I became interested in pursuing the project while I was assisting Enhanced Care Planning research team this summer. I am interested in what factors help patients achieve success when attempting to make a health behavior change. As an aspiring family medicine physician, I am also interested in preventative medicine, including lifestyle modification. The data collected from the care plans had not yet been pulled and analyzed, so I decided to use my month there to look at what goals patients were making. My hope is in the future, we could see if number or type of strategies affect patients’ progress toward their goal.
Background: Addressing physical inactivity and poor nutrition are crucial to managing chronic conditions. However, with time and staffing constraints on primary care, these aspects may be overlooked. The ongoing Enhanced Care Planning study is investigating a care planning intervention that screens patients for needs, prompts them to create a care plan, and connects them to a patient navigator who can offer community resources. I set out to understand which actions enrolled patients selected to reach their physical activity/nutrition/weight loss goals. Setting and participants: Patients 18 years-75 years old with 2 or more chronic conditions (cardiovascular disease, hypertension, hyperlipidemia, diabetes, obesity, or depression) are eligible for the study. Methods: I reviewed 149 care plans with 1,222 selected actions to determine frequency of evidence-based strategies chosen. Results: Most patients selected fewer than 10 actions, with a median of 6 actions. The most commonly selected actions were “walk more every day” (n=72) and “eat more vegetables” (n=70). Domains of selected resources, included nutrition (48%), exercise (43%), and weight loss (9%). 66% of the selected actions were self-directed, meaning the patient can do them at home or without a navigator connecting them. Conclusion: These findings illustrate the feasibility of the care planning intervention, as patients prefer actions they can complete on their own. Practices may consider creating a list of nutrition resources, as this domain was most prioritized by patients.
Co-Author(s): Timothy Yu, MD, CAQSM
This patient presented to our sports medicine clinic at the Inova Fairfax Primary Care Sports Medicine Fellowship program. Further research on this topic was helpful to better understand the cause, epidemiology, pathophysiology, and management of cluneal neuropathy and iliopsoas bursitis.
A 76 year old male presented with a 6-month history of left-sided low back pain and left hip pain. He denied inciting event or injury. Physical exam revealed tenderness to palpation of the left iliac spine and iliac crest. Tenderness was elicited in the left iliac crest with resisted flexion of the left hip. X-ray of the left hip showed mild osteoarthritis in the left hip joint. There was concern for cluneal neuropathy and iliopsoas bursitis, given the location of the pain and the physical exam findings. Under ultrasound guidance, a cluneal nerve block was done by injecting 3cc of Lidocaine 1% and 40mg of Kenalog was injected into the superior aspect of the iliac crest. Under ultrasound guidance, 4cc of Lidocaine 1% and 40mg of Kenalog was injected into the iliopsoas bursa. The patient reported immediate improvement of his pain following the injection. The patient reported complete resolution of his pain as he ambulated out of the clinic. The patient was given a referral to physical therapy and was advised to follow up in 6 weeks. The cluneal nerves are sensory nerves providing cutaneous innervation of the buttocks and posterior presacral region. Damage or entrapment of one of the three sets of cluneal nerves (superior, middle, and/or inferior cluneal nerves) represents a cause of low back pain/hip pain that is often overlooked.
Co-Author(s): Praveen Fernandopulle
Mentor/Program Director: Dr. Ashley McGuire
I wanted to understand the connection between addiction, nutrition, and mental health: Learn about the bidirectional relationship between addiction, nutrition, and mental health, including how nutrient imbalances can contribute to mental health disorders and how addiction can exacerbate existing mental health conditions.
Introduction: Substance use disorder impairs control over drug, alcohol, or medication use. Nutrition is crucial in preventing and treating substance use disorders, especially with marijuana and alcohol. Dietary factors significantly impact outcomes, highlighting the need to integrate nutrition into treatment plans. Addressing nutritional deficiencies and promoting a healthy diet improves treatment outcomes and supports long-term recovery. Methods: We used cross-sectional data (n=438,693) from the 2021 Behavioral Risk Factor Surveillance System, a nationally representative U.S. telephone-based survey of adults aged 18 years or older. Logistic regression analyses were conducted to test the association between low fruit consumption, low vegetable consumption, and substance use outcomes. We coded low fruit/vegetable consumption binary, with 1 representing less than once a month in the last year, and 0 for having fruit/vegetables monthly. Substance use outcomes include past year marijuana use, past year alcohol use, and current smoking. We controlled for race, gender, income, depression, age, and educational attainment. Results: Overall, 7.8% (n=34.393) reported low vegetable consumption, while 3.3% (n=14.654) reported low fruit consumption. Low vegetable consumption was associated with higher odds of marijuana use (OR=1.07, 95% CI, 1.04, 1.09), and current smoking (OR=1.34, 95% CI, 1.30,1.39). Low fruit consumption was associated with higher odds of smoking (OR=1.90, 95% CI, 1.83, 1.98). Low fruit consumption and low vegetable consumption were not associated with alcohol use. Conclusion: Addressing nutritional deficiencies and promoting a healthy diet improves treatment outcomes and supports long-term recovery. Further research is needed to better understand the intricate relationship between nutrition and substance abuse, leading to evidence-based interventions that effectively address these issues.
This project was inspired by patients who asked questions regarding what they should eat to prevent breast cancer. I wanted to be able to provide my patients with accurate evidence-based information regarding diet and its role in breast cancer prevention. As family doctors, we should not only focus on finding existing cancers, but also preventing those cancers in the first place. Therefore, by having a knowledge translation tool that easily communicates the evidence linking diet and breast cancer, we can efficiently our breast cancer prevention efforts to not only address secondary prevention (via mammograms) but also primary prevention (via diet).
Background: The current approach to breast cancer prevention (mammograms) focuses on secondary prevention. Providing dietary information to family medicine patients is a potential avenue for promoting primary prevention of breast cancer. Objective: To conduct a review investigating the quantity of the foods/nutrients that are associated with increased/decreased risk for breast cancer, in order to inform a knowledge translation project, enabling the delivery of this information to family medicine patients. Data sources: PubMed and Scopus. Study selection: An existing review published by in 2017 by Buja et al, identified 13 foods/nutrients that were associated with breast cancer. Of those, six (mushrooms, fiber, folate, carotenoids, red/processed meat and high GI foods) had up-to-date meta-analyses reporting dose-response relationships. A review of 79 abstracts published since 2017 was undertaken and updated systematic reviews reporting dose-response relationship were found for three foods/nutrients (vegetables, vitamin D, soy isoflavones). For two foods/nutrients (eggs and calcium), new contradictory information was published and for one food (fruit) new data was published. A dose-response was not reported for two foods/nutrients (lignans and citrus fruit), therefore, in these instances, the cohorts that comprised the meta-analyses cited by Buja et al were reviewed. Synthesis: Red meat (150 g/day), processed meat (50g/day) and a high glycemic index diet (10 unit increases) were associated with increased risk for breast cancer. Vegetables and fruits (100 mg/day), mushrooms (1g/day), vitamin D (100 IU/day), folate (100 ug/day), fiber (10 g/day), carotenoids (500 ug/day), lignans (1.2 mg/day) and soy isoflavones (10 mg/day) were associated with decreased risk for breast cancer. Conclusion: Modest quantities of several foods and nutrients were associated with increased/decreased risk for breast cancer and can be communicated to patients in family practice settings.
Co-Author(s): Dr. Elise Morris
During my family medicine rotation, I frequently encountered skin conditions that can present differently in skin of color. One such condition was atopic dermatitis, which negatively impacted the quality of life of patients, affecting both their physical and emotional health. This personal experience deepened my interest in pursuing this research project, as I witnessed firsthand the need for better understanding and tailored management of AD in skin of color populations. Understanding differences in the clinical manifestation of this disease and finding effective treatment approaches can lead to improved healthcare outcomes and quality of life for this patient population.
Atopic dermatitis (AD), a chronic relapsing inflammatory skin condition, presents differently in patients with skin of color (SOC), posing unique diagnostic and management challenges. AD typically manifests as pruritic erythematous plaques on flexor surfaces, but SOC patients may exhibit subtle violaceous erythema and greater extensor involvement. SOC patients are also prone to lichenification and post-inflammatory hyperpigmentation. Although AD affects individuals of all ethnic backgrounds, research has shown that AD disproportionately impacts African American and Asian populations. Specific ethnic groups may display unique clinical characteristics; for instance, Asian patients may present with psoriasiform features, while black patients may present with a papular variant, diffuse xerosis, and prurigo nodularis. While topical corticosteroids and calcineurin inhibitors remain first-line therapies for AD flare ups, managing AD in SOC patients requires tailored approaches. For instance, high doses of topical corticosteroids can lead to hypopigmentation which is especially prominent in SOC. Moisturization and gentle skincare routines are important to preserving skin barrier function, particularly in individuals with SOC, who may experience decreased ceramide levels in the skin. Severe or refractory cases of AD may require specialist referral to incorporate phototherapy and systemic agents into treatment algorithms. These therapies have shown promise in achieving disease control while minimizing side effects. Further research is essential to optimize interventions and improve outcomes for AD in SOC populations.
I am currently an MS2 student at EVMS interested in primary care. As a physician I want to be able to see patients periodically and for a longer time, a quality I desire in my career. In order to be a successful primary care doctor, I want to be educated on research in preventative medicine and population health. I believe research in these fields allow for relatively better improvement in patient outcomes with little expense to the healthcare system. Preventative medicine especially matters to me because it’s unfair that a patient should suffer from an illness that could have been prevented through lifestyle change instruction or education. As a future provider, I believe I hold responsibility in educating my community on disease prevention, which I can learn more about through research. The research I perform now as a student will help me understand future research projects, as I witness changes and improvements in the field. This is how I became interested in this project, as it is a direct example of how parents can prevent their child from developing obesity and subsequent comorbidities at an early age.
Introduction: The rise in childhood obesity partially arises from the gap in care between follow-up appointments between families and providers, as parents are unaware of how to start lifestyle changes. LittleSteps4Health (LS4H) is a local solution to this gap in care, providing parents guidance on how to start these changes. This project aims to determine if LS4H is a feasible program to successfully change behavior among families and to understand how families responded to the program. Methods: Families in LS4H independently completed 1 module per week for 6 weeks that introduced a new healthy behavior. Weekly individual interviews assessed family acceptance of the program, impacts on knowledge, and changes in awareness or behaviors. Qualitative data analysis on 84 family responses were recorded using Qualtrics and themed into categories using spreadsheet software. Results: Of 66 families registered, 25 families completed at least one module. Major themes included changes in knowledge, awareness, and behavior for each module topic. Across all 6 modules, 100% of families reported continuing the respective module behavioral goal as a new habit moving forward and majority reported they would have continued the program without weekly follow-ups, but with reservations. Conclusion: The results of this program demonstrated that the initial feasibility pilot was well received by families and majority were successfully able to change behaviors related to small goals. Families who participated in the program indicated follow-ups and reminders were important to their success. Ultimately, these small steps towards behavior change can gradually progress towards childhood weight loss.
Catatonia has always fascinated me, ever since we learned about the condition during pre-clinicals. It is curious how one clinical presentation can have a myriad of possible etiologies, ranging from depression to psychosis to autoimmune disease. As an aspiring psychiatrist interested in the intersection between psychiatry, medicine, and inflammation, that there could possibly be an immunological basis for catatonia is fascinating. The paucity of knowledge around catatonia as a whole, in addition to the even scarcer body of knowledge for catatonia in 22q11.2DS inspired me to learn more and present this case report.
Introduction: 22q11.2 deletion syndrome (22q11.2DS) is characterized by increased risk of neuropsychiatric disorders, including primary psychiatric illness and catatonia. Catatonia is a relatively rare, poorly understood condition characterized by various psychomotor disturbances. To our knowledge, there are only 5 case reports and 1 case series with 13 subjects describing the catatonic presentation in 22q11.2 (Rogers et al., 2019). This report adds to the scare body of literature by providing a clinical manifestation, assessment, and management of catatonia in 22q11.2, contributing to our understanding of catatonia as a whole. Case Description: Patient is an 11 year old female with 22q11.2DS, resolving mononucleosis, and COVID-19/Group A Streptococcus positivity who was admitted for bizarre behavior and auditory/visual hallucinations, concerning for psychosis. Psychiatric history was only notable for ADHD and one-time suicidal ideation. On admission, Bush Francis Catatonia Score (BFCS) was 10. On day 2, BFCS was 17 with notable signs including: immobility, mutism, staring, automatic obedience, Mitgehen, Gegenhalten, and ambitendency. In response, Ativan challenge was administered with 1 mg PO Ativan, upon which the patient’s BFCS decreased from 17 to 10. BFCS decreased to consistent 0 after a total of 7 mg of PO Ativan. However, after resolution of catatonia, psychotic symptoms persisted. Clinical picture was complicated by the possibility of adolescent imaginative thinking. Conclusion: Given that the patient had multiple concurrent infections, lacked significant psychiatric history, and the presence of immune dysregulation in 22q11.2DS, this report provides further evidence for an immunological understanding of catatonia.