Case Report: 44-Year-Old Male with Shortness of Breath, Cough, and Weight Loss

Statement of Significance Lower respiratory pathologies exhibit a broad spectrum of clinical courses ranging from self-limited to chronic and from benign to fatal. During the present COVID-19 pandemic, the prompt and proper diagnosis of respiratory disease carries even greater importance. Apart from this patient’s presentation with respiratory symptoms during a respiratory pandemic, he demonstrated several concerning features for severe disease including 20 lbs of weight loss and hemoptysis. This teaching case examine the differential diagnosis, workup, clinical considerations, and management of patients presenting with severe respiratory pathology of unknown etiology.

Regulating the Use of Solitary Confinement in US Prisons

Statement of Significance: This article aims to summarize relevant literature on the topic of prolonged solitary confinement from the perspective of the medical sciences to outline the detrimental health impacts associated with this practice, evaluate the extent to which the current use of this practice in the United States (US) aligns with the recommendations outlined in human rights literature, and offer recommendations to further regulate the use of solitary confinement in prisons to better align with the rehabilitative goals of the US criminal justice system. This review details the well-studied physical and psychological harms associated with prolonged solitary confinement to support the notion that restrictions should be placed on the use of this practice for the well-being of incarcerated individuals. Additionally, it reviews the recommendations for appropriate use of this practice outlined in human rights literature and examines how the contemporary utilization of solitary confinement within US prisons fails to meet these proposed standards. Finally, this article offers specific recommendations regarding the appropriate settings in which solitary confinement should be used, key regulations to limit the extent of its use, and additional measures to minimize harm to incarcerated individuals. The limitations of this study include the decision to pursue a targeted literature review, as opposed to an exhaustive systematic review, which may have excluded specific arguments relevant to this paper’s discussion. Further, the scope of this article was focused on a discussion on the topic of prolonged solitary confinement and did not comment on the separate issue regarding the moral permissibility of the solitary confinement, as a whole. Finally, the cultural differences between the US and other high-income countries may limit the ability to compare models of rehabilitation in correctional institutions between these nations, suggesting that the proposed impact of the chosen recommendations should be interpreted with caution.

Ethical and Global Health Perspectives on Obstetric Healthcare and Safe Abortions in Refugee and Internally Displaced Populations

Statement of Significance Literature demonstrates women living in poverty in remote areas are less likely to receive adequate health care, particularly in regard to obstetrics and gynecology. Lack of medical care during childbirth is associated with significant maternal mortality due to otherwise readily prevented or treated causes. While reproductive healthcare for women in all 'developing nations' merits consideration, this catch-all term for under-resourced regions obscures disproportionate burdens faced by a heterogeneous collection of communities facing disparate barriers to health care. Displaced women, both externally as refugees or within their nation of origin, face maternal morbidity and mortality rates at nearly twice the world average. Displaced women and those in countries deemed as undergoing a humanitarian crisis, represent the majority of all maternal deaths—both globally and among developing nations. This article considers the current state of women's health in displaced populations. Data on morbidity, mortality, and disparities in reproductive health demonstrate a violation of their human rights as defined by well-established ethical paradigms and international declarations. The onus of guaranteeing human rights to reproductive health falls well within the purview of the international medical community. Medical providers and medical organizations have a responsibility to recognize and amend these disparities and this article concludes by offering practical approaches toward this end.

Examining Differences Between Groups by Race, Sex, and Insurance Status in Treatment of Rotator Cuff Pathology

Statement of Significance: The purpose of this study was to investigate disparities in the treatment of rotator cuff pathology by sex, race, and insurance status. The findings suggested that disadvantaged groups did not receive less interventions within the clinic of interest. The study was limited by a small sample size in a single clinic in rural North Carolina. Future studies are needed to make the findings generalizable across different clinic settings. Background: Rotator cuff pathology (RCP) affects a significant portion of the global population and can cause notable pain and reduction in function. Many treatment options exist for RCP, including physical therapy, injections, and surgery. Literature indicates management disparities exist between demographic groups, such as racial self-identity, gender, and socioeconomic status. Studies suggest women, non-white patients, and those of low socioeconomic status are less likely to receive definitive surgical treatment and experience increased time from presentation to surgery. Methods: We conducted a retrospective chart review to determine if race, gender, or socioeconomic status affected treatment decisions for RCP at a sports medicine clinic in western North Carolina. Data from patients with clinically suspected RCP from January 2018–April 2020 were assessed for associations between demographic factors and differences in the management. Management options included MRI, physical therapy, injection, or referral to orthopedic surgery. Results: 178 patients were included in the study. There was not a statistically significant difference in treatments between genders, although females showed a trend towards more referrals to orthopaedic surgery (p=0.06). Non-white patients were found to receive MRI at a higher rate (p<0.05), but race and insurance status otherwise exhibited no significant differences in management. Conclusions: Our data did not observe management disparities based on sex, race, or insurance status, which was used as a surrogate for socioeconomic status, in the sample population.

A Look into Women’s Preventative Care, Contraception Practices and Cesarean Delivery Rates in Rural Guanajuato, Mexico in Comparison to the United States

Statement of Significance: According to the World Health Organization (WHO), a third of health issues for women aged 15 and 44 years are sexual and reproductive health problems with unsafe sex practices being a major risk factor.1 Additionally, “every day in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth.”2 Although there have been improvements in prenatal and postpartum care, these benefits do not extend worldwide. Cervical and breast cancer represent additional issues in women’s health wherein adequate preventative medicine can dramatically improve patient outcomes. Our findings provide insight into the use of accessible contraception, preventive screenings, and cesarean deliveries based on the self-reported experience of a rural population near Guanajuato, Mexico. The results stand to inform future research and public health efforts in the region aiming to improve knowledge and use of contraception, investigate increasing cesarean delivery rates, and improve screening rates for cervical and breast cancer. Background: The objective of this study was to evaluate preventative screening for breast and cervical cancer, contraceptive practices, and cesarean section rates for women in rural Guanajuato Mexico. Understanding this data is important because such accessibility and healthcare practices can influence the safety of this population’s lives as well as provide insight to the impact of public healthcare programs. Methods: A twenty-one question oral survey was administered to both male and female participants of health fairs and screenings in seven rural communities around the cities of Juventino Rosas and San Miguel de Allende. The survey covered diet and exercise habits as well as women’s health topics for participants who self-identified as female. Women’s health topics included questions about mammography & Papanicolaou test (Pap test) history as well as contraception use and cesarean section history. Results: A total of 155 participants. Mean respondent age was 46 years and a majority of respondents were female (81%, n = 155). Of female respondents, almost half reported a previous cesarean section. More women in the younger cohort (aged <50 years) reported a history of cesarean section compared to the older cohort (aged >50 years), but not at a level of statistical significance. Almost half of the women of childbearing age denied contraception utilization. Most women (72%, n = 110) reported a Pap test within the past five years and about a third had one within the past year. Of the women aged >40 years, almost half had not received mammography. Conclusions: Younger women appeared more likely to have had at least one cesarean delivery than older women, but the sample size provided inadequate power for statistical significance. Access to contraception did not appear to be a barrier to contraception utilization in this region, an important finding for future investigations of associated topics, such as rates of unplanned pregnancies or the spread of communicable sexual diseases. Though the Pap test rates were comparable to that of the United States, mammogram rates lagged. Further studies should investigate increasing cesarean delivery rates in rural Guanajuato, Mexico, strategies to increase education regarding contraceptive modalities, and approaches to improve screening and treatment of cervical and breast cancer.

Increasing Postpartum Depression Screening in the Pediatric Setting

Statement of Significance: Undetected postpartum depression has adverse health effects on both the affected mother and her child. In the context of growing literature supporting universal screening for postpartum depression, this quality improvement project aimed to implement screening within the context of pediatric well child visits. Screening for postpartum depression in the pediatric setting is feasible and can lead to identification of postpartum women in need of further evaluation that might not otherwise garner provider attention. Implementing simultaneous quality improvement processes in two different sites and sharing lessons learned with a broader healthcare network can expedite effective innovation. Background: Postpartum depression (PPD) affects 10-15% of new mothers. The long-term of untreated PPD on both the mother and child are well documented in the literature. Historically, formal screening has not been a standard part of pediatric visits since the focus of the visit is on the infant as the patient. However, the frequent check-ups throughout the first year of life serve as a reliable touchpoint during which screening can be done, and the American Academy of Pediatrics (AAP) recommends screening in this setting. Methods: Two clinics simultaneously aimed to improve the usage of the Edinburgh Postpartum Depression Scale as a screening tool for PPD at the 1-month, 2-month, 4-month, and 6-month well child checks. Clinic A is a pediatrics practice, and clinic B is a combined internal medicine and pediatrics practice. After an initial roll-out period in February 2019, Plan-Do-Study-Act cycles were conducted over a 3-month period (March to May 2019) to determine how to reliably and universally incorporate this screening into all applicable visits in the two different clinic settings. Results: The overall screening rate at clinic A rose from 57% at the beginning of March to 90% at the end of May. Clinic B’s rose from 44% at the beginning of March to 89% at the end of May. With increased screening, there was a rise in both the percentage and the absolute number of women with positive screens. Conclusions: Screening for PPD in the pediatric setting is feasible and can lead to identification of caregivers in need of further evaluation for PPD that might not have otherwise come to provider attention. Implementing simultaneous quality improvement processes in different sites and sharing findings with a broader healthcare network can expedite effective innovation.

Assessment of Contemporary Virtual Reality Programs and 3D Atlases in Neuroanatomical and Neurosurgical Education

Statement of Significance: The utilization of innovative technologies in medical education has received increasing attention in both undergraduate and graduate medical curricula. Understanding spatial, physiological, and pathological aspects of neuroanatomy are important for medical students and residents, alike. As virtual reality applications and platforms become more accessible to educators, learners, and the general public, such technology now represents a feasible modality of neuroanatomical education. This qualitative observational study compares and evaluates five programs based on the accessibility, breadth of content, and utility for various learner populations. Objective: Virtual reality (VR) is a growing technology of interest in medical education, particularly as the millennial generation has become the primary learners. We sought to compare the five available and affordable neuroanatomical programs with objective comparisons of the neuroanatomy, format, and target audience. Methods: The following programs were included: Sharecare VR, Organon VR, The Neurosurgical Atlas 3D Operative Neuroanatomy, BioDigital 3D Human Anatomy, 3D Brain. These programs were selected based on their price ($0-30) and platform (HTC Vive, Oculus Rift, iOS, Google Chrome). The following neuroanatomical categories were assessed: CNS, Cranial Nerves, PNS Skull, and Spine. Neuroanatomical level of detail was scored from 0 (absence of structure) to 3 (operative anatomy). Points were provided if programs included explanations of neuroanatomical relevance, models of pathology & physiology, references, and quiz features. These scores were tallied and compared. Results: The Neurosurgical Atlas and BioDigital scored highest (22 points each), followed by Organon VR (11), 3D Brain (9), and Sharecare VR (6). The Neurosurgical Atlas had the most detail with a score of 3 in each neuroanatomical category. BioDigital included more, but simpler, models. 3D Brain included simple CNS models, but useful explanations and references. Disappointingly, the VR-exclusive programs had entertainment-only models (Score = 1). Conclusions: The Neurosurgical Atlas is the most relevant and detailed model of neuroanatomy and is most appropriate for resident- or attending-level anatomic review. The remaining programs lacked detailed neuroanatomy limiting their potential for a neurosurgical audience.

Case Report: Refractory Immune-Mediated Necrotizing Myositis and Limited English Proficiency

Statement of Significance: We report the case of a 76-year-old Spanish-speaking patient with a three-year history of statin induced immune-mediated necrotizing myositis (IMNM) who presented with worsening symptoms and increasing creatinine kinase levels despite escalating treatment strategies. IMNM is a rare and challenging diagnosis. This case report details a myositis flare refractory to first and second-line therapies. Our report also examines limited English proficiency as a structural barrier to care in the United States, particularly in the setting of visits conducted via telehealth modalities. Purpose: To report a rare presentation of statin-induced IMNM and the clinical impacts of language barriers and telehealth. Methods: Case report. Results: A 76-year-old male with a three-year history of statin-induced IMNM presented for follow-up to the rheumatology clinic. He reported worsening weakness after beginning leucovorin to mitigate side effects ascribed to methotrexate therapy. He had previously achieved baseline strength and normal creatinine kinase (CK) levels with a regimen of weekly methotrexate and monthly infusion of intravenous immunoglobulin (IVIG). His decline in condition appeared to result from inappropriate medication scheduling due to a language barrier. The patient was taking weekly leucovorin on the day before his weekly dose of methotrexate, thus mitigating the efficacy of methotrexate. However, his condition continued to decline with three months of the recommended treatment schedule. The patient was then switched to mycophenolate mofetil as an alternative immunosuppressant. This therapy has demonstrated benefit thus far and provided the patient with symptomatic relief.

Comparative Analysis of COVID-19 Prevalence in Coastal Versus Inland Populations of North Carolina

Statement of Significance: This study aimed to assess geographic trends in COVID-19 cases and deaths across North Carolina (NC). Our study found that population-adjusted COVID-19 cases and deaths were lower in the coastal region of NC during the study period, independent of demographic composition and population-density within the region. This represents an interesting finding regarding COVID-19 transmission that deserves further investigation. One possible explanation for this finding is differing environmental conditions between the inland and coastal region. Background: Existing literature has explored the geographic and spatial variations in COVID-19 prevalence. Some studies suggest that the transmission and total prevalence of COVID-19 is diminished in areas with low levels of air pollution, high humidity, and more sunlight. The coastal regions of NC are more likely to have these environmental characteristics than the inland regions. Given these trends, we analyzed and compared population-adjusted COVID-19 case and death counts in the coastal and inland regions of NC. Methods: Time series data displaying the prevalence of population adjusted COVID-19 case and death counts from 15 March 2020 to 15 August 2020 were plotted for a variety of North Carolina regional and population density classifications. A local regression analysis was computed to further assess the observed relationships. Basic demographic characteristics were also compared for the coastal versus inland region. Results: There were fewer population-adjusted COVID-19 cases and deaths in the coastal region (889 cases/100,000; 12.5 deaths/100,000) than in the inland region (1426 cases/100,000; 23.5 deaths/100,000) at the endpoint of this study. This trend is observed even when controlling for population density, and in the absence of significant demographic differences between the two regions. Conclusions: The prevalence of population-adjusted COVID-19 cases and deaths was lower in coastal versus inland NC during this study period. Given that the NC coastal region is associated with lower pollution, higher humidity, and more exposure to sunlight, our findings suggest that more research should be done to explore the correlation between environmental variables and the spread of COVID-19.