Letter to Sonora Dodd from J. P. Tumulty, May 14, 1918

Letter to Sonora Dodd from J. P. Tumulty, with envelope. Joseph P. Tumulty served as Secretary to Woodrow Wilson, President of the United States, from 1911 until 1921.https://digitalcommons.whitworth.edu/fathers-day-correspondence/1033/thumbnail.jp

Case report: Acute necrotizing encephalopathy: a report of a favorable outcome and systematic meta-analysis of outcomes with different immunosuppressive therapies

Acute Necrotizing Encephalopathy (ANE) is a condition characterized by symmetric, bilateral lesions affecting the thalamus and potentially other areas of the brain following an acute febrile illness. It manifests clinically as abrupt development of encephalopathy, or alteration in mental status that often includes development of seizures and progression to coma. Treatment strategies combine immunosuppressive therapies and supportive care with varying levels of recovery, however there are no universally accepted, data-driven, treatment algorithms for ANE. We first report a case of a previously healthy 10-year-old female with acute onset diplopia, visual hallucinations, lethargy, and seizures in the setting of subacute non-specific viral symptoms and found to have bilateral thalamic and brainstem lesions on MRI consistent with ANE. She was treated with a combination of immunomodulatory therapies and ultimately had a good outcome. Next, we present a meta-analysis of 10 articles with a total of 158 patients meeting clinical and radiographic criteria for ANE. Each article reported immunosuppressive treatments received, and associated morbidity or mortality outcome for each individual patient. Through our analysis, we confirm the effectiveness of high-dose, intravenous, methylprednisolone (HD-IV-MP) therapy implemented early in the disease course (initiation within 24 h of neurologic symptom onset). There was no significant difference between patients treated with and without intravenous immunoglobulin (IVIG). There was no benefit of combining IVIG with early HD-IV-MP. There is weak evidence suggesting a benefit of IL-6 inhibitor tocilizumab, especially when used in combination with early HD-IV-MP, though this analysis was limited by sample size. Finally, plasma exchange (PLEX) improved survival. We hope this meta-analysis will be useful for clinicians making treatment decisions for patients with this potentially devastating condition

Hypertriglyceridaemia as a risk factor for critical care admission in acute pancreatitis: A prospective study

Background and aimsHypertriglyceridaemia is both a primary cause of acute pancreatitis and an epiphenomenon. This study aimed to define the associations between hypertriglyceridaemia and clinical outcomes in patients admitted with acute pancreatitis.MethodsThis single-centre prospective observational study included patients with a confirmed clinical, biochemical or radiological diagnosis of acute pancreatitis from August 2017 to September 2018. Baseline demographics, aetiology of pancreatitis, and fasting triglyceride concentrations were recorded and assessed against the surrogate markers of severity: admission to critical care, length of stay (LOS), readmission to hospital, and mortality.ResultsIn total, 304 patients with a mean ± SD age of 56.1 ± 19.7 years met the inclusion criteria. There were 217 (71.4%) patients with normotriglyceridaemia ([less than] 150 mg/dL or [less than] 1.7 mmol/L), 47 (15.5%) with mild hypertriglyceridaemia (150–199 mg/dL or 1.7–2.25 mmol/L) and 40 (13.2%) with moderate-to-severe hypertriglyceridaemia (≥200 mg/dL or >2.25 mmol/L). The underlying aetiologies of acute pancreatitis were gallstones (55%), alcohol (18%), idiopathic (15%), hypertriglyceridaemia (9%), iatrogenic (2%) and bile duct abnormalities (1%). Patients with hypertriglyceridaemia were younger than those with normotriglyceridaemia (p [less than] 0.05). On multivariate regression, moderate-to-severe hypertriglyceridaemia (OR 5.66, 95% CI: 1.87 to 17.19, p = 0.002) and an elevated C-reactive protein concentration ≥120 mg/L (OR 1.00, 95% CI: 1.00–1.01, p = 0.040) were associated with admission to critical care. Moderate-to-severe hypertriglyceridaemia was also associated with an increased LOS (p = 0.002) but not readmission (p = 0.752) or mortality (p = 0.069).ConclusionModerate-to-severe hypertriglyceridaemia in all aetiological causes of acute pancreatitis was predictive of admission to critical care and prolonged LOS but not readmission or mortality

Good physicians from the perspective of their patients

BACKGROUND: It is not currently known what is the patient's viewpoint of a "good" physician. We set out to define patient's priorities regarding different physician's attributes in 3 domains important in medical care. METHODS: Patients hospitalized or attending clinics at a large teaching hospital selected the 4 attributes that they considered most important out of 21 listed arbitrarily in a questionnaire. The questionnaire included 7 items each in the domains of patient autonomy, professional expertise and humanism. RESULTS: Participating patients (n = 445, mean age 57.5 ± 16 years) selected professional expertise (50%), physician's patience and attentiveness (38% and 30%, respectively), and informing the patient, representing the patient's interests, being truthful and respecting patient's preferences (25–36% each) as the most essential attributes. Patient's selections were not significantly influenced by different demographic or clinical background. Selections of attributes in the domain of patient's autonomy were significantly more frequent and this was the preferred domain for 31% and as important as another domain for 16% – significantly more than the domain of professional expertise (P = 0.008), and much more than the domain of humanism and support (P < 0.0005). CONCLUSIONS: Patients studied want their physicians to be highly professional and expert clinicians and show humaneness and support, but their first priority is for the physician to respect their autonomy

Job satisfaction and motivation of health workers in public and private sectors: cross-sectional analysis from two Indian states

<p>Abstract</p> <p>Background</p> <p>Ensuring health worker job satisfaction and motivation are important if health workers are to be retained and effectively deliver health services in many developing countries, whether they work in the public or private sector. The objectives of the paper are to identify important aspects of health worker satisfaction and motivation in two Indian states working in public and private sectors.</p> <p>Methods</p> <p>Cross-sectional surveys of 1916 public and private sector health workers in Andhra Pradesh and Uttar Pradesh, India, were conducted using a standardized instrument to identify health workers' satisfaction with key work factors related to motivation. Ratings were compared with how important health workers consider these factors.</p> <p>Results</p> <p>There was high variability in the ratings for areas of satisfaction and motivation across the different practice settings, but there were also commonalities. Four groups of factors were identified, with those relating to job content and work environment viewed as the most important characteristics of the ideal job, and rated higher than a good income. In both states, public sector health workers rated "good employment benefits" as significantly more important than private sector workers, as well as a "superior who recognizes work". There were large differences in whether these factors were considered present on the job, particularly between public and private sector health workers in Uttar Pradesh, where the public sector fared consistently lower (<it>P </it>< 0.01). Discordance between what motivational factors health workers considered important and their perceptions of actual presence of these factors were also highest in Uttar Pradesh in the public sector, where all 17 items had greater discordance for public sector workers than for workers in the private sector (<it>P </it>< 0.001).</p> <p>Conclusion</p> <p>There are common areas of health worker motivation that should be considered by managers and policy makers, particularly the importance of non-financial motivators such as working environment and skill development opportunities. But managers also need to focus on the importance of locally assessing conditions and managing incentives to ensure health workers are motivated in their work.</p

The establishment of a primary spine care practitioner and its benefits to health care reform in the United States

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. We explain the reasons we think a primary spine care practitioner would be beneficial to patients, the health care system and society, some of the obstacles that will need to be overcome in establishing a primary spine care specialty and the ways in which these obstacles can be overcome.https://doi.org/10.1186/2045-709X-19-1