A stepped-wedge randomized trial protocol of a community intervention for increasing lung screening through engaging primary care providers (I-STEP)

Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet few eligible high-risk patients receive it annually. This protocol describes a community-partnered intervention (Toolkit) designed to support primary care practices in making referrals for lung screening and guiding patients into appropriate screening pathways. This study uses a stepped-wedge implementation design. Screening centers are randomized by readiness level to enter the intervention phase in three-month "steps" with pre-intervention data serving as the control. The primary outcome is whether delivery of the Toolkit to primary care practices results in a monthly increase in number of initial LDCT screenings. Six participating centers will identify 10 practices and reach 2-3 providers per practice to train them to use the Toolkit. The Toolkit will address known barriers to screening and referral at the patient and provider levels and provide support for required elements of screening. Toolkit components include adaptable evidence-based interventions to maximize compatibility with workflows. We hypothesize that after nine months of intervention delivery, the number of initial screening per center will double. Involving 60 practices achieves 80% power at 5% level of significance. Implementation outcomes such as adoption, acceptability, feasibility, adaptation, and sustainability will be assessed through field-notes and activity logs. LDCT for lung cancer screening currently reaches a small fraction of eligible adults. To reach the full potential to reduce mortality, primary care practices are an important venue for increasing appropriate referrals. This multidisciplinary trial will encourage acceptability and sustainability by using local knowledge and promoting partnership between providers and patients. Trial registration: ClinicalTrials.gov, NCT03958253.

Disseminated actinomycosis with spinal cord compression: report of two cases

We studied two patients with vertebral actinomycosis and symptoms of spinal cord compression. Both patients had a chronic illness characterized by multiple draining skin lesions, weight loss, and progressive leg weakness. They responded to antibiotic therapy and corticosteroids without neurosurgical intervention. The patients were treated with antibiotics for 12 months, and remained well, without major neurologic disorder, for 2 years after stopping medication.

Legionnaires' disease in Vermont, May to October 1977

Thirty-two confirmed and 24 highly probable cases of Legionnaires' disease occurred in Vermont between May 1 and Oct 15, 1977. Confirmed cases had positive results for direct fluorescent antibody testing of lung tissue or fourfold rise in antibody titer. Highly probable cases had one elevated titer (greater than or equal to 1:256) and a compatible illness. Forty-eight (86%) had underlying chronic disease, and 22 (39%) were immunocompromised. Prominent early symptoms were fever, cough, chills, and malaise. All but one patient had verified pneumonia. Courses ranged from a pneumonia not requiring hospitalization to respiratory failure necessitating support with mechanical ventilation. Seventeen patients died. Although the clinical presentation was variable, rapid development of high fever and leukocytosis together with negative cultures of lower respiratory tract secretions strongly suggested the diagnosis in an epidemic setting.