Diagnostic Criteria of Takotsubo Cardiomyopathy in the Clinical Setting: A Case Report

Introduction Takotsubo cardiomyopathy (TTS) is a rare condition related to stress featuring apical hypokinesis. Current guidelines suggest that the exclusion of other causal factors like myocarditis is required to diagnose TTS. However, we propose that the existing diagnostic criteria for TTS, particularly, required exclusion of myocarditis, adds to the challenge of making this diagnosis in the clinical setting. Hereby, we present a case with basal hypokinesis that could have been attributed to a conjunction of reverse Takotsubo syndrome (rTTS) with viral or toxic myocarditis. Case Presentation: A 29-year-old female complained of acute persistent chest pain, palpitations, and vomiting after smoking marijuana. She was tachycardic without hemodynamic instability or hypoxia. Electrocardiogram showed sinus tachycardia. Troponin peaked at 16.1 ng/ml. Urine drug screen was positive for amphetamines. Echocardiogram and catheterization showed left ventricular reduced ejection fraction (25-30%) with basal hypokinesia and apical hyperkinesis, suggestive of reversed Takotsubo cardiomyopathy. Cardiac magnetic resonance (CMR) also showed delayed contrast enhancement suggestive of myocarditis. Viral panel noted positive Coxsackie B titer on day 7 of hospitalization. She was treated with goal-directed medical therapy and repeat echocardiogram 6 days after showed normalized left ventricular systolic function. Discussion: Guidelines recommend the use of clinical history, inflammatory markers, and CMR to exclude infectious myocarditis before diagnosing rTTS. The clinical scenario in this case presented evidence of a catecholamine-related substance exposure known to trigger takotsubo cardiomyopathy and of an elevated Coxsackie B titer. The CMR showed features explainable by myocarditis and partially by rTTS. This case highlights the complexity of diagnosing TTS or rTTS with infective myocarditis as exclusion criteria. While imaging, history, and labs play a vital role, a lack of complete understanding about the pathophysiology of this disease as well as existing diagnostic criteria complicate the ability to make this diagnosis in the clinical setting

Adolescent HIV Pre-Exposure Prophylaxis Prescribing Practices Among Family Medicine Physicians: Limited Immediate Uptake

Introduction: In the United States, individuals aged 13-24 made up 21% of new HIV infections in 2016. In 2018, the FDA approved tenofovir/emtricitabine as HIV pre-exposure prophylaxis (PrEP) for adolescents aged 15-17. In 2019, we examined adolescent PrEP prescribing practices among family medicine physicians at an academic family medicine practice. Methods: Physicians were invited to complete an online questionnaire assessing PrEP knowledge, attitudes, and prescribing practices. Differences in PrEP knowledge and attitudes among providers who prescribe PrEP to adolescents versus those who do not were examined using independent samples t-tests. Results: 50 out of 99 surveys were completed. Respondents were 90% White, 84% heterosexual, 50% attendings, 50% residents/fellows, and 2% HIV specialists. All respondents had heard of PrEP before the survey, 76% had prescribed PrEP and 70% reported being aware of the FDA approval of PrEP for adolescents. While 86% reported treating patients aged 15-17, only 6% reported having prescribed PrEP to this demographic. Physicians who reported prescribing PrEP to adolescents reported greater comfort assessing for indications for PrEP, t(48)= -2.23, p \u3c 0.05, greater PrEP knowledge, t(47)= -3.34, p \u3c 0.005, and felt PrEP was safer, t(48)= -2.09, p \u3c 0.05, compared to physicians who had not. Conclusion: Despite universal awareness of PrEP, high rates of prescribing to adults, and awareness of FDA approval of PrEP for adolescents, PrEP prescribing to adolescents in our sample remains limited. Differences between providers who have and have not prescribed PrEP to adolescents suggest targeted training may boost prescribing to this demographic

Accelerating Primary Care Transformation at Jefferson (JeffAPCT): Reflections from a Five- Year HRSA Grant

JeffAPCT Overview Five year HRSA-funded grant (7/1/15-6/30/20) Leadership team from Family Medicine, Internal Medicine, Physician Assistant Program Objective 1: To improve/ expand primary care and population health curriculum across the continuum of primary care providers and trainees (students, residents, and practitioners) Objective 2: To create an enhanced, sustainable model of primary care physician faculty development for PCMH Transformation Objective 3: To create a new, sustainable model of faculty development for community-based primary care preceptors (MD/DO, PA, NP, others

“Taking the Pulse of Jefferson Primary Care: Provider and Team Wellness Survey Results and Next Steps”

Agenda Context (Randa Sifri) Results (Amy Cunningham) Action Steps (Keith Sweigard) Q&

Repair results of 2-tendon rotator cuff tears utilizing the transosseous equivalent technique

Background: The purpose of this study was to examine the healing rate of 2-tendon rotator cuff tears repaired by the use of a transosseous-equivalent (TOE) suture bridge technique. Materials and methods: Forty-three patients with combined supraspinatus and infraspinatus tendon tears underwent arthroscopic repair using TOE technique. Forty of these patients were then evaluated by MRI and clinical exam at a minimum of 1-year follow-up to determine the rate of healing of the repair and clinical outcomes associated with healing. Results: Eighty-three percent of the repairs demonstrated intact rotator cuff repairs at a mean of 16 months post-op. Larger tears (3.5 vs 2.8 cm) were associated with failure (P ¼ .01), as was more advanced fatty infiltration (Goutallier 1.3 vs 0.3, P ¼ .01). Age was not different between intact and nonintact tendons. Strength was the only clinical finding that differed between intact and nonintact tendons. Conclusion: Two-tendon tears of the rotator cuff can heal at a high rate with the use of TOE suture bridge repair technique. Furthermore, tear size and Goutallier grading were negatively correlated with postoperative healing. The incremental improvement in the rate of observed rotator cuff healing still does not translate to statistical differences in the objective shoulder scoring systems. Level of evidence: Level IV, Case Series, Treatment Study

Renal Stone Disease in Children

Summary: Renal stone disease has been regarded as an uncommon problem in children compared to adults. However, increased awareness of this problem in children may lead to early intervention preventing long-term consequences on the kidney and the urinary tract. This article reviews the epidemiology, pathogenesis, and the most common etiologies of renal stones in children. The clinical features and diagnostic and therapeutic modalities for the specific etiologies are also outlined. Using these guidelines may be helpful not only in the treatment but also in the prevention of renal stones. Clin Pediatr. 1998;37:583-60

Understanding Affordability of Healthcare in Vermont

Background: As of April 2023, 25% of Vermonters were enrolled in Medicare. Among Medicare beneficiaries nationally, half spent at least 12% of their income on healthcare costs, and one-quarter spent at least 23%. The purpose of this project is to understand healthcare affordability for low-income Vermonters transitioning to Medicare. Methods: An electronic survey about perceptions of healthcare affordability was sent to Vermont primary care providers. Interviews were conducted with a patient, providers, and support services including Community Health Workers (CHW), Community Health Team (CHT), and financial programs. De-identified interviews were coded to identify themes. Results: The interviewed patient expressed emotional distress over the complex and confusing transition from Medicaid to Medicare. Support services expressed concern that difficulty navigating the system can lead to financial penalties to patients and impact decisions about receiving care. During interviews, providers expressed frustration over cost and coverage limiting patients’ access to care. The confines Medicare coverage caused providers to prescribe less ideal medications. 77% of those who responded to the survey agree that patient insurance status or ability to afford care may influence recommendations for treatment. Conclusion: Navigating a transition to Medicare is daunting for patients, both in its complexity and cost. Increases in out-of-pocket costs for patients cause emotional distress and impact their ability to receive optimal care. This project emphasizes the need for stakeholders, such as advocates, lawmakers, and the medical community, to focus their efforts on addressing and understanding how medical debt and affordability impact access to healthcare and health outcomes for low-income Vermonters

Copy Number Variation Analysis in Single-Suture Craniosynostosis: Multiple Rare Variants Including RUNX2 Duplication in Two Cousins With Metopic Craniosynostosis

Little is known about genes that underlie isolated single-suture craniosynostosis. In this study, we hypothesize that rare copy number variants (CNV) in patients with isolated single-suture craniosynostosis contain genes important for cranial development. Using whole genome array comparative genomic hybridization (CGH), we evaluated DNA from 186 individuals with single-suture craniosynostosis for submicroscopic deletions and duplications. We identified a 1.1 Mb duplication encompassing RUNX2 in two affected cousins with metopic synostosis and hypodontia. Given that RUNX2 is required as a master switch for osteoblast differentiation and interacts with TWIST I, mutations in which also cause craniosynostosis, we conclude that the duplication in this family is pathogenic, albeit with reduced penetrance. In addition, we find that a total of 7.5% of individuals with single-suture synostosis in our series have at least one rare deletion or duplication that contains genes and that has not been previously reported in unaffected individuals. The genes within and disrupted by CNVs in this cohort are potential novel candidate genes for craniosynostosis. (C) 2010 Wiley-Liss, Inc

Developing a video expert panel as a reference standard to evaluate respiratory rate counting in paediatric pneumonia diagnosis: protocol for a cross-sectional study

INTRODUCTION: Manual counting of respiratory rate (RR) in children is challenging for health workers and can result in misdiagnosis of pneumonia. Some novel RR counting devices automate the counting of RR and classification of fast breathing. The absence of an appropriate reference standard to evaluate the performance of these devices is a challenge. If good quality videos could be captured, with RR interpretation from these videos systematically conducted by an expert panel, it could act as a reference standard. This study is designed to develop a video expert panel (VEP) as a reference standard to evaluate RR counting for identifying pneumonia in children. METHODS AND ANALYSIS: Using a cross-sectional design, we will enrol children aged 0–59 months presenting with suspected pneumonia at different levels of health facilities in Dhaka and Sylhet, Bangladesh. We will videorecord a physician/health worker counting RR manually and also using an automated RR counter (Children’s Automated Respiration Monitor) from each child. We will establish a standard operating procedure for capturing quality videos, make a set of reference videos, and train and standardise the VEP members using the reference videos. After that, we will assess the performance of the VEP as a reference standard to evaluate RR counting. We will calculate the mean difference and proportions of agreement within±2 breaths per minute and create Bland-Altman plots with limits of agreement between VEP members. ETHICS AND DISSEMINATION: The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 39315022021) and Edinburgh Medical School Research Ethics Committee (EMREC), Edinburgh, UK (REC Reference: 21-EMREC-040). Dissemination of the study findings will be through conference presentations and publications in peer-reviewed scientific journals