Medicine and Health Sciences Commons^™

Geographic Distribution Of Melanoma Cases In Maine: Identifying Vulnerable Counties For Targeted Intervention, Joshua R. Parbs, Madeline Prentiss, Calla Hladky, Henry Stoddard, Kathryn Stevens, Elizabeth V. Seiverling, Peggy Cyr

Journal of Maine Medical Center

Introduction: Maine has the twelfth highest incidence of melanoma in the United States. The purpose of this study was to determine which Maine counties were the most impacted by melanoma through the use of geographical methods. Identification of counties with the highest prevalence of melanoma will help in targeting future training and public health interventions.

Methods: All melanoma cases (n=5,340) reported to the Maine CDC Cancer Registry from 2013 to 2018 were sorted by pathologic T stage. Data were sorted by county and population-adjusted. Population data and provider data came from Area Health Resource Files. County and zip-code maps were …

Sports-Related Concussion Management And Guideline Awareness In The Primary Care Setting, Stephanie K. Eble, Oleksandra Pashchenko, William Patterson, Christina T. Holt, William Dexter, Kristine Karlson

Journal of Maine Medical Center

No abstract provided.

Barriers To Care For Children With Cerebral Palsy In The Rural State Of Maine: A Mixed-Methods Study, Rayne L. Whitten, Anya K. Cutler, Alexa K. Craig

Journal of Maine Medical Center

Introduction: Guidelines on orthopedic hip surveillance in children with cerebral palsy have been published to minimize the effects of cerebral palsy and maximize quality of life. Researchers aimed to identify barriers to cerebral palsy care and to assess adherence to national hip-surveillance guidelines among a small subset of children with cerebral palsy who live in a rural state.

Methods: Parents of children with cerebral palsy were interviewed, and thematic analyses were performed on the recorded transcripts. Patient-specific data about imaging and demographics were manually extracted from the electronic health record to perform a mixed-methods analysis.

Results: Twenty-one parents were interviewed, …

New Onset, Refractory Hyperglycemia With Diabetic Ketoacidosis After Enfortumab Vedotin Treatment: A Case Report, Ross E. Heinrich, Marie Caldwell

Journal of Maine Medical Center

Introduction: A patient with no prior diagnosis of diabetes presented with diabetic ketoacidosis (DKA) and severe insulin resistance after being treated with enfortumab vedotin (EV). EV-associated DKA is uncommon—described in only a few case reports—and has unknown pathophysiology. This case characterizes the unique features of DKA in this patient and an unusual amount of insulin resistance not typically seen in patients with diabetes.

Clinical Findings: A 71-year-old male presented with fatigue, xerostomia, and increased thirst. He had a history of obesity, hypertension, and invasive, high-grade papillary urothelial carcinoma. His laboratory results were consistent with DKA.

Clinical Course: The patient was …

Referral Patterns For Pediatric Sports-Related Concussion In One New England Health Care System, Joseph Benert, Amy Haskins Phd, Christina T. Holt, Krystian Bigosinski

Journal of Maine Medical Center

Introduction: Patients with concussion may benefit from care provided by professionals from multiple disciplines based on the constellation of symptoms being reported. This study analyzed referral patterns from primary care and sports medicine clinicians for pediatric patients with sports-related concussion in one health care system.

Methods: A retrospective chart review identified referrals placed to physical therapy, occupational therapy, speech pathology, optometry, psychology, neuropsychology, audiology, neurology, ophthalmology, otolaryngology, psychiatry, and sports medicine for pediatric patients with sports-related concussion. These patients were evaluated at MaineHealth family medicine, internal medicine/pediatrics, pediatrics, and sports medicine clinics in southern Maine between February 2019 and June …

Under One Roof – An Integrated Clinic For Substance Use Disorder And Viral Hepatitis/Hiv Treatment, Sarah Hipkens, Emily Caron, Wendy Craig, Kinna Thakarar

Journal of Maine Medical Center

Introduction: Integration of viral hepatitis/HIV care and substance use disorder (SUD) treatment has been shown to improve patient outcomes, but data are lacking in rural states like Maine. Our study objective was to assess the baseline characteristics and outcomes of patients with SUD who receive combined substance use and viral hepatitis/HIV treatment at a recently established “Bridge Program” in our rural state.

Methods: We conducted a retrospective chart review of patients enrolled in the Bridge Program between January 2020 and November 2021. We then performed a descriptive analysis of demographics, health characteristics, preventive services, and treatment outcomes.

Results: A total …

A Case Of Congenital Coronary Sinus Ostial Atresia With Persistent Left Superior Vena Cava, Laura Onderko, Thomas A. Miller, Sean Novak, Jeffrey Rosenblatt

Journal of Maine Medical Center

Introduction: The coronary sinus is responsible for venous drainage of the heart. Congenital anomalies of the coronary sinus are rare and typically associated with other anomalies, such as atrial septal defects or other congenital heart malformations.

Clinical Findings: We present a case of incidentally found atresia of the coronary sinus ostium with associated persistent left superior vena cava. This case involved a 52-year-old patient who initially presented with a supraventricular tachycardia and elevated troponin.

Clinical Course: The patient underwent cardiac workup with a coronary computed tomographic angiography scan. This scan showed no obstructive coronary artery disease, but did show congenital …

Being There: Engaging In Conversations About A Child’S Future When They Are Facing Serious Illness, Christine Bennett Md

Journal of Maine Medical Center

No abstract provided.

Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation Of A Quality Improvement Project In A Large Health System, Sarah Hemphill Ba, Kristen Silvia Md, Marc D. Kimball Md

Journal of Maine Medical Center

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions

Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent …

Urticarial Rash In A Patient With Alpha-Gal Syndrome Caused By Subcutaneous Heparin At Prophylactic Dosing: A Case Report, Russell G. Behmer, Randolph S. Thomas, Hani T. Jarawan

Journal of Maine Medical Center

Introduction: We report a patient with a history of red meat allergy, or alpha-gal syndrome, who had an urticarial rash after exposure to unfractionated heparin at a dose typically used for prophylaxis of deep venous thrombosis. Although anaphylactic reactions have been reported with systemic intravenous heparin, we believe this case is the first report of an immunoglobulin E–mediated reaction to subcutaneous heparin at prophylactic dosing.

Clinical Findings: An 85-year-old male had a 3-year history of red meat allergy and was intolerant of pork and beef. He developed an immunoglobulin E–mediated allergic reaction to subcutaneous heparin at a dose of 5000 …

Association Between Primary Care Provider Status And Preventive Health Care Among People Who Inject Drugs, E Katherine Nenninger, Katherine Sharp, Bianca Bustamente, Kim Murray, Kinna Thakarar

Journal of Maine Medical Center

Introduction: People who inject drugs (PWID) are at increased risk for preventable, communicable infections, such as hepatitis B. Preventive care, such as hepatitis B vaccination, is often delivered through primary care providers (PCPs). However, PWID may not have access to PCPs and, therefore, may receive preventive care through other sites. We aimed to characterize PCP and preventive care use among PWID in Maine.

Methods: This is a cross-sectional study of PWID hospitalized with infections associated with injection drug use in Maine from January 2019 to May 2020. Descriptive analyses were used to identify characteristics of participants, rates of screening, and …

Cardiotoxicity From Immune Checkpoint Inhibitors: Myocarditis, Laura Onderko, Elizabeth Bennett, Sanjeev Francis

Journal of Maine Medical Center

Importance: Immune checkpoint inhibitors (ICIs) are a class of immunotherapies that have significant clinical efficacy in treating many cancer types, but they are also associated with systemic effects, including myocarditis.

Objective: This review describes potential mechanisms underlying ICI-associated myocarditis; data on epidemiology, including possible risk factors; diagnostic criteria for ICI-associated myocarditis; and recommendations for managing ICI-associated myocarditis.

Review: This paper is a narrative literature review that summarizes existing literature to increase awareness of ICI-associated cardiotoxicities, including myocarditis.

Findings: Reported cardiovascular adverse events include myocarditis, cardiomyopathy, arrhythmias, pericarditis, vasculitis, atherosclerotic cardiovascular events, Takotsubo syndrome, and venous thromboembolism. Myocarditis is associated with …

A Descriptive Analysis Of Patient Demographics At A Sports Medicine Clinic During The Covid-19 Pandemic, William S. Douglas, Williams Dexter, Amy Haskins Phd, Christina Holt

Journal of Maine Medical Center

No abstract provided.

Telemedicine Consultation To Assess Neonatal Encephalopathy In Rural Community Hospitals And Tertiary Care Centers, Rachel Coffey, Misty Melendi, Anya K. Cutler, Alexa K. Craig

Journal of Maine Medical Center

Introduction: Teleconsultation is used in tertiary care hospitals to evaluate neonatal encephalopathy. Neonates born in community hospitals, however, often experience delayed evaluation due to transport to the tertiary care center. We studied teleconsultations in community hospitals to decrease this disparity.

Methods: Prospective observational study in 9 community hospitals and 1 neonatal intensive care unit. Inclusion criteria: gestational age greater than or equal to 35 weeks and one of the following: umbilical cord pH less than or equal to 7.2, 5-minute Apgar less than 7, prolonged respiratory support, perinatal event, or abnormal neurological exam. We performed synchronized, unscheduled telemedicine consults with …

Senior Academic Ranks In Us Anesthesiology Programs: Differences Between Women And Men And Examination Of Independent Factors For Success, Brenda Lee, Farhad Zahedi, Ina Zaimi, Roman Schumann

Journal of Maine Medical Center

Introduction: Gender equality among faculty is a challenge in academic medicine, including anesthesiology. We investigated the likelihood that several factors were associated with academic success in the United States (US), defined as having achieved a senior academic rank (SAR) in a US anesthesiology training program.

Methods: We collected data available on the Internet on 131 anesthesiology programs, including faculty academic rank, gender, number of faculty, graduate status from an American medical school, fellowship training status, number of residents, number of program fellowships, and geographic location. SAR was defined as either associate professor or professor. Data were analyzed with logistic regression. …

A Rare Entity: Case Report Of Recurrent Hypertrophic Pyloric Stenosis, Astrid A. Gleaton, Kartikey Pandya

Journal of Maine Medical Center

Introduction: Hypertrophic pyloric stenosis (HPS) is well known in pediatric surgery and has good outcomes after pyloromyotomy.1 Emesis in the immediate postoperative period occurs in 40% of patients with HPS and is attributed to gastroparesis from prolonged gastric distention.2 Emesis presenting weeks to months after pyloromyotomy prompts an evaluation that often yields pathology unrelated to HPS. Because recurrent HPS is rare, making this diagnosis highlighted the importance of practicing broad differential diagnoses, ruling out most common causes, and including obscure etiologies.

Clinical Findings: A 3-week-old male born after full-term gestation with a history of HPS underwent an uncomplicated laparoscopic pyloromyotomy. …

Spouses With Pulmonary Mycobacterium Avium Complex Infections: A Case Report, Gregg Raymond Md, Emily Wood Md

Journal of Maine Medical Center

Introduction: Mycobacterium avium complex (MAC) is the most common cause of pulmonary infections due to nontuberculous mycobacterium in the United States. While there have been reports of geographic variations in incidence as well as disease clusters among genetically related individuals, there have been no published reports describing clusters of co-occurring pulmonary MAC disease among genetically unrelated individuals.

Clinical Findings: Patient 1 was a 56-year-old male with worsening asthma exacerbations associated with recurrent bronchitis. Patient 2 was a 55-year-old female with worsening asthma exacerbations, progressive dyspnea, and recurrent bronchitis. The 2 patients lived together, were immunocompetent, and genetically unrelated. They were …

Total Body Photography And Sequential Digital Dermoscopy Imaging For Melanoma Surveillance In Patients Starting Natalizumab For Multiple Sclerosis, Tyler Nussinow Ba, Amanda Robinson Np, Biljana Beretich Md, Kathryn Stevens Np, Elizabeth Seiverling Md

Journal of Maine Medical Center

Introduction: Natalizumab is an integrin receptor antagonist that has been approved by the Food and Drug Administration to treat multiple sclerosis and Crohn’s disease. The drug has been linked to an increased risk of melanoma. This brief report highlights an innovative clinical approach for monitoring the skin of patients prescribed natalizumab.

Methods: We include 2 cases from our skin oncology clinic and a literature review on the incidence of melanoma in patients prescribed natalizumab between 2004 and 2019.

Results: In addition to our 2 cases, we found 193 reports of patients with melanoma who were prescribed natalizumab. We propose an …

Implementing A Clinical Practice Guideline For Pediatric Appendicitis Safely Reduced Health Care Use And Improved Antimicrobial Stewardship, Jack Vernamonti, Robin Cotter, Jennifer Jubulis, Kartikey Pandya

Journal of Maine Medical Center

Introduction: Appendicitis is the most common emergency surgical disease in children. Those with perforated appendicitis have a more complicated and varied course. Through a clinical practice guideline (CPG), we sought to reduce computed tomography scans, laboratory draws, and exposure to broad-spectrum antibiotics without adversely affecting length of stay, hospital readmission, or repeat antibiotic administration.

Methods: Electronic records were retrospectively reviewed before and after CPG implementation, and data was collected in REDCap.

Results were reported as mean or percent incidence, and statistical analysis was done using a Student’s t-test, Mann-Whitney U test, or Pearson’s χ2 with P < .05 considered significant. Results: One hundred patients with a perforated appendix (50 before and 50 after CPG implementation) were included in our analysis. Length of stay (4.98 vs 4.46 days; P = .25), hospital readmission rate (10% vs 14%; P = .54), and additional antibiotic administration (2% vs 4%; P = .56) did not change. We observed no difference in the Pediatric Appendicitis Score (9 vs 9; P = .48) and a trending increase in evaluation at an outside hospital (56% vs 74%; P = .06). Rates of computed tomography scans did not differ overall (50% vs 40%; P = .31), but showed a decreasing trend at our institution (30% vs 12%; P = .06). We also found fewer post-operative laboratory studies (90% vs 38%; P < .01) and patients who received broad-spectrum intravenous antibiotics (92% vs 18%; P < .01).

Discussion: Through implementing the …

Genetic Testing Reveals Germline Mutations Among Patients Undergoing Surgery For Colorectal Carcinoma In A Community Hospital Setting, Alex R. Jones, Dana Greer Rn, Bsn, Ocn, Karin L. Cole Md

Journal of Maine Medical Center

Introduction: Defined germline mutations contribute to 5% to 10% of cases of colorectal carcinoma (CRC). While protocols for universal tumor screening have been adopted to detect mismatch repair (MMR) protein deficiency, widespread multigene panel testing has not been achieved. Barriers to implementing testing protocols may occur in community settings.

Methods: A total of 160 patients presenting for surgical management of CRC between 2011 and 2020 were considered for retrospective analysis in a single-surgeon, single-institution, community-based cohort. The rate of multigene panel testing and prevalence of germline mutations were calculated, and patient characteristics were assessed.

Results: A total of 32/160 (20%) …

Missed Opportunities: Documentation And Referral Rates Among Children And Adults With Obesity, Heidi Walls, Christina Holt, Amy Haskins Phd, Williams Dexter

Journal of Maine Medical Center

Introduction: Our study reports rates of obesity documentation on the problem list (PL) and numbers of referrals to obesity medicine specialists and dietitians among pediatric and adult patients with obesity.

Methods: All pediatric and adult patients with obesity seen at 14 primary care clinics between 7/1/2017 and 6/30/2019 were evaluated for inclusion of obesity on the PL and referrals to obesity medicine specialists or dietitians.

Results: For children with BMI >95% for age, obesity was documented in 31.2%, and 12.5% received a referral. For adults with BMI >30, obesity was documented in 54.2%, and 8.4% received a referral. Significantly more …

Focused Hospital Medicine Cme On Pulmonary Point-Of-Care Ultrasound Through Just-In-Time Training During The Covid-19 Pandemic, Matthew Buttarazzi, Kristen Bartlett, Katherine Stebbins, Monica Thim

Journal of Maine Medical Center

Introduction: We describe the use of focused CME with just-in-time training in pulmonary point-of-care ultrasound (POCUS) for hospitalists as part of our response to coronavirus disease 2019 (COVID-19). This training served as a pilot for developing a longitudinal training program for our inpatient adult medicine providers.

Methods: In mid-March 2020, ultrasound education and image review were deployed within hospital medicine at a large academic medical center. Faculty were provided (1) a small-group lecture focused on ultrasound findings in pneumonia, (2) weekly review of imaging, and (3) a monthly review conference of ultrasound imaging.

Results: Use of POCUS for pulmonary pathology …

The Implementation Of Telemedicine In The Covid-19 Era, Rebecca K. Bell, Katherine Badger, Kerri L. Barton Mph, Michael Kohut Phd, Michael Clark Md

Journal of Maine Medical Center

Introduction: During the COVID-19 global pandemic in 2020, social distancing policies called for health care providers to turn to telemedicine platforms for most of their patient encounters. We aimed to better understand the experiences and perspectives of patients and providers who used telemedicine in the primary care setting.

Methods: This study included semi-structured interviews with patients and providers who participated in telemedicine visits during the beginning of the COVID-19 pandemic. Patients (n = 14) were from a rural Maine practice and providers (n = 10) were from practices within 100 miles of a tertiary care center. The interviews were analyzed …

Access To Point-Of-Care Ultrasound In Maine Emergency Departments, Christina N. Wilson, Campbell Belisle Haley

Journal of Maine Medical Center

Introduction: Point-of-care ultrasound (POCUS) is an essential tool in emergency medicine. We evaluated access to bedside ultrasound machines and characterized POCUS use in Maine emergency departments (EDs).

Methods: We conducted a cross-sectional electronic survey of all ED medical directors in Maine. The survey included questions on ED characteristics, access to ultrasound machines, POCUS use patterns, POCUS administration, and barriers to use.

Results: Thirty-four EDs were identified, and 24 medical directors completed the survey, yielding a response rate of 71%. EDs were predominantly small and rural. Only 21% identified as urban, and 54% reported less than 20 000 annual visits. Surveys …

Effectiveness Of Two Frequently Used Screening Tools In Identifying Depression And Anxiety In Collegiate Athletes, Adriana C. Isacke Do, Amy Haskins Phd, Christina Holt Md, Msc, Williams Dexter Md, Facsm

Journal of Maine Medical Center

Introduction: To determine whether the Electronic Pre-participation Physical Examination (EPPE), a proprietary and frequently used tool, is an effective method for depression and anxiety screening in the collegiate athlete population as compared to the Patient Health Questionnaire-4 (PHQ-4).

Methods: College athletes at a Division III university completed PHQ-4 questionnaires and a proprietary EPPE. Positive reponse rates to depression and/or anxiety for both questionnaires were collected and analyzed with a kappa (κ) statistic.

Results: Among 420 students, we found that 9 (2%) reported depression and/or anxiety via the EPPE. Of the 26 students (6%) who answered positively on the PHQ-4, we …

Connected: Using A Novel In-House Communication System To Efficiently Deliver Imaging Results, Daniel Greentree, Brendan R. Calhoun, Steven Farraher

Journal of Maine Medical Center

Introduction: The primary objective was to investigate the effectiveness of a fully staffed electronic communication system (1Connect) in delivering timely critical imaging results and incidental findings. The secondary objective was to evaluate the financial impact of this system on a radiology practice.

Methods: From January 2014 through June 2016, the 1Connect database was retrospectively reviewed and sorted by category of submission type: Critical (1-hour communication time), STAT (2 hours), or Unexpected finding (3 business days). The percent of successful communications completed within the appropriate time frame was calculated for each priority category and used as a measure of the system’s …

Lessons From An Evidence-Based Medicine Exploration: When Transparency And Sensitivity (Analyses) Can Change The Take-Home Message, Nadi N. Kaonga, Toby Fitzgerald

Journal of Maine Medical Center

No abstract provided.

Strengthening The Evidence Base For Telehealth For Abortion Service Delivery, Nadi Kaonga

Journal of Maine Medical Center

Telehealth – which is the use of information and communication technology to provide clinical services to patients remotely – provides an opportunity to extend safe abortion services to women. A recent review article on telehealth for abortion service delivery found it to be acceptable, feasible and safe when compared to in-person service delivery. Despite the promising findings, the evidence base can and should be strengthened to optimize the impact of such services for women. Areas for improvement include evaluating the efficacy and effectiveness of telehealth implementations in more remote settings and with women across variable levels of technoliteracy, conducting cost-effectiveness …

Association Of Palliative Care Consultation With Advance Directive Completion For Patients Admitted With An Acute Heart Failure Exacerbation, Michelle Crispo, Doug Sawyer, Kathleen Fairfield, Rebecca N. Hutchinson

Journal of Maine Medical Center

No abstract for research letter

A Fatal Rectus Sheath Hematoma After A Myasthenia Crisis Case Report, Robert G. Michaud, Lesley B. Gordon

Journal of Maine Medical Center

Introduction: Rectus sheath hematomas (RSH) generally occur due to damage to the inferior epigastric artery. They are rare causes of abdominal pain or acute blood loss anemia, but are an important diagnostic consideration because they can be cryptic and are potentially fatal.

Clinical Findings: An 85-year-old female who had been admitted to the hospital for 10 days with a myasthenia crisis was found to be abruptly hypotensive with a tender abdominal mass in the left lower quadrant subtly crossing midline. She was on prophylactic anticoagulation during her hospitalization.

Main diagnosis, therapeutics, interventions, and outcomes: The patient was initially stabilized with …