CASE REPORT A 68-year-old woman with hypertension and asthma presented to the emergency department with three days of progressively worsening dyspnea and two weeks of left upper extremity swelling. She had a remote history of squamous cell carcinoma (SCC) of the left lung treated with total left pneumonectomy. One year before this admission, she developed cough and dyspnea, and computed tomography (CT) of the chest demonstrated a new mass encasing the right upper lobe bronchus with lymphangitic carcinomatosis. CT-guided tissue biopsy confirmed recurrence of SCC. Given her heavy disease burden and the compromised state of her airway and thoracic inlet, she was not a surgical candidate. She was treated with five cycles of systemic combined chemotherapy of carboplatin, abraxane, and pembrolizumab followed by maintenance pembrolizumab alone. On this admission, review of systems revealed progressively worsening left upper extremity swelling, facial flushing, cyanosis of the lips, and orthopnea. She denied fever, chills, increased sputum production, and visual changes. Vital signs were significant for tachycardia to 119 beats per minute, blood pressure 162/81 mmHg, respiratory rate of 21 breaths per minute, temperature of 98.7°F, and oxygen saturation of 99% on ambient air. Physical examination revealed bilateral upper extremity edema (left greater than right), left breast edema, left periorbital edema, and extensive venous collateralization on the anterior chest wall (Figure 1). Bilateral arm elevation did not cause facial plethora (Pemberton’s sign). Laboratory workup was unremarkable. CT of the chest with and without contrast showed marked interval disease progression from two weeks prior with increased size of numerous pulmonary nodules, a right apical mass that increased in size from 2.8 x 1.8 to 3.2 x 2.8 cm, and a mediastinal mass that increased in size from 4.8 x 4.4 to 5.4 x 5.4 cm. The mediastinal mass encased the right upper lobe bronchus, right upper lobe pulmonary artery, and superior vena cava (SVC). Numerous venous collaterals within the right anterior and posterior chest wall were demonstrated, and the SVC was nearly completely occluded with only minute, threadlike flow (Figure 2). These clinical and diagnostic findings were consistent with SVC syndrome. She underwent endovascular stent placement in the SVC, and her symptoms improved (Figure 3). Palliative radiation was then administered to reduce stress on the SVC, other vasculature, and airways. Repeat CT venacavogram demonstrated patency of the SVC stent, and she was discharged with home oxygen, a prednisone taper, and plans to continue palliative radiation.
INTRODUCTION:We simulated an on-site, multi-hospital mass casualty incident (MCI) to educate emergency medicine providers in the principles of trauma resuscitation and collaboration with administration and staff during an MCI.METHODS:We implemented high-fidelity manikins, inflatable manikins, and actors to simulate a sarin gas bombing. Learners triaged patients at a decontamination tent using the simple triage and rapid treatment (START) tool, or they participated in a simulation in a resuscitation bay.RESULTS:Forty participants anonymously rated the learning impact of the exercise, the clinical relevance to emergency medicine, and the effectiveness of the faculty facilitation and debriefing on a 1-5 Likert scale. The average responses to all questions were 4.45 or greater, and 98% of respondents recommended adding the scenario to the standard curriculum.DISCUSSION:We successfully executed a novel, multi- hospital, MCI drill that was rated to be a better alternative to sequential simulation in a simulation center.
OBJECTIVE:The COVID-19 pandemic brought about many social, psychological, and economic changes. We sought to compare pregnancy and birth outcomes immediately preceding the COVID-19 lockdown to those 12 months later.STUDY DESIGN:This was a retrospective cohort study of people giving birth at a large-volume tertiary medical center in Rhode Island. We compared those who gave birth in February 2020 to those in February 2021. Results: Fewer people delivered in 2021 than 2020 (562 vs. 655). There was a non-significant decrease in the number of primary cesarean deliveries from 2020 to 2021. Insurance status modified this effect as there was a significant decrease in the number of patients with private insurance undergoing primary cesarean (63.6 vs 36.4%, p=0.004). Neonatal complications significantly decreased (55.4% vs 47.4%, p=0.006).CONCLUSION:There were differences in sociodemographic characteristics and outcomes of birthing people between 2020 and 2021. The socioeconomic and healthcare landscape caused by COVID-19 altered statewide birthing patterns.
During the COVID-19 pandemic, there was an increase in several risk factors for child maltreatment. There was also a sudden decrease in the systems available to identify and support at risk children and families. This study aims to describe the number of children presenting to specialized medical care for suspected child abuse and neglect during the first seven months of the COVID-19 pandemic compared to the three previous years. This was a retrospective chart review of all cases evaluated by the child abuse team in Rhode Island from March 1st until September 30th of 2017, 2018, 2019 and 2020. During the first seven months of the COVID-19 pandemic, there were 10% fewer children evaluated by the child abuse team with the most significant decrease (35%) in the number of children evaluated for physical abuse. With the known increased risk factors for physical abuse due to COVID-19, the decrease in the number of children evaluated for physical abuse is unlikely due to a decrease in the incidence of physical abuse. This decrease is most likely due to physical abuse not being identified or children not being referred to specialized medical care. Without the ability to see and interact with children in person, professionals' ability to identify child victims of abuse is limited. Professionals working with children and families at risk should develop strategies to be able to continue to provide in-person services in the future if another pandemic or natural disaster occurs.
OBJECTIVES:The purpose of the current study was to estimate prevalence of pornography use and addiction in Rhode Island young adults, identify sociodemographic disparities, and determine if use and addiction were associated with mental illness.METHODS:Data from n=1022 participants of the Rhode Island Young Adult Survey were used. Pornography use and addiction, depression, anxiety, and suicide ideation were assessed. Multivariable logistic regressions controlled for age, social status, sex, gender, sexual orientation, and race/ethnicity.RESULTS:54% indicated pornography use; 6.2% met the criteria for addiction. Odds of pornography use were 5 times higher (95%CI=3.18,7.71), and addiction 13.4 times higher (95%CI=5.71,31.4) among heterosexual cis-males. Pornography addiction was associated with increased odds of depression (OR=1.92, 95%CI=1.04,3.49) and suicide ideation (OR=2.34, 95%CI=1.24,4.43).CONCLUSIONS:Pornography use is highly prevalent, and addiction may be associated with mental illness. New screenings, media literacy training, and developing new therapeutic interventions should be considered.
The HIV epidemic continues to cause a significant amount of morbidity and mortality. Globally, over 38 million people were living with HIV and 1.5 million acquired HIV in 2021.1 In the United States, there were over 36,000 cases of HIV diagnosed in 2021.2 Additionally, significant disparities persist among gay, bisexual, and other men who have sex with men (MSM). In the United States, MSM have a one in six lifetime risk of acquiring HIV, which increases to as high as a one in five lifetime risk among Hispanic/Latino MSM, and a one in two lifetime risk among Black/African American MSM.3 In Rhode Island, remarkable progress has been made across the last couple of decades in addressing HIV.4 Advances and improved approaches in HIV testing and treatment have led to these significant declines. The United States Preventative Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) all recommend routine HIV testing.5
BACKGROUND:Patients experiencing homelessness have increased disease burden, increased severity of illness, and increased barriers to accessing care. The provision of high-quality palliative care is therefore essential for this population. State of Homelessness: 18 out of every 10,000 people in the US and 10 out of every 10,000 Rhode Islanders (down from 12 in 2010) experience homelessness. Conceptual Model: High-quality palliative care for patients experiencing homelessness requires a foundation of patient-provider trust, well-trained interdisciplinary teams, coordinated transitions of care, community support, integrated healthcare systems, and comprehensive population and public health measures.CONCLUSIONS:Improving access to palliative care for those experiencing homelessness requires an interdisciplinary approach at all levels from individual providers to broader public health policies. A conceptual model rooted in patient-provider trust has the potential to address high-quality palliative care access disparities for this vulnerable population.
BACKGROUND:Smartphone addiction is a rising problem in the United States. The current study estimated the prevalence of smartphone addiction in Rhode Island young adults and its associations with mental illness.METHODS:The 2022 Rhode Island Young Adult Survey measured smartphone addiction, depression, anxiety, and suicide ideation. Covariates included age, sex/gender minority status, race/ethnicity, and social status.RESULTS:The prevalence of smartphone addiction was 34%. Odds of experiencing depression (OR[95%CI]=2.69 [2.05,3.52]), anxiety (OR[95%CI]=2.06 [1.58,2.69]), and suicide ideation (OR[95%CI]=1.55 [1.08,2.20]) were greater in participants with smartphone addiction. The relationship between smartphone addiction and depression was strongest in heterosexual cis-males (OR[95%CI] = 8.45 [3.53, 20.3]).DISCUSSION:Smartphone addiction is prevalent among Rhode Island's young adults and may be associated with depression, anxiety, and suicide ideation. Heterosexual cis-males may be particularly vulnerable. Screening programs and interventions to reduce smartphone use for all young adults, and particularly young men, should be considered.
BACKGROUND:Multidisciplinary Geriatric-Oncology (GO-MDC) clinic performed comprehensive geriatric assessment (CGA) to determine frailty and chemotherapy toxicity risk.METHOD:Retrospective cohort study of patients ≥65 years seen between April 2017 to March 2022. We compared Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) to CGA as a determinant of frailty and risk of toxicity from chemotherapy.RESULTS:Mean age of the 66 patients was 79 years. Eighty-five percent were Caucasian. Predominant cancers were breast (30%), and gynecological (26%). One-third were stage 4. The CGA identified fit (35%), vulnerable (48%), and frail (17%) patients whereas ECOG-PS classified 80% as fit. CGA assessed 57% of ECOG-fit patients as vulnerable or frail (p<0.001). High chemotherapy toxicity risk using CGA was 41% and using ECOG was 17% (p=0.002).CONCLUSION:At GO-MDC, CGA was a better predictor of frailty and toxicity risk than ECOG-PS. Treatment modification was recommended in one-third of patients.
BACKGROUND:The relationship between operative times and patient outcomes in total hip arthroplasty (THA) has not been well defined.METHODS:From January 2016 to December 2019, data were prospectively collected for THA patients in the FORCE-TJR registry and hospital EMR of an academic total-joint center.RESULTS:1,123 patients were included. Operative times ranged from 36 to 366 minutes, with a mean operative time of 111.26+/-31.37 minutes. Unadjusted GLM showed HOOS pain, ADL, and QoL scores differed across operative times, with patients who had operative times between 106 and 120 minutes having significantly lower pain, higher function, and better quality of life at 12 months, especially compared to patients with operative times < 90 minutes. Patients who had operative times between 106 and 120 minutes had significantly better VR-12 PCS and MCS at 12 months. Although statistically significant, differences were small and did not persist after controlling for within-surgeon effects, patient socio-demographics and baseline patient-reported outcomes, suggesting that patient characteristics or within-surgeon effects may play a more significant role in these patient-reported outcomes than operative time.CONCLUSION:This study showed that among THA patients, operative times were significantly associated with patient-reported outcomes at 12 months post-operatively, but is one of many surgeon and patient-related factors with effect on THA outcome.
Kidney stone disease is a common condition with an increasing prevalence. Diet is an important, modifiable risk factor of an individual's risk of developing kidney stone disease, particularly for those without genetic causes of kidney stone disease. Prospective and epidemiological evidence suggest that adequate fluid intake, limited sodium ingestion, and sufficient calcium and potassium intake can decrease the risk of developing kidney stones. Metabolic risk factors for KSD found on 24-hour urine studies can be used to tailor dietary modifications recommended to reduce subsequent risk of kidney stone formation.
OBJECTIVE:This study aimed to examine the patterns of complaints filed against physicians in Rhode Island, investigate the factors associated with complaint rates and outcomes, and assess the impact of the implementation of a new Framework for Just Culture.METHODS:Complaint data from the Rhode Island Department of Health's complaint tracker and physician licensing database were analyzed for the period of 2018 to 2020. Descriptive and statistical process control analyses were conducted to assess complaint rates, investigation rates, and adverse outcomes.RESULTS:Over the three-year period, 1672 complaints were filed against Rhode Island physicians, with approximately 40% of complaints being opened for investigation. The implementation of the Framework for Just Culture coincided with a sustained decrease in the rate of complaints opened. Failure to meet the minimum standard of care was the most common allegation, and male physicians and those aged 40-50 were more likely to have complaints filed against them.CONCLUSIONS:The study highlights the importance of complaint investigations in upholding standards for medical licensure and clinical competence. The Framework for Just Culture may have influenced the investigation process, resulting in fewer investigations opened without compromising the identification of cases requiring disciplinary action. These findings provide insights into physician accountability and the need for ongoing monitoring and improvement in complaint handling systems.
Small bowel obstructions are common surgical presentations that are most often caused by adhesions following abdominopelvic surgeries. However, in patients with no history of abdominal surgical interventions, assessment of the cause of a small bowel obstruction is more complex, and such patients frequently require operative intervention. We present a case of a 65-year-old man who presented with a small bowel obstruction caused by an inadvertent ingestion of a bread tag that was not identified on preoperative imaging. The sharp end of the bread tag had eroded through the small bowel leading to a walled-off perforation of the small bowel. Surgical resection was required.
