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Rare case of schwannomatosis presenting with cauda equina syndrome: a case report
No full textBackground: Schwannomatosis is a rare disorder characterized by multiple schwannomas without vestibular schwannomas or other features of neurofibromatosis type 2 (NF2). It commonly presents with neuropathic pain, neurological deficits, and soft tissue tumors but rarely leads to cauda equina syndrome, a serious condition requiring urgent intervention.
Materials and methods: We report a 28-year-old Pakistani female with progressive back pain, lower limb weakness, sensory deficits, bladder and bowel incontinence, and multiple tender swellings, consistent with cauda equina syndrome. Neurological examination revealed right-sided lower limb weakness. MRI of the brain showed no vestibular schwannomas, while spinal MRI identified a heterogeneously enhancing schwannoma from D11 to L5 with cystic extension into the neural foramina, proximal central canal dilation, and spinal cord compression. Multiple additional schwannomas were detected. Right thigh mass biopsy confirmed schwannoma, showing Antoni A and B regions, Verocay bodies, and S-100 positivity. Genetic testing was not performed due to financial constraints.
Results: The patient underwent partial spinal schwannoma resection, leading to spinal decompression and resolution of cauda equina syndrome symptoms. Symptomatic cutaneous schwannomas were excised. Neuropathic pain was managed with pregabalin and NSAIDs. At 6-month follow-up, she showed improved lower limb strength, resolution of incontinence, and no significant tumor regrowth.
Conclusion: This case highlights schwannomatosis presenting with cauda equina syndrome, emphasizing the importance of early recognition, spinal decompression, and differentiation from NF2 for optimal management.
Keywords: case report; cauda equina syndrome; nerve sheath tumors; schwannomatosis; spinal schwannoma
Retrograde femoral access flipped antegrade technique and its effect on patient outcomes following lower extremity angiography
No full textBackground: Common femoral artery access is a critical step in the endovascular treatment of peripheral artery disease. Traditionally, access is obtained either by a retrograde approach from the contralateral leg with an up-and-over aortic bifurcation technique, or in an antegrade fashion in the ipsilateral leg. Retrograde arterial access flipped antegrade in the ipsilateral femoral artery incorporates the technical ease of retrograde access with mechanical advantages of antegrade access. There are limited studies directly comparing these techniques. The objective of this study is to describe and compare the different techniques for accessing the common femoral artery for diagnostic and therapeutic endovascular infrainguinal interventions.
Methods: This is a retrospective cohort study of patients undergoing lower extremity diagnostic and therapeutic angiography through either contralateral retrograde (RA), ipsilateral antegrade (AA), or retrograde access flipped antegrade (RAFA) between October 1st 2018 and September 30th 2020. Outcomes measured were technical success, complications including hematoma, hemorrhage requiring transfusion, pseudoaneurysm and repeat operative intervention. Differences in patient and treatment characteristics were analyzed using two-sample t-test, Fisher\u27s exact test and Chi-squared test. Multivariable logistic regression analysis was performed to identify associations with different access techniques and study outcomes.
Results: Of the 342 lower extremity endovascular procedures, 156 (45.6%) used RA access, 82 (24.0%) AA access and 104 (30.4%) RAFA access. There were no significant differences in the mean age, gender, and body mass index between patients undergoing different access method cohorts (p\u3e0.05). The RAFA cohort had a significantly higher percentage of patients taking Plavix (46%) than retrograde (24%) and antegrade (34%) patients (p\u3c 0.001). Patients undergoing RAFA access were less commonly active smokers (p=0.003) or had COPD (p=0.001). Fluoroscopic confirmation of arterial puncture occurred less frequently in the AA cohort (p=0.037). Technical success rate during therapeutic intervention was highest in the AA cohort (RA, 84%; AA, 98%; RAFA, 91%; p=0.024). The AA cohort had the highest overall complication rate (RA, 10%; AA, 23% RAFA, 8.0%; p=0.025) and the highest rate of requiring return to OR (RA, 4.7%; AA, 17%; RAFA, 4.5%; p=0.021). There were no significant differences in the incidence of hematoma, pseudoaneurysm, or death between all three cohorts (p\u3e0.05).
Conclusion: The use of a retrograde access flipped antegrade technique for infrainguinal diagnostic and therapeutic endovascular therapy is not well studied. Our study demonstrates that this technique had a high rate of technical success without increasing the risk for access site complications compared to the traditional femoral artery access.
Keywords: Antegrade; Complication; Endovascular procedure; Femoral access; Retrograde
Motivators and Barriers to Obtaining Cardiac Vascular Certification Among Acute Care Nurses
No full textBackground
Cardiovascular diseases are highly prevalent in the United States. Nurses play a crucial role in supporting patients with these conditions and should seek verification of advanced cardiac knowledge through certification. Method
This descriptive survey was conducted in a large academic hospital in the northeastern United States. Participants included RNs who had obtained or were eligible for cardiac-vascular certification. Surveys were distributed via work email between October 2022 and February 2023. Results
Among 63 participants, 31 were certified and 32 were not certified. Certified nurses had higher agreement with Perceived Value of Certification Tool statements, with a mean score of 31.3 versus 27.8 for non-certified nurses. Common barriers to certification included “other” (40.6%), testing discomfort (31.3%), and the pandemic (31.3%). Conclusion
Nurses reported positive perceptions of cardiac-vascular certification. Certified nurses indicated that certification demonstrated competence, confidence, accomplishment, and commitment. Hospitals and professional organizations should encourage certification and address barriers to obtaining it. Further research is needed to understand motivations and barriers
Impact of Medicaid Coverage of Tele-Mental Health Services on Postpartum Mental Health Services: Evidence from Massachusetts
No full textBackground: Tele-mental health services have the potential to reduce barriers to postpartum mental health care, particularly for Medicaid-insured individuals who face geographic and logistical challenges. In January 2019, Massachusetts Medicaid became one of the few states to implement payment parity for tele-mental health services before the COVID-19 pandemic, ensuring equal coverage for tele-mental health and in-person visits. This policy change provides a unique opportunity to evaluate whether payment parity improves postpartum mental health service utilization. This study aimed to estimate the impact of Massachusetts Medicaid\u27s coverage of tele-mental health services at parity with in-person visits on postpartum mental health service utilization among Medicaid-insured birthing individuals. Methods: A difference-in-differences (DD) analysis using the Massachusetts All-Payer Claims Database from January 1, 2016, to March 10, 2020. This study compared Medicaid and privately insured individuals before and after Massachusetts implemented tele-mental health payment parity in January 2019. Results: Among the 138,669 individuals in the sample, 81,494 were covered by Medicaid, and 57,175 were privately insured. Postpartum tele-mental health use was minimal across the sample (0.07%). The adjusted DD analysis indicated no statistically significant increase in tele-mental health utilization among Medicaid enrollees compared to privately insured individuals (adjusted difference: 0.08 percentage points; 95% CI: -0.02 to 0.17). Conclusion: The implementation of tele-mental health payment parity did not significantly increase tele-mental health utilization among Medicaid-insured birthing individuals in Massachusetts. Despite policy changes, systemic barriers likely limited the uptake of tele-mental health services, highlighting the need for additional interventions to improve access to postpartum mental health care.
Keywords: Medicaid; payment parity; postpartum mental health; tele-mental health
Editorial: The epidemiology of missed and delayed medical diagnosis: implications for health equity and public health
No full textBenefits of Cardiac Rehabilitation: Mechanisms to Restore Function and Clinical Impact
No full textCardiac rehabilitation (CR) has evolved from foundations as a postmyocardial infarction mobilization strategy for patients who were typically unstable, into a comprehensive, multidisciplinary program for most patients with cardiovascular disease aimed at optimizing cardiovascular health, reducing morbidity, and enhancing functional recovery. Although contemporary CR patients are now usually more stable from a cardiovascular perspective, needs have expanded for comprehensive approaches to exercise, lifestyle, care coordination, risk factor modification, and stress management. Furthermore, contemporary CR patients now typically include older adults who are contending with cardiovascular disease in the context of multimorbidity, frailty, sarcopenia, sensory limits, and cognitive impairment. The physiological mechanisms underlying exercise intolerance in cardiovascular disease include impairments in cardiac output, vascular function, and skeletal muscle metabolism and relate to elemental biological mechanisms that are common to all 3 as well as to noncardiovascular disease and aging. CR provides an important opportunity to address such aggregate risk. Nonetheless, CR remains underutilized, particularly by older adults, women, and those struggling with cognitive impairments, frailty, logistics, and social barriers to care. Emerging strategies, such as home-based and hybrid CR models, resistance training, and digital health technologies, are expanding the potential for access and effectiveness. Future research brings important opportunities to hone personalized CR strategies tailored to contemporary patient populations, including optimized exercise prescriptions as well as pharmacological, nutritional, and technological adjuncts. Related prospects to distinguish the biological mechanisms underlying patient-preferred clinical end points (eg, independence, quality of life) remain critical to augmenting CR\u27s value in the contemporary therapeutic landscape.
Keywords: aging; cardiovascular diseases; digital health; quality of life; sarcopenia
Automated Reminders Improve Feedback in Surgical Training
No full textBackground: Feedback is an essential component of medical residency, particularly in subspecialty fields like otolaryngology where residents must adapt to a wide array of surgical techniques. However, a lack of timeliness or insufficient frequency can hurt feedback quality. Faculty may believe feedback is timelier and of higher quality compared to their trainees\u27 impressions.
Objective: We aimed to improve faculty and resident feedback satisfaction.
Methods: We conducted a month-long survey and automated text message intervention in 2023 to assess perceptions of the existing feedback system in an Otolaryngology residency program and measure postintervention changes. Text message reminders to give oral feedback and complete a pre-existing competency-based form were timed to arrive as the last surgical case ended.
Results: Out of 29 surgical faculty and 15 PGY-2 through PGY-5 residents invited to participate, 17 faculty (58% response rate) and 11 residents (73% response rate) completed both the pre- and postsurvey. Completed competency ACGME feedback forms increased from 4 in the previous month to 54 in the month of the intervention, a 13-fold increase. Overall, resident and faculty satisfaction with feedback improved, with the former reaching statistical significance. Faculty and residents agreed on major barriers to successful feedback: faculty forgetfulness, resident discomfort asking for feedback, and faculty time constraints. Opportunities for continued improvement noted in the postsurvey included quality of feedback and frequency.
Conclusions: Automated reminders can increase timeliness and quantity of feedback. This study presents preliminary data for a simple intervention that can be iterated upon to improve feedback in residency programs nationwide.
Keywords: automation; feedback; quality improvement; residency programs; surgical training
Healthy at Home for COPD: An Integrated Digital Monitoring, Treatment, and Pulmonary Rehabilitation Intervention
No full textBackground: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality in the United States. Frequent exacerbations result in higher use of emergency services and hospitalizations, leading to poor patient outcomes and high costs. The objective of this study is to demonstrate the feasibility of a multimodal, community-based intervention in treating acute COPD exacerbations.
Results: Over 18 months, 1,333 patients were approached and 100 (7.5%) were enrolled (mean age 66, 52% female). Ninety-six participants (96%) remained in the study for the full enrollment period. Fifty-five (55%) participated in tele-pulmonary-rehabilitation. Participants wore the smartwatch for a median of 114 days (IQR 30-210) and 18.9 hours/day (IQR16-20) resulting in a median of 1034 minutes/day (IQR 939-1133). The rate at which participants completed scheduled survey instruments ranged from 78-93%. Nearly all participants (85%) performed COPD ecological momentary assessment at least once with a median of 4.85 recordings during study participation. On average, a 2.48-point improvement (p=0.03) in COPD Assessment Test Score was observed from baseline to study completion. The adherence and symptom improvement metrics were not associated with baseline patient activation measures.
Conclusions: A multimodal intervention combining preventative care, symptom and biometric monitoring, and MIH services was feasible in adults living with COPD. Participants demonstrated high protocol fidelity and engagement and reported improved quality of life.
Keywords: Chronic Obstructive Pulmonary Disease; Community Health; Community Paramedicine; Decentralized Trial; Digital Health; Mobile Integrated Health; Remote Monitoring
