compared with vancomycin (ICER up to $21 488 per treatment success, all 16 studies' ICERs

Pulmonary Paragonimiasis: A Case Series.

Paragonimiasis contributes to significant foodborne zoonosis worldwide. The major mode of transmission in humans is by consumption of uncooked or undercooked crabs and crayfish harbouring Paragonimus metacercariae. It begins with symptoms like fever and lower respiratory involvement from a few months to a year, mimicking those of tuberculosis and leading to diagnostic delay. Here, we report two cases of paragonimiasis during a period of nine months. Both cases presented with symptoms of productive cough with rusty sputum, chest pain, along with eosinophilia, and pleural effusion and had a history of consumption of smoked crab from the local river. The diagnosis was established by microscopic demonstration of Paragonimus ova in the sputum. They were treated with praziquantel and recovered. Indeed, it is challenging to diagnose paragonimiasis due to the lack of its specific symptoms but should be considered in the differential diagnosis of eosinophilia and pleural effusion in such lung diseases. Keywords: case reports; eosinophilia; paragonimiasis; pleural effusion.

Influence of Obesity on Blood Pressure Responses to Antihypertensive Drug Therapy in an Urban Hypertension Specialty Clinic.

BACKGROUND: Previous studies have reported that lean hypertensives have worse clinical outcomes than obese hypertensives as obesity confers pharmacological resistance to antihypertensive therapy. We explored whether the higher prescribed doses of antihypertensives in obese hypertensives were adequate for the attainment of similar on-treatment blood pressure (BP) versus leaner hypertensives. METHODS: A retrospective chart review of predominantly African American females from a deidentified urban referral clinic was conducted (N = 851; median follow-up = 11.3 months). Body mass index (BMI, kg/m2) was categorized as either below or above or equal to 30. Antihypertensive therapeutic intensity score (TIS) was calculated as the total daily antihypertensive dose/maximum United States Food and Drug Administration (USFDA) approved daily dose, summed across all hypertensive drugs. General linear models were used to estimate the significance of continuous variables across BMI categories. RESULTS: At baseline, systolic blood pressure (SBP) was similar between groups (P = 0.14), though 2.7 mm Hg higher in the highest BMI group. Antihypertensive TIS was greater in the highest BMI category at both baseline and end of follow-up (both P < 0.001). After covariate adjustment end of follow-up SBP and diastolic blood pressure was higher in the obese group by 3.4 (0.6-6.1) and 1.8 (0.1-3.53) mm Hg, respectively (P = 0.02, P = 0.04). CONCLUSIONS: Attained on-treatment BP is higher in obese than non-obese hypertensives despite greater prescription of antihypertensive medications. Whether even more prescription of medications or other interventions will equalize BP responses relative to non obese hypertensives merits further study.

Nonalcoholic Fatty Liver Disease: Could It Be the Next Medical Tsunami?

Nonalcoholic fatty liver disease (NAFLD) is a rapidly increasing cause of chronic liver disease with excess fat deposition in the liver, without an identifiable cause. NAFLD's benign form is called nonalcoholic fatty liver (NAFL), which can progress to nonalcoholic steatohepatitis (NASH) with or without fibrosis. Over time, NASH can progress to cirrhosis and eventually hepatocellular carcinoma (HCC) or progress to HCC without cirrhosis. Its incidence and prevalence are increasing to epidemic proportions, making it the most common cause of chronic liver disease in the western world. This review article attempts to understand the epidemiology, pathophysiology, evaluation, and management, and, most importantly, to generate awareness of this disease process.

Pancreatic Cancer with a Skeletal Muscle Metastasis-A Case Presentation and Literature Review.

One-half of patients with newly diagnosed pancreatic cancer will have metastatic disease at the time of diagnosis, mainly due to its non-specific initial clinical presentation which includes abdominal pain, dyspepsia, weight loss, bowel habit changes, jaundice and pruritus. The signs, symptoms and stage of the disease at initial diagnosis depends on the origin of the primary tumor, with tumors of the head presenting earlier with obstructive symptoms while tumors of the body/tail are often diagnosed at an advanced stage due to their non-specific presentation. The most common sites of metastasis are the lymph nodes, liver, lung, and peritoneum. The presence of metastatic disease in the skeletal muscles is a rare manifestation of pancreatic cancer and has been described in a limited number of cases. We report the case of a pancreatic cancer patient with a solitary muscle lesion as the only site of extra-nodal metastasis upon initial presentation.

Fitting the Pieces of the Puzzle Together: A Case of Median Arcuate Ligament Syndrome.

Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is one of the many rare vascular compression syndromes attributed to celiac trunk compression by the median arcuate ligament of the diaphragm, with presentations ranging from completely asymptomatic to myriad gastrointestinal symptoms, including chronic abdominal pain (CAP), post-prandial pain, nausea and vomiting, anorexia, early satiety, and subsequently weight loss. We present a case of a 50-year-old female presenting with ongoing multiple chronic gastrointestinal symptoms, later attributed to the marked narrowing of her celiac axis secondary by the median arcuate ligament.

Double Whammy: A Case of Concurrent Alcohol Use and Hereditary Hemochromatosis Leading to Avascular Necrosis of the Femur.

Avascular necrosis (AVN) of the femur is due to damage to the vasculature of the bone and can include a multitude of causes including medications, alcohol intake, hemoglobinopathies, thrombophilias, and connective tissue disorders, among others. Hereditary hemochromatosis is not a common cause of AVN but should be considered prior to labeling such cases as idiopathic. If a patient has symptoms of persistent hip pain and plain radiography has been unremarkable, one should proceed with magnetic resonance imaging (MRI) of the affected joint due to its sensitivity in detecting osteonecrosis. We present a case report of a 54-year-old male patient with a significant history of alcohol intake and a diagnosis of hereditary hemochromatosis who presented with persistent left hip pain and further imaging revealed the presence of osteonecrosis of the femur.

Constipation Misperception: Could It Be Familial Adenomatosis Polyposis?

Colorectal cancer is the second leading cause of cancer deaths in the United States. Familial adenomatosis polyposis (FAP) is a rare cause of colorectal cancer. The United States Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in average-risk, asymptomatic adults aged 50 to 75 years. While age is the most important risk factor, we need to consider the family history of colorectal cancer. FAP is a rare cause of colorectal cancer, leading to high morbidity and mortality if undetected and undiagnosed. It is easy to overlook the family history in a busy primary care clinic with limited patient encounter times. Clinicians mustn't forget this important piece of information as it can give leads for further patient evaluation. We present a case report of a 21-year-old male who presented to our clinic to establish primary care and with vague abdominal complaints. Still, the concerning family history of early onset colon cancer in his half-sister raised red flags and directed us to further evaluate. Further evaluation revealed our patient, in fact, had FAP.

Paradoxical Insomnia in a Frustrated Patient Treated With Hypnotics for Ten Years.

Insomnia remains a common complaint for which patients present to their primary care providers. The reflex response by most primary care providers to treat insomnia is by prescribing hypnotics. The most commonly prescribed hypnotic is a sedative, such as a benzodiazepine or a benzodiazepine receptor agonist (BRZA). Paradoxical insomnia is a subtype of insomnia described as a complaint of severe insomnia disproportional to the presence of objective sleep disturbance or daytime impairment. Previously known as sleep-state misperception, this subtype of insomnia is not well known among the primary care community. We present a case of a 60-year-old female who had been prescribed multiple hypnotics for over 10 years and presented to our sleep clinic frustrated due to failure of treatment with each medicine. She was eventually diagnosed with paradoxical insomnia after an evaluation of her sleep parameters. This was effectively treated with cognitive-behavioral therapy. This case report aims to raise awareness of this subtype of insomnia in patients at the primary care level and to help minimize the use of hypnotics.

Food Insecurity and Diabetes: The Role of Federally Qualified Health Centers as Pillars of Community Health.

Food insecurity is a complex public health problem affecting millions of people globally. It leads to negative health outcomes in the afflicted population and the society at large. There is a self-perpetuating vicious cycle between food insecurity and chronic health conditions like diabetes. It is important for healthcare professionals to be aware of its existence, to be able to recognize it, and to work with their patients to find solutions for it. Simultaneously, the providers should advocate for their patients and make program administrators, policymakers, and legislatures aware of this crisis. During the current coronavirus disease 2019 (COVID-19) pandemic, when economies have been badly affected and many people have lost their jobs, this subject has arguably assumed much greater importance. In this article, we discuss the magnitude of the problem, its relation to diabetes mellitus, and the role that a Federally Qualified Health Center (FQHC) can play in mitigating this problem.

Antibiotic Use in Broiler Poultry Farms in Kathmandu Valley of Nepal: Which Antibiotics and Why?

Inappropriate antibiotic use in food-producing animals is associated with the emergence and spread of antibiotic resistance. In industrial broiler poultry farms in three districts of Kathmandu valley, Nepal, we assessed antibiotic use prevalence, and their classes, types, and quantities. A cross-sectional questionnaire study involving field visits to large poultry farms (flock size ≥ 3000) of the Kathmandu, Bhaktapur, and Lalitpur districts was conducted. Of 30 farms (total flock size 104,200; range 3000-6000), prevalence of antibiotic use was 90% (95% CI: 73-98%). Six (22%) farms used antibiotics as prophylaxis, while 21 (78%) used it for therapeutics. Seven antibiotics from six classes (including quinolones, macrolides, and polymyxins) were used. The most commonly used antibiotics were tylosin (47%), colistin (47%), and dual therapies with neomycin and doxycycline (33%). A total of 50,000 grams of antibiotics (total weight including active and inactive ingredients) were used (0.5 grams/chicken/45 days of flock life) with eight (26%) farms using more than two antibiotics. No farms had records on clinical indications for prophylaxis or treatment. No post-mortem records of sick birds were available. Prevalence of antibiotic use in broiler farms of Kathmandu valley is high and includes "highest priority critically important antibiotics" for human use, with direct implications on public health.

Clinical indicators for progression of nonalcoholic steatohepatitis to cirrhosis.

Non-alcoholic fatty liver disease (NAFLD), is a disease spectrum characterized by fat accumulation in hepatocytes presenting as hepatic steatosis to advance disease with active hepatic inflammation, known as nonalcoholic steatohepatitis. Chronic steatohepatitis will lead to progressive hepatic fibrosis causing cirrhosis and increased risk for developing hepatocellular carcinoma (HCC). Fatty liver disease prevalence has increased at alarming rates alongside obesity, diabetes and metabolic syndrome to become the second most common cause of cirrhosis after alcohol related liver disease worldwide. Given this rise in prevalence, it is becoming increasingly more important to find non-invasive methods to diagnose disease early and stage hepatic fibrosis. Providing clinicians with the tools to diagnose and treat the full spectrum of NAFLD will help prevent known complications such as cirrhosis and HCC and improve quality of life for the patients suffering from this disease. This article discusses the utility of current non-invasive liver function testing in the clinical progression of fatty liver disease along with the imaging modalities that are available. Additionally, we summarize available treatment options including targeted medical therapy through four different pathways, surgical or endoscopic intervention.

Daith Piercing: Wonder Treatment or Untested Fad?

Daith piercing is a form of body piercing that involves the crux of the ear's helix. While daith piercing has been used as an esthetic piercing since the 1990s, it is gaining popularity in the general population as an alternative treatment in chronic headaches, especially migraines. Despite its use, the evidence is currently lacking. Postulated hypotheses include vagal neuromodulation vs. placebo effect. We present a case of a 47-year-old female patient suffering from refractory cluster headache who underwent daith piercing. We aim to raise awareness among the general practitioners of this health-related practice prevalent in the community.

Clinicians Beware, Ewing's Sarcoma After 60 Is Elusive and Rare!

Ewing's sarcoma is the second most common malignant bone tumor in children, with the worst outcomes seen in patients over the age of 20. However, the onset of the disease is much less common in people over the age of 30. This case represents the diagnostic dilemma posed by an otherwise "straight forward" case of back pain. Keeping the differential diagnosis sufficiently broad to include bone malignancies, so as not to delay diagnosis and treatment, provides the best chance at a positive outcome.

'Shawl Sign' as a Paraneoplastic Dermatosis.

Dermatomyositis (DM) is an idiopathic condition characterized by inflammation of muscles and skin lesions. It is often a paraneoplastic manifestation of internal malignancy. Hence, early recognition of this disorder is important. Although not all dermatomyositis are associated with malignancies, the ones with such association regress with the treatment of associated malignancy. In clinical practice, symptoms of muscle weakness can be vague, and skin lesions can be dismissed as sunburn. We present a case of an elder adult female who presented with dermatomyositis as a paraneoplastic syndrome secondary to an underlying Mullerian malignancy.

New Diagnosis of Obstructive Sleep Apnea Following Anterior Cervical Discectomy Complicated by Rheumatoid Arthritis: A Case Report.

Obstructive sleep apnea (OSA) is the most common variant of sleep-disordered breathing that often goes undiagnosed. OSA is characterized mainly by anatomical obstruction or partial collapse of upper airways during sleep. The obstruction is multifactorial, and a lesser-known fact is that damage to the pharyngeal plexus during head and neck procedures or placement of hardware in the cervical area can lead to narrowing or collapse of the upper airway. We present such a case of a 59-year-old female who developed new-onset OSA after undergoing anterior cervical discectomy and fusion (ACDF). The severity of OSA worsened with the progression of her rheumatoid arthritis (RA) in the cervical region. This case report aims to raise awareness of such an association among clinicians to enable them to screen appropriate patients for sleep-disordered breathing and treat them accordingly.

Using Generalized Anxiety Disorder-2 (GAD-2) and GAD-7 in a Primary Care Setting.

Anxiety disorders are highly prevalent in the primary care setting and are responsible for significant morbidity as well as a loss of productivity. Evaluation by mental health specialists and behavioral specialists can sometimes be confounded with problems of availability, accessibility, and the patient's hesitancy to talk to new providers due to lack of prior relationship and trust. Primary care providers already have the advantage of being available for their patients, and have built years of trust behind them to strengthen this relationship. The biggest problems which confront primary care are the time constraints as well as the presence of multiple medical demands. This leads to a constant need for tools that facilitate early recognition and diagnosis of mental health disorders while also providing judicious utilization of clinic time. This article attempts to review the use of two of these popular tools: Generalized Anxiety Disorder scale-2 (GAD-2) and GAD-7 in the primary care setting.

Analysis of ABO and Rh Blood Type Association With Acute COVID-19 Infection in Hospitalized Patients: A Superficial Association Among a Multitude of Established Confounders.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has affected millions of people worldwide, and considerable effort is focused on identifying certain populations at increased risk. ABO blood types have been associated with disease susceptibility; however, evidence remains limited. Our aim was to determine the association between ABO/Rh blood type with disease susceptibility and mortality among admitted COVID-19 patients. METHODS: A retrospective analysis of patients with COVID-19 requiring admission was undertaken. Demographics and pertinent medical history were analyzed with respect to ABO/Rh blood type: between the cases and a control population; as well as with respect to mortality in the COVID-19 population in univariate analysis. Potential confounding factors were evaluated by multivariate models. The main outcomes were disease susceptibility by comparison of blood type prevalence between populations, and mortality within the COVID-19 population. RESULTS: A total of 825 cases (admitted with confirmed COVID-19 infection by reverse transcriptase-polymerase chain reaction (RT-PCR)) and 396 controls (seen at the same institution during the calendar year of 2019) were included. The COVID-19 population was older with male predominance. It was heavily represented by blood types O-positive (53%) and A-positive (23%), while lower representation was observed in groups B-positive (odds ratio (OR): 0.61, P = 0.013) and AB-positive (OR: 0.46, P = 0.014). Neither relationship remained significant in pairwise analysis. Within the COVID-19 population, no mortality difference was appreciated between ABO groups (P = 0.312), but higher mortality was observed in Rh negative group (P = 0.01). The latter of which was significantly confounded by age (P < 0.001), sex (P = 0.022), body mass index (BMI) (P = 0.001), and hemoglobin A1c (HbA1c) (P < 0.001) in multivariate analysis. CONCLUSIONS: While type A blood appears to be weakly more prevalent with respect to B and AB types in hospitalized patients, strong confounders of age and sex dilute this significance. Rh-negative patients appear to have a higher mortality, although this too is strongly confounded. Overall, ABO and Rh blood types do not have a significant relationship with susceptibility and mortality with COVID-19 infection in our population.