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A Retrospective Study Examining the Importance of Early Postpartum Follow Up in Uncomplicated Vaginal Deliveries
No full textPurpose: Holistic postpartum care, including a comprehensive postpartum visit, is essential for long-term maternal and fetal health. However, many women navigate the early postpartum period independently until the traditional postpartum visit 4-6 weeks after delivery. In a national study, less than half of women attending a postpartum visit reported that they received adequate information on postpartum depression, birth spacing, healthy eating, exercise, or changes in their sexual health. This lack of attention to maternal health needs impedes identification and adequate management of postpartum depression, breastfeeding challenges, access to effective contraception, and chronic health conditions. In efforts to remediate this gap in care, the American College of Obstetrics and Gynecology recommends that all women have contact with their obstetric care provider within the first 3 weeks postpartum. This should be followed with ongoing care with a comprehensive postpartum visit no later than 12 weeks after birth. Preliminary studies incorporating these guidelines have indicated favorable health outcomes among mothers in the early postpartum period. In a randomized controlled trial, 15 minutes of discharge instructions, followed by a phone call at 2 weeks, reduced symptoms of depression and increased breastfeeding duration through 6 months postpartum among African American and Hispanic women. While previous studies have analyzed the benefit of earlier postpartum follow up for specific health challenges, few studies have holistically investigated the benefit of the earlier postpartum follow up in office. This study aims to characterize and compare outcomes of early postpartum follow up in uncomplicated vaginal deliveries. Methods: The medical records for all patients receiving prenatal care over a 2-year interval at the Medical City Arlington GME clinic were retrospectively reviewed to identify 228 patients that had received a postpartum visit within 3 weeks of delivery. The early postpartum visit records were reviewed for evidence of PPD screening and intervention, hypertension assessment and intervention, breast-feeding support and intervention, contraceptive counseling, hospital readmission or emergency room transfer, and primary care referral. Results:68% of patients were counseled on contraception, 2% were referred to a PCP for ongoing care, and 1% were sent for hospital readmission. Of the 45 patients who had a blood pressure check, 5% were initiated on anti-hypertensive therapy. Of the 172 patients screened for PPD, 5% received initial treatment for PPD. Utilizing Chi-square analyses, it was found that multiparous patients were 2.47 times more likely to get contraceptives ordered compared to nulliparous patients (p < .0109). Furthermore, there was a statistically significant difference in the frequency of PCP referrals and initial prenatal care (p= 0.0308). Those who started their prenatal care early were more likely to be referred to a PCP (7.78%) compared to those with late prenatal care (1.45%). Conclusion: Early postpartum follow-up allows for timely recognition and intervention of hypertension and mood disorders, earlier initiation of contraception, and earlier transition of care to a PCP. These interventions may improve long term maternal health outcomes and reduce the likelihood of preventable complications
Presentations of Cutaneous Disease in Various Skin Pigmentations: Tinea Corporis
No full textBackground
Tinea corporis, a superficial fungal skin infection, typically manifests as pruritic annular erythematous scaly plaques with central clearing. This condition can involve every body region. Here we present tinea corporis across various skin pigmentations. The goal is to highlight distinctions and similarities in light, medium, and dark skin tones, using the Fitzpatrick scale for stratification of skin types. We hope this can aid primary care clinicians in early recognition of this common condition.
Case Information
We present a series of cases illustrating the diverse manifestations of tinea corporis across different Fitzpatrick skin types. In Figure 2, a 28-year-old with Fitzpatrick I displays well-defined, scaly plaques on the inner thigh. Figure 3 features a 3-year-old of Fitzpatrick II with a large, poorly defined plaque on the right posterior thigh. A 33-year-old Fitzpatrick III male of showcases an erythematous, scaly plaque extending from the groin (Figure 4). Figure 5 presents a 15-year-old with Fitzpatrick IV, exhibiting well-demarcated erythematous plaques on the left arm with inflamed papules on the neck and arm. A 69-year-old female of Fitzpatrick V displays pink to violaceous plaques with hyperpigmentation and white/gray scales (Figure 6). These cases highlight the diverse clinical presentations that can be seen in different Fitzpatrick skin types.
Conclusions
Tinea corporis is a common superficial fungal infection of the skin that tends to be more prevalent in younger demographics and thrives in humid environments. Trichophyton rubrum is the most common dermatophyte culprit for this fungal infection. It can spread easily between different parts of the body, accentuating the need for comprehensive evaluations encompassing various anatomical areas. Diagnosis of tinea corporis across various skin tones involves recognizing the influence of age, environmental factors, and the Fitzpatrick scale on its clinical presentation. Variations can be observed in the degree of scaling and the amount of erythema. Bright red erythema is harder to distinguish in darker Fitzpatrick skin types (IV-VI). Instead, erythema may appear more hyperpigmented. Likewise, scale may be more easily seen in these skin types. Identifying tinea corporis in light, medium, and dark skin tones is crucial for early intervention. Confirmatory diagnostic procedures, such as KOH scrapings and fungal cultures from lesion swabs are valuable in confirming the presence of dermatophyte involvement
Identifying Stigmatizing Language in Maternal Mortality Medical Health Records
No full textIssue: This presentation endeavors to comprehensively address the ever-growing issue of stigmatizing language within medical health records, particularly in regards to maternal mortality. Maternal mortality remains a pressing health concern, with stark disparities persisting among different demographic groups. There is a notable gap in the identification of bias and disparities within medical records, with stigmatizing language being one manifestation of this bias. Stigmatizing language in medical records perpetuates harmful stereotypes, undermines patient trust, exacerbates disparities, and hinders equitable care delivery. This review focuses on the Maternal Mortality Case Preparation process which involves a systematic review of maternal death cases to identify contributing factors in hopes of reducing maternal mortality rates.
Setting: The objective is to equip maternal mortality abstractors with the necessary resources to identify and abstract stigmatizing language present in maternal death medical records, fostering a more accurate and unbiased documentation process.
Project: Efforts were directed towards refining a specialized tool to primarily assist Maternal Mortality Case abstractors and MMMRC Reviewers in identifying bias and stigmatizing language within medical records. The tool helps abstractors and Reviewers identify instances of discrimination within medical records that may have contributed to maternal death, ensuring a comprehensive approach to mitigating biases and promoting equitable maternal healthcare. Additionally, an accompanying PowerPoint presentation was developed to raise awareness about the harmful impact of stigmatizing language and provide guidance on alternative language usage to promote inclusivity and sensitivity in medical documentation.
Results: Through a comprehensive literature review, common forms of stigmatizing language prevalent in medical health records have been identified. These include the use of quotations, which may inadvertently portray certain patient attributes or conditions in a derogatory manner. Moreover, language that utilizes doubt markers and judgemental language indicates a lack of trust or skepticism towards the patient's reported experiences or medical history. Lastly, blaming patients by using disapproving language not only perpetuates negative stereotypes but also undermines patient autonomy and dignity. By recognizing and categorizing these common forms of stigmatizing language, healthcare professionals can become more aware of their inadvertent biases and strive towards promoting more respectful and patient-centered communication within medical documentation.
Conclusion: The development and refinement of this tool and educational resource represent significant progress in addressing stigmatizing language within medical health records. By raising awareness on the harmful implications of stigmatizing language, we can work towards improving the quality of care provided and reducing disparities in maternal health outcomes. Furthermore, the lessons learned from this initiative emphasize the broader significance for promoting equity and inclusivity within healthcare systems, underscoring the importance of addressing bias and discrimination in medical documentation across all healthcare specialties. Through continued research, education, and advocacy efforts, we can strive towards a healthcare system that is truly inclusive, equitable, and respectful of all patients' diverse backgrounds and experiences
Integrating Fall Prevention Strategies into EMS Services to Reduce Falls and Associated Healthcare Costs for Older Adults
Get PDFPURPOSE: The purpose of this study is to detail the implementation of fall prevention initiatives through emergency medical services (EMS) and associated outcomes. METHODS: Paramedics with MedStar Mobile Healthcare utilized the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall prevention model to screen and direct intervention through 9-1-1 emergency response, High Utilization Group (HUG), and 30-day Hospital Readmission Avoidance (HRA) programs. Outcomes from 9-1-1 calls measured the number of older adults screened for falls and identified risk factors. The HUG and HRA programs measured change in quality of life with EuroQol-5D, referral service utilization, falls, emergent healthcare utilization, and hospital readmission data. Analysis included costs associated with reduced healthcare usage. RESULTS: Emergency paramedics provided fall risk screening for 50.5% (n=45,090) of adults aged 65 and older and 59.3% were at risk of falls, with 48.1% taking medications known to increase the risk of falls. Services provided through the HUG and HRA programs, along with additional needed referral services, resulted in a 37.2% reduction in fall-related 9-1-1 calls and a 29.5% increase in overall health status related to quality of life. Analysis of the HUG program revealed potential savings of over 19,053. The HRA program demonstrated a 16.4% hospital readmission rate, in comparison to a regional average of 30.2%, and a cost-savings of 15,618 per enrolled patient. CONCLUSION: Implementation of the STEADI model into EMS services provides an effective and cost-saving model for addressing fall prevention for older adults, provides meaningful and impactful improvement for older adults, and could serve as a model for other EMS programs. This study explored the feasibility and impact of implementing an evidence-based fall prevention model into emergency medical services for older adults. The outcomes resulted in an efficient and effective manner to screen older adults for falls during emergency response services and connect high-risk older adults with in-home follow-up care from community paramedics. In addition, fall prevention services were provided for vulnerable adults following a recent discharge from hospital care. These initiatives to address fall prevention resulted in a majority of older adults receiving preventive fall risk screening during emergency response calls, significant changes in quality of life measures for adults with multiple comorbidities and fall risk, and significant potential cost savings in reduced healthcare services.This project was supported by grant funding from the Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS), under grant number U1QHP28735
Discovery-driven Label-free Quantitative Proteomics Study to Understand Estradiol-mediated Neuronal Processes in the Hippocampus and its Implication in Alzheimer’s Disease in Ovariectomized Rats
No full textPurpose: Alzheimer’s disease (AD) is a debilitating neurodegenerative disorder that affects millions of people globally. Studies report an increased susceptibility to the development of AD in post-menopausal women. There is renewed interest in utilizing estrogen therapies due to its neuroprotective effects on the brain; however, the mechanisms of these neuroprotective effects are poorly understood. The hippocampus is involved in memory formation and is a critical region where early damage in AD is often seen. This discovery-driven proteomics study elucidates several candidate proteins and biological pathways mediated via E2 and implicated in neurological signaling in the hippocampus. Methods: Ovariectomized female Sprague-Dawley rats were treated with daily subcutaneous injections of either vehicle or 50μg/kg E2 for five days before the rats were sacrificed with the hippocampus collected for proteomics. Protein extracts were taken from centrifugated hippocampal tissue and prepared via a series of steps including urea incubation, disulfide bond reduction, carbamidomethylation of thiol groups, and digestion via trypsin with subsequent quenching. The digested proteins were dried, reconstituted in solvent, and processed via nano-LC-MS/MS. The MS/MS spectra were searched against a Rattus norvegicus proteome database for peptide fragment and protein identification via ProteomeDiscover (Thermo Fisher Scientific) using Mascot as a search engine and validated using Scaffold (Proteome Software). Bioinformatic analysis using Ingenuity Pathway Analysis (Quiagen) allowed the construction of associative and predicted protein networks. Results: The processed MS/MS data proteins revealed several candidates for future targeted validation. Among those proteins, calcium/calmodulin-protein kinase II implicated in memory and learning processes, such as long-term signal potentiation in the hippocampus, was more abundant in the treatment group (p = 0.00052) with fold changes in the protein cluster abundances ranging from 1.3 to 1.5 versus control. Other proteins, such as microtubule-associated protein tau, implicated in AD, also had a marked fold change of –2.5 abundance in treatment versus control (p = 0.00014). There substantial overall difference in protein abundances for neurological disease pathways, including AD, identified in Ingenuity Pathway Analysis (p = 8.9e-7) as well as in pathways involving nervous system development and function (p= 4.57e-7) between E2-treated and vehicle-treated rats. Conclusion: This dataset analysis aims to evaluate the effects of E2 on the proteome of the hippocampus in ovariectomized rats. The evident increased fold changes in calcium-dependent and calcium-associated proteins in the context of neuronal processes suggest increased downstream modulation of synaptic signaling, which could be further examined by microdialysis assay of neurotransmitters. Future studies utilizing microdialysis may examine E2’s estrogen receptor-mediated effects on cholinergic neuronal signaling in the hippocampus, which could further understand AD in the context of cholinergic neuron loss.This study was supported by The Welch Foundation (endowment BK-0031 to L.P.), the National Institutes of Health (grants AG031535 to L.P., and EY027005 to K.P.-T.) and a predoctoral bridge funding by the Graduate School of Biomedical Sciences at the University of North Texas Health Science Center
Do sociodemographic, health behaviors, and clinical factors predict levels of hs-CRP stratified by race and ethnicity?
No full textPurpose: Health disparities between different racial and ethnic groups exist for many preventable chronic conditions, such as cardiovascular disease and diabetes. High- sensitivity C- reactive protein (hs-CRP) is a marker of systemic inflammation, and it is known that inflammation is one of the many components associated with physiologic deterioration, or chronic illness. Research has shown disparities in elevations of hs-CRP within different races and ethnicities. Furthermore, research has also demonstrated which factors can lead to elevations in hs-CRP within the general population. However, there is a need to determine factors and clarify relationships predictive of elevated HS-CRP for different racial and ethnic groups. The purpose of this analysis was to identify sociodemographic, health behavior, and clinical factors that predict hs-CRP by race / ethnicity.
Methods: A secondary analysis of the 2017-2020 National Health and Nutrition Examination Survey (NHANES) was conducted. Briefly, the NHANES is a nationally representative survey assessing physical activity, chronic disease, and other health behaviors among adults 18 years of age and older in the United States. The outcome variable was hs-CRP levels, which was log-transformed due to non-normal distributions. Covariates included demographics (e.g., age, biological sex, education, marital status), insurance, BMI, sleep, depression, alcohol drinks, physical activity, and number of chronic conditions. Due to missing data, 5 datasets were imputed and combined in a multivariate manner using Rubin’s rules. Regression analyses were conducted stratified by race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Mexican American, Other Hispanic, and Other/Multi-Racial) to determine significant risk factors. Analyses were weighted to be representative of the U.S. population.
Results: The analytic sample consisted of 15,476 adults ages 18 years or older (M= 38.5,SE =0.19). Diverging patterns emerged regarding hs-CRP levels, such that significant risk factors included BMI, biological sex (female), and health status. For white individuals, identifying as female (b = 0.13), increased BMI (b = 0.07), and poor sleep (b = 0.07) were significant predictors of inflammation. Regarding Black individuals, increased age (b = 0.01), identifying as female (b = 0.19), and increased BMI (b = 0.07) were significant predictors of inflammation. Pertaining to Mexican American individuals, identifying as female (b = 0.44), reporting good/fair/poor health (b = 0.28), and increased BMI(b = 0.08) were significant predictors of inflammation. Good/fair/poor health (b = 0.33) and increased BMI (b = 0.07) were significant predictors of inflammation for Other Hispanic individuals, while never being married decreased the risk for inflammation (b = -0.45). For Asian individuals, increased poverty (b= 0.08) and increased BMI (b = 0.09) were significant predictors. Finally, for multi-racial individuals, identifying as female (b = 0.37) and increased BMI (b = 0.04) were significant predictors of inflammation.
Conclusion: This study identified racial/ethnic differences in sociodemographic, health behavior, and clinical factors that predict hs-CRP. Understanding disparities in risks for elevated hs-CRP could help clinicians identify potential biomarkers and intervene to reduce the impact of elevated inflammation among racial/ethnic minorities. Future research should include other social determinants of health such as environment, shift work, and nutrition
Addressing risk through Community Treatment for Infectious disease and Opioid use disorder Now (ACTION) among Justice-involved Populations
No full textPurpose: ACTION is a 5-year randomized controlled trial comparing the effectiveness of a patient navigation model versus a mobile health unit (MHU) model to link individuals during re-entry from incarceration to healthcare services, with emphasis on prevention and treatment for HIV, hepatitis C, opioid use disorder. The current study examined secondary outcomes, comparing the type of referrals made (treatment vs ancillary services) at the initial MHU visit and the correlation between the number of MHU visits during the first six weeks of the intervention and having a primary care physician (PCP) prior to incarceration (before joining ACTION).
Methods: Participants (N=34) who attended at least one in-person MHU visit within the first six weeks of the intervention were included in the analysis. Demographics, PCP status, and referral type were collected from RealTime, an electronic health records system used on the TCU MHU and confirmed in the main study database. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) and Microsoft Excel.
Results: At the initial MHU visit, 97% of participants were given referrals for medical/health needs, 94% were given referrals for socio-economic needs, and 91% received referrals for both medical/health and socio-economic needs. Top medical/health referrals made were dental (71%), general medical care (53%), vision (41%), mental health (35%), and specialty care (26%).
Participants with a PCP prior to joining ACTION attended a mean of 0.97 MHU visits, while those who did not have a PCP attended an average 1.32 visits. Having a PCP prior to joining the study was negatively correlated to MHU visits (r = - 0.24). 46.2% of females (n=13) reported having a PCP, compared to 19% of males (n=21). Females averaged fewer MHU visits than males during the first six weeks of the intervention.
Conclusions: More participants received referrals at the initial MHU visit for health-related needs compared to socio-economic needs such as housing, transportation, and identification documents. The negative correlation between having a PCP prior to incarceration and frequency of MHU visits suggests that participants without a PCP are likely to attend more MHU visits. Future research should examine if individuals with a PCP experience trust issues with the healthcare system (compared to those without a PCP), experiences that could impact healthcare-seeking behavior. Females averaged fewer visits to the MHU than did males, and females were more likely than males to have previously had a PCP. These findings are preliminary and based on a small sample size but suggest interesting directions for future analysis on women’s health issues.National Institute on Drug Abus
Multimorbidity and chronic pain management with opioids and other therapies among adults in the United States: A cross-sectional study
Get PDFBACKGROUND: Multimorbidity, defined as the concurrent presence of >/= 2 chronic conditions, and chronic pain (i.e., pain lasting >/=3 months) often co-exist. Multimodal pain management that includes non-pharmacologic treatment and non-opioid therapy is recommended to prevent serious risks associated with opioids. PURPOSE: Estimate the prevalence of types of pain treatment and analyze their associations with multimorbidity using a nationally representative survey in the United States (US). METHODS: Data was collected from the 2020 National Health Interview Survey among adults with chronic pain and chronic conditions (N= 12,028). Chronic pain management was grouped into four categories: opioid therapy; non-opioid multimodal pain treatment; pain treatment with monotherapy; and no pain treatment. Chi-square tests and multivariable multinomial logistic regressions were used to analyze the association of multimorbidity with types of pain treatment after controlling for age, sex, social determinants of health (SDoH), and lifestyle characteristics. RESULTS: Among NHIS respondents, 68% had multimorbidity. In adjusted multinomial logistic regressions with "pain management with monotherapy" as the reference group, those with multimorbidity were more likely to utilize opioids (AOR=1.63, 95% CI=1.23, 2.17). Those with severe pain were also more likely to use opioid therapy (AOR=19.36, 95% CI=13.35, 28.06) than those with little pain. Those with low income and education were less likely to have multimodal pain management without opioids. CONCLUSION: Seven in 10 adults had multimorbidity. Those with multimorbidity reported severe pain and relied on opioids for pain control. Regardless of multimorbidity status, SDoH was associated with types of chronic pain management.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by The National Institute on Minority Health and Health Disparities through the Texas Center for Health Disparities (NIMHD) [grant number 5U54MD006882-10]
Influence of Diet on Reproducible Corticosterone Levels in a Mouse Model of Maternal Separation with Early Weaning
No full textMaternal separation with early weaning (MSEW) is a popular early life stress (ELS) model in rodents, which emulates childhood neglect through scheduled mother-offspring separation. Although variations of ELS models, including maternal separation and MSEW, have been published for the mouse species, the reported results are inconsistent. Corticosterone is considered the main stress hormone involved in regulating stress responses in rodents-yet generating a robust and reproducible corticosterone response in mouse models of ELS has been elusive. Considering the current lack of standardization for MSEW protocols, these inconsistent results may be attributed to variations in model methodologies. Here, we compared the effects of select early wean diet sources-which are the non-milk diets used to complete early weaning in MSEW pups-on the immediate stress phenotype of C57BL/6J mice at postnatal day 21. Non-aversive handling was an integral component of our modified MSEW model. The evaluation of body weight and serum corticosterone revealed the early wean diet to be a key variable in the resulting stress phenotype. Interestingly, select non-milk diets facilitated a stress phenotype in which low body weight was accompanied by significant corticosterone elevation. Our data indicate that dietary considerations are critical in MSEW-based studies and provide insight into improving the reproducibility of key stress-associated outcomes as a function of this widely used ELS paradigm.This research was funded by the National Institutes of Health/National Institute on Aging (T32 AG020494) and the National Institute on Minority Health and Health Disparities (5U54MD006882-10). Additional support was provided by an intramural grant funded by the Department of Microbiology, Immunology, and Genetics
"Going on 18" Examining Survey Responses from Adolescent and Young Adult Cancer Patients
No full textPurpose:
Cancer survival rates among adolescents and young adults (AYAs) (aged 15-39 years) have improved at a lower rate than pediatric and older adult populations since 1975. This disparity in survival rate improvement is termed the “AYA gap” in cancer care. AYAs have lower enrollment in clinical trials and are diagnosed at later stages of cancer compared to other age groups. Young adults underutilize healthcare compared to older adults, which leads to worse health outcomes. Financial instability and low medical decision-making confidence have been identified as obstacles to healthcare use in young adults and are increasingly recognized as barriers to AYA cancer care. Cancer requires a high frequency of expensive treatments for optimal management, and identifying and addressing the financial and medical decision-making treatment challenges unique to AYAs may improve survival rates.
The purpose of this project is to examine AYA cancer patients’ survey responses related to financial status and medical decision-making confidence.
Methods:
A site-developed “Going on 18” questionnaire was administered to AYA patients at Cook Children’s Hospital in Fort Worth, TX between 6/2021 and 8/2022. The survey asked questions about demographics, socioeconomic factors, education, mental health, relationships, and thoughts about becoming a young adult. Four questions were selected as determinants of financial status. The frequencies of responses to these questions and the relative percentages of each response were calculated for each categorical variable. Two questions were selected as indicators of feelings toward increased medical responsibility. The content of the subjective responses to these questions was analyzed by authors to separate them into positive, negative, and mixed or neutral attitudes.
Results:
25 participants completed the survey. AYA cancer patients feel mostly confident and enthusiastic about their increased medical decision-making responsibilities, stable in their financial situation (71%), and believe they understand their insurance benefits (73%). However, AYAs are remaining financially dependent on their parents into early adulthood (70%).
Conclusions:
Patients identified specific responsibilities associated with turning 18, expressed feelings of freedom, and are willing to learn. Their responses suggest they want to be in charge of their care and would be receptive to an intervention that provides education and encourages them to think critically about their medical responsibilities.
Reliance on parents to manage financial matters may limit participants’ knowledge of treatment-related expenses. Although participants reported high levels of financial stability and understanding of benefits, this result may be due to a lack of involvement in insurance matters. Therefore, patients, especially those who will become financially independent upon turning 18, may still benefit from interventions related to financial responsibilities