Olufunso W. Odunukan

Provider and Interpreter Preferences Among Somali Women in a Primary Care Setting

Objectives: Somali people are among the largest refugee populations to resettle in North America and Europe over the past 2 decades, and health disparities are well documented, including barriers to effective navigation of primary health care systems. Patient–provider gender discordance has been described as a barrier to health-seeking behaviors and effective communication by Somali women in past qualitative work. The objective of this study was to elucidate provider and interpreter preferences during clinical encounters according to gender and race among Somali women in the United States. Methods: Fifty Somali women empanelled to a large primary care practice completed pictorial surveys to elucidate preferences of Somali women for providers of different genders and race for different components of the clinical examination using a Likert-type scale. Results: We found that Somali women generally preferred a female provider for conducting the physical examination, particularly for the pelvic, breast, and abdominal examinations. Likewise, Somali women strongly preferred female interpreters to be present during the physical examination. There was no stated preference for patient–provider racial concordance. Conclusions: These findings have implications for structural health care changes aimed at delivering culturally sensitive and effective primary care to Somali patients.

The value of telephone triage for patients with appendicitis

Although it has been assumed that telephone triage can directly benefit patients by facilitating early diagnosis and treatment, this potential benefit has not been well documented. Using appendicitis cases ascertained from claims data, we compared telephone triage recommendations with what the callers originally intended to do. Over a two-year period, there were 20,230 calls to a telephone triage centre in the US where insurance information was available. Of these, 12,709 calls (63%) had insurance claims made within seven days of the call. Among these calls, 46 had a diagnosis of appendicitis. In 72% of calls concerning appendicitis, the telephone triage recommendation was for a more rapid evaluation than the caller originally intended (P < 0.0001). In 91% of the appendicitis cases, triage nurses directed callers to care within 8 h, but without triage advice, only 39% of callers stated they would have sought care within 8 h (P < 0.0001). Telephone triage significantly reduced the delay in care for appendicitis in comparison with what the caller would have done. This suggests that telephone triage potentially reduces the morbidity associated with appendicitis.

CALL ME SENILE NO MORE: AN UNUSUAL CASE OF HEART FAILURE SECONDARY TO CARDIOPULMONARY AMYLOIDOSIS

Amyloidosis causing heart failure in elderly African Americans is often assumed to be senile systemic amyloidosis. A 78-year-old African-American male non-smoker presented with a 1 year history of reduced exercise capacity and 2 months of lower extremity swelling. His medical history included

Ascending aortic dissection presented as inferior myocardial infarction: a clinical and diagnostic mimicry

Acute ST segment elevation myocardial infarction (STEMI) is typically associated with acute coronary thrombosis or plaque rupture. Rarely, STEMI can be associated with ascending aortic dissection, which represents the majority of acute aortic syndrome aetiologies and carries dreadful outcomes. Routine cardiac intervention with emergent cardiac catheterisation may lead to a higher mortality rate in this group of patients. We present a case of painless inferior STEMI in the setting of ascending aortic dissection. The patient had an inferior STEMI due to the involvement of the right coronary artery as an extension of the ascending aortic dissection. In this era of protocol-driven practice and the pressure to fulfil quality measures, we aim to alert emergency physicians, cardiologists and interventionalists of the possible presentation of painless ascending aortic dissection as an STEMI. The two pathologies characterise by crucial differences in their initial and ultimate management.

IMAGING DEBAKEY’S DEBACLE: AN UNUSUAL CASE OF PAINLESS ACUTE ST ELEVATION MYOCARDIAL INFARCTION

Acute STEMIs are in 1-2% of cases associated with cardiovascular catastrophes other than acute coronary thrombosis. We present a case of an acute aortic dissection presenting as a case of acute inferior ST elevation without chest pain. A 77-year-old female smoker with a history of COPD was

Impact of Exercise Stress Testing on Diagnostic Gene Expression in Patients With Obstructive and Nonobstructive Coronary Artery Disease

A blood-based gene expression test can diagnose obstructive coronary artery disease (CAD). The test is sensitive to inflammatory and immune processes associated with atherosclerosis. Acute exercise engages short-term inflammatory pathways, and exercise stress testing may affect results of gene expression testing during the same diagnostic workup. The objective of this study was to evaluate the effect of exercise on diagnostic gene expression testing. Ten patients with obstructive CAD (≥50% stenosis) and 10 with no/minimal CAD (≤20% stenosis) were identified by angiography. Blood samples for gene expression were obtained at baseline, peak exercise, 30 to 60 minutes after testing, and 24 to 36 hours after testing. Core-lab gene expression analysis yielded raw gene expression scores (GES) for each time point. Linear models were used to estimate changes in GES, adjusting for CAD status and other covariates. GES increased during peak exercise across both genders, with no significant differences as a function of CAD status. The overall adjusted mean GES increase at peak exercise was 0.29 (95% confidence interval 0.22 to 0.36; p <0.001). GES after exercise were not significantly different from baseline. The change in gene expression levels during peak exercise may reflect a transient inflammatory response to acute exercise that may be independent of patient gender or CAD status. In conclusion, CAD GES increase at peak exercise testing and rapidly return to baseline. Such may reflect a transient inflammatory response to acute exercise independent of gender or extent of CAD.

48-Year-Old Man With Cough and Leg Swelling

A 48-year-old man with no remarkable medical history was sent to the emergency department from a local urgent care facility because of cough, dyspnea, mild chest discomfort, lower extremity edema, and a blood pressure (BP) of 210/150 mm Hg. He had no fever, constitutional symptoms, blurry vision, headaches, back pain, weakness, palpitations, or tremors and no personal or family history of hypertension. He did not use alcohol, tobacco, or illicit drugs.

504 ADDRESSING THE CARE OF CHRONIC DISEASES IN POST DISASTER RESPONSES

Background: Medical response in many disaster situations typically consists of sporadic ‘medical missions’ aimed at addressing communicable illnesses with little attention to chronic diseases. Objective: To study the management of hypertension in evacuation camps after Typhoon Sendong hit the Philippines on December 16, 2011. Design and methods: Methods included direct observations during medical missions to 4 evacuation camps, nine key informant interviews conducted with patients with hypertension and 2 interviews with volunteer staff. Lists of available medications were analyzed. Results: Adults were routinely screened for hypertension using a single BP measurement. Most hypertension patients seen in the Sendong camps were previously diagnosed and middle aged (range 44 – 65 years). Patients reported worsened blood pressure (BP) control due to lack of access to medications; increased stress and poor diet. Disaster food rations for victims were high sodium content items including instant noodles, dried salted fish and canned goods. Of the 55 medications supposedly available, only 4 were anti-hypertension medications and only 1 (metoprolol) was available for dispensing. Patients with uncontrolled BP were given a limited supply without a long-term supply plan. Conclusions: Post disaster medical missions routinely screen adults in evacuation camps for hypertension but lack a defined plan for management. Antihypertensive medications were in short supply. BP control may be further worsened by dietary rations with high sodium content. Future disaster responses need to incorporate plans for the care of chronic conditions.