Implementation, Reach, and Effectiveness of the Direct Observation of Residents in Clinic Program.

BACKGROUND: Direct observation is important, yet medical residents are rarely observed. We implemented and evaluated a direct observation program in resident clinics to increase the frequency of observation and feedback and improve perceptions about direct observation. METHODS: We assigned faculty as observers in our resident clinics between June 2019 and February 2020. We surveyed residents and faculty before and after the program. Faculty completed a form for each observation performed. We analyzed surveys to examine changes in barriers, frequency and type of observations and feedback, and attitudes toward observation. The analytical sample included 38 and 37 pre- and postresident surveys, respectively, and 20 and 25 pre- and postfaculty surveys, respectively. RESULTS: Resident survey response rates were 32.3% (40/124) pre- and 30.7% (39/127) postintervention. Most residents (76% [pre], 86% [post], P = 0.258) reported being observed in at least one of the four areas: history, examination, counseling, or wrap-up. We received observation tracking forms on 68% of eligible residents. Observed history taking increased from 30% to 79% after the program (P = 0.0010). Survey response rates for faculty were 64.7% (22/34) pre- and 67.5% (25/37) postintervention. Fewer faculty reported time (80% [pre], 52% [post], P = 0.051) and competing demands (65% [pre], 52% [post], P = 0.380) as barriers postintervention. Fewer faculty postintervention viewed observation as a valuable teaching tool (100% [pre], 79% [post], P = 0.0534). All faculty who did not view observation as valuable were the least experienced. DISCUSSION: Assigning faculty as observers can increase observation, especially in history taking, though data suggest an increase in negative perceptions of observation by faculty.

Analysis of Decreasing Adverse Events with Endoscopic Ultrasound in a New Advanced Endoscopy Program Over Time.

OBJECTIVE: New innovations and increasing utility of endoscopic ultrasound (EUS) are associated with rare but serious risks. We investigate the rates and risk factors for post-procedural complications over a four-year period at a new advanced endoscopy program. METHODS: We conducted a retrospective review of all adult patients who underwent upper EUS at an academic level-1 trauma center between April 2015 and November 2019. The primary outcome was the incidence of adverse events within 1 week of EUS. Secondary outcomes included emergency department visits and mortality within 30 days after EUS. Chi-square test, t test, and multivariable logistic regression were used to assess risk factors for post-procedural complications. RESULTS: A total of 968 EUS procedures were performed on 864 patients (54% female; 79% Caucasian; mean age 61 years). The overall incidence of post-procedural adverse event with EUS was 5.6%. The probability of an adverse event decreased by an average of 22% per year (p =0.01, OR 0.78). The risk for adverse events were 3.3% acute pancreatitis, 1.9% clinically significant bleeding, 0.3% bacteremia, 0.2% perforation, and 2.4% 30-day mortality. The adverse event rate was highest among low volume proceduralists (p =0.04). The 30-day mortality was more than threefolds among patients who had an adverse event within 7 days after EUS. CONCLUSION: The overall incidence of post-procedural adverse events at a new EUS program was 5.6%, with an average of 22% relative decrease in adverse events per year in the first 4 years.

Oxidative and carbonyl stress in pregnant women with obstructive sleep apnea.

PURPOSE: Pregnant women are particularly susceptible to sleep-disordered breathing. Obstructive sleep apnea (OSA) in pregnancy is associated with poor pregnancy and fetal outcomes. Oxidative stress caused by intermittent hypoxemia and reoxygenation may impact pregnancy health. We hypothesize that pregnant women with OSA have a pronounced oxidative stress profile. METHODS: A case-control study was performed to study oxidative stress markers in the serum of pregnant women with or without OSA. Patients with OSA were identified between 2003 and 2009. Contemporaneous controls were pregnant subjects without apnea, gasping, or snoring around the time of delivery. Serum markers of oxidative and carbonyl stress were measured by spectrophotometric/fluorometric methods. Multiple linear regression analysis was used with a model including age, body mass index at delivery, history of diabetes, and gestational age. RESULTS: Serum samples from 23 OSA cases and 41 controls were identified. Advanced oxidation protein products, a marker for oxidative stress, and advanced glycation end products (AGEs), a marker for carbonyl stress, were significantly lower in women with OSA than in controls (p value <0.0001). Total antioxidant capacity was higher in women with OSA in comparison to controls (p value <0.0001). The difference in AGEs remained significant even after adjusting for confounders. CONCLUSION: Contrary to our hypothesis, the results of this study suggest that pregnant women with OSA have higher antioxidant capacity and lower oxidative and carbonyl stress markers compared to controls, suggesting a possible protective effect of intermittent hypoxia. Whether OSA in pregnancy impacts oxidative stress differently than OSA in the general population remains to be confirmed.

Medical Neighborhood Model for the Care of Chronic Kidney Disease Patients.

BACKGROUND: The patient-centered medical home is a popular model of care, but the patient-centered medical neighborhood (PCMN) is rarely described. We developed a PCMN in an academic practice to improve care for patients with chronic kidney disease (CKD). The purpose of this study is to identify the prevalence of CKD in this practice and describe baseline characteristics, develop an interdisciplinary team-based approach to care and determine cost associated with CKD patients. METHODS: Patients with CKD stage 3a with comorbidities through stage 5 were identified. Data collected include demographics, comorbidities and whether patients had a nephrologist. Using a screening tool based on the 2012 Kidney Disease Improving Global Outcomes guidelines, a nurse care manager (NCM) made recommendations about management including indications for referral. A pharmacist reviewed patients' charts and made medication-related recommendations. Blue Cross Blue Shield (BCBS) insurance provided cost data for a subset of patients. RESULTS: A total of 1,255 patients were identified. Half did not have a formal diagnosis of CKD and three-quarters had never seen a nephrologist. Based on the results of the screening tool, the NCM recommended nephrology E-consult or full consult for 85 patients. The subset of BCBS patients had a mean healthcare cost of $1,528.69 per member per month. CONCLUSIONS: We implemented a PCMN that allowed for easy identification of a high-risk, high-cost population of CKD patients and optimized their care to reflect guideline-based standards.

Preventing HIV Transmission Among Partners of HIV-Positive Male Sex Workers in Mexico City: A Modeling Study.

Mexico has a concentrated HIV epidemic, with male sex workers constituting a key affected population. We estimated annual HIV cumulative incidence among male sex workers' partners, and then compared incidence under three hypothetical intervention scenarios: improving condom use; and scaling up HIV treatment as prevention, considering current viral suppression rates (CVS, 60.7 %) or full viral suppression among those treated (FVS, 100 %). Clinical and behavioral data to inform model parameterization were derived from a sample (n = 79) of male sex workers recruited from street locations and Clínica Condesa, an HIV clinic in Mexico City. We estimated annual HIV incidence among male sex workers' partners to be 8.0 % (95 % CI: 7.3-8.7). Simulation models demonstrated that increasing condom use by 10 %, and scaling up HIV treatment initiation by 50 % (from baseline values) would decrease the male sex workers-attributable annual incidence to 5.2, 4.4 % (CVS) and 3.2 % (FVS), respectively. Scaling up the number of male sex workers on ART and implementing interventions to ensure adherence is urgently required to decrease HIV incidence among male sex workers' partners in Mexico City.

Knowledge and approach towards Helicobacter pylori diagnosis and management among primary care physicians in Cameroon: a cross-sectional study.

BACKGROUND: Low- and middle-income countries have a high prevalence of Helicobacter pylori infection (HPI). In Cameroon, the majority of HPIs are diagnosed and treated by primary care physicians (PCPs). We sought to assess the knowledge and practices of PCPs in the diagnosis and management of HPI in Cameroon. METHODS: A hospital-based cross-sectional study was carried out in four randomly selected regions of Cameroon from November 2021 to June 2022. In each of the selected regions, PCPs were recruited by non-probability convenience sampling and interviewed using a pre-structured questionnaire. Chi-squared, Fisher's exact and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to examine associations between knowledge and practice, with the model adjusted by age of the PCP, geographic region, number of patients and years in practice. Analysis was performed in SAS version 9.4 (SAS Institute, Cary, NC, USA). RESULTS: A total of 382 PCPs were included in the analysis. The majority (60.0%) were males between the ages of 20-29 y (64.1%). Most PCPs (80.9%) reported that HPI is the cause of gastroesophageal reflux disease and 41.8% reported that HPI is the main cause of dyspeptic symptoms. The dominant diagnostic tests used for HPI were serology (52.8%) and stool antigen (30.9%). The most frequently used first-line therapies were amoxicillin (AMX), clarithromycin (CLA), metronidazole (MNZ) and proton pump inhibitor (PPI) concomitant therapy (32.2%), AMX-CLA-PPI triple therapy (18.6%) and AMX-MNZ-PPI triple therapy (13.1%). Half of the practitioners (48.6%) treat HPI empirically, without positive H. pylori testing. About half of the PCPs (48%) do not request laboratory confirmation of H. pylori eradication following treatment. CONCLUSIONS: There is inadequate knowledge and significant differences in the clinical approach towards HPI among PCPs in Cameroon. We recommend more teaching programs and continuous medical education on HPI.

Assessment of Frailty and Risk of Chemotherapy Toxicity at a Geriatric-Oncology Multidisciplinary Clinic.

BACKGROUND: Multidisciplinary Geriatric-Oncology (GO-MDC) clinic performed comprehensive geriatric assessment (CGA) to determine frailty and chemotherapy toxicity risk. METHOD: Retrospective cohort study of patients ≥65 years seen between April 2017 to March 2022. We compared Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) to CGA as a determinant of frailty and risk of toxicity from chemotherapy. RESULTS: Mean age of the 66 patients was 79 years. Eighty-five percent were Caucasian. Predominant cancers were breast (30%), and gynecological (26%). One-third were stage 4. The CGA identified fit (35%), vulnerable (48%), and frail (17%) patients whereas ECOG-PS classified 80% as fit. CGA assessed 57% of ECOG-fit patients as vulnerable or frail (p<0.001). High chemotherapy toxicity risk using CGA was 41% and using ECOG was 17% (p=0.002). CONCLUSION: At GO-MDC, CGA was a better predictor of frailty and toxicity risk than ECOG-PS. Treatment modification was recommended in one-third of patients.

Impact of Geriatric Trauma Co-Management on 1-Year Mortality in Older Adults with Multiple Rib Fractures.

BACKGROUND: Rib fractures in older adults are associated with higher morbidity and mortality. Geriatric trauma co-management programs have looked at in-hospital mortality but not long-term outcomes. METHODS: A retrospective study of multiple rib fracture patients 65 years and older (n=357), admitted from September 2012 to November 2014 comparing Geriatric trauma co-management (GTC) vs Usual Care by trauma surgery (UC). The primary outcome was 1-year mortality. RESULTS: 38.9% (139) were cared for by GTC. Compared to the UC, GTC patients were older (81.6±8.6 years vs 79±8.5) and had more comorbidities (Charlson 2.8±1.6 vs 2.2±1.6). GTC patients had 46% less chance of dying in 1-year compared to UC (HR 0.54, 95% CI [0.33-0.86]).  Conclusions: GTC showed a significant reduction in 1-year mortality even though patients were overall older and more comorbid. This shows multidisciplinary teams are crucial to patient outcomes and should continue to be further explored.

Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs.

BACKGROUND: Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs. METHODS: Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration). RESULTS: All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group. CONCLUSIONS: A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.

An Evaluation of Contraceptive Methods After Implementation of a Novel LARC Program in a Residency Primary Care Clinic.

BACKGROUND AND OBJECTIVE: Internal medicine (IM) residency programs have inadequate education and training around contraception, creating and perpetuating a potential barrier for patients. Contraceptive access is a critical part of primary care, yet few IM residency programs offer long-acting reversible contraception (LARC) in their clinic. To address the LARC needs of our patients and education needs of our residents, one attending (MS) created a procedure clinic and provided LARC in our residency clinic in 2015. In this initial study, we sought to determine the use of contraceptive methods among reproductive age women at our residency clinic two years after offering LARC. This data will shape future care provision and resident education. STUDY DESIGN AND METHODS: Data were extracted from 1,182 female patients ages 20-39 years attributed to the Rhode Island Hospital Center for Primary Care (CPC) between February 2017 to August 2018. Of the total, 260 patients were excluded because they had not been seen in the clinic within the preceding 12 months or had left the practice. Descriptive and bivariate methods were used to calculate the proportion of women using any contraception and long-acting reversible contraception (LARC) and to test for associations with demographic characteristics. PRIMARY RESULTS: Fifty-five percent used any contraception and 19% used LARC. LARC use was higher among women ages 20-29 when compared to women 30-39. Demographic characteristics other than age were not associated with contraceptive use. PRINCIPAL CONCLUSIONS: In this clinic, LARC usage exceeds the national average (19.0% v 10.3%). Residency training is ideal for learning skills around this aspect of medical care, providing the ability to ensure appropriate oversight and supervision. This initial study suggests almost one fifth (18%) of patients who utilize LARC find access at an IM residency primary care clinic acceptable. Internal medicine primary care clinics can address the nonsurgical contraceptive needs of their patients by providing access to LARC. To achieve this goal, internal medicine residents should receive training in and exposure to LARC provision.

How to Build It So They'll Come: Faculty Opinion on Faculty Development.

BACKGROUND: Residents report low satisfaction with faculty evaluation and feedback. To improve skills, successful faculty development interventions must be accessible and acceptable. METHODS: A faculty development survey was admin- istered to 145 specialty and non-specialty Internal Medicine faculty at the Warren Alpert Medical School of Brown University, Providence, RI. Analyses assessed demographics, opinion regarding evaluation and feedback and interest in faculty development. RESULTS: Only 70% of faculty were satisfied with their evaluation ability and only 59% were satisfied with their feedback skills. Despite this, 32% had limited interest in faculty development. Non-specialty faculty were more interested than subspecialty faculty, p-value=0.02. Faculty preferred short electronic audio slideshows and 38% reported participation barriers. CONCLUSIONS: Although faculty report evaluation and feedback are important skills, not all were satisfied with their abilities. Subspecialty faculty were less interested than non-specialty in faculty development. Our findings suggest that more effective ways to engage faculty in the process of faculty development are needed.

Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections.

OBJECTIVE: To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs). DESIGN: Retrospective before-and-after study that took place between March 2013 and February 2017. SETTING: An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU. PATIENTS: Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI. INTERVENTION: Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods. RESULTS: There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532). CONCLUSIONS: Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.

Mindfulness in Residency: A Survey of Residents' Perceptions on the Utility and Efficacy of Mindfulness Meditation as a Stress-Reduction Tool.

PURPOSE: Mindfulness meditation can help reduce burnout in medical students and attendings, yet has not demonstrated efficacy in residents. The authors surveyed internal medicine residents to determine their prior experience with and interest in mindfulness meditation. METHODS: An anonymous survey was given to 130 internal medicine residents at the Alpert Medical School at Brown University during the 2016-2017 academic year. The survey assessed prior experience, perceived efficacy, and interest in learning about mindfulness meditation. RESULTS: Of 104 completed surveys, 61% reported prior use of mindfulness and 25% reported current weekly or greater use. Eighty-seven percent of residents believed mindfulness meditation would help with stress reduction, and 87% were interested in receiving mindfulness training. CONCLUSIONS: Though a minority of residents currently practice mindfulness meditation, most believe it is an effective stress reduction tool and are interested in receiving further training. These results support the inclusion of mindfulness training within residency wellness initiatives.

The impact of errors on healthcare professionals in the critical care setting.

PURPOSE: Medical errors occur at high rates in intensive care units (ICUs) and have great consequences. The impact of errors on healthcare professionals is rarely discussed. We hypothesized that issues regarding blame and guilt following errors in the ICU exist and may be dependent on type of practitioner, level of experience, and error type. MATERIALS AND METHODS: An online survey was conducted of members of a large critical care medical society addressing three clinical scenarios of procedural, diagnostic and treatment errors. RESULTS: Nine hundred one practitioners responded. In all scenarios, negative feeling after medical errors occurred in all practitioners regardless of experience or field. Surgeons and anesthesiologists showed higher negative responses after procedural errors while internal medicine and emergency medicine practitioners had higher negative responses after diagnostic errors. Survey respondents identified multiple ways to address these adverse feelings, including debriefing with the medical team (68%), talking with colleagues (68%) and discussing with patients and families (36%). CONCLUSIONS: In critical care, blame and guilt after medical errors are common and affect all providers. Critical care practitioners have identified methods which may help mitigate adverse feeling after medical errors, including debriefing and talking with colleagues. Hospitals may benefit from developing these types of strategies after medical errors.

Obstructive Sleep Apnea in Gestational Diabetes: A Pilot Study of the Role of the Hypothalamic-Pituitary-Adrenal Axis.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) in pregnancy is associated with gestational diabetes mellitus (GDM). This propensity toward heightened insulin resistance in OSA patients has not been well characterized and may be related to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. The aim of this study was to (1) assess the prevalence of OSA in pregnant women with GDM, (2) evaluate whether HPA axis dysregulation relates to OSA, and (3) investigate the relation between insulin resistance and OSA. We hypothesized that OSA is prevalent among pregnant women with GDM and that women with OSA will have higher levels of insulin resistance and dysregulation of the HPA axis. METHODS: Twenty-five pregnant women in whom GDM was diagnosed were enrolled. Subjects answered sleep questionnaires and underwent in-home sleep studies using a level III device. The presence of OSA was defined by apnea-hypopnea index ≥ 5 events/h. Homeostasis Model Assessment of insulin resistance was derived from measurements of fasting glucose and C-peptide levels. Three salivary cortisol levels were obtained across 1 day to assess circadian variation. Multivariable linear regression analyses were used to assess associations between variables. RESULTS: The sample consisted of 54% Caucasian pregnant women with a median body mass index of 36.1 and interquartile ratio of 10.6 kg/m2. OSA was diagnosed in 17% of participants. Circadian variation of cortisol was preserved in women with OSA. Women with OSA displayed blunted cortisol awakening responses. CONCLUSIONS: OSA is prevalent in women with GDM. OSA is associated with preserved circadian variation and blunted cortisol awakening responses.

Improving the Perception of Outpatient Practice: A Second Continuity Experience for Internal Medicine Residents.

BACKGROUND: The challenges trainees experience in the traditional medical clinic are felt to be one deterrent to choosing a primary care career. OBJECTIVE: We examined whether participation in a second outpatient continuity experience (Second Site) affects trainee perception of primary care practice. METHODS: 241 current and former graduates of the Brown Alpert Medical School Internal Medicine training programs were surveyed about their experiences with Second Site. RESULTS: Of the 232 potential responders, 160 completed the survey. Although most did not feel that the experience altered their chosen career path, a positive perception of outpatient practice was noted by 97% of the primary care respondents and 92% of the subspecialty respondents. CONCLUSION: Second Site improved the perception of outpatient practice. A large number of our residents enter primary care, thus, few residents' careers were influenced by Second Site. Despite this, Second Site might enhance interest in primary care careers at other institutions. [Full article available at http://rimed.org/rimedicaljournal-2017-04.asp].

Evaluating HIV prevention strategies for populations in key affected groups: the example of Cabo Verde.

OBJECTIVES: We used an individual-based model to evaluate the effects of hypothetical prevention interventions on HIV incidence trajectories in a concentrated, mixed epidemic setting from 2011 to 2021, and using Cabo Verde as an example. METHODS: Simulations were conducted to evaluate the extent to which early HIV treatment and optimization of care, HIV testing, condom distribution, and substance abuse treatment could eliminate new infections (i.e., reduce incidence to less than 10 cases per 10,000 person-years) among non-drug users, female sex workers (FSW), and people who use drugs (PWUD). RESULTS: Scaling up all four interventions resulted in the largest decreases in HIV, with estimates ranging from 1.4 (95 % CI 1.36-1.44) per 10,000 person-years among non-drug users to 8.2 (95 % CI 7.8-8.6) per 10,000 person-years among PWUD in 2021. Intervention scenarios prioritizing FWS and PWUD also resulted in HIV incidence estimates at or below 10 per 10,000 person-years by 2021 for all population sub-groups. CONCLUSIONS: Our results suggest that scaling up multiple interventions among entire population is necessary to achieve elimination. However, prioritizing key populations with this combination prevention strategy may also result in a substantial decrease in total incidence.