INTRODUCTION:The authors' objective was to assess knowledge of and perceived access to long-acting reversible contraceptives (LARC) among individuals in the United States considering tubal sterilization. METHODS:Using online convenience sampling through social media advertisements, the authors recruited 442 US-born individuals considering tubal sterilization for this cross-sectional study. Eligibility criteria included age 21-45 years, female sex, premenopausal, desire to avoid future pregnancy, and no history of tubal sterilization, hysterectomy, or infertility treatment. After confirming eligibility, participants completed a 45-item online survey assessing sociodemographic characteristics, contraceptive and pregnancy history, and awareness of LARC. Chi-square tests and multivariate linear regression were used to identify sociodemographic variables associated with knowledge of and perceived access to LARC. RESULTS:Among these diverse (39% Black, 36% White, 10% Hispanic and Latinx) participants, 89% had heard of the implant and 92% had heard of the intrauterine device (IUD). Less than half reported having discussed LARC with a clinician in the past year; 47% had discussed IUDs and 31% the implant. Participants correctly answered an average of 37% of implant knowledge questions and 39% of IUD knowledge questions. Misconceptions that IUD (73%) or implant (83%) use may cause weight gain were particularly prevalent. In multivariate analyses, participants residing in the south had less knowledge of the implant than those in the midwest (β = -.50; 95% CI, -0.92 to -0.09). DISCUSSION:US individuals considering tubal sterilization may lack information about LARC relevant to informed contraceptive decision-making. CONCLUSION:Person-centered contraceptive counseling and shared decision-making should ensure that patients considering tubal sterilization are well informed about and can access alternative contraceptives, including LARC.
Alveolar rhabdomyosarcoma (ARMS) of the larynx is an exceedingly rare malignancy with only 3 cases previously documented. This fourth case was a 54-year-old female patient who presented with progressive dyspnea, dysphonia, dysphagia, and otalgia. Positron emission tomography/computed tomography imaging revealed a 2.8 × 2.3 × 1.9 cm fluorodeoxyglucose-avid supraglottic mass centered in the left aryepiglottic fold with mild regional lymph node uptake. Histopathologic examination demonstrated nests of small round tumor cells with alveolar-like spaces, staining positive for myogenin, desmin, smooth muscle actin, and CD56. Molecular analysis confirmed a FOXO1 rearrangement, consistent with ARMS. Treatment with ARST 1431 protocol resulted in partial response with tumor reduction and no evidence of fluorodeoxyglucose-avid metastatic disease on follow-up positron emission tomography/computed tomography. This case highlighted the diagnostic challenge of laryngeal ARMS due to its rarity, nonspecific presentation, and resemblance to more common laryngeal lesions such as squamous cell carcinoma. Accurate diagnosis and treatment require multidisciplinary integration of histopathology, immunochemistry, molecular testing, chemotherapy, and surgical assessment. Recognition is critical, as early identification and multimodal treatment may improve outcomes and help preserve laryngeal function. This fourth reported case of laryngeal ARMS, which has thus far resulted in a favorable patient outcome, contributed invaluable insight into this disease's presenting features and response to therapy.
BACKGROUND:Chronic musculoskeletal pain remains a vexing clinical challenge, and health care systems have struggled to identify effective, scalable, and safe treatment alternatives to opioids and other higher-risk interventions. Remotely delivered cognitive behavioral therapy for chronic pain (CBT-CP) offers an evidence-based approach to meet this need. METHODS:The qualitative portion of the study aimed to advance understanding of how clinicians and health care system administrators perceive remotely delivered CBT-CP and to inform its dissemination and practical integration into health care systems. Specifically, semistructured interviews were conducted with 9 health care system representatives involved in chronic pain care as part of a large NIH-funded trial testing the comparative effectiveness of 2 CBT-CP interventions: online self-completed vs delivered by master's level behavioral health practitioners via phone/videoconferencing. RESULTS:Interviewees included clinicians, administrators, and staff involved in the delivery of care for chronic pain at the health care systems participating in the trial. They found both programs promising with good supporting evidence and felt that both could be helpful in alleviating staffing challenges, expanding therapeutic options, and providing access to chronic pain services in rural areas. CONCLUSIONS:In summary, evidence-based, remotely delivered CBT-CP interventions provide opportunities for closing care gaps and better meeting the needs of patients, particularly those residing in rural or other medically underserved areas. Health care leaders saw CBT-CP as an effective nonpharmacologic tool for improving care, and their perspectives can serve to guide the implementation and broad dissemination of these programs.
Synovial sarcoma (SS) is a rare, high-grade mesenchymal malignancy accounting for 5% to 10% of all soft tissue sarcomas, most commonly arising in the extremities of adolescents (ages 13-17) and young adults (ages 18-24). Head and neck involvement is uncommon, representing approximately 5% of cases, with primary involvement of the hyoid bone being exceedingly rare. To date, only 2 cases of SS of the hyoid bone have been reported in the literature. The authors have presented the third reported case of SS originating from the hyoid bone, successfully treated with a trimodality approach. A 62-year-old of male sex presented with a left-sided neck mass and was diagnosed with translocation (X;18) (p11.2; q11.2)-positive SS. The patient underwent neoadjuvant chemotherapy with an anthracycline- and ifosfamide-based regimen, followed by surgical resection and adjuvant radiation therapy, achieving a pathologic complete response. The patient remains disease-free 5 years following treatment. This case highlighted the importance of multidisciplinary management and supported the potential role of neoadjuvant chemotherapy in optimizing outcomes for rare head and neck SS.
Thrombotic microangiopathy (TMA) encompasses disorders characterized by endothelial injury, microvascular thrombosis, and end organ injury. Although systemic TMA is typically identified through anemia, thrombocytopenia, elevated lactate dehydrogenase, suppressed haptoglobin and schistocytes, these markers lack sensitivity, particularly in renal-limited TMA. A patient presented with acute kidney injury requiring dialysis whose renal biopsy revealed extensive TMA despite the absence of schistocytes or other systemic features. Diagnosis and management required coordinated collaboration among nephrology, hematology, pathology, and pharmacy teams, enabling rapid interpretation of biopsy findings and timely initiation of complement component 5b inhibition. This multidisciplinary approach led to recovery of kidney function and discontinuation of dialysis. The case highlighted how team-based evaluation and shared decision-making improved diagnostic accuracy and treatment efficiency, ultimately elevating quality of care. It also reinforced the importance of early biopsy and reconsideration of TMA in patients without hematologic abnormalities. Recognition of renal-limited TMA and prompt initiation of complement-directed therapy are essential to prevent irreversible renal injury and optimize outcomes.
Fournier's gangrene is a rare, life-threatening disease that presents a substantial diagnostic challenge. The authors have presented a case of a patient with diabetes, sodium-glucose cotransporter 2 inhibitor use, and Aboriginal heritage, illustrating a unique confluence of risk. Clinical vigilance and the rapid mobilization of resources enabled secondary prevention through early antibiotic administration, surgical consultation, and diagnostic imaging. This strategy mitigated morbidity and mortality, facilitating a favorable clinical outcome. Emergency practitioners must recognize these converging risk factors to maintain high vigilance for this diagnostic challenge.
BACKGROUND:Youth-directed cannabis messaging is often generic, adult-centered, and does not reflect contemporary patterns of cannabis use. This study examined adolescents' perceptions of cannabis-related messaging and identified messaging strategies they find relevant. METHODS:The authors conducted qualitative interviews with adolescents aged 14-17 years with past 30-day cannabis use. Interviews were analyzed using thematic analysis with constant comparison. Data collection continued until no new themes were identified (N = 7). RESULTS:Adolescents reported that fear-based and abstinence-only messaging were ineffective. They viewed nonjudgmental, autonomy-supportive, and youth-centered messaging as more credible. Participants emphasized that clinicians should acknowledge the perceived benefits of cannabis to build trust and credibility. Messages that focused on immediate consequences of cannabis use, such as brain fog and memory impairment, were more effective than generalized long-term harms. Adolescents expressed greater trust in harm reduction messaging and communication strategies that integrate real-world adolescent experiences with clinician expertise. CONCLUSIONS:These preliminary findings suggest that clinicians should consider framing cessation messaging around cognition and memory. Although the long-term goal is cannabis cessation, clinicians should remain ready to transition toward harm reduction guidance, based on adolescents' receptiveness and their response to initial abstinence-focused conversation, reflecting an adaptive framework that shifts in intensity and orientation with the patient's response rather than following a static treatment algorithm. Although these strategies may enhance engagement and mitigate treatment dropout, larger-scale studies are needed before these strategies can be broadly recommended for clinical practice. Ethical incorporation of peer-lived experiences to support harm reduction and cessation should be considered.
The most common sites of breast cancer metastasis include the bone, lung, liver, and brain. Metastasis to the uterine cervix and endometrium is uncommon and can mimic primary gynecologic malignancies, leading to substantial diagnostic challenges. The authors have reported a 56-year-old postmenopausal woman with metastatic invasive mammary carcinoma of the left breast, including biopsy-confirmed liver metastasis, who presented after a syncopal event following an episode of heavy vaginal bleeding. Following her presentation, she underwent cervical and endometrial biopsies. Cervical biopsy revealed scattered discohesive tumor cells positive for GATA3, mammoglobin, TRPS1, AE1/3, and CAM5.2 and negative for PAX8, which were consistent with metastatic breast carcinoma. Endometrial biopsy showed cohesive nests of atypical carcinoma with diffuse p16, p63, and CK5/6 positivity and negative staining for mammoglobin, TRPS1, SOX10, and PAX8, initially raising concern for a human papillomavirus-associated squamous cell carcinoma. Following multidisciplinary evaluation, it was established that these features represented metastatic breast human papillomavirus-associated squamous cell carcinoma to the endometrium rather than a new primary gynecologic malignancy. This case highlighted the importance of considering metastatic disease in patients with breast cancer presenting with abnormal uterine bleeding and demonstrated the value of multidisciplinary evaluation in determining an accurate diagnosis.
INTRODUCTION:Although the long-term effects of adverse childhood experiences (ACEs) are well studied, there is a lack of literature about how patients understand and prefer to discuss these issues in health care settings. This qualitative study explored patients' knowledge of ACEs, their preferences for learning about the health effects of trauma, and their perspectives on integrating ACEs education, including patient education posters, into primary care visits. METHODS:Two focus groups were conducted with 8 patients at an internal medicine clinic in the midwestern United States. Discussions were transcribed verbatim and analyzed using inductive thematic content analysis to identify key themes related to health literacy, patient preferences for ACEs screening and discussions in clinical care, and reactions to ACEs educational posters. RESULTS:Three main themes emerged: 1) understanding of ACEs, including varying levels of health literacy and familiarity with the concept; 2) preferences for learning about ACEs, with participants emphasizing the importance of optional screening and trauma-informed communication; and 3) responses to posters, where infographic-style posters were viewed as effective conversation starters but required careful attention to language, imagery, and inclusivity. CONCLUSIONS:Patients were willing to engage in discussions about ACEs during primary care visits when approached with compassion and expertise. Findings highlight the need to tailor communication strategies to individual readiness and literacy levels. Incorporating patient feedback into ACEs education and screening processes may enhance trust, improve patient-clinician relationships, and support holistic care.
INTRODUCTION:The COVID-19 pandemic forever changed health care delivery and led to a rapid uptake in telehealth visits. However, the quality and equity of these visits compared to in-person visits are unknown. This analysis interviewed oncology practitioners to understand how US-based cancer centers considered care quality and equity in the implementation and sustainability of telehealth programs. METHODS:This qualitative study employed semistructured interviews to explore practitioners' experiences and perceptions regarding care equity and quality within integrated telehealth services. Primary data collection occurred through interviews conducted between October 2021 and January 2023. These interviews were audio-recorded, transcribed, and analyzed using qualitative thematic analysis. RESULTS:Four main themes, representing interviews with 39 professionals from 16 organizations, were identified: 1) organization-level diversity, equity, and inclusion (DEI) efforts remained conceptual and disconnected from oncology telehealth services, 2) equity and quality-related actions were predominately reactive rather than proactive, 3) equity was misinterpreted as providing equal care to all patients, and 4) telehealth quality and equity were not systematically measured or prioritized. DISCUSSION:These findings highlight how organizational DEI efforts did not translate to tangible operational practices in oncology telehealth care. These results suggest limited organization DEI maturity and practice-level accountability for equity and quality and a lack of understanding of equity. CONCLUSION:To deliver high-quality and equitable oncology telehealth, cancer centers and other health care organizations must progress beyond awareness of equity issues. They need to implement concrete resources, support systems, and policies that facilitate effective strategy execution.
This review aims to compare the FICA (faith, importance/influence, community, address in care) and HOPE (sources of hope, organized religion, personal spirituality/practices, effects on care) spiritual screening tools across multiple domains, including clinical utility, implementation feasibility, and psychometric properties, in order to synthesize evidence and provide guidance to health care practitioners and educators regarding the relative strengths and limitations of the 2 tools. This review of published literature involved a structured search in PubMed, CINAHL, Embase, and PsycINFO, from which 2 reviewers independently screened, extracted, and synthesized data using predefined criteria. The studies included in the review assessed the use of the FICA and/or HOPE tools with adult patient populations and health care professionals in multiple countries, primarily within academic and hospital-based settings. FICA was more frequently used in clinical and educational settings and was noted for its structured format and integration into serious illness care. Meanwhile, HOPE was noted for its open-ended format and greater flexibility in exploring personal spirituality, particularly among patients identifying as spiritual but not religious. Although there does not seem to be research validating or using psychometric resources to analyze these tools, qualitative studies indicated their perceived value in enhancing holistic care. Both FICA and HOPE are valuable frameworks for initiating spiritual screenings in clinical practice. FICA may be more suitable in fast-paced environments because of its concise structure, whereas HOPE offers greater depth and personalization. Further research should focus on developing validated outcome measures and examining the impact of spiritual screenings on patient care.
INTRODUCTION:Patient portals are central to health care communication, yet disparities in adoption persist among underserved populations. Most implementation strategies draw on general population research, but adoption mechanisms may differ substantially in safety-net settings. METHODS:This mixed-methods cross-sectional study examined portal adoption barriers at a student-run free clinic serving predominantly uninsured, Spanish-speaking adults (n = 112 patients, N = 42 practitioners), with comparison to the Health Information National Trends Survey 6 (n = 5232). Exploratory cluster analysis identified patient engagement patterns. Semistructured interviews (n = 11) contextualized quantitative findings. Logistic regression models compared behavioral predictors across settings. RESULTS:Portal adoption was 22.3% locally vs 66.1% nationally. Cluster analysis identified 4 engagement patterns reflecting distinct barriers, including patients with high health confidence but low information access. Qualitative interviews revealed system usability and trust barriers rather than health literacy deficits. A logistic regression model using behavioral predictors performed well nationally (area under the curve = 0.78) but poorly locally (area under the curve = 0.37), suggesting different adoption mechanisms in safety-net settings. Only 44.3% of practitioners found the portal easy to use. CONCLUSIONS:Equitable digital health implementation requires community-specific barrier assessment rather than reliance on generalized national models. System-level usability and trust barriers, rather than individual behavioral deficits, may drive low portal adoption in underserved populations.
BACKGROUND:Hemodialysis (HD) patients with arteriovenous fistula (AVF) or arteriovenous graft (AVG) are often prescribed anticoagulation to prevent thrombosis, though evidence supporting this practice is limited. This study aimed to compare AVF and AVG thrombosis rates in HD patients with and without anticoagulation to inform clinical practice. METHODS:The authors conducted a retrospective analysis within Kaiser Permanente Northern California, an integrated health care system serving 4.6 million members. Patients initiating HD between January 1, 2013, and December 31, 2021, were identified and categorized based on anticoagulation use after dialysis initiation. Thrombosis rates of AVF and AVG were assessed within 1 year. RESULTS:A total of 9079 HD patients were included; 1837 received anticoagulation for various indications, 7242 did not. Compared to non-users, the anticoagulation cohort was older, had higher Charlson comorbidity scores, greater prevalence of hypertension and peripheral vascular disease, and lower aspirin use. After 1 year, AVF thrombosis rates were similar between groups. However, AVG thrombosis and bleeding events were more frequent among anticoagulated patients. No substantial differences in thrombosis or bleeding outcomes were observed between warfarin and apixaban users. CONCLUSION:Anticoagulation in HD patients did not reduce AVF or AVG thrombosis and was associated with increased bleeding risk. These findings may reflect differences in baseline patient characteristics. Randomized prospective studies are needed to clarify the role of anticoagulation in maintaining vascular access patency.
INTRODUCTION:Colorectal cancer (CRC) disproportionately affects American Indian and Alaska Native communities. One approach to increasing CRC screening is to develop tailored messages and materials. In collaboration with the Great Plains Tribal Leaders Health Board (GPTLHB) and the South Puget Intertribal Planning Agency (SPIPA), the authors employed an adapted approach of boot camp translation (BCT), a validated community-based participatory method, to co-create tailored CRC materials. METHODS:To enhance cultural relevance, the authors reframed the BCT process and renamed the sessions as "listening sessions." Listening sessions were conducted with GPTLHB in Rapid City, South Dakota, and with SPIPA in Shelton, Washington. Each included a 1-day in-person meeting and 2 virtual conferences. The objectives were to co-create materials and messages that motivate members to complete CRC screening and identify preferred communication channels for CRC-related information within the tribal community. RESULTS:The authors met with 53 tribal members across organizations. Both GPTLHB and SPIPA sessions emphasized the need for a multigenerational approach and culturally and locally relevant imagery, language, and traditions. GPTLHB members wished to include Lakota words, simple illustrations for colon health education, and recognition of traditional healing practices. SPIPA members underscored the importance of water as a symbol of healing and local intertribal milestones, such as the canoe journey. Preferred dissemination channels included physical fact sheets, posters, visual stories, animated videos, and live-action videos. CONCLUSION:Using modified BCT, the authors partnered with American Indian and Alaska Native communities to co-create screening messages for CRC and identified favored dissemination networks tailored to each community's context.
BACKGROUND:Postpartum hemorrhage remains a leading cause of severe maternal morbidity and mortality. The association between mild thrombocytopenia and postpartum blood loss or red blood cell transfusion has not been well studied. OBJECTIVE:To evaluate whether mild thrombocytopenia at admission to labor and delivery is associated with increased rates of postpartum hemorrhage and packed red blood cell transfusion. STUDY DESIGN:The authors performed a retrospective cohort study of pregnancies delivered within a large health maintenance organization from 2008 to 2020. Maternal characteristics and outcomes of those with mild thrombocytopenia were compared to those with typical platelet levels before delivery. The primary outcome was the rate of red blood cell transfusion. Secondary outcomes included quantity of red blood cell transfusion, postpartum hemorrhage, additional procedures performed, and use of uterotonic medications. Statistical analysis was done using χ2 or Mann-Whitney U test. A multivariable logistic regression was also performed. RESULTS:Data from a total of 305,794 pregnancies were included in this study. Mild thrombocytopenia was associated with a small but statistically significant increase in postpartum red blood cell transfusion compared with typical platelet levels (1.2% vs 0.9%, P < .0001). Mild thrombocytopenia was also associated with a higher rate of 2 or more red blood cell transfusions (0.33% vs 0.19%), postpartum hemorrhage (2.4% vs 2.0%), use of uterotonics, and additional procedures performed (all P values < .05). These outcomes all remained statistically significant after adjusting for confounding variables. CONCLUSIONS:Mild thrombocytopenia prior to delivery is associated with a small increased chance of red blood cell transfusion, postpartum hemorrhage, uterotonic use, and the need for additional procedures postpartum.
