Browsing by Author "Kremer, Timothy"
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Item Evaluating student responses to incorporate Vulnerable Patient Population centered content into the curriculum(2023) Panzanaro, Victoria; Kremer, Timothy; Srivastava, Prakriti; Valdez, Alia; Wiemann, Natalia; Basha, Riyaz; Garcia, JoannaPurpose: Vulnerable patient populations are considered groups of people who cannot access healthcare resources or services due to social barriers. Despite advances in the healthcare system and medical education, providers still report feeling less comfortable caring for these patients, and medical students around the country report not feeling this topic is adequately addressed in their curricula. The goal of this project was to evaluate students’ responses to introducing an optional curriculum dedicated to discussing four vulnerable populations (Transgender Patients, Incarcerated Patients, Housing Insecure Patients, and Intellectually and Developmentally Disabled Patients). Our expectation is that students will feel more comfortable being a part of these patient’s healthcare teams, and determine the value of providing students with a manageable curriculum focused on these topics. Methods: The tested curriculum consists of four modules, with each dedicated to one of the populations. Each module consists of a pre-recorded video lecture, a supplemental article, and an optional 30 minute interactive session with a content expert who is currently a healthcare provider focused on each population. Texas College of Osteopathic Medicine students voluntarily participated in this evaluation activity. A literature review was performed to create the content outline and objectives. This information was presented in a short pre-recorded video lecture taught by peers. Supplemental articles were chosen to pair with each video. After completing the modules, participants had the option to a virtual interactive meeting where a content expert that works with each of these patient populations had 30 minutes to talk about their experiences and answer questions. The students then consented to an anonymous post-survey to evaluate if they feel that taking this course has benefited their educational experience and if they feel more prepared to be a part of a healthcare team for these patients. All content and materials were reviewed by content experts. Results: 26 students signed up to take the course, and 20 students completed the modules and attended the optional content expert session. Of those 20 students, 90% completed the post-course survey. The survey showed that students feel vulnerable patient populations are important to learn about, that each population has specific healthcare considerations that should be taught, and that a course similar to this is beneficial to their education. Participants reported feeling more informed about caring for these patients and have taken away information that will be valuable in their future practice. Conclusion: Medical students feel that vulnerable patient populations and their barriers to healthcare are important topics that should be discussed in medical school curriculums. Students recognize that each population has specific healthcare needs that should be individualized to them, and that incorporating a course that discusses this would be beneficial to their classroom and clinical training. The participating students reported that they gained new, useful knowledge that will help them be more supportive for these patients, and wish to see similar content incorporated into the curriculum and expanded on in the future. In conclusion these results are interesting and suggest conducting a research study in the future.Item Faculty, Resident, and Nursing Attitudes Regarding Transitions of Care of Antepartum, Postpartum, and Gynecology Patients in the County Hospital Setting(2017-03-14) Hoang, Christine; Jackson, Angalene; Marshall, Hayley; Kremer, TimothyPurpose: To evaluate attitudes about a transition of care system and identify opportunities to improve the safety and quality of care involving antepartum, postpartum, and gynecology patients. Background: Handoffs and transitions of care have been a central part of patient safety goals at John Peter Smith Hospital. With twice daily shift changes for physician and nurses, the Department of Obstetrics and Gynecology introduced a new interdisciplinary team transition of care system. Initial anecdotal feedback suggested that the handoff process was suboptimal and communication efforts could be improved. A survey was developed to evaluate opinions about the process and identify areas for improvement. Methods: An anonymous online survey was administered to physicians and nurses participating in the new handoff system. The results were analyzed to identify opportunities for improvement. Results: Responses were analyzed from 21 members of the interdisciplinary team. 47% of the respondents found the transition of care system helpful. 55% felt their goals for handoffs were accomplished. All respondents reported importance in addressing updates on patient plans of care and anticipated discharge dates. Content of handoffs should focus on the acute and critically ill patients. The attending physician, chief resident, and nursing team leaders should participate in the handoff process. Conclusions: Differences in goals and content focus between nurses and physician contributed to suboptimal communication and handoffs. Identifying the deficits allow opportunities for improvement in transitioning care and ultimately the safe and quality of care provided to patients. Participation in the process should include faculty physicians, chief residents, and nursing leaders.Item A Paravaginal Epidermal Inclusion Cyst Presenting as Chronic Bilateral Pelvic Pain(2024-03-21) Shah, Krusha; Kremer, TimothyBackground: Epidermal inclusion cysts are benign masses that typically present as subcutaneous nodules with a visible central punctum. These cysts are lined with stratified squamous epithelium and become filled with keratin as they grow below the skin. In the case of unmanaged cyst growth, surrounding structures may be affected, resulting in pain and impairment of bodily function. Epidermoid cysts may be seen anywhere on the body, often coinciding with inflamed hair follicles. These cysts are one of the most common types of vulvar cysts, but are rarely seen originating deep in the paravaginal region. Previous literature has reported a few cases of paravaginal epidermoid cysts, but there is limited clinical information regarding epidermoid cysts without a visible protuberance on physical examination. The lack of reported cases suggests that this clinical presentation is rare. Case Presentation: A 21-year old nulliparous female initially presented to the clinic with chronic bilateral pelvic and lower back pain that started one week prior to her menstrual cycle. The patient reportedly faced similar symptoms for many months with progressive pain and bloating. She disclosed a known history of fibromyalgia, but denied any history of trauma to her pelvic or lower back area. Given the patient’s complaints, the patient was initially treated with a Depo-Provera injection for possible endometriosis and was counseled on further steps if the injection did not provide relief of her symptoms. The patient returned to the clinic months later for evaluation of a pelvic mass found in the emergency department via imaging. The patient stated that the Depo-Provera injection did not alleviate her symptoms and reported additional symptoms of frequent urination, and urinary retention requiring increased effort. Diagnostic imaging revealed an approximately 6 cm x 4 cm tender cystic mass in the left lower pelvis displacing the left posterior wall of the bladder and abutting the rectum. There was no visual distention of the perineum, vulva, or vagina. The unusual location of the cyst concealed its visualization on physical examination, an atypical presentation of a subcutaneous cyst. Surgical excision was performed and pathological analysis revealed a deep epidermal inclusion cyst filled with caseous debris extending into the ischiorectal fossa. Conclusion: This case study examines an unusual presentation of a symptomatic paravaginal epidermal inclusion cyst extending into the ischiorectal fossa without a visual protuberance on examination nor identifiable risk factors such as prior trauma and surgery.Item Prevalence of high-risk human papillomavirus types among substance abusing women screened for cervical and anal cancer.(2015-03) Felini, Martha; Tod, Nicole; Kremer, Timothy; Bangara, Saritha; Igenoza, Oluwatosin; Jegede, Opeyemi; Anderson, Ralph; Qualls-Hampton, Raquel Y.Purpose Prevalence studies of HPV in the general US population have provided important baseline data for monitoring HPV vaccination efforts. As the field of HPV progresses, funders are calling for HPV studies to be conducted in more meaningful and high risk populations to uncover new leads in HPV infection. Our primary objective in this cross-sectional study was to estimate the seroprevalence of high-risk HPV (hr-HPV) among a high risk population - substance abusing women. Further investigation was conducted to assess concordance of hr-HPV infection between cervical and anal sites. Methods Women were recruited from Nexus Recovery Center – the largest female only substance abuse recovery center in DFW. Cervical and anal pap smears were used to collect samples for hr-HPV co-testing. HPV results were received from 318 cervical samples and 243 anal samples. Chi-square and t-tests were used to determine differences in hr-HPV status by age, race, smoking, high risk sexual activity, cytology, and concordance. Results Seropositivity for cervical hr-HPV was 29%. Anal hr-HPV was observed significantly more often (32%) compared to cervical sites. Seropositivity for hr-HPV among women with abnormal cervical cytology was 63%; for those with normal cervical cytology hr-HPV was 47%. However, only 39% of abnormal anal cytology tested seropositive for hr-HPV. hr-HPV status differed by age and cervical cytology, but not by race, smoking, sexual activity, or anal cytology. Of those testing positive for either cervical or anal hr-HPV, nearly half (46%) had infection concurrently at both sites. Conclusion Our study population demonstrated higher rates of cervical and anal hr-HPV infections compared to US women (23% and 19%, respectively). As expected, hr-HPV status differed by cervical cytology results. Contrary to our hypothesis, hr-HPV status was similar regardless of anal cytology results. This unexpected finding may suggest a different ability of anal hr-HPV clearance, or it could reflect the younger age of our study group given the older age predilection of anal dysplasia. Concordance of hr-HPV between cervical and anal sites is generating a separate study of type-specific hr-HPV at cervical, anal, and oral sites. Our findings lend importance to determining whether anal Pap smears and/or anal hr-HPV testing should be included in well woman exams and also presents baseline HPV prevalence for the first time in this high risk population.Item A Retrospective Study Examining the Importance of Early Postpartum Follow Up in Uncomplicated Vaginal Deliveries(2024-03-21) Shah, Krusha; Hussain, Anusha; Kremer, TimothyPurpose: Holistic postpartum care, including a comprehensive postpartum visit, is essential for long-term maternal and fetal health. However, many women navigate the early postpartum period independently until the traditional postpartum visit 4-6 weeks after delivery. In a national study, less than half of women attending a postpartum visit reported that they received adequate information on postpartum depression, birth spacing, healthy eating, exercise, or changes in their sexual health. This lack of attention to maternal health needs impedes identification and adequate management of postpartum depression, breastfeeding challenges, access to effective contraception, and chronic health conditions. In efforts to remediate this gap in care, the American College of Obstetrics and Gynecology recommends that all women have contact with their obstetric care provider within the first 3 weeks postpartum. This should be followed with ongoing care with a comprehensive postpartum visit no later than 12 weeks after birth. Preliminary studies incorporating these guidelines have indicated favorable health outcomes among mothers in the early postpartum period. In a randomized controlled trial, 15 minutes of discharge instructions, followed by a phone call at 2 weeks, reduced symptoms of depression and increased breastfeeding duration through 6 months postpartum among African American and Hispanic women. While previous studies have analyzed the benefit of earlier postpartum follow up for specific health challenges, few studies have holistically investigated the benefit of the earlier postpartum follow up in office. This study aims to characterize and compare outcomes of early postpartum follow up in uncomplicated vaginal deliveries. Methods: The medical records for all patients receiving prenatal care over a 2-year interval at the Medical City Arlington GME clinic were retrospectively reviewed to identify 228 patients that had received a postpartum visit within 3 weeks of delivery. The early postpartum visit records were reviewed for evidence of PPD screening and intervention, hypertension assessment and intervention, breast-feeding support and intervention, contraceptive counseling, hospital readmission or emergency room transfer, and primary care referral. Results:68% of patients were counseled on contraception, 2% were referred to a PCP for ongoing care, and 1% were sent for hospital readmission. Of the 45 patients who had a blood pressure check, 5% were initiated on anti-hypertensive therapy. Of the 172 patients screened for PPD, 5% received initial treatment for PPD. Utilizing Chi-square analyses, it was found that multiparous patients were 2.47 times more likely to get contraceptives ordered compared to nulliparous patients (p < .0109). Furthermore, there was a statistically significant difference in the frequency of PCP referrals and initial prenatal care (p= 0.0308). Those who started their prenatal care early were more likely to be referred to a PCP (7.78%) compared to those with late prenatal care (1.45%). Conclusion: Early postpartum follow-up allows for timely recognition and intervention of hypertension and mood disorders, earlier initiation of contraception, and earlier transition of care to a PCP. These interventions may improve long term maternal health outcomes and reduce the likelihood of preventable complications.Item An Unusual Presentation of Subcutaneous Inguinal Hematoma Mimicking Ovarian Torsion: A Case Report and Review of Literature(2023) Panzanaro, Victoria; Stallworth, Chrystal; Kremer, TimothyBackground: Ovarian torsion is a condition in which an ovary rotates around one of the supporting ligaments that provides stabilization and perfusion in the pelvis, and can present as a medical emergency due to the rotation hindering blood flow. This is most often the infundibulopelvic (IP) ligament which connects the ovary to the lateral pelvic wall, but can also occur with other ligaments as well. Inguinal hematomas tend to present as a post-operative finding due to procedures such as inguinal hernia repairs. However, there are little to no reported occurrences of ovarian torsion presenting with inguinal hematoma. Case Presentation: A 36 year-old female presented to the emergency department with a chief complaint of left lower pelvic pain presenting with a large inguinal hematoma which had occurred two days earlier after intercourse. The patient stated she has a history of inguinal hematomas occurring after intercourse, however she stated that the bruising from this incidence was larger, more painful, and longer lasting than previous occurrences. Patient history includes a hysterectomy with bilateral salpingectomy and a left ovarian cyst that still remained. All laboratory values were unremarkable and vital signs were within normal limits. Using transvaginal ultrasound arterial blood flow to the left ovary was difficult to visualize, however venous blood flow was accounted for. The patient was suspected to have a left ovarian torsion and underwent a diagnostic laparoscopy. The decision was also made with the patient to perform a left oophorectomy due to her left ovarian cyst which can increase the occurrence of ovarian torsion, and was most likely contributing to her recurrence of this type of injury. At the time of surgery, the laparoscopy revealed that the left ovary was not extensively torsed and was adequately perfused. However, during the procedure an aberrant vessel was identified branching off of the IP ligament and terminating along the pelvic wall at the same location in which the inguinal hematoma was presenting externally. This aberrant vessel was ligated via electrocautery, and the patient tolerated the rest of the surgery without complications. The patient recovered and was discharged home with two week and two month follow-up appointments scheduled. These follow-up appointments revealed that her inguinal hematoma and pelvic pain resolved completely and that there was no negative impact to ligating the vessel. Conclusion: This case investigates a cause of pelvic pain due to aberrant vessels which can present similarly to a case of ovarian torsion. This case serves to provide a possible etiology of pelvic pain presenting with inguinal hematoma, in which there are not many situations similar to this case in the current literature.Item Vulvar Crohn’s Disease Progression Over 20 Years: A Case Study(2024-03-21) Veeramachineni, Shruti; Kremer, TimothyBackground: Vulvar Crohn’s disease (VCD) is a rare cutaneous manifestation of general Crohn’s disease (GCD), characterized by non-caseating granulomas in the vulvar region. VCD occurs independently of fistulization, and in 25% of cases, the vulvar manifestation precedes gastrointestinal symptoms. This case presentation describes the disease course in a patient followed longitudinally over 2 decades. The case report aims to provide insights into the presentation, diagnosis, and management of VCD, as well as highlight the challenges and considerations in clinical practice. Case information: An 18-year-old female initially presented with a two-week history of worsening pain in her vulvar area. (See Figure 1.) She had vaginal discharge and noticed multiple open lesions in the vulvar area. She was sexually active. The patient denied any gastrointestinal symptoms such as abdominal pain, diarrhea, or bloody stool. Primary differentials on initial presentation included donovanosis, lymphogranuloma venereum, hidradenitis suppurative, HIV, and cancer. Biopsy of the vulvar lesions revealed non-caseating granulomas, which are consistent with Crohn’s disease as depicted in Figure 2. The ulcerations spontaneously resolved one year after initial diagnosis as shown in Figure 3. Over the next 20 years, the patient had progressive disease despite use of immunosuppressive agents. The disease has now progressed to a rectovaginal fistula and complete obliteration of the vulvovaginal and anal architecture. (See Figure 4.) Management challenges for this patient included intermittent access to care due to socioeconomic factors and suboptimal response to immunosuppressive therapy. Conclusion: There are fewer than 300 cases of VCD reported in literature. VCD presents a unique diagnostic challenge, often confused with infectious etiologies. The differential of VCD should be considered in patients with vulvar fissures and edema. Management of VCD is more intricate than diagnosis and is not well understood. The literature shows that intestinal disease may be well controlled with a TNF-inhibitor, but VCD may continue to flare. A multidisciplinary approach involving multiple specialists is essential for optimal management. This topic requires further research on therapeutic approaches to improve patient outcomes.