Workplace Violence Against Primary Care Clinicians: A Narrative Review.

Workplace violence (WPV) is a commonly reported occupational hazard in healthcare and its prevalence is increasing. WPV occurs in all types of practice settings, but little is known about WPV in primary care settings in the United States (US). Because primary care practice settings differ from the inpatient settings, further examination of WPV in primary care is warranted. Our objective was to summarize the available literature highlight important gaps. We conducted a search using Pubmed and OVID for US studies of WPV in US-based adult primary care practices. Studies including only pediatric populations were excluded. Due to the lack of available literature conducted in US primary care settings, we expanded our search to include international studies. We identified 70 studies of which 5 were US based. Due to the lack of significant numbers of US-based studies, we opted to conduct a narrative review of all available studies. The evidence shows that WPV is a common occurrence in primary care settings in many countries and that the majority of primary care clinicians have experienced at least some form of non-physical violence in their careers. Most of the studies conducted were cross-sectional in design and reported on both non-physical and physical forms of WPV. There was not a consistent trend between genders in experiencing the major forms of WPV, but women were consistently more likely to be subjected to sexual harassment. Potential root causes for WPV could generally be categorized as patient-level, clinician-level, clinical encounter specific, and operational root causes. While most WPV was found to be non-physical, it still had significant emotional and job-related impacts on clinicians. These troubling results highlight the need for further studies to be conducted in the US.

Random Occurrence or Real Association? Primary Hyperparathyroidism in a Young Man With Sickle Cell Disease.

A 32-year-old man with sickle cell disease (SCD) was admitted to the hospital for sickle cell crisis, during which laboratory workup revealed primary hyperparathyroidism. His treatment regimen included hydration, calcitonin, and calcimimetics. A parathyroid nuclear scan revealed anomalous parathyroid tissue. The precise relationship between primary hyperparathyroidism (PHPT) and SCD remains incompletely understood but may involve factors such as vitamin D deficiency, elevated erythropoietin levels, and the influence of growth factors on the development of parathyroid adenomas. Furthermore, the concurrent occurrence of both PHPT and SCD at an earlier age may potentiate adverse long-term outcomes. Effective management of PHPT in SCD entails addressing hypercalcemia and treating the underlying cause of hyperparathyroidism. While a potential association between PHPT and SCD exists, further research is essential to better elucidate their interaction, prevalence, clinical presentations, and outcomes.

A COVID-19 patient with intense burning pain.

A woman in her forties with asthma and COPD was admitted to a general medical floor with respiratory symptoms, body aches, and anosmia. Reverse transcription polymerase chain reaction detected severe acute respiratory syndrome coronavirus-2. Admission labs, including biomarkers of the systemic immunological dysfunction seen in many cases of coronavirus disease 2019 (COVID-19), were within normal ranges. On the second day of admission, she developed neck and back pain that was constant, burning in quality, and exacerbated by light touch and heat. Wearing clothing caused pain and interfered with her sleep. The area was tender to light finger stroke. The patient was given acetaminophen, NSAIDs, and opioids with no relief of pain. However, gabapentin was effective. At follow-up 1 month later, her symptoms were improved and still relieved by gabapentin. Neuropathic pain was seen in over 2% of COVID-19 patients in one observational study. The pain seen in our case was bilateral, involved an area innervated by multiple levels of spinal nerves, and was limited to the back. While it is rare, a significant number of COVID-19 patients are afflicted by neuropathic pain, and our case illustrates that gabapentin may be effective.

Anal condyloma treatment and recurrence in HIV-negative men who have sex with men.

BACKGROUND: Men who have sex with men have increased prevalence of both human papillomavirus and anogenital condyloma. OBJECTIVE: Risk factors for multiple treatment and recurrence of anal condyloma were examined. DESIGN: This is a retrospective study of HIV-negative men who have sex with men who were treated for anal condyloma. SETTINGS: This study was conducted in a private surgical practice. PATIENTS: The patients were HIV-negative men who have sex with men, aged 18 years or older. INTERVENTION(S): Ablation with electrocautery or CO2 laser was performed, as well as excision and topical imiquimod condyloma treatment adjuvant. MAIN OUTCOME MEASURES: Primary clearance, defined as 4 months of condyloma-free survival posttreatment, and recurrence, defined as any anal condyloma diagnosis after primary clearance. RESULTS: Of 231 participants, 207 achieved primary clearance (median age, 32.0 years) and were followed (median, 18.2 months) after primary treatment. Most had intra-anal and perianal condyloma (56%), were treated with electrocautery ablation (79.2%), and required 1 treatment (range, 1-6) for clearance. There were 57 recurrences (median, 12 months). One-third each had minimal, moderate, or extensive disease. Forty-six percent of patients received imiquimod posttreatment adjuvant. High-grade dysplasia was found in 31% at presentation and 43% during follow-up. Factors associated with requiring multiple treatments for clearance were participants having moderate disease (adjusted odds ratio, 6.0 (1.7-21.4)) and receiving imiquimod adjuvant (adjusted odds ratio, 4.7 (2.0-10.6)). No single factor predicted recurrence, but those with moderate disease experienced recurrences significantly sooner (median, 25 months of follow-up). LIMITATIONS: This was a retrospective chart review, it was limited to a single practice, and it excluded those who did not achieve primary clearance. CONCLUSIONS: Most men who have sex with men have intra-anal and perianal condyloma and concomitant high-grade dysplasia is common. Most achieved clearance with 1 treatment. Having both intra-anal and perianal condyloma, increased severity of disease, and imiquimod adjuvant were significant predictors of requiring multiple treatments for clearance. No identified risk factors proved a significant predictor of recurrence.

Prevention of anal condyloma with quadrivalent human papillomavirus vaccination of older men who have sex with men.

BACKGROUND: The quadrivalent human papillomavirus vaccine (qHPV) is FDA-approved for use in males 9 to 26 years old to prevent anogenital condyloma. The objective of this study is to determine if qHPV is effective at preventing anal condyloma among men who have sex with men (MSM) aged 26 years and older. METHODS: This post-hoc analysis of a nonconcurrent cohort study evaluated 210 patients without history of anal condyloma and 103 patients with previously-treated anal condyloma recurrence-free for at least 12 months prior to vaccination/time zero. We determined the rate of anal condyloma development in vaccinated versus unvaccinated patients. RESULTS: 313 patients with mean age 42 years were followed for median 981 days. During 773.6 person-years follow-up, condyloma developed in 10 (8.6%) vaccinated patients (incidence of 3.7 per 100 person-years) and 37 (18.8%) unvaccinated patients (incidence 7.3 per 100 person-years; p = 0.05). Multivariable hazards ratio showed that qHPV was associated with decreased risk of anal condyloma development (HR 0.45; 95% CI 0.22-0.92; p = 0.03). History of anal condyloma was associated with increased risk of anal condyloma development (HR 2.28; 95% CI 1.28-4.05; p = 0.005), as was infection with oncogenic HPV (HR 3.87; 95% CI 1.66-9.03; p = 0.002). CONCLUSIONS: Among MSM 26 years of age and older with and without history of anal condyloma, qHPV reduces the risk of anal condyloma development. A randomized controlled trial is needed to confirm these findings in this age group.

Prevention of recurrent high-grade anal neoplasia with quadrivalent human papillomavirus vaccination of men who have sex with men: a nonconcurrent cohort study.

BACKGROUND: Most squamous cell anal cancers and precancerous lesions are attributed to human papillomavirus (HPV) infection. By preventing HPV infection, quadrivalent HPV vaccine (qHPV) reduces risk of anal cancer/precancerous lesions in young men who have sex with men (MSM) without history of anal cancer/precancerous lesions. In our practice, many persons with history of precancerous anal lesions or high-grade anal intraepithelial neoplasia (HGAIN) have been vaccinated electively. We determined whether qHPV is effective at preventing recurrence of HGAIN. METHODS: This nonconcurrent cohort study evaluated 202 patients with a history of previously treated HGAIN. Eighty-eight patients were vaccinated, and 114 patients were unvaccinated. We determined the recurrence rate of histologic HGAIN in vaccinated versus unvaccinated patients. RESULTS: During 340.4 person-years follow-up, 12 (13.6%) vaccinated patients and 35 (30.7%) unvaccinated patients developed recurrent HGAIN. Multivariable hazards ratio (HR) analysis showed testing positive for oncogenic HPV genotypes within 8 months before study entry was associated with increased risk of recurrent HGAIN at 2 years after study entry (HR 4.06; 95% confidence interval [CI], 1.58-10.40; P = .004), and qHPV was associated with decreased risk of recurrent HGAIN (HR .50; 95% CI, .26-.98; P = .04). Among patients infected with oncogenic HPV, qHPV was associated with decreased risk of recurrent HGAIN at 2 years after study entry (HR .47; 95% CI, .22-1.00; P = .05). CONCLUSIONS: qHPV significantly reduces HGAIN recurrence among MSM and may be an effective posttreatment adjuvant form of therapy. A randomized controlled trial is needed to confirm these results.

The changing picture of high-grade anal intraepithelial neoplasia in men who have sex with men: the effects of 10 years of experience performing high-resolution anoscopy.

BACKGROUND: Ten years ago, we published findings from anal dysplasia screening in a metropolitan surgical practice where the majority of men who have sex with men had biopsy-proven high-grade anal intraepithelial neoplasia. OBJECTIVE: This study aimed to determine the effect of 10 years of experience in anal dysplasia screening on the prevalence of high-grade anal intraepithelial neoplasia. DESIGN: A retrospective chart review was performed of all anal cytology results of 1189 men who have sex with men screened in a 1-year period, with subsequent high-resolution anoscopy and biopsy as necessary. PATIENTS: The patients studied were men who have sex with men. MAIN OUTCOME MEASURE: The main outcome measure was biopsy-proven high-grade anal intraepithelial neoplasia. RESULTS: : There were 315 (37.2%) biopsy-verified instances of high-grade anal intraepithelial neoplasia. Regression analysis determined that age, HIV status, infection by high-risk human papillomavirus, and abnormal cytology results were significant predictors of high-grade anal intraepithelial neoplasia. In a 1-year period, the number of men who have sex with men screened was nearly 7 times greater than in the 2-year period studied 10 years earlier. LIMITATIONS: We did not separately analyze patients who had previously been treated for high-grade anal intraepithelial neoplasia. CONCLUSIONS: Severity of cytology and infection with high-risk human papillomavirus are the most significant predictors of high-grade anal intraepithelial neoplasia, underscoring the importance of anal dysplasia screening. Our ability to identify high-grade anal intraepithelial neoplasia has improved with 10 years of experience performing high-resolution anoscopy.

Communicable and non-communicable diseases among recent immigrants with implications for primary care; a comprehensive immigrant health approach.

Data on health status of immigrants and practice recommendations for providers are scarce. We evaluated 99 recent immigrants from developing nations in an immigrant clinic in New York City to assess epidemiology of diseases and to recommend potential screening. Providers received ongoing training. Majority patient was from West Africa and Central America with a mean of 2.1 years in the US. Two thirds were uninsured. Half had positive PPD. Half had prior hepatitis B infection, which was higher in Africans. One quarter had intestinal parasites. Two thirds were overweight; 33% had hypercholesterolemia, 26% were hypertensive, and 25% of women had a Pap smear previously. Eosinophila was higher in African and males (P < 0.05) but didn't predict stool O&P. Recent immigrants were at risk for chronic non-communicable diseases, similar to the US population. Providers should balance their focus on communicable and non-communicable diseases. We recommend practice-based training and on-site comprehensive health services.

2009 Pandemic Influenza A (H1N1): Diagnosis, Management, and Prevention- Lessons Learned.

The 2009 pandemic influenza A (H1N1) was responsible for the first influenza pandemic of the 21st century. The virus- a previously unknown triple-reassortant virus containing segments of avian, human, and swine origins- generally caused mild disease. Unlike seasonal influenza, 2009 pandemic influenza A (H1N1) primarily affected adults 18 to 64 years of age. During the course of the pandemic, public health officials tried to facilitate diagnostic procedures and share information about treatment modalities globally. Efforts to contain the spread of 2009 pandemic influenza A (H1N1) included personal protective mechanisms and the 2009 H1N1 vaccine, which was not produced quickly enough or in large enough quantities. The lessons learned from this pandemic should be applied to ensure better preparedness in case of future pandemics.

First Season of 2009 H1N1 Influenza.

The 2009 H1N1 influenza virus is responsible for the first influenza pandemic of the 21st century. Within 5 months after its emergence in Mexico, it had affected more than 290,000 patients and caused at least 3486 deaths on 6 continents. This report provides information about influenza viruses, previous pandemics, and the virology, clinical features, and epidemiology of 2009 H1N1 influenza in order to elucidate the current pandemic and outline the questions that remain.

Risk factors for the development of fulminant Clostridium difficile colitis.

BACKGROUND: The development of fulminant Clostridium difficile colitis (FCDC) requires prompt operative intervention and is associated with a high mortality rate. The aim of this study was to use a case-control design to define the clinical and laboratory parameters that predict which patients with Clostridium difficile infection are most likely to progress to FCDC. METHODS: Cases from 1994 to 2006 with documented in-hospital progression of Clostridium difficile infection to FCDC were matched retrospectively at the start of medical therapy by age, sex, and intensive care unit (ICU) status to controls with Clostridium difficile infection who did not develop FCDC. Chi-Square and multivariable logistic regression were used to identify risk factors for progression to FCDC. RESULTS: A total of 35 patients with FCDC were matched to 70 controls with Clostridium difficile infection who did not develop FCDC. The patients with FCDC underwent colectomy after an average of 4.6 days of medical therapy and had a mortality rate of 40%. On multivariate analysis, independent risk factors for the development of FCDC were a WBC > 16,000 cells/mm(3) (P < .01) at initiation of therapy, operative therapy within the last 30 days (P = .03), a history of inflammatory bowel disease (P = .04), and a history of intravenous immunoglobulin treatment (P < .01). CONCLUSIONS: Leukocytosis, recent prior operative therapy, and a history of inflammatory bowel disease and intravenous immunoglobulin treatment were negative prognostic indicators for patients with Clostridium difficile infection. The presence of these factors merits close observation for progression to FCDC and acceleration of the planning process for operative intervention.