Marc Altshuler

Can the Medical Home Reduce Cancer Morbidity and Mortality

Addressing our current health care crisis will demand 2 forms of health care reform: reform of health care coverage and transformation of health care delivery. Most policy makers have accepted that primary care must play a prominent role in a new health care delivery vehicle. A new concept, the medical home, has emerged as a possible model of how primary care can improve performance and help control costs. Although the medical home concept has not yet been applied to cancer care, elements of the concept have the potential to improve cancer prevention efforts and to help coordinate care of individuals diagnosed with cancer. This article explores the possible role of the medical home in the war on cancer.

Development of unilateral cervical and supraclavicular lymphadenopathy after human papilloma virus vaccination.

A 26‐year‐old woman developed significant unilateral anterior cervical and supraclavicular lymphadenopathy 3 days after receiving her first dose (of a total of three doses) of human papilloma virus (HPV) vaccine. She had no history of lymphadenopathy after other previous immunizations, and had received no vaccines other than HPV at that time. The left‐sided lymphadenopathy developed after she was vaccinated in the left deltoid muscle. The spatial and temporal relationships between the appearance of the lymphadenopathy and receipt of the vaccine in the absence of other causal agents strongly suggest that the HPV vaccine was the causal agent. Use of the Naranjo adverse drug reaction probability scale indicated that the HPV vaccine was a probable (score of 6) cause of the patients adverse reaction. The patient received her second dose of the HPV vaccine 2 months later without further lymphadenopathy. To prevent unnecessary lymph node biopsies and patient concern, clinicians should be aware that lymphadenopathy may occur after HPV vaccination.

Cervical Cancer Screening Outcomes in a Refugee Population

Cervical cancer is the second most common cause of female cancer mortality worldwide, accounting for approximately 274,000 deaths annually (Parikh, Brennan, & Boffetta, 2003; World Health Organization, 2002). Of the estimated 500,000 new cases of cervical cancer diagnosed each year, 80% of these occur in developing countries, with the highest rates occurring in Africa, Asia, and Central and South America (de Sanjose et al., 2010; Ferlay et al., 2010; Lipson et al., 1995; Parikh et al., 2003; World Health Organization, 2002, 2011). Human papillomavirus (HPV) has been detected in 99% of cervical cancer cases, and infection with HPV is a prerequisite to the development of invasive cervical cancer (de Sanjose et al., 2010; Dunne et al., 2007; Ferlay et al., 2010; Lipson et al., 1995; Parikh et al., 2003; World Health Organization, 2002, 2011). Seventy percent of cervical cancers are due to high-risk (HR) HPV types 16 and 18, and although there is some geographic variation in the prevalence of HPV, global data suggests that the eight most common high-risk oncogenic HPV genotypes (16, 18, 21, 33, 35, 45, and 52) contribute to over 90% of the cervical cancer in all world regions [de Sanjose, 2010; Dunne, 2007; World Health Organization, 2011].

Erythema Multiforme After Meningitis Vaccine: Patient Safety Concerns with Repeat Immunization

A 20‐year‐old college student developed an immunologic hypersensitivity reaction, erythema multiforme minor, 1–2 weeks after receiving a meningococcal conjugate vaccine. He had no history of erythema multiforme, nor had he received any other vaccine or drug therapy. The temporal relationship between the development of erythema multiforme and the vaccination suggests that the meningitis vaccine probably was the causal agent. The occurrence of this distinct cutaneous reaction, with the potential for a serious complication such as erythema multiforme major or Stevens‐Johnson syndrome on rechallenge, should serve as a warning against repeated booster vaccinations in patients who develop reactions such as this one.

An opportunity for coordinated cancer care: intersection of health care reform, primary care providers, and cancer patients.

The US health care system has become increasingly unsustainable, threatened by poor quality and spiraling costs. Many Americans are not receiving recommended preventive care, including cancer screening tests. Passage of the Affordable Care Act in March 2010 has the potential to reverse this course by increasing access to primary care providers, extending coverage and affordability of health insurance, and instituting proven quality measures. In order for health care reform to succeed, it will require a stronger primary care workforce, a new emphasis on patient-centered care, and payment incentives that reward quality over quantity. Innovations such as patient-centered medical homes, accountable care organizations, and improved quality reporting methods are central features of a redesigned health care delivery system and will ultimately change the face of cancer care in the United States.

The management of keloids: hands-on versus hands-off.

Keloids are benign fibrous growths that appear in scar tissue. The lesions can be severely disfiguring and early recognition of genetic lesions is crucial. This case report outlines and reviews the important management strategies for these lesions and the requirement for extensive counseling for the patient and their family. Many potential medical and surgical interventions exist. Unfortunately, these lesions tend to recur and overall outcomes remain poor. Given patient susceptibility to disfiguring results, surgical intervention should be used with extreme caution.

Evaluation of latent tuberculous infection and treatment completion for refugees in Philadelphia, PA, 2010-2012.

SETTING Philadelphia, PA, USA. OBJECTIVES To compare the evaluation and treatment of latent tuberculous infection (LTBI) in refugees seen at member clinics of the Philadelphia Refugee Health Collaborative (PRHC) vs. non-PRHC clinics. DESIGN Refugees with Class B (non-communicable) tuberculosis (TB) admitted to the United States from 2010 to 2012 who were being treated at PRHC clinics were compared to those treated at non-PRHC clinics. Odds ratios (ORs) for attending a follow-up appointment, completing treatment, and time from arrival to the United States to the first TB screening test were calculated. RESULTS Of the 2094 refugees who arrived in Philadelphia in 2010-2012, the Philadelphia Department of Public Health was notified of 149 who required additional evaluation for TB. Among these, 57 (38.3%) were confirmed to have LTBI, and none were diagnosed with active TB. All LTBI cases were recommended for anti-tuberculosis prophylaxis and 43 (75.4%) completed treatment. Refugees receiving care from PRHC clinics were more likely to be screened within 30 days of arrival (OR 4.70, 95%CI 2.12-10.44), attend a follow-up appointment (OR 4.53, 95%CI 1.36-16.27), and complete treatment (OR 9.44, 95%CI 2.39-37.3). CONCLUSION Refugees who attended PRHC clinics were more likely to be evaluated promptly and to complete LTBI treatment. The PRHC clinics serve as a model for communities seeking to improve refugee health care.

Vaccine-preventable diseases and foreign-born populations

According to the most recent census data, foreign-born individuals account for more than 12% of the US population. Because many vaccine-preventable outbreaks in the United States have been correlated with disease importation, Congress has mandated vaccinations for numerous immigrant populations. It is essential for primary care physicians to be knowledgeable about the unique immunization-related needs of foreign-born individuals to recognize some of the cultural and linguistic challenges that immigrants have accessing health care and to remember to use each medical encounter as an opportunity to provide necessary vaccinations.

Leveraging Structural Changes in an Electronic Health Record Tool to Standardize Written Handoff

Miscommunications during patient handoff can lead to harm. The I-PASS bundle has been shown to improve safety outcomes. Although effective training reliably improves verbal handoffs, research has demonstrated a lack of effect on written handoffs. The objective was to compare written handoff before and after integration of a standardized electronic health record (EHR) tool. Interns at a large urban academic medical center underwent I-PASS handoff training. The EHR handoff tool was then revised to prompt the I-PASS components. Handoff documents were obtained before and after the intervention. More handoffs included Illness Severity (33% to 59%, P < .001) and Action List (65% to 83%, P = .005) after the intervention. There was no change in handoffs with miscommunications (12.5% to 10%, P = .566) or omissions (8% to 11%, P = .447). Handoffs including tangential or unrelated information decreased (20% to 4%, P = .001). A written handoff tool can reinforce the effect of training and increase adherence to I-PASS.

Global Health at Home: A Student-Run Community Health Initiative for Refugees

Free, student-run health initiatives for refugees fill a gap in needed health services and prepare medical students for understanding cross-cultural and systems-based medical practice.