Sutter Santa Rosa Regional Hospital

Importance: Individuals with low socioeconomic status (SES) bear a disproportionate share of the coronary heart disease (CHD) burden, and CHD remains the leading cause of mortality in low-income US counties. Objective: To estimate the excess CHD burden among individuals in the United States with low SES and the proportions attributable to traditional risk factors and to other factors associated with low SES. Design, Setting, and Participants: This computer simulation study used the Cardiovascular Disease Policy Model, a model of CHD and stroke incidence, prevalence, and mortality among adults in the United States, to project the excess burden of early CHD. The proportion of this excess burden attributable to traditional CHD risk factors (smoking, high blood pressure, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, type 2 diabetes, and high body mass index) compared with the proportion attributable to other risk factors associated with low SES was estimated. Model inputs were derived from nationally representative US data and cohort studies of incident CHD. All US adults aged 35 to 64 years, stratified by SES, were included in the simulations. Exposures: Low SES was defined as income below 150% of the federal poverty level or educational level less than a high school diploma. Main Outcomes and Measures: Premature (before age 65 years) myocardial infarction (MI) rates and CHD deaths. Results: Approximately 31.2 million US adults aged 35 to 64 years had low SES, of whom approximately 16 million (51.3%) were women. Compared with individuals with higher SES, both men and women in the low-SES group had double the rate of MIs (men: 34.8 [95% uncertainty interval (UI), 31.0-38.8] vs 17.6 [95% UI, 16.0-18.6]; women: 15.1 [95% UI, 13.4-16.9] vs 6.8 [95% UI, 6.3-7.4]) and CHD deaths (men: 14.3 [95% UI, 13.0-15.7] vs 7.6 [95% UI, 7.3-7.9]; women: 5.6 [95% UI, 5.0-6.2] vs 2.5 [95% UI, 2.3-2.6]) per 10 000 person-years. A higher burden of traditional CHD risk factors in adults with low SES explained 40% of these excess events; the remaining 60% of these events were attributable to other factors associated with low SES. Among a simulated cohort of 1.3 million adults with low SES who were 35 years old in 2015, the model projected that 250 000 individuals (19%) will develop CHD by age 65 years, with 119 000 (48%) of these CHD cases occurring in excess of those expected for individuals with higher SES. Conclusions and Relevance: This study suggested that, for approximately one-quarter of US adults aged 35 to 64 years, low SES was substantially associated with early CHD burden. Although biomedical interventions to modify traditional risk factors may decrease the disease burden, disparities by SES may remain without addressing SES itself.

Here we perform the first genome-wide association study (GWAS) of multiple myeloma (MM) survival. In a meta-analysis of 306 MM patients treated at UCSF and 239 patients treated at the Mayo clinic, we find a significant association between SNPs near the gene FOPNL on chromosome 16p13 and survival (rs72773978; P=6 × 10−10). Patients with the minor allele are at increased risk for mortality (HR: 2.65; 95% CI: 1.94–3.58) relative to patients homozygous for the major allele. We replicate the association in the IMMEnSE cohort including 772 patients, and a University of Utah cohort including 318 patients (rs72773978 P=0.044). Using publicly available data, we find that the minor allele was associated with increased expression of FOPNL and increased expression of FOPNL was associated with higher expression of centrosomal genes and with shorter survival. Polymorphisms at the FOPNL locus are associated with survival among MM patients. Multiple myeloma is an incurable blood cancer with family history being a strong contributing risk factor. Here Ziv et al.perform a genome-wide association study for genetic variation associated with myeloma survival, identifying FOPNL variants associated with worse clinical outcomes.

BACKGROUND: Multiple scoring systems have been developed for both the intensive care unit (ICU) and the emergency department (ED) to risk stratify patients and predict mortality. However, it remains unclear whether the additional data needed to compute ICU scores improves mortality prediction for critically ill patients compared to the simpler ED scores. METHODS: We studied a prospective observational cohort of 227 critically ill patients admitted to the ICU directly from the ED at an academic, tertiary care medical center. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Score (SAPS) II, Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), Prince of Wales Emergency Department Score (PEDS), and a pre-hospital critical illness prediction score developed by Seymour et al. (JAMA 2010, 304(7):747-754). The primary endpoint was 60-day mortality. We compared the receiver operating characteristic (ROC) curves of the different scores and their calibration using the Hosmer-Lemeshow goodness-of-fit test and visual assessment. RESULTS: The ICU scores outperformed the ED scores with higher area under the curve (AUC) values (p = 0.01). There were no differences in discrimination among the ED-based scoring systems (AUC 0.698 to 0.742; p = 0.45) or among the ICU-based scoring systems (AUC 0.779 to 0.799; p = 0.60). With the exception of the Seymour score, the ED-based scoring systems did not discriminate as well as the best-performing ICU-based scoring system, APACHE III (p = 0.005 to 0.01 for comparison of ED scores to APACHE III). The Seymour score had a superior AUC to other ED scores and, despite a lower AUC than all the ICU scores, was not significantly different than APACHE III (p = 0.09). When data from the first 24 h in the ICU was used to calculate the ED scores, the AUC for the ED scores improved numerically, but this improvement was not statistically significant. All scores had acceptable calibration. CONCLUSIONS: In contrast to prior studies of patients based in the emergency department, ICU scores outperformed ED scores in critically ill patients admitted from the emergency department. This difference in performance seemed to be primarily due to the complexity of the scores rather than the time window from which the data was derived.

Health care facilities that utilize patient and family advisors are experiencing improved outcomes in decreased length of stay, and improved reimbursements and patient satisfaction. Patient and family advisors can be strong allies in ongoing performance improvement efforts. Perhaps even more importantly, involving advisors in health care systems encourages treatment of the whole patient as he or she would want to be treated

When it comes to the capacity to regenerate damaged parts of the body, humans are by no means the most advanced among animal species. At the level of single cell populations, humans do exhibit some degree of regenerative potential--for example, hepatocytes have the ability to restore up to 75% of a surgically removed or damaged liver. However, as every schoolchild knows, salamanders and starfish can regrow entire amputated appendages, a remarkable feat well beyond the scope of human capacity. Accordingly, the standing consensus position of the scientific community has deemed mammals fundamentally and unalterably different from those more "primitive" yet regeneration-competent species. Current approaches for the restoration of organ function in humans have therefore been limited to allogeneic organ or cell transplantation--strategies that, while effective, nonetheless exhibit major limitations based on availability of donor tissues and the risk of rejection unless extensive immunosuppression is induced.

Introduction: There is a paucity of prevalence data for genital angiokeratomas in adults. The objective of this article is to determine prevalence of genital angiokeratomas in adults as a function of sex, age, and race/ethnicity. Methods: A cross-sectional study was conducted over 11 months during 2013 and 2014 using a convenience sample of adult men and women consenting to genital examination during melanoma screening and surveillance by a senior dermatologist in an outpatient clinic. The analysis was conducted from April through December 2016. Results: Of 213 white/European American adults examined (127 men and 86 women), genital angiokeratomas were detected in 30.0% (64/213). Presence of at least one genital angiokeratoma was significantly associated with male sex (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3-4.5; P < .001) and age older than 50 years (OR, 3.4; 95% CI, 1.7-6.7; P = .008). Conclusions: Genital angiokeratomas are relatively common in adults of white/European American origin and important to recognize because of their benign nature and occasional confusion with other tumors.

BACKGROUND: The criminal justice-involved population has a higher disease burden than the general population and a high risk of death post-incarceration. However, this group underutilizes healthcare, especially preventive and primary care services. Sixteen in-person, semi-structured interviews were conducted with formerly incarcerated individuals in Milwaukee to explore health impacts of incarceration, barriers and facilitators to healthcare access, and what ideal health service provision would look like following incarceration. Interviews were transcribed, coded, and analyzed using an immersion/crystallization approach. RESULTS: Overall, people perceived incarceration to have a negative impact on their physical and mental health and expressed dissatisfaction with care in correctional settings. Many faced lapses in care following incarceration, frequently due to insurance challenges. CONCLUSIONS: Participants offered advice for designing an ideal clinic including formal coordination with corrections and provision of additional social services. Staff demeanor that created a welcoming and caring environment was highlighted as an important component and facilitator of care.

Abortion is healthcare. Bodily autonomy is a fundamental human right. As chief resident physicians representing family medicine residency programs in the Greater Bay Area and Central California in the University of California San Francisco Family Medicine Alliance, we share a deep commitment to promoting health equity, advancing social justice, and eliminating health disparities. The 2022 Supreme Court decision in Dobbs v. Jackson Women's Health Organization to overturn Roe v. Wade contradicts the inherent rights of patients to make their own reproductive healthcare decisions. This is a clarion call for all people to engage in activities to raise awareness and prompt discussion about abortion, reproductive rights, and maternal mortality.

BACKGROUND: Type 1 diabetes (T1D) management exerts a considerable financial burden on patients, caregivers, and developing nations at large. In Ghana, a key governments effort to attenuate the financial burden of T1D on patients was to fashion safety-net mechanisms through financial risk pooling/sharing known as the National Health Insurance Scheme (NHIS). However, there is limited research on patients and caregivers' experiences with the cost of managing T1D within the NHIS in Ghana. OBJECTIVE: This study explored the cost of T1D management, and the impact of the NHIS policy on mitigating costs of care. METHODS: A semi-structured interview guide was developed to collect qualitative data from 28 young people living with T1D (PLWD), 12 caregivers, 6 healthcare providers, and other stakeholders in Western, Central and the Greater Accra regions. Multiple data collection techniques including mystery client and in-depth interviews were used to collect data. Thematic content analysis was performed with QSR NVivo 14. RESULTS: Five key domains/themes which are: cost of T1D management supplies; cost of clinical care; cost of transportation; cost of diet; and NHIS were identified. The daily cost of blood glucose testing and insulin injection per day was between GHC 5-7 (US$ 0.6 to 1.0). The NHIS did not cover supplies such as strips, glucometers, HbA1c tests, and periodic medical tests. Even for those cost which were covered by the NHIS (mainly pre-mixed insulin), marked government delays in funds reimbursement to accredited NHIS facilities compelled providers to push the financial obligation onto patients and caregivers. Such cost obligations were fulfilled through out-of-pocket top-up or full payment of insulin of about GHC 15-25 (US$ 2-4), and GHC 25-50 (US$4-8) depending on the region and place of residence. CONCLUSION: The cost of managing T1D was a burden for patients and their caregivers. There was a commodification of life-saving insulin on the Ghanaian market, and the NHIS did not function well to ease the cost-burden of T1D management on patients and caregivers. The findings call for the need to scale up NHIS services to include simple supplies, particularly test strips, and always ensure the availability of life-saving insulin in healthcare facilities.

Integrative medicine (IM) fellowships have grown significantly over the past decade. This review examines gaps in the original IM competencies and key revisions aligned with the Accreditation Council for Graduate Medical Education (ACGME) domains, informed by a multi-phase stakeholder engagement process. A task force from the Academic Consortium for Integrative Medicine and Health conducted a systematic review of existing IM competencies, ACGME core competencies, and relevant Diversity, Equity, and Inclusion (DEI) frameworks. A survey was sent to 23 IM fellowship programs, yielding a 96% response rate. Competencies were revised and refined through stakeholder input via conferences, focus groups, and surveys. Thematic analysis in December 2024 identified priorities for final revisions. Key updates include inclusive language and integration of underrepresented areas such as health equity, trauma-informed care, clinician well-being, interprofessional collaboration, and planetary health. Cultural humility and epistemic inclusivity are emphasized throughout, with health equity principles embedded across all domains. These updates mark a shift toward an inclusive, equity-centered model of whole-person care. Future efforts will focus on implementation, faculty development, and standardized assessment to support adoption in IM fellowship programs.

Background: Chagas Disease (ChD), a prevalent Neglected Tropical Disease in Latin America, affects millions and poses significant challenges in Brazil's primary healthcare system. Despite the availability of diagnostic tools and effective drugs, screening and treatment rates remain alarmingly low. This study aims to identify barriers and facilitators in ChD management, focusing on integrating services into routine healthcare operations. Methods: An exploratory sequential mixed-methods approach was used, combining focus groups with primary care physicians, in-depth interviews, and quantitative surveys with healthcare professionals. The Theoretical Domains Framework (TDF) and the Capability Opportunity Motivation-Behaviour (COM-B) model guided the analysis of decision-making processes in ChD management. Intervention strategies were developed using the Behaviour Change Wheel (BCW) framework, emphasizing educational programmes, hands-on training, and infrastructural improvements. Findings: The study identified key barriers, including limited awareness of ChD among healthcare professionals, reliance on symptomatic diagnosis, environmental constraints, and inadequate public and professional engagement with ChD. We proposed tailored interventions to enhance primary healthcare personnel competencies through education, training, and infrastructure adjustments. Interpretation: The study advocates for a paradigm shift in ChD management towards early intervention and comprehensive care. It highlights the importance of a team-based strategy aligned with the WHO's Neglected Tropical Diseases roadmap, particularly in remote areas. This approach addresses healthcare workers' challenges, fostering a more proactive and informed ChD management strategy. Funding: The NIH supported the study under the Sami-Trop cohort study (Grant n. U01AI168383).

The development of gynecologic oncology as a specialty has contributed to the progress of the treatment and management of women with genital and reproductive cancers. The trend toward less aggressive and less invasive surgery has yielded an improved quality of life for women with gynecologic cancer. Multimodal interdisciplinary care is the principle and practice of gynecologic oncology. Prevention and screening have not always kept stride with the other advances in treatment, which include diagnostic imaging, laparoscopic surgery, chemotherapy, genetic susceptibility, and tumor marker assays. Educating patients and health care providers is the challenge in gynecologic oncology.

Pioglitazone produces a reduction in A1C levels similar to that produced by other drugs. One trial found that although pioglitazone, used as an adjunct to other antihyperglycemic medications, may lead to a statistically significant reduction in morbidity and mortality in patients with established macrovascular disease, it also increases the likelihood of hospitalization for heart failure. There is no evidence on the effectiveness of pioglitazone monotherapy for reducing morbidity and mortality. Patients taking pioglitazone, alone or in combination, are more likely to experience edema, weight gain, or congestive heart failure compared with patients taking other antihyperglycemic medications.

Objective: This study aimed to examine perspectives on challenges, design requirements, and implementation considerations for developing a granular, patient-facing consent tool that enables meaningful control over sensitive health data sharing in real-world healthcare settings. Methods: Guided by the National Science Foundation I-Corps framework and conducted in collaboration with Shift-a national consortium for patient-driven sharing of health information-we conducted semi-structured interviews with 16 expert stakeholders representing clinical, health IT, governance, and policy domains. Transcripts were analyzed using thematic analysis with combined deductive and inductive coding to identify key challenges, user needs, and system constraints. Results: Participants most frequently emphasized the need for patient-centered, trauma-informed user experiences that recognize prior experiences of stigma, discrimination, surveillance, or harm associated with disclosure of sensitive health information, and that use plain language and education to support meaningful consent (75%). Lack of trust, stigma, and workflow burden were major barriers to sensitive data sharing (63%), alongside technical limitations in EHRs that prevent reliable segmentation and enforcement of preferences (56%). Granular, computable consent-allowing patients' choices-was viewed as essential (50%), though legal and policy fragmentation complicates implementation (50%). Additional considerations included proxy and adolescent-aware configurations (44%) and interoperability standards such as Fast Healthcare Interoperability Resources (FHIR) Consent and Data Segmentation for Privacy (19%). Conclusion: Findings suggest that effective consent management requires alignment between patient-centered design, technical computability, and governance. Enforceable consent integrated into routine workflows and paired with transparency may reduce stigma-driven nondisclosure while supporting clinical safety. Granular, patient-directed consent can translate privacy expectations into practice. Embedding computable consent within interoperable standards and trauma-informed design offers a path toward more trustworthy, equitable, and safe health data sharing.

BACKGROUND: Chagas disease (CD) is a neglected endemic infectious disease. Primary health care (PHC) is responsible for delivering care to patients with CD in an integrated manner with other levels of the health system. We aimed to describe the use of implementation science (IS) as a tool for developing a care pathway for patients with CD from the perspective of the Brazilian Chronic Care Model (BCCM). METHODS: This study was conducted in the large municipality of Minas Gerais, Brazil. A diagnostic phase was conducted to identify barriers and facilitators related to CD care. The findings from this stage were analyzed using IS frameworks. Subsequently, the BCCM was adapted as a logical model to guide the creation of a care pathway. Health managers and professionals from the municipalities were trained to implement the proposed actions. After implementation, process and outcome indicators were monitored over a 12-month period. RESULTS: IS proved to be an effective strategy for applying BCCM to patients with CD in PHC settings. A total of 267 health professionals were trained. After the intervention, the following indicators increased: risk factor screening, serological testing, diagnosis, and antiparasitic treatment for CD. CONCLUSION: The development of a CD care pathway using IS tools integrated with the BCCM enabled the incorporation of processes into PHC and suggested that this model may be replicated in other contexts as well as for other chronic conditions requiring longitudinal care.

Background: Cervical cancer screening is effective; however, it is unclear whether older migrant and seasonal farmworker (MSFW) Latinas have equitable screening utilization. Methods: Retrospective observational study of electronic health record data to assess cervical cancer screening patterns (human papillomavirus [HPV]-only, Papanicolaou [Pap], or both) among 21,294 MSFW and non-MSFW Latinas aged 50-65 years with ≥1 face-to-face visit at 348 US community health centers (CHCs) in 17 states between 2012 and 2017. We conducted generalized estimating equation logistic regression, adjusting for demographics, health care use, and health status. Results: MSFW Latinas had higher rates of cervical cancer screening and HPV-only screening than non-MSFW Latinas (59% vs 49% and 49% vs 36%, respectively). MSWF Latinas, compared to non-MSFW Latinas, had higher odds of ever undergoing any type of cervical cancer screening (odds ratio [OR], 1.37; 95% CI, 1.16-1.61), a HPV-only screening (OR, 1.26; 95% CI, 1.11-1.44), and a Pap smear (OR, 1.22; 95% CI, 1.02-1.47). Conclusions: In CHCs, MSFW Latinas have higher odds of undergoing cervical cancer screening than non-MSFW Latinas. CHCs may play an important role in delivering cervical cancer screening among older MSFW Latinas. Further research is warranted to better understand the facilitators of care and differences in utilization between these populations. Impact: Given the increasing rates of overdue cervical cancer screening in the United States, resource investment in CHCs remains critical to help sustain and expand the capacity to serve the growing and aging Latina population.

In the pursuit of healthcare excellence, regulatory compliance is essential—but it’s only the beginning. Sustainable quality and safety emerge when organizations move beyond checklists and audits to embrace a culture of purpose, collaboration, and continuous learning.In this keynote, Neha Chowrasia, a nationally recognized Clinical Effectiveness Consultant with deep expertise in healthcare administration, quality improvement, and patient experience, shares insights from leading cross-functional initiatives across large health systems. With a unique blend of clinical and operational perspective, Neha illustrates how culture—not just protocols—drives lasting transformation.Through compelling examples and practical strategies, this session will explore how healthcare teams can elevate patient safety, align leadership and frontline staff around shared goals, and embed high-reliability principles into daily operations. Special focus will be placed on fostering psychological safety, leveraging patient feedback for system redesign, and balancing regulatory readiness with meaningful, people-centered care.Attendees will leave equipped with actionable tools to shift from reactive compliance to proactive reliability—and from rule-following to culture-building.

Collagenous sprue (CS) is a rare autoimmune gastrointestinal disorder characterized by specific histologic changes in the small intestine. It often presents with more severe symptoms and a worse prognosis compared to celiac disease, including significant malabsorption, weight loss, and nutrient deficiencies. Despite treatment with a gluten-free diet, symptom improvement is limited, with only a small fraction of patients responding positively. This case report highlights the diagnostic challenges and clinical features of CS in a 74-year-old woman, whose symptoms resolved following cessation of olmesartan. The case emphasizes the importance of recognizing medication-induced forms of the disease and outlines the need for targeted management strategies to improve patient outcomes.

Warfarin has been widely used for its anticoagulant properties. It has a narrow therapeutic range with complex interactions with various dietary products, herbal supplements, and with other medications. We recently encountered a case of warfarin coagulopathy in a patient that had been on stable doses of warfarin since 2011 with successful maintenance of international normalized ratio in the therapeutic range. By the process of elimination, the cause was attributed to the patient's recent inclusion of pineapple papaya smoothies in her diet. This study highlights the importance of detailed history taking with a focus on diet changes and supplements in patients on warfarin. Warfarin has an extensive list of interactions with prescription and over-the-counter medications, various vegetables, fruits, and herbal supplements through an effect on warfarin metabolism by cytochrome 450 enzymes. While it is a well-known fact that green leafy vegetables diminish warfarin therapeutics due to their high Vitamin K content, warfarin interactions with fruits are less well known. The focus of this article is a review of the literature about the plausible interactions of pineapple and papaya with warfarin. We have briefly touched on the interactions of warfarin with other fruits.