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Achalasia: Diagnosis and Management
No full textAchalasia is an incurable condition of the esophagus involving the inflammation and degeneration of inhibitory neurons of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Typical symptoms of achalasia are dysphagia, retrosternal chest pain, regurgitation, and weight loss. Three studies are typically required for the diagnosis of achalasia: barium swallow, high-resolution esophageal manometry, and esophagogastroduodenoscopy. Differential diagnosis includes gastroesophageal reflux disease, pseudoachalasia, neoplasm, and nonachalasia esophageal motility disorders such as scleroderma, jackhammer esophagus, distal esophageal spasm, and nutcracker esophagus.
Keywords: Achalasia; Botulinum toxin injection; Chicago classification; Heller myotomy; High-resolution esophageal manometry; POEM; Pneumatic dilatation
Medicaid Policy and Hepatitis C Treatment Among Rural People Who Use Drugs
No full textBackground: Restrictive Medicaid policies regarding hepatitis C virus (HCV) treatment may exacerbate rural health care disparities for people who use drugs (PWUD). We assessed associations between Medicaid restrictions and HCV treatment among rural PWUD.
Methods: We compiled state-specific Medicaid treatment policies across 8 US rural sites in 10 states and merged these with participant survey data. We hypothesized that local restrictions regarding prescriber type, sobriety, and fibrosis estimates were associated with HCV treatment outcomes. We conducted a cross-sectional, ecological analysis of treatment restrictions and HCV treatment outcomes using bivariate analyses to characterize differences between PWUD who initiated HCV treatment and unadjusted logistic regressions to assess associations between restrictions and treatment.
Results: Among 944 participants, 111 (12%) reported receiving HCV treatment. Participants receiving treatment were older [median age (interquartile range): 42 (34-53) vs. 35 (29-42), P\u3c0.001], more likely to receive disability support (32% vs. 20%, P=0.002), and less likely to be Medicaid-insured (57% vs. 71%, P \u3c 0.001). More PWUD in states without any restrictions reported receiving treatment (17% vs. 11%, P=0.08) and achieving HCV cure/clearance (42% vs. 30%, P=0.01) than in states with restrictions. Restrictions were associated with lower odds of receiving HCV treatment (odds ratio=0.61, 95% CI: 0.35-1.06, P=0.08). Sensitivity analyses showed a similar association with HCV cure/clearance (odds ratio=0.60, 95% CI: 0.40-0.91, P=0.02).
Conclusions: We identified significant unadjusted associations between Medicaid restrictions and receipt of HCV treatment and cure, which has substantial implications for health outcomes among rural PWUD. Lifting remaining Medicaid restrictions will be critical to achieving HCV elimination
Commentary: Is Your Department Ready to Educate Generation Z?
No full textIt is estimated that Generation Z will outnumber the next closest generation, the Millennials (born between 1981 and 1996), by 2040.Only a small number of them are currently in residency training; however, they have already entered the workforce in other professions. Many companies have studied Generation Z and have recognized major differences compared with older generations. Medical professionals can learn from the work already done to adjust for a smooth transition to medical training and postgraduate practice
A Rare Case of Pediatric Pulmonary Sarcoidosis Without Lymph Node Involvement Presenting With Centrilobular Ground-Glass Opacities
No full textA 17-year-old previously healthy male presented with acute hypoxic respiratory failure after one month of progressively worsening dyspnea on exertion, non-productive cough, fevers, and weight loss. He was initially discharged on oral steroids with a working diagnosis of cryptogenic organizing pneumonia, but was readmitted after one month for acute hypoxic respiratory failure. Extensive laboratory workup, including serum angiotensin converting enzyme level, hypersensitivity pneumonitis panel, and bronchoalveolar lavage fluid cultures, was normal. Computed tomography scan of the chest revealed diffuse centrilobular ground-glass opacities and a 4-mm solid right lower lobe pulmonary nodule, and he underwent a video-assisted thoracoscopic surgery (VATS) procedure with segmental resection of the lingula. Pathology ultimately showed non-necrotizing granulomatous inflammation in the interstitium of the lung parenchyma, airways, and blood vessels, consistent with sarcoidosis. Diagnosis of interstitial lung disease is difficult when histologic diagnosis requires an invasive, costly VATS biopsy, but prompt recognition of sarcoidosis is critical to prevent potentially fatal pulmonary fibrosis or cardiac sarcoidosis. To our knowledge, this is the first case report of pediatric pulmonary sarcoidosis with ground-glass opacities lacking any lymphadenopathy, skin, or neurologic manifestations.
Keywords: cryptogenic organizing pneumonia; diagnostic error; ground glass opacities; high-value care; pediatric hospital medicine; pulmonary sarcoidosis; sarcoidosis
Oncology Journal Club: Disseminating New and Updated Knowledge
No full texthttps://scholarlycommons.libraryinfo.bhs.org/nursing_artof_questioning_innovation2025/1017/thumbnail.jp
IV Smart Pump Alarms and Thier Role in Alarm Fatigue: A Hospital Perspective
No full texthttps://scholarlycommons.libraryinfo.bhs.org/nursing_artof_questioning_innovation2025/1006/thumbnail.jp
Patterns of Felt Stigma Among Rural-Dwelling People Who Use Drugs: A Latent Class Analysis
No full textBackground: Stigma is a barrier to help-seeking in rural-dwelling people who use drugs. However, little is known about whether stigma is experienced in patterned ways, and what characteristics are associated with these patterns.
Methods: Data came from a cohort of people who use drugs at eight geographically diverse Rural Opioid Initiative sites (n = 3048). We used three-step latent class analysis to classify participants by patterns of felt substance use stigma, then used multinomial logistic regression to explore demographic, health, and substance-related covariates associated with class membership.
Results: Based on fit statistics and interpretability, we selected a five-class solution. Four classes were patterned by severity: Low Stigma (23.7%), Medium-Low Stigma (12.5%), Medium-High Stigma (34.9%), and High Stigma (24.7%). The fifth class ( High Fearers/Low Perceivers, 4.3%) reported high shame and fear of rejection but low perceived stigma from others. Members of higher stigma classes were more likely to have criminal-legal system involvement, inject drugs, and avoid healthcare and drug treatment. In contrast analyses, High Fearers/Low Perceivers were more likely to be younger and women, and less likely to have criminal-legal system involvement, experience homelessness, or inject drugs compared with other classes.
Conclusion: Rural people who use drugs experience substance use stigma in distinct severity-based patterns, with four classes ranging from low to high stigma across all dimensions. A fifth, smaller class reports high internalized stigma despite low perceived stigma from others, potentially suggesting non-disclosure of substance use. These distinct profiles and their correlates offer targets for tailored stigma interventions.
Keywords: Stigma; latent class analysis; opioids; rural health; substance use
Correction: Testing a Machine Learning-Based Adaptive Motivational System for Socioeconomically Disadvantaged Smokers (Adapt2Quit): Protocol for a Randomized Controlled Trial
No full textOutcomes of Adding Computed Tomography Angiography for Pre-procedural Planning of Left Atrial Appendage Occlusion: a Systematic Review and Meta-analysis
No full textBackground: Multi-society expert consensus statements on catheter-based left atrial appendage occlusion (LAAO) suggest transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) for pre-procedural planning. However, evidence comparing the outcomes of adding CCTA to TEE on procedural success is limited.
Objective: Perform a systematic review and meta-analysis to determine the impact of adding CCTA to TEE for pre-procedural planning in patients undergoing LAAO.
Methods: We systematically searched Cochrane, Embase, and Medline for observational studies and randomized controlled trials (RCTs) comparing the addition of CCTA vs. TEE alone. The primary endpoint was procedural success. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled across studies using a random-effects model.
Results: Systematic review identified four studies for meta-analysis, three RCTs and one observational study, including a total of 824 patients, of whom 496 (60.2%) underwent additional CCTA. In the pooled analysis, procedural success was higher with added CCTA (RR 1.10; 95% CI 1.01-1.19; p = 0.022; I²=52%). A subgroup analysis of only RCTs confirmed these findings with a slightly higher magnitude of effect and lower heterogeneity (RR 1.15; 95% CI: 1.06-1.25; I2 = 0%).
Keywords: Atrial fibrillation; Cardiac CT; Left atrial appendage occlusion; Transesophageal echocardiography
Trends in sex, racial, and ethnic disparities in cardiac arrest mortality in the United States: Insights from the CDC WONDER database 1999-2020
No full textBackground: Sex, racial, and ethnic disparities have been documented in survival after cardiac arrest. Whether knowledge of these disparities has led to their mitigation remains unclear. We evaluated trends in sex and racial disparities in cardiac arrest mortality over a 22-year period.
Methods: Crude death rates (CDRs) for cardiac arrest per 100,000 individuals aged ≥15 years were obtained from the CDC WONDER database from 1999 through 2020. Inferential statistics and linear regression were performed to assess average annual percentage change (AAPC).
Results: Among 364,531 cardiac arrest deaths (CDR of 6.7 per 100,000; 95 % confidence interval [CI] 6.7-6.8), mortality declined significantly from 1999 through 2020 (slope -0.1, 95 % CI -0.14 to -0.05; p \u3c 0.001). No difference was noted in CDR between Women and Men (6.59 vs 6.97; p = 0.117). By race, African Americans had the highest CDR (8.68), and Native Americans had the lowest (2.32), with significant differences across races (p \u3c 0.001). Hispanics had a significantly lower CDR (1.38) than non-Hispanics (7.64; p \u3c 0.001). Trend analysis showed a significant decline in CDR (AAPC -1.4, 95 % CI -1.4 to -1.7), with women experiencing a greater reduction (-2.1) than men (-0.88). Whites had the largest AAPC decline (-1.6; p \u3c 0.001), while African Americans had the smallest (-0.6; p = 0.04). Hispanics showed a non-significant AAPC increase (0.77; p = 0.28).
Conclusions: Cardiac arrest mortality declined over two decades, but the decline was not equal across sexes, races, and ethnicities. Further work is required to develop interventions to address these disparities.
Keywords: Cardiac arrest; Disparities; Mortality; Race; Sex