Diagnosis and Treatment of Low-Grade Marginal Zone B-cell Lymphoma With Psychiatric Overlap.

This case report delineates the intricate interplay between psychiatric and oncological pathology in a 72-year-old male diagnosed with low-grade marginal zone B-cell lymphoma and severe psychiatric disturbances, including catatonia. The presentation of severe psychiatric symptoms initially obscured the underlying lymphoma, delaying diagnosis and complicating clinical management. Notably, the lymphoma itself may have precipitated or exacerbated the psychiatric condition, underscoring the potential for oncological diseases to manifest with rapidly progressive dementia and catatonia. A multidisciplinary approach was employed, utilizing electroconvulsive therapy (ECT) for rapid resolution of catatonia, which facilitated significant mental health improvements and clearer delineation of the oncological underpinnings. Concurrently, the patient was treated with rituximab, targeting the lymphoma. This case highlights the critical need for a comprehensive evaluation in patients presenting with psychiatric symptoms, particularly in the elderly, to uncover potential medical causes and illustrates the efficacy of ECT in managing psychiatric conditions that may overshadow or complicate concurrent medical issues.

Unraveling Complexity: A Case of Possible Overlapping Between Mixed Connective Tissue Disease and Systemic Lupus Erythematosus With Renal Involvement.

Autoimmune diseases, a term encompassing conditions where the immune system targets its own cells, consist of various pathologies, two of which are systemic lupus erythematosus (SLE) and mixed connective tissue disorder (MCTD). We present the unique case of an anti-ribonucleoprotein (RNP)-positive patient exhibiting renal pathology consistent with lupus nephritis and an additional collapsing variant of focal segmental glomerulonephropathy, who initially presented to the emergency department with signs and symptoms of pneumonia and portal vein thrombosis that were subsequently treated. Conflicting accounts of her autoimmune history led to an extensive workup during her stay, which yielded a tentative diagnosis of SLE vs. MCTD during her current hospitalization for pneumonia. The diagnostic labs revealed conflicting serological markers, with delayed anti-Smith positive results favoring lupus due to its high specificity. A subsequent renal biopsy showed complex renal involvement, suggesting SLE, despite initial positive anti-RNP antibodies known to be protective against renal pathology and classic for MCTD. Complicating matters further, the renal biopsy findings extended beyond common SLE pathology, including additional focal segmental glomerulonephritis (FSGS) involvement. Despite this uncertainty, the patient was treated as if solely having SLE, and immunosuppressives that could have been utilized for the possible MCTD component were avoided due to minimal signs of inflammation/immune response and normal kidney function. This case highlights the difficulty in accurately classifying lupus and MCTD, emphasizing the need for precise diagnosis for tailored patient care. Ongoing research is crucial to refine diagnostic criteria and improve patient outcomes.

Exploring Primary Care Non-Attendance: A Study of Low-Income Patients.

INTRODUCTION: While evidence has been established on the impact of medical appointment non-attendance on the healthcare system and patient health, previous research has not focused on how poverty and rurality may influence patient experiences with non-attendance. This paper explores patient perceptions of non-attendance among those experiencing poverty in a rural U.S county to better inform providers to the context in which their patients make attendance-related decisions. METHODS: Using a grounded theory approach, we conducted semi-structured interviews with 32 U.S. low-income adults in the rural Western U.S. who recurrently missed primary care appointments. We also used a questionnaire to assess individual characteristics related to health, resiliency, personal mastery, medical mistrust, life chaos, and adverse childhood experiences. RESULTS: Participants identified 3 barriers to attending appointments: appointment disinterest, competing demands, and insufficient systems. Appointment disinterest stemmed from physical and mental health issues, misalignment between needs and treatment, and comfort with the provider. Competing demands included family responsibilities, employment, and relationships. Finally, participants reported that current scheduling and transportation systems were helpful but insufficient. To provide further context, participants also reported low overall health, moderate levels of medical mistrust, life chaos, and mastery, moderate to low resilience, and very a high number of adverse childhood experiences. CONCLUSIONS: Results point to the need for modified structures that allow low-income patients more control over their personal health and highlight opportunities for clinics to address patients' lack of interest and fear in the medical encounter.

An Exploratory Study of a Novel Approach to Improve Readiness for a Rural Family Medicine Residency.

BACKGROUND AND OBJECTIVES: Transitioning from medical school to residency is challenging, especially in rural training programs where a comprehensive scope of practice is needed to address rural health disparities. Oregon Health & Science University partnered with Cascades East Family Medicine Residency in Klamath Falls, Oregon to create an integrated fourth-year medical student experience (Oregon Family medicine Integrated Rural Student Training (Oregon FIRST). Participants may then enter this residency to complete their training with the intention to practice in rural underresourced settings. METHODS: In this exploratory study, we conducted key informant interviews with 9 of ten Oregon FIRST participants to determine how Oregon FIRST contributed both to their readiness for residency training and their choice to practice in rural underserved locations. Interviews were conducted between June 10, 2020 and July 8, 2020. We analyzed field notes taken during interviews for emergent themes using classical content analysis. RESULTS: Emergent themes included logistical ease, relationship development, key curricular elements, and commitment to rural practice. Overwhelmingly, Oregon FIRST participants reported the experience had many challenging and demanding components because they served as subinterns for their entire fourth year of medical school, but this prepared them very well for internship. When asked if they would choose to enroll in Oregon FIRST again, given what they now know about physician training and patient care, all nine (100%) said they would. CONCLUSIONS: This study demonstrated that Oregon FIRST students felt better prepared for the rigors of residency and are committed to practicing in rural areas.

Depressed prostaglandins and leukotrienes in veterans with Gulf War illness.

Background: There is need to understand biological markers and mechanisms in Gulf War illness (GWI). Goal: To examine whether and how eicosanoids - prostaglandins and leukotrienes - are altered in veterans with GWI. Methods: Seventy participants including 37 GWI and 33 healthy controls, shared exposure information, and had plasma eicosanoids assessed - prostaglandin F2 alpha (pgf2α), prostaglandin D2 (pgd2), leukotriene B4 (lb4) among others. Values were compared for GWI versus controls. Eicosanoid intercorrelations were compared in cases vs. controls. For the most significantly altered eicosanoid in GWI, exposure and symptom relations were assessed. Results: Prostaglandins and leukotrienes were depressed in GWI, strongest for pgf2α, then lb4. Eicosanoid intercorrelations differed in GWI vs. controls. Fuel-solvent, pesticide, radioactive chemicals and metal exposures related negatively to pgf2α; as, in GWI, did chemical attack and vaccines. Multivariate predictors included fuels-solvents and radioactive chemicals (negative); tetanus vaccine and herbicides (positive). Fuels-solvents and radioactive chemicals predicted lower pgf2α in cases, controls, and all participants controlled for case status. Lower pgf2α related to GWI "Kansas criteria" domains of pain, respiratory, and (borderline significantly) skin symptoms. Conclusion: Multiple eicosanoids are depressed in GWI, particularly pgf2α and lb4. Prior fuel-solvent exposures, radioactive chemicals, and (in GWI cases) vaccines were linked to lower pgf2α.

Inhalation of two putative Gulf War toxins by mice.

We employed our inhalation methodology to examine whether biomarkers of inflammation and oxidative stress would be produced in mice following inhalation of aerosols containing carbonaceous particles or the vapor of pesticides prevalent during the first Gulf War. Exposure to two putative Gulf War Illness toxins, fine airborne particles and the pesticide malathion, increased biomarkers of inflammation and oxidative stress in Friend virus B (FVB) female mice. Mice inhaling particles 24 h before had increased lung lavage and plasma Leukotriene B4 (LTB4) (a biomarker of inflammation) and PGF2α (a biomarker of oxidative stress) levels, lung lavage protein and lung lavage lactic dehydrogenase (LDH) levels. These changes were a function of particle density and exposure time. Compared to particle inhalation, mice inhaling malathion 24 h before had small increase in plasma LTB4 and PGF2α levels but no increase in lung lavage LTB4, lung lavage protein, lung lavage LDH, and lung lavage alveolar macrophage (AM) levels compared to unexposed control mice. AM from particle-exposed mice contained phagocytosed particles, while AM from malathion-exposed mice showed no abnormalities. Our results indicate that inhaling particles or malathion can alter inflammatory and oxidative biomarkers in mice and raise the possibility that these toxins may have altered inflammation and oxidative stress biomarkers in Gulf War-exposed individuals.

Stepwise sequential aneuploidy screening in clinical practice.

PURPOSE: To evaluate stepwise sequential screening (SSS) efficiency in clinical practice. METHODS: All singletons undergoing SSS in a single practice by NTQR (Nuchal Translucency Quality Review Program)-credentialed providers in a 2-year period were included. Prenatal diagnosis was offered to all screen-positive women and those with a nuchal translucency ≥3.5 mm or cystic hygroma at the 11- to 14-week scan. Data were extracted from prospectively ascertained serum screening and genetics databases. RESULTS: A total of 2,726 patients were screened, with SSS detecting all eight cases of trisomy 21 and all seven cases of other aneuploidies at a 4.3% screen-positive rate. CONCLUSIONS: Stepwise sequential screening offers excellent aneuploidy screening efficiency when introduced into clinical practice.

Effects of fine carbonaceous particles containing high and low unpaired electron spin densities on lungs of female mice.

The negative impacts on human health that accompany inhalation of atmospheric particles are documented in numerous epidemiologic studies, but the effect of specific chemical properties of the particles is generally unknown. We developed and employed technology for generating inhalable aerosols of carbonaceous air pollution particles that have specific physical and chemical properties. We find that inhaling particles with greater unpaired electron spin (free radical) densities stimulates greater lung inflammatory and oxidative stress responses. Cultured alveolar macrophages take up more particles of greater free radical content, develop mitochondrial abnormalities, and release more leukotriene B(4) (LTB(4)) than alveolar macrophages exposed to lesser free-radical-containing particles in vitro. Mice exposed to high free radical particles in vivo also develop mitochondrial abnormalities in alveolar macrophages and increased oxidative stress, which is reflected by increases in lung nitrotyrosine staining and lung lavage nitrogen oxide levels compared with those of lesser free radical density. These results provide insight for the unexplained geographic differences and have implications for fossil fuel combustion conditions and the impact of fine particles on health and disease.

Development, deployment and usability of a point-of-care decision support system for chronic disease management using the recently-approved HL7 decision support service standard.

Clinical decision support is recognized as one potential remedy for the growing crisis in healthcare quality in the United States and other industrialized nations. While decision support systems have been shown to improve care quality and reduce errors, these systems are not widely available. This lack of availability arises in part because most decision support systems are not portable or scalable. The Health Level 7 international standard development organization recently adopted a draft standard known as the Decision Support Service standard to facilitate the implementation of clinical decision support systems using software services. In this paper, we report the first implementation of a clinical decision support system using this new standard. This system provides point-of-care chronic disease management for diabetes and other conditions and is deployed throughout a large regional health system. We also report process measures and usability data concerning the system. Use of the Decision Support Service standard provides a portable and scalable approach to clinical decision support that could facilitate the more extensive use of decision support systems.

Integrated serum screening for Down syndrome in primary obstetric practice.

OBJECTIVES: Integrated serum screening for Down syndrome is potentially more effective than current second-trimester screening. We report results of an intervention trial of integrated serum screening that involved 229 primary prenatal care practitioners throughout Maine. METHODS: Women provided a first-trimester serum (for PAPP-A) followed by a second-trimester serum (for AFP, uE3, hCG, and DIA). These five marker measurements were used to calculate a Down syndrome risk in the second trimester. Screen-positive women (risk > or = 1:100) were managed according to standard practice. RESULTS: During 24 months' enrollment, 11 159 women provided a first-trimester sample (61% of women receiving screening services). Nine thousand seven hundred twenty-three women also provided a second-trimester sample; 8773 women satisfied gestational age criteria for testing in both trimesters. Integrated serum screening detected 14 of 16 Down syndrome cases (87%) and 79% after adjustment for trimester-of-ascertainment bias. The initial false-positive rate was 3.2% and was 2.7% when restricted to ultrasound-dated pregnancies. Performance was better than any combination of second-trimester markers. Implementation challenges included initial samples being collected too early and sample matching. CONCLUSIONS: Integrated serum screening for Down syndrome was successfully implemented in primary care settings; screening performance was consistent with predictions. It provides an accessible and acceptable alternative to screening protocols that require nuchal translucency measurements.