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The number of Americans aged 65 years or older is expected to increase in the coming decades. Because the risk for disability increases with age, more persons will need long-term services and supports (LTSS) to help with bathing, eating, dressing, and other everyday tasks. Long-term services and supports are delivered in nursing homes, assisted living facilities, the person's home, and other settings. However, the LTSS sector faces several challenges, including keeping patients and staff safe during the COVID-19 pandemic, workforce shortages, quality problems, and fragmented coverage options. In this position paper, the American College of Physicians offers policy recommendations on LTSS coverage, financing, workforce, safety and quality, and emergency preparedness and calls on policymakers and other stakeholders to reform and improve the LTSS sector so that care is high quality, accessible, equitable, and affordable. [ABSTRACT FROM AUTHOR]

This paper is part of the American College of Physicians' policy framework to achieve a vision for a better health care system, where everyone has coverage for and access to the care they need, at a cost they and the country can afford. Currently, the United States is the only wealthy industrialized country that has not achieved universal health coverage. The nation's existing health care system is in efficient, unaffordable, unsustainable, and inaccessible to many. Part 1 of this paper discusses why the United States needs to do better in addressing coverage and cost. Part 2 presents 2 potential approaches, a single-payer model and a public choice model, to achieve universal coverage. Part 3 describes how an emphasis on value-based care can reduce costs. [ABSTRACT FROM AUTHOR]

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Reductions in non-financial barriers to care and improvements in social determinants of health are also necessary. This ACP position paper calls for ending discrimination based on personal characteristics; correcting work force shortages, including the under supply of primary care physicians; and understanding and ameliorating social determinants of health. The ACP calls for in creased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems in order to achieve ACP's vision for a better U.S. health care system. [ABSTRACT FROM AUTHOR]

Purpose: To study antibody production to Pseudomonas aeruginosa protease IV (PIV) for immunoassay development and to assess the possible role of antibody in arresting corneal damage. Methods: Rabbits were immunized with PIV, urea-soluble recombinant PIV (rPIV), or precipitated rPIV. Antibody was analyzed by ELISA and Western blotting. Antibody-mediated inhibition of PIV activity was tested by colorimetric assay and during keratitis by slit-lamp examination of infected eyes. Results: Antibody was not produced after PIV immunization but was induced by rPIV. Rabbits immunized first with soluble and then precipitated rPIV produced high titers (log 10 ) to rPIV (4.28 ± 0.09) and significantly higher titers to PIV (3.90 ± 0.06) compared to the other immunized groups. Antibody to rPIV reacted with PIV, but neither neutralized enzyme activity in vitro nor protected infected rabbits in vivo . Conclusions: The present study demonstrates that PIV is a virulence factor which can escape a protective immune response. [ABSTRACT FROM AUTHOR]

PURPOSE. The purpose of this study was to developan animal model of Serratia keratitis that is suitable to demonstratethe pathology of specific strains. METHODS. Serratia marcescens ocular strains 93-1399-1 and 94-EI-185-2,and an environmental strain (ATCC 14041) were characterized in vitro in terms of their motility, metabolic profiles, ribotypes, and protease production.The strains were then analyzed in the rabbit intrastromal injection model.Slit lamp examination (SLE) and enumeration of bacteria in the cornea wasconducted every 6 hours for 30 hours post-infection. In vivo motilitieswere analyzed by quantification of bacteria in the peripheral and centralareas of infected rabbit corneas. RESULTS. All strains were similar in their metabolic activity and productionof extracellular proteases. The ocular isolates were distinct from the environmentalstrain in their ribotyping patterns and in their motility. Each strain grewlogarithmically in the cornea up to 6 hours post-infection. SLE scores increasedfrom 0 to 30 hours post-infection for strains ATCC 14041 and 93-1399-1, whilethe SLE score of strain 94-EI-185-2 reached its maximum at 18 hours post-infection.Strain-specific differences in pathology were noted from 18 to 30 hours post-infection.Strain 94-EI-185-2 produced iritis but only mild corneal changes. Strain 93-1399-1produced a severe corneal infiltrate encompassing the entire corneal surfaceas well as severe conjunctival inflammation and iritis. Strain ATCC 14041produced a localized, severe, exudative corneal abscess that contained infectingbacteria. CONCLUSIONS. A rabbit model of Serratia keratitis was developedin which bacterial growth kinetics and strain-specific ocular pathologic changeswere reproducible. [ABSTRACT FROM AUTHOR]

PURPOSE. Staphylococcus aureus causessevere corneal infections that often result in corneal scarring and blindness.Presently, therapy often involves the use of a fluoroquinolone antibiotic.This study, employing an experimental rabbit model of Staphylococcus keratitis, compared the effectiveness of two commonly prescribed formulationsof fluoroquinolones to an experimental formulation, ciprofloxacin with polystyrenesulfonate (ciprofloxacin-PSS). The ciprofloxacin-PSS formulation uses an ionexchange resin to aid in the delivery of drug to the cornea. METHODS. Early (4–9 h postinfection, PI) and late (10–15 hPI) therapies were studied, employing 5 groups: ciprofloxacin-PSS, ciprofloxacin,ofloxacin, PSS vehicle, and untreated. Dosing regimens were: every 30 min,60 min, or a single drop applied at 9 h PI. Eyes were observed by slit lampexamination (SLE) and bacterial colony forming units (CFU) per cornea weredetermined. RESULTS. Early phase therapy with ciprofloxacin-PSS, ciprofloxacin, orofloxacin administered every 30 or 60 min were equally effective (P ≥ 0.2880),decreasing CFU per cornea by >5 log. Ciprofloxacin was significantly moreactive than ciprofloxacin-PSS or ofloxacin (P ≤ 0.0410) when applied asa single drop. Late therapy with ciprofloxacin-PSS, ciprofloxacin, or ofloxacinadministered every 30 or 60 min resulted in >3 log decrease in CFU per cornearelative to controls (P ≤ 0.0001). CONCLUSIONS. Topical treatment of experimental Staphylococcus keratitis with ciprofloxacin-PSS, ciprofloxacin, or ofloxacin was effective.The effectiveness of ciprofloxacin-PSS suggests that improved drug deliverysystems employing an ion exchange resin could be useful in an ocular fluoroquinoloneformulation. [ABSTRACT FROM AUTHOR]

Primary aldosteronism PA is a secondary cause of hypertension that is often missed due to inadequate clinical evaluation and the lack of classically described laboratory abnormalities. Based on guidelines from the Endocrine Society, primary aldosteronism should be suspected in young patients with moderate to severe hypertension, patients with hypertension and coexisting hypokalemia, any patient with hypertension and an incidental adrenal adenoma, and hypertension in the setting of a significant family history of early onset hypertension or cerebral vascular accident in a first degree relative less than 40 years of age.1 In previous years, primary aldosteronism was attributed to less than one percent of all causes of secondary hypertension. However, recent research and increased utilization of aldosterone plasma renin ratio ARR as a method for screening has led to the understanding that majority of patients with PA are not hypokalemic, and the current literature now places the incidence of PA between 5-13 percent. Additionally, a growing body of evidence has demonstrated inflammatory, fibrotic, and remodeling effects on the cardiovascular and renal tissue that appear to be independent of PA- induced hypertension. Therefore a high suspicion for PA must be incorporated into evaluation of hypertensive patients, as diagnosis and subsequent treatment not only improves blood pressure control, but also acts to diminish cardiovascular morbidity and mortality. Here we present a case of a young woman with a seven-year history of hypertension prior to receiving a diagnosis of Conn's Syndrome.

A 63-year-old woman with a history of infiltrating ductal breast cancer, status post-mastectomy and chemotherapy, was in remission for 18 months prior to being admitted to the hospital with complaints of a pruritic erythematous macular rash involving her head, chest, and bilateral upper and lower extremities. Along with the dermatologic manifestations, physical exam revealed proximal symmetrical muscle weakness and bilateral axillary lymphadenopathy. Initial workup for muscle weakness revealed a creatine kinase of 2,200 IU/L (normal 20-180 IU/L). After administration of intravenous fluids for renal protection, serum sodium dropped to 121 mEQ/L (normal 135-145 mEQ/L). Computed tomography of the chest showed axillary and supraclavicular lymphadenopathy. Biopsy of a supraclavicular node revealed infiltrating ductal cancer with histologic and morphologic characteristics similar to her previous breast cancer. Following an extensive laboratory workup, we concluded that our patient's myositis and hyponatremia were paraneoplastic syndromes secondary to her recurrent breast cancer.

Budd Chiari syndrome is a rare disorder resulting from hepatic venous outflow tract obstruction anywhere from the small hepatic veins to the suprahepatic inferior vena cava. This patient has a hypercoagulable state secondary to heterozygous mutation of factor V and the JAK2 mutation and is being anticoagulated. We hypothesize that the low protein C and low antithrombin III levels seen in this patient resulted from decreased synthetic function of the liver and were not indicative of actual deficiencies. Indeed, reports of coexisting protein C and antithrombin III deficiencies are not existent in the literature and likely are not compatible with life. All patients with BCS warrant a hypercoagulable work up and JAK2 mutation is increasingly recognized as a contributing factor, even in those patients without obvious signs of polycythemia vera.