RESUMO
Bariatric surgery is a commonly performed procedure for patients who have failed to achieve weight loss through medical and lifestyle interventions. However, the altered gastrointestinal anatomy resulting from the surgery can significantly impact the bioavailability of antidepressants in patients with generalized anxiety disorder, potentially leading to uncontrolled anxiety symptoms. This case report describes a patient with generalized anxiety disorder who underwent Roux-en-Y gastric bypass surgery and subsequently experienced increased anxiety symptoms due to poor antidepressant bioavailability. The patient's medication was adjusted to a sublingual formulation, resulting in improved anxiety control and reduced side effects. Healthcare providers should be aware of the potential impact of bariatric surgery on medication absorption and closely monitor patients with generalized anxiety disorder for potential psychiatric medication-related complications postoperatively. The use of alternative routes of administration, such as sublingual medication, may be beneficial in improving drug bioavailability and managing anxiety symptoms. Creating awareness in primary care offices about poor drug absorption and using alternatives such as the sublingual route of administration to achieve optimal systemic delivery requires a multifaceted approach involving education and training for healthcare providers as well as patient education to ensure they are informed and engaged in their own care. By implementing these strategies, primary care providers can improve patient outcomes and prevent unnecessary referrals to specialists.
RESUMO
Background Low back pain is known to be one of the leading causes of disability among the young and elderly population. Low back pain can stem from multiple sources, including spinal degeneration, injury, herniated discs, sciatica, and other contributing causes. This symptom significantly influences the quality of life of affected individuals. Its implications include extensive social and economic costs. Economic considerations arise from the fact that not all healthcare facilities accept the insurance plans available to retired individuals under Medicare. This places an additional burden on patients who must bear the financial responsibility for healthcare services not covered by their insurance plan. Florida, renowned as a favored state for retirement, consists of a demographic composition wherein 21% of its residents are aged 65 or older. A significant proportion of this demographic qualifies for Traditional Medicare (TM) and/or Medicare Advantage (MA) plans. Thus, understanding the disparities in healthcare access between Medicare and Medicare Advantage plans is crucial. This study aims to evaluate different Medicare insurances available in the market and their impact on the ease of accessibility to pain management specialists for the treatment of lower back pain in Florida patients. Methods We analyzed the Florida Department of Health database to identify the four counties in Florida with the highest Medicare enrollment rates in 2022: Miami-Dade, Palm Beach, Broward, and Pinellas County. Using the U.S. News and Report directory, 25 Pain Management-trained anesthesiologists were randomly selected from each of the four counties. Each office was contacted four times via telephone by four different team members to assess appointment availability for a fictional 65-year-old grandfather seeking treatment for chronic low back pain. The study examined appointment availability and accepted insurance types, including Cigna (commercial insurance), TM, Humana Gold Plus HMO (Medicare Advantage plan), and Blue Medicare Select PPO (Medicare Advantage plan). Practices without contact information or retired physicians were excluded from the analysis. Time to appointment was measured in business days. Results Of the 100 Pain Management Physicians contacted, 44 fit the inclusion criteria of being non-retired physicians, still practicing in one of the four counties with open offices and valid contact information. Blue Medicare Select PPO was accepted by 47.73%, Humana Gold Plus HMO by 56.82%, TM by 93.18%, and Cigna by 93.18% of the encounters. Blue Medicare select PPO and Humana Gold Plus HMO were accepted at significantly lower rates when compared to Traditional Medicare and Cigna with P values of P < .00001 and P < .000176, respectively. There was no significant difference found in the time to appointment between insurances with P value < 7. Conclusion The study found that patients enrolled in Medicare Advantage plans have significantly decreased access to care when compared to those enrolled in TM or commercial insurance. Further research is needed to elucidate the reasons behind differences in access to care across different insurances, as identified in the study.
RESUMO
Hypertensive disorders of pregnancy, particularly preeclampsia, are significant contributors to maternal and fetal mortality worldwide. HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome constitutes a severe manifestation of preeclampsia. Subcapsular liver hematoma (SLH) is a rare complication of HELLP syndrome, resulting from blood accumulation between the liver parenchyma and the Glisson's capsule. We present a unique case of a pregnant patient with HELLP syndrome complicated by SLH, leading to gastric outlet obstruction (GOO). The patient's medical history, clinical presentation, diagnostic evaluation, and management are discussed. The patient, with a history of pregnancy-induced hypertension, presented with HELLP syndrome at 34 weeks of gestation. Elevated blood pressure, liver enzymes, and low platelet count were observed. Postpartum, the patient developed SLH causing GOO. Conservative management, including intravenous fluids, pain control, and a nasogastric tube, was employed. Imaging confirmed SLH and GOO. Multidisciplinary collaboration guided the treatment approach, emphasizing close monitoring, nonoperative strategies, and dietary adjustments. The patient's condition improved, and she was discharged on postpartum day 20. This case report underscores the challenges of managing HELLP syndrome complications, especially SLH-induced GOO. Early diagnosis, appropriate medical interventions, and interdisciplinary coordination are pivotal in ensuring positive outcomes. Conservative management can be effective in stable patients, but timely recognition and monitoring remain crucial for averting potential complications. This case contributes to the limited literature on managing such complex scenarios and highlights the importance of tailored strategies in multifaceted medical conditions.
