No abstract

Food insecurity is associated with many poor health outcomes yet is not routinely addressed in clinical settings. The purpose of this study was to implement a food insecurity screening and referral program in Student-run Free Clinics (SRFC) and to document the prevalence of food insecurity screening in this low-income patient population. All patients seen in three SRFC sites affiliated with one institution in San Diego, California were screened for food insecurity using the 6-item United States Department of Agriculture (USDA) Food Security Survey between January and July 2015 and referred to appropriate resources. The percentage of patients who were food insecure was calculated. The screening rate was 92.5% (430/463 patients), 74.0% (318/430) were food insecure, including 30.7% (132/430) with very low food security. A food insecurity registry and referral tracking system revealed that by January 2016, 201 participants were receiving monthly boxes of food onsite, 66 used an off-site food pantry, and 64 were enrolled in the Supplemental Nutrition Assistance Program (SNAP). It is possible to implement a food insecurity screening and referral program into SRFCs. The prevalence of food insecurity in this population was remarkably high yet remained largely unknown until this program was implemented. Other health care settings, particularly those with underserved patient populations, should consider implementing food insecurity screening and referral programs.

Among 47 patients with thrombotic thrombocytopenic purpura (TTP), 8 patients were diagnosed to have postoperative-TTP. Two patients underwent vascular surgery, 5 patients coronary artery bypass grafts, and 1 patient resection of myocardial sarcoma. Prior to surgery, all patients except one had normal hemograms and platelet counts, and blood smears showed no schistocytes. Five to 19 days after surgery, all 8 patients developed postoperative TTP, which clinical feature was characterized by unexplained progressive encephalopathy, thrombocytopenia, and microangiopathic hemolytic anemia. In addition, in 3 patients, progressive gangrene of the toes also developed. Four patients achieved complete remission following exchange plasmapheresis and 1 patient spontaneous remission. Due to complicated surgical settings after surgery, recognition of TTP was often delayed and it contributed to death in 3 patients despite treatment with exchange plasmapheresis. In view of occurrence of postoperative TTP following cardiac and vascular surgeries, pathogenic mechanism for postoperative TTP may be explained on the basis of injury of diseased endothelial surface and release of a humoral factor(s) that results in platelet aggregation in the capillaries and arterioles. Our experience with these cases indicates that TTP may occur as a serious complication of cardiac and vascular surgeries, and early recognition of the diagnosis and institution of exchange plasmapheresis are of paramount importance for favorable outcome.