Early Effects of the COVID-19 Pandemic on Patients in a Virtual Multicenter Spontaneous Coronary Artery Dissection (SCAD) Registry.

Background: The COVID-19 pandemic effects among patients with a history of spontaneous coronary artery dissection (SCAD), a cause of acute coronary syndrome associated with emotional and physical stress, are unknown. Methods: For this cross-sectional cohort study, participants of the Mayo Clinic "Virtual" Multicenter SCAD Registry were surveyed about the COVID-19 pandemic. Results: Among 1352 participants, 727 (53.8%) completed surveys between June 2, 2021 and September 29, 2021. The majority of respondents (96.7%) were female, with a mean age of 54.9 ± 9.4 years. At the time of completing the survey, which was early in the pandemic, 91 respondents (12.6%) reported having prior COVID-19 symptoms, with < 1% experiencing hospitalization (n = 4) or cardiac complications (n = 6). A total of 14% had ≥ moderate anxiety symptoms, per the General Anxiety Disorder-7 item survey, and 11.8% had ≥ moderate depressive symptoms, per the Patient Health Questionnaire-9 item. Higher stress scores on the Likert scale were correlated with pandemic-related reduction in work hours and/or pay and/or unemployment (P = 0.013), remote work and/or change of job (P < 0.001), and loss of insurance and/or medical coverage (P = 0.025). A higher anxiety level, as measured on the Likert scale, was correlated with pandemic-related remote work and/or change of job (P = 0.007) and loss of insurance and/or medical coverage (P = 0.008). Since the start of the pandemic, 54% of respondents reported having at least monthly chest pain. Chest pain and COVID symptoms were each associated with higher scores on the General Anxiety Disorder-7 item survey and the Patient Health Questionnaire-9 item. Conclusions: Early in the pandemic, COVID-19 symptoms, hospitalization, and cardiac complications were uncommon among SCAD patients. The burden of anxiety and depressive symptoms was minimal to mild, similar to that in prior reports. Likert-scale measures of stress and anxiety were higher among persons with work and/or pay reduction and/or unemployment, remote work and/or change of job, and loss of insurance and/or medical coverage. Over half of respondents reported experiencing chest pain, which was correlated with depressive and anxiety symptoms, highlighting an overarching clinical need.

Contexte: On ne connaît pas les effets de la pandémie de COVID-19 sur les personnes ayant des antécédents de dissection spontanée de l'artère coronaire (DSAC), une cause du syndrome coronarien aigu qui est une source de stress physique et émotionnel. Méthodologie: Pour les besoins de cette étude de cohorte transversale, les participants au registre « virtuel ¼ multicentrique sur la DSAC de la clinique Mayo ont été interrogés dans le cadre d'une enquête sur la pandémie de COVID-19. Résultats: Parmi les 1 352 participants au registre, 727 (53,8 %) ont répondu à l'enquête entre le 2 juin et le 29 septembre 2021. La majorité des répondants (96,7 %) étaient des femmes, et l'âge moyen était de 54,9 ± 9,4 ans. Au moment de l'enquête, réalisée au début de la pandémie, 91 répondants (12,6 %) avaient indiqué avoir déjà présenté des symptômes de COVID-19, et < 1 % avaient été hospitalisés (n = 4) ou avaient présenté des complications cardiaques (n = 6). Au total, 14 % des participants présentaient des symptômes d'anxiété à tout le moins modérés d'après le questionnaire GAD-7 (General Anxiety Disorder-7 item) et 11,8 %, des symptômes dépressifs à tout le moins modérés d'après le questionnaire PHQ-9 (Patient Health Questionnaire-9 item). Une corrélation a été établie entre un score de stress plus élevé sur une échelle de Likert et une réduction des heures de travail et/ou du salaire, une période de chômage (p = 0,013), le télétravail et/ou un changement d'emploi (p < 0,001) et la perte de l'assurance et/ou de la couverture médicale (p = 0,025) en lien avec la pandémie. Une corrélation a également été établie entre un niveau d'anxiété plus élevé mesuré sur une échelle de Likert et le télétravail et/ou un changement d'emploi (p = 0,007) et la perte de l'assurance et/ou de la couverture médicale (p = 0,008) en lien avec la pandémie. Depuis le début de la pandémie, 54 % des répondants ont indiqué ressentir une douleur thoracique au moins une fois par mois. La douleur thoracique et les symptômes de la COVID-19 ont par ailleurs été associés à des scores plus élevés aux questionnaires GAD-7 et PHQ-9. Conclusions: Au début de la pandémie, les symptômes de la COVID-19, les hospitalisations et les complications cardiaques n'étaient pas fréquents chez les patients présentant une DSAC. Le fardeau des symptômes anxieux et dépressifs allait de minime à léger, comme en faisaient état les rapports précédents. L'anxiété et le stress mesurés sur une échelle de Likert ont été plus élevés chez les personnes ayant connu une réduction des heures de travail et/ou du salaire ou une période de chômage, ayant dû recourir au télétravail et/ou changer d'emploi, ou ayant perdu leur assurance et/ou couverture médicale. Plus de la moitié des répondants ont indiqué ressentir une douleur thoracique, laquelle a été mise en corrélation avec les symptômes d'anxiété et de dépression, ce qui souligne l'existence d'un besoin clinique important.

Characteristics of systemic testosterone therapy for female hypoactive sexual desire disorder-a claims database analysis.

BACKGROUND: Testosterone therapy (TTh) is recommended for postmenopausal women with hypoactive sexual desire disorder (HSDD); however, there remain insufficient data to support use of TTh in premenopausal women with sexual dysfunction. AIM: In this study, we used a large national database to evaluate prescribing trends of TTh for women with HSDD. METHODS: We conducted a cohort analysis of information from electronic health records acquired from the data network TriNetX Diamond. The study cohort consisted of women 18-70 years of age with a diagnosis of HSDD. We analyzed trends of testosterone prescriptions, routes of testosterone administration, and coadministration of testosterone with estrogen. OUTCOMES: Despite an increase in rates of testosterone prescriptions for HSDD, there remains a high degree of variability in the duration of treatment, route of administration, and coadministration of estrogen with significant underprescription of testosterone. RESULTS: Our query of the TriNetX database led to the identification of 33 418 women diagnosed with HSDD at a mean age of 44.2 ± 10.8 years, among whom 850 (2.54%) women received a testosterone prescription. The testosterone prescriptions were highly variable with regard to duration and route of administration and coadministration with estrogen. For all patients until 2015, the prevalence of testosterone prescriptions for HSDD showed a positive quadratic relation was observed. Since 2015 a linear increase in prevalence was observed, with the highest rate of increase for patients aged 41-55 years. CLINICAL IMPLICATIONS: The findings of this study reveal a significant need for further research investigating the optimal use of TTh to enhance the sexual health of women with HSDD, and further studies on the long-term effects of testosterone use must be undertaken to ensure that patients have access to safe and effective treatment. STRENGTHS AND LIMITATIONS: Limitations to this study include patient de-identification and lack of availability of testosterone dosage data. However, this study also has many strengths, including being the first, to our knowledge, to characterize the prescribing trends of testosterone for women with HSDD. CONCLUSION: Testosterone therapy should be considered as a potential therapy for premenopausal female patients with HSDD. Further studies on the long-term effects of testosterone use must be undertaken to address disparities in the management of HSDD and to ensure patients can access treatment.

Characteristics and Perspectives of Human Trafficking Education: A Survey of U.S. Medical School Administrators and Students.

Objective: To assess the timing, duration, methodology, and content of human trafficking (HT) curricula in U.S. medical schools. Methods: An anonymous, cross-sectional survey was sent through email and phone to administrators of 199 U.S. allopathic and osteopathic medical schools. A supplementary survey was sent to students and faculty through email listservs and social media links. Data collection occurred from April to October 2020 and findings were analyzed through SAS software. All study measures were approved by the institutional review board. Results: Administrators were from 22 states and 34 schools (n = 51/199 schools; response rate: 25.6%) and n = 41 responded to all questions. Of these, 32% (13/41) self-identified as deans, 34.1% (14/41) as faculty, and 29.3% (12/41) as other administrators. Less than half (41.5%, n = 17/41) reported an HT curriculum. There was a wide range in length (average = 3 hours) and when present was almost always mandatory (n = 51, 88.2%). Few curricula mentioned labor (23.5%) or organ (5.9%) trafficking, or at-risk populations such as lesbian, gay, bisexual, trans, queer, and intersex (LGBTQI) members (13.7%), foreign nationals (7.8%), victims of political conflict (3.9%), and indigenous peoples (2.0%). Students and staff (n = 242) were from 34 states and 83 schools, and n = 36 (27.5%) reported a curriculum. Less than half (44.4%) felt the length (average 4.1 hours) was sufficient. Conclusions: Less than half of respondents reported an HT curriculum. It is unclear how well this curriculum prepares students to treat victim-survivors of HT. Future work is necessary to incorporate effective education on HT for trainees and evaluate patient outcomes after curricular implementation.

Physician Leadership and Advocacy for Team-Based Care.

Team-based care is a strong focus and narrative in medical and health education and within health care systems. Yet it is essential to consider that there are vast differences in power, education, compensation, and job security among team members in most health professional teams. How should clinicians of status play a role in advocating for lower status members of their health care teams, and why is that role important in improving equity within clinic walls and equity and better patient care for the communities they serve?

Stellate ganglion block as a treatment for vasomotor symptoms: Clinical application.

Vasomotor symptoms, also called hot flashes, hot flushes, and night sweats, are common during the menopause transition. Severe symptoms can substantially decrease quality of life. The authors first review current hormonal and nonhormonal therapies, then review evidence supporting the potential use of stellate ganglion block for managing vasomotor symptoms in perimenopausal and postmenopausal women.

Right radial nerve decompression for refractory radial tunnel syndrome.

BACKGROUND: Radial tunnel syndrome arises due to compression of the radial nerve through the radial tunnel.[1,5] The radial nerve divides into superficial and deep branches in the forearm. The deep branch travels posteriorly through the heads of the supinator where compression commonly occurs.[3,9,7] This syndrome results in pain in the hand and forearm with no motor weakness.[8] This condition can be treated conservatively with splinting and anti-inflammatory medication.[2,4,6] For cases of refractory radial tunnel syndrome, surgical management can be considered. Herein, we have presented a step-by-step video guide on how to perform a radial nerve decompression with a review of the relevant anatomy and surgical considerations. CASE DESCRIPTION: A 68-year-old right-handed woman presented to the Mayo Clinic (Scottsdale, AZ) with the right elbow pain which radiated to the forearm causing significant difficulties with daily tasks. She had been dealing with worsening symptoms for 4 months. The patient's history of gardening and clinical presentation allowed for diagnosis of radial tunnel syndrome. After conservative measures failed and other differential diagnoses were excluded, surgical decompression was recommended to treat her symptoms. The patient's right arm was marked preoperatively between the brachioradialis and extensor carpi radialis longus (ECRL) muscles. The posterior cutaneous nerve of the forearm was identified which allowed for the determination of the interval between the brachioradialis and ECRL. Separation of the two muscles allowed for the identification of the radial sensory nerve. A nerve stimulator was used to confirm the sensory nature of this nerve. The nerve to the extensor carpi radialis brevis (ECRB) was identified and retracted with a vessel loop. Dorsal to the nerve to the ECRB is the posterior interosseous nerve (PIN), which was identified and retracted with a vessel loop. The fascia of the ECRB was divided both longitudinally and transversely and the supinator below was identified. The supinator muscle was carefully divided to further decompress the PIN. Informed consent for publication of this material was obtained from the patient. CONCLUSION: The patient tolerated the procedure well and reported significantly reduced pain at 7-month follow-up. To the best of our knowledge, video tutorials on this procedure have not been published. This video can serve as an educational guide for peripheral nerve specialists dealing with similar lesions.

"You are not alone": a qualitative study to explore barriers to ART initiation and implications for a proposed community-based youth treatment club among young adults newly diagnosed with HIV in South Africa.

In South Africa, despite universal antiretroviral therapy (ART) availability, 60% of persons living with HIV (PLWH) ages 15-24 are not on treatment. This qualitative study aimed to identify barriers to ART initiation and the implications for a proposed community-based Youth Treatment Club to improve ART initiation for young PLWH in limited-resource, high HIV-prevalence communities in Cape Town, South Africa. Recruiting participants at community testing sites from 2018 to 2019, we conducted semi-structured interviews, informed by Social Action Theory (SAT), with 20 young adults, ages 18- to 24-years-old, newly diagnosed with HIV, along with 10 healthcare providers. Through systematic qualitative analysis, we found that young PLWH face barriers to treatment initiation in three SAT domains: (1) stigmatizing social norms (social regulation processes); (2) challenges coping with a new diagnosis (self-regulation processes); and (3) anticipated stigma in the clinic environment (contextual factors). Participants shared that a proposed community-based Youth Treatment Club for newly diagnosed youth would be an acceptable strategy to promote ART initiation. They emphasized that it should include supportive peers, trained facilitator support for counseling and education, and a youth-friendly environment.

Training Nonradiologist Clinicians in Diagnostic Breast Ultrasound in Rural Rwanda: Impact on Knowledge and Skills.

OBJECTIVE: To assess the effectiveness of diagnostic breast ultrasound training provided for general practitioners and nurses in Rwanda via intensive in-person and subsequent online supervision and mentorship. METHODS: Four breast radiologists from Brigham and Women's Hospital trained two general practitioner physicians and five nurses in Rwanda over 9 total weeks of in-person training and 20 months of remote mentorship using electronic image review with emailed feedback. Independently recorded assessments were compared to calculate the sensitivity and specificity of trainee assessments, with radiologist assessments as the gold standard. We compared performance in the first versus second half of the training. RESULTS: Trainees' performance on written knowledge assessments improved after training (57.7% versus 98.1% correct, P = .03). Mean sensitivity of trainee-performed ultrasound for identifying a solid breast mass was 90.6% (SD 4.2%) in the first half of the training (period 1) and 94.0% (SD 6.7%) in period 2 (P = .32). Mean specificity was 94.7% (SD 5.4%) in period 1 and 100.0% (SD 0) in period 2 (P = .10). Mean sensitivity for identifying a medium- or high-suspicion solid mass increased from 79.2% (SD 11.0%) in period 1 to 96.3% (SD 6.4%) in period 2 (P = .03). Specificity was 84.4% (SD 15.0%) in period 1 and 96.7% (SD 5.8%) in period 2 (P = .31). DISCUSSION: Nonradiologist clinicians (doctors and nurses) in a rural sub-Saharan African hospital built strong skills in diagnostic breast ultrasound over 23 months of combined in-person training and remote mentorship. The sensitivity of trainees' assessments in identifying masses concerning for malignancy improved after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.

Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process.

PURPOSE: The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings. METHODS: To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda. RESULTS: Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda. CONCLUSION: A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.