Challenges in the Management of and Biologic Use in Incarcerated Patients With Inflammatory Bowel Disease.

Background: Therapy and management of inflammatory bowel disease (IBD) require commitment from both the provider and patient to ensure optimal disease management. Prior studies show vulnerable patient populations with chronic medical conditions and compromised access to health care, such as incarcerated patients, suffer as a result. After an extensive literature review, there are no studies outlining the unique challenges associated with managing prisoners with IBD. Methods: A detailed retrospective chart review of 3 incarcerated patients cared for at a tertiary referral center with an integrated patient-centered IBD medical home (PCMH) and a review of literature was performed. Results: All 3 patients were African American males in their 30s with severe disease phenotypes requiring biologic therapy. All patients had challenges with medication adherence and missed appointments related to inconsistent access to clinic. Two of the 3 cases depicted better patient-reported outcomes through frequent engagement with the PCMH. Conclusions: It is evident there are care gaps and opportunities to optimize care delivery for this vulnerable population. It is important to further study optimal care delivery techniques such as medication selection, though interstate variation in correctional services poses challenges. Efforts can be made to focus on regular and reliable access to medical care, especially for those who are chronically ill.

An Unsuspected Case of Rocky Mountain Spotted Fever: A Lesson to Keep a Broad Differential.

Rocky Mountain spotted fever (RMSF), a tick-borne illness, can cause serious illness or death even in a healthy individual. Unfortunately, this illness can be difficult to diagnose as symptoms are nonspecific and oftentimes mimic benign viral illnesses. Delayed diagnosis can be detrimental as the timing of antibiotic administration is critical to prevent associated morbidity and mortality. A careful travel and social history can sometimes provide clues to make the diagnosis. Being aware of lesser-known objective findings such as hyponatremia, neurologic derangements, transaminitis, and thrombocytopenia may help raise suspicion for the disease. This is a case of a 72-year-old woman who presented with nonspecific symptoms and hyponatremia without known tick exposure. She was eventually diagnosed with RMSF. The timing of her presentation corresponded with a surge in COVID-19 infections throughout her area of residence, which further complicated her presentation and contributed to a delayed diagnosis.

Ascitic Fluid Analysis Leading to the Diagnosis of Constrictive Pericarditis in 2 Patients.

Although well documented, constrictive pericarditis is a rare entity and an uncommon cause of heart failure. A stiff and noncompliant pericardium creates the disease's unique hemodynamics and leads to elevated venous pressures, hepatic sinusoidal congestion, and draining of protein-rich fluid into the peritoneal cavity presenting as ascites. The low incidence in addition to its varied and subtle clinical presentations can often lead to a delay in diagnosis. Here, we present 2 clinical cases of constrictive pericarditis in which ascitic fluid analysis was important-one patient who presented with new-onset ascites with concern for cirrhosis and another patient who presented with symptoms concerning for heart failure with ascites. Through their hospital course and workup, we highlight the importance of diagnostic sampling of ascitic fluid to prompt the consideration of constrictive pericarditis followed by utilizing advanced diagnostics, such as echocardiogram and cardiac catheterization to reach the correct diagnosis in an otherwise often overlooked pathology.