Utilizing Home Visits to Assess Social Determinants of Health During Family Medicine Residency.

INTRODUCTION: Home visits can improve quality of care and health outcomes and provide a unique opportunity to learn more about patients' social context and assess patients' various social determinants of health (SDH). The objectives of this study were to assess patient self-reported SDH, resident reflections on patient social status, the utility of a SDH survey during home visits, and resident comfort levels addressing patient SDH. METHODS: This was a mixed-methods pilot study utilizing patient self-reported data and open-ended reflection questions. Participants included adult patients aged more than 18 years from an urban safety-net clinic and family medicine residents who provide their care. RESULTS: We received forty-two surveys from 42 home visits. Most patients were female (61.9%) and African-American (45.2%), aged from 25 to 88 years (mean=60.24). Top patient-reported SDH include transportation, paying bills, and food insecurity. Common themes of resident responses included positive utility of the survey for assessing patient SDH; variation in comfort level when inquiring about patient SDH with positive influence from prior experience, assistance from colleagues, or prior good relations with patients; and expressed intention to include SDH assessment in future practice. CONCLUSIONS: Residents recognized the value of assessing SDH during home visits and expressed intent to include it in future practice. Thorough assessment of patient SDH may help to craft a more robust and standardized system to prioritize patients who would most benefit from receiving home visits.

Known structure, unknown function: An inquiry-based undergraduate biochemistry laboratory course.

Undergraduate biochemistry laboratory courses often do not provide students with an authentic research experience, particularly when the express purpose of the laboratory is purely instructional. However, an instructional laboratory course that is inquiry- and research-based could simultaneously impart scientific knowledge and foster a student's research expertise and confidence. We have developed a year-long undergraduate biochemistry laboratory curriculum wherein students determine, via experiment and computation, the function of a protein of known three-dimensional structure. The first half of the course is inquiry-based and modular in design; students learn general biochemical techniques while gaining preparation for research experiments in the second semester. Having learned standard biochemical methods in the first semester, students independently pursue their own (original) research projects in the second semester. This new curriculum has yielded an improvement in student performance and confidence as assessed by various metrics. To disseminate teaching resources to students and instructors alike, a freely accessible Biochemistry Laboratory Education resource is available at http://biochemlab.org.

Tumors masquerading as hematomas.

Suboptimal patient management can occur when malignant soft tissue tumors with internal hemorrhage masquerade as simple hematomas. We retrospectively reviewed 31 patients with malignancies who had diagnostic delays averaging 6.7 months (range, 1.0-49.3 months). The diagnoses included soft tissue sarcomas (27), metastatic cancers (three), and lymphoma (one). History of subcutaneous ecchymosis was positive in only five patients (three of whom had trauma), negative in 18, and unknown in eight. Ecchymosis was present in two patients, absent in 20, and unknown in nine. Previous treatments included observation and reassurance (21), aspiration (11), incision and drainage (10), unplanned resections (seven), physical therapy (seven), medication administration (six), and arthroscopy (one). Interpretations of initial MRI (21) and ultrasound (four) did not raise suspicion of underlying cancers. Traumatic hemorrhage usually causes subcutaneous ecchymosis. However, intratumoral hemorrhage often is contained by a pseudocapsule, which prevents fascial plane tracking and subcutaneous ecchymosis, thus providing a diagnostic clue. Magnetic resonance imaging and ultrasound studies may not accurately diagnose questionable lesions. Diagnostic delay or inappropriate treatment may result if patients do not receive appropriate followup, biopsy (usually open), or referral whenever the diagnosis is in doubt.

Diffuse pigmented villonodular synovitis: preliminary results with intralesional resection and p32 synoviorthesis.

Because of the high local recurrence rate associated with surgical resection alone, patients with diffuse intraarticular pigmented villonodular synovitis were treated with surgical resection followed by colloidal chromic P32 synoviorthesis. The medical records of nine consecutive patients treated in this manner were reviewed retrospectively to determine the recurrence rate of pigmented villonodular synovitis. All patients had either one or two surgical resections (arthroscopy in one patient, open resection in seven, arthroscopy and open resection in one). The involved joints included six knees and one each, ankle, elbow, and hip. Eight of the nine patients remained recurrence free at a mean followup of 38 months (range, 19-60 months) after surgery. One patient had a suspected asymptomatic recurrence documented by magnetic resonance imaging 29 months after surgery. Seven patients reported their normal activities as unrestricted. Five reported improved activity levels, one reported the activity level remained the same, and one reported activity as the same or better. None reported reduced activity levels. In these patients synoviorthesis with colloidal chromic P32 following gross resection of all obvious pigmented villonodular synovitis provided local disease control in all but one.

A new paradigm for post-cardiac event resistance exercise guidelines.

Existing guidelines for resistance exercise in cardiac rehabilitation are vague and/or overly restrictive, limiting the ability of cardiac rehabilitation programs to help patients achieve their desired levels of daily activity in a timely manner after cardiac events. This study examines the illogical nature of the existing guidelines in relation to the activities of daily living patients are expected or required to carry out during the period of cardiac rehabilitation and the existing recommendations for dynamic exercise in cardiac rehabilitation. An improved method is proposed for prescribing resistance exercise in cardiac rehabilitation. A tool is presented that stratifies the risk associated with each of 13 common resistance exercises for 3 cardiac rehabilitation diagnosis groups (myocardial infarction [MI], pacemaker or implantable cardioverter defibrillator implantation, and coronary artery bypass graft surgery) that, if used in conjunction with blood pressure and heart rate measurements, will safely facilitate more efficacious resistance training in cardiac rehabilitation patients. In conclusion, changing the approach to resistance exercise in cardiac rehabilitation will accelerate patients' return to their desired levels of daily activity, improving patient satisfaction and decreasing cardiac rehabilitation program attrition.