Primary Care Patients' Perspectives on Health Care Screening for Firearms in a Diverse, Urban Area: A Qualitative Study.

Importance: Firearm violence is increasingly recognized as a public health issue, but whether physicians should intervene remains politically contested. Objective: To explore self-described patient perspectives about the appropriateness and acceptability of health care screening for firearms. Design, Setting, and Participants: This qualitative study recruited 50 adult patients from a primary care clinic in Chicago, Illinois, from June 7, 2019, to January 11, 2021, to participate in 1 of 12 one-time qualitative focus groups. Focus group discussions were facilitated using an in-depth, semistructured guide, transcribed verbatim from audio recordings, and analyzed for major themes using a pragmatic approach to basic thematic analysis, which is commonly used in implementation science, between December 12, 2019, and November 29, 2022. Main Outcomes and Measures: Patient perspectives of health care screening for firearms were evaluated to examine complexities of a practice change goal. Results: Participants were a median age of 60.0 (IQR, 50.5-66.5) years and predominantly female (37 [74%]; male, 11 [22%]; nonbinary, 1 [2%]; transgender, 1 [2%]) and non-Hispanic Black (42 [84%]; non-Hispanic Asian or Pacific Islander, 2 [4%]; non-Hispanic White, 5 [10%]). Two-thirds (32 [64%]) of participants thought that health care screening for firearms was at least sometimes appropriate, recognizing clear benefits, for instance, among patients at risk for suicide. However, few (2 [4%]) had ever discussed firearms with a physician or other health care professional. Even among those who recognized benefits, several barriers to acceptability were described, especially related to bias, stigma, and increased risk for criminal legal involvement. Other major themes included insufficient time to address firearms during health care visits and doubts about a clinician's ability to intervene. Facilitators to acceptability included screening strategies that were patient centered, sensitive to racial bias, clinically efficient, and accompanied by tangible resources. Conclusions and Relevance: Incorporating these findings and emergent themes into clinical practice may guide efforts to make firearm screening more acceptable for patients from historically marginalized communities.

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs.

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient-clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers' work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

Keeping Your Guard Up: Hypervigilance Among Urban Residents Affected By Community And Police Violence.

Hypervigilance, a state of heightened awareness and watchfulness, is a consequence of violence that has been linked to adverse psychosocial outcomes. Although well documented in veteran populations, it remains poorly quantified in community populations that are exposed to high levels of neighborhood violence. In-person surveys of 504 adults were conducted in Chicago, Illinois, in 2018 to assess the relationships between hypervigilance and exposure to neighborhood violence, including community and police altercations. Exposure to police violence was associated with a 9.8-percentage-point increase in the hypervigilance score (on a 100-point scale)-nearly twice that associated with exposure to community violence (a 5.5-percentage-point increase). Among participants who reported having had a police stop, experiencing the stop as a traumatic event (defined as exposure to actual or threatened death or serious injury) was associated with a 20.0-percentage-point increase in the hypervigilance score. Scoring in the highest quartile of hypervigilance was associated with higher systolic blood pressure (an increase of 8.6 mmHg). Understanding hypervigilance and, importantly, its linkages with violence and health may help inform policing practices and health care responses to violence in urban communities.

An Outbreak of Synthetic Cannabinoid-Associated Coagulopathy in Illinois.

BACKGROUND: In March and April 2018, more than 150 patients presented to hospitals in Illinois with coagulopathy and bleeding diathesis. Area physicians and public health organizations identified an association between coagulopathy and synthetic cannabinoid use. Preliminary tests of patient serum samples and drug samples revealed that brodifacoum, an anticoagulant, was the likely adulterant. METHODS: We reviewed physician-reported data from patients admitted to Saint Francis Medical Center in Peoria, Illinois, between March 28 and April 21, 2018, and included in a case series adult patients who met the criteria used to diagnose synthetic cannabinoid-associated coagulopathy. A confirmatory anticoagulant poisoning panel was ordered at the discretion of the treating physician. RESULTS: A total of 34 patients were identified as having synthetic cannabinoid-associated coagulopathy during 45 hospitalizations. Confirmatory anticoagulant testing was performed in 15 of the 34 patients, and superwarfarin poisoning was confirmed in the 15 patients tested. Anticoagulant tests were positive for brodifacoum in 15 patients (100%), difenacoum in 5 (33%), bromadiolone in 2 (13%), and warfarin in 1 (7%). Common symptoms at presentation included gross hematuria in 19 patients (56%) and abdominal pain in 16 (47%). Computed tomography was performed to evaluate abdominal pain and revealed renal abnormalities in 12 patients. Vitamin K1 (phytonadione) was administered orally in all 34 patients and was also administered intravenously in 23 (68%). Red-cell transfusion was performed in 5 patients (15%), and fresh-frozen plasma infusion in 19 (56%). Four-factor prothrombin complex concentrate was used in 1 patient. One patient died from complications of spontaneous intracranial hemorrhage. CONCLUSIONS: Our data indicate that superwarfarin adulterants of synthetic cannabinoids can lead to clinically significant coagulopathy. In our series, in most of the cases in which the patient presented with bleeding diathesis, symptoms were controlled with the use of vitamin K1 replacement therapy. The specific synthetic cannabinoid compounds are not known.

Rationales for expanding minority physician representation in the workforce: a scoping review.

OBJECTIVES: The purpose of this study was to conduct a scoping review of the literature and to categorically map a 15-year trajectory of US undergraduate medical education rationales for and approaches to expanding under-represented minority (URM) physician representation in the medical workforce. Further aims were to comparatively examine related justifications and to consider international implications. METHODS: From 1 June to 31 July 2015, the authors searched the Cochrane Library, ERIC, PsycINFO, PubMed, Scopus, Web of Science and Google Scholar for articles published between 2000 and 2015 reporting rationales for and approaches to increasing the numbers of members of URMs in undergraduate medical school. RESULTS: A total of 137 articles were included in the scoping review. Of these, 114 (83%) mentioned workforce diversity and 73 (53%) mentioned concordance. The patient-physician relationship (n = 52, 38%) and service commitment (n = 52, 38%) were the most commonly cited rationales. The most frequently mentioned approaches to increasing minority representation were pipeline programmes (n = 59, 43%), changes in affirmative action laws (n = 32, 23%) and changes in admission policies (n = 29, 21%). CONCLUSIONS: This scoping review of the 2000-2015 literature on strategies for and approaches to expanding URM representation in medicine reveals a repetitive, amplifying message of URM physician service commitment to vulnerable populations in medically underserved communities. Such message repetition reinforces policies and practices that might limit the full scope of URM practice, research and leadership opportunities in medicine. Cross-nationally, service commitment and patient-physician concordance benefits admittedly respond to recognised societal need, yet there is an associated risk for instrumentally singling out members of URMs to fulfil that need. The proceedings of a 2001 US Institute of Medicine symposium warned against creating a deterministic expectation that URM physicians provide care to minority populations. Our findings suggest that the expanding emphasis on URM service commitment and patient-physician concordance benefits warrants ongoing scrutiny and, more broadly, represent a cautionary tale of unintended consequences for medical educators globally.

Acute Chest Syndrome Progressing to ARDS in a Patient of 25-Week Gestation.

Acute chest syndrome is a complication of sickle cell disease and represents the highest cause of mortality in those afflicted with the disorder. Pregnancy represents an increased risk for complications of sickle cell disease in both the mother and fetus. We present a case of a 20-year-old patient with known sickle cell disease who was at 25-week gestation and developed acute chest syndrome refractory to conventional therapies and requiring emergency cesarean section. Following delivery, the patient developed acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO). The patient and infant eventually made full recoveries. This case highlights the importance of aggressive management of ACS and careful monitoring in a pregnant patient.

Perspectives on non-neoformans cryptococcal opportunistic infections.

Non-neoformans Cryptococcus species, including C. laurentii and C. albidus, have historically been classified as exclusively saprophytic. However, recent studies have increasingly implicated these organisms as the causative agent of opportunistic infections in humans. Herein, the case is presented of C. laurentii meningitis in a critically ill patient receiving corticosteroids. C. laurentii has been implicated in an additional 18 cases of opportunistic infection, predominantly of the skin, bloodstream, and central nervous system. The most clinically significant risk factors for non-neoformans cryptococcal infections include: impaired cell-mediated immunity, recent corticosteroid use, and invasive catheter placement. This article provides a comprehensive review of the clinical relevance, pathogenesis, risk factors, and treatment of non-neoformans Cryptococcus species.

Adherence to Guideline Recommendations in Patients with Thyroid Nodules.

INTRODUCTION: Thyroid nodules are common and fine-needle aspiration (FNA) biopsy is the standard of care for work-up to exclude thyroid cancer. In this study, we examined the discrepancy between daily practice and recommended diagnostic approach for management of thyroid nodules, based on history taking, laboratory, and imaging studies. METHODS: This was a retrospective chart review of 199 patients who had ultrasound-guided fine needle aspiration (UGFNA) performed at a Midwest academic medical center from January 2010 to December 2011. The quality measures were selected based on recommended clinical practice guidelines, including family history, history of neck radiation, neck symptoms, TSH test, and thyroid ultrasound. RESULTS: The majority of patients were Caucasian females. Family history of thyroid cancer and childhood neck radiation exposure were documented in 79 subjects (40%) and 76 subjects (38%), respectively. Neck symptoms were documented in most subjects, including dysphonia (56.8%), dysphagia (69.9%), and dyspnea (41.2%). Most subjects had a TSH measured and an ultrasound performed prior to biopsy (75% and 86%, respectively). CONCLUSIONS: It appears there is a gap between current patient care and clinical practice guidelines for management of thyroid nodules. Clinical history and ultrasound features for risk stratification of UGFNA were lacking, which could reflect physicians' unfamiliarity with the guidelines. As thyroid nodules are common, enhancing knowledge of the current guidelines could improve appropriate work-up. Further studies are needed to identify factors associated with the poor compliance with clinical guidelines in management of thyroid nodules.

Syphilis: an atypical case of sepsis and multiple anogenital lesions in secondary syphilis.

The incidence of syphilis has historically been cyclical in nature, often in relation to the rise and fall of public health initiatives directed toward eradication along with social attitudes toward sexual practices. The incidence of syphilis has increased by 15% in the last 6 years in the United States, with similar increases worldwide. Herein, we present an atypical case of syphilis presenting with severe septic shock and multiple anogenital lesions in an immunocompetent host. A 22-year-old male with no significant past medical history presented with fevers, chills, sore throat, diaphoresis, and diarrhea. He was febrile, tachycardic, hypotensive, and unresponsive to fluid resuscitation requiring short-term vasopressor support. Physical exam revealed diffuse lymphadenopathy; lower extremity macular rash involving the soles of the feet; papular non-pustular lesions on the scrotum; and a 0.5 cm non-tender irregular, healing lesion on the shaft of the penis. Laboratory analysis was significant for leukocytosis and elevated creatinine. Serum screening rapid plasma reagin was positive, and further testing revealed a titer of 1:32, with confirmation via fluorescent treponemal antibody absorption test. The patient was diagnosed with secondary syphilis, which was determined to be the underlying etiology of the sepsis as all other serological evaluations were negative. He was treated with penicillin G benzathine 2.4 million units intramuscular and supportive management, with improvement of symptoms. The patient engaged in high-risk sexual behaviors, including prior unprotected sexual contact with males. New research indicates that up to one-third of patients may present with atypical cutaneous manifestations, as demonstrated by this patient. It is important for physicians to familiarize themselves with the varied clinical presentations of syphilis, which include multiple anogenital lesions and tender primary lesions in primary or secondary syphilis.

Use of the Tower of London - Drexel University, Second Edition (TOLDX) in adults with traumatic brain injury.

The Tower of London - Drexel University, Second Edition (TOL(DX)) was investigated in order to determine the efficacy of using this instrument in evaluating the impact of traumatic brain injury on cognitive functioning in adults. Performance on the TOL(DX) was compared among 56 individuals with complicated mild to severe traumatic brain injury ("sTBI"), 68 individuals with uncomplicated, mild traumatic brain injury ("mTBI"), and 124 demographically matched, healthy controls. Both TBI groups performed worse than controls on TOL(DX) measures of executive time (ET) and number of moves used (TMS), but only patients with sTBI were more likely to be impaired on TMS (i.e., performing at least 1.5 SD below the mean). Poorer performance on TMS was associated with increasing length of coma. Although poor sensitivity of this measure limits its use in isolation, the TOL(DX) may provide a complementary measurement of aspects of problem-solving deficit in TBI that may not be captured by other tests.

Bacterial flagellin stimulates Toll-like receptor 5-dependent defense against vancomycin-resistant Enterococcus infection.

Treatment of vancomycin-resistant Enterococcus (VRE) infections is limited by the paucity of effective antibiotics. Administration of broad-spectrum antibiotics promotes VRE colonization by down-regulating homeostatic innate immune defenses. Intestinal epithelial cells and Paneth cells express antimicrobial factors on direct or indirect stimulation of the Toll-like receptor (TLR)-myeloid differentiation factor 88-mediated pathway by microbe-derived molecules. Here, we demonstrate that the TLR5 agonist flagellin restores antibiotic-impaired innate immune defenses and restricts colonization with VRE. Flagellin stimulates the expression of RegIIIgamma, a secreted C-type lectin that kills gram-positive bacteria, including VRE. Systemic administration of flagellin induces RegIIIgamma expression in intestinal epithelial cells and Paneth cells along the entire length of the small intestine. Induction of RegIIIgamma requires TLR5 expression in hematopoietic cells and is dependent on interleukin 22 expression. Systemic administration of flagellin to antibiotic-treated mice dramatically reduces VRE colonization. By enhancing mucosal resistance to multidrug-resistant organisms, flagellin administration may provide a clinically useful approach to prevent infections in patients treated with broad-spectrum antibiotics.