Medicine Residents are Unprepared to Effectively Treat Patients with Obesity: Results from a U.S. Internal Medicine Residency Survey.

BACKGROUND: In an obesity epidemic, physicians are unprepared to treat patients with obesity. The objective of this study was to understand how obesity is currently addressed in United States (U.S.) Internal Medicine (IM) residency programs and benchmark the degree to which curricula incorporate topics pertaining to the recently developed Obesity Medicine Education Collaborative (OMEC) competencies. METHODS: Invitations to complete an online survey were sent via postal mail to U.S IM residency programs in 2018. Descriptive analyzes were performed. RESULTS: Directors/associate directors from 81 IM residencies completed the online survey out of 501 programs (16.2%). Although obesity was an intentional educational objective for most programs (66.7%), only 2.5% of respondents believed their residents are "very prepared" to manage obesity. Formal rotation opportunities in obesity are limited, and at best, only one-third (34.6%) of programs reported any one of the core obesity competencies are covered to "a great extent." Many programs reported psychosocial components of obesity (40.7%), weight stigma (44.4%), etiological aspects of obesity (64.2%) and pharmacological treatment of obesity (43.2%) were covered to "very little extent" or "not at all." Lack of room in the curriculum and lack of faculty expertise are the greatest barriers to integrating obesity education; only 39.5% of residency programs have discussed incorporating or expanding formal obesity education. CONCLUSIONS: Our study found the current obesity curricula within U.S. IM residency programs do not adequately cover important aspects that address the growing obesity epidemic, suggesting that obesity education is not enough of a priority for IM residency programs to formalize and implement within their curricula.

Standardising hospitalist practice in sepsis and COPD care.

BACKGROUND: Hospitalist medicine was predicated on the belief that providers dedicated to inpatient care would deliver higher quality and more cost-effective care to acutely hospitalised patients. The literature shows mixed results and has identified care variation as a culprit for suboptimal quality and cost outcomes. Using a scientifically validated engagement and measurement approach such as Clinical Performance and Value (CPV), simulated patient vignettes may provide the impetus to change provider behaviour, improve system cohesion, and improve quality and cost efficiency for hospitalists. METHODS: We engaged 33 hospitalists from four disparate hospitalist groups practising at Penn Medicine Princeton Health. Over 16 months and four engagement rounds, participants cared for two patients per round (with a diagnosis of chronic obstructive pulmonary disease [COPD] and sepsis), then received feedback, followed by a group discussion. At project end, we evaluated both simulated and real-world data to measure changes in clinical practice and patient outcomes. RESULTS: Participants significantly improved their evidence-based practice (+13.7% points, p<0.001) while simultaneously reducing their variation (-1.4% points, p=0.018), as measured by the overall CPV score. Correct primary diagnosis increased significantly for both sepsis (+19.1% points, p=0.004) and COPD (+22.7% points, p=0.001), as did adherence to the sepsis 3-hour bundle (+33.7% points, p=0.010) and correct admission levels for COPD (+26.0% points, p=0.042). These CPV changes coincided with real-world improvements in length of stay and mortality, along with a calculated $5 million in system-wide savings for both disease conditions. CONCLUSION: This study shows that an engagement system-using simulated patients, benchmarking and feedback to drive provider behavioural change and group cohesion, using parallel tracking of hospital data-can lead to significant improvements in patient outcomes and health system savings for hospitalists.

Effects of Elastase Digestion on the Murine Vaginal Wall Biaxial Mechanical Response.

Although the underlying mechanisms of pelvic organ prolapse (POP) remain unknown, disruption of elastic fiber metabolism within the vaginal wall extracellular matrix (ECM) has been highly implicated. It has been hypothesized that elastic fiber fragmentation correlates to decreased structural integrity and increased risk of prolapse; however, the mechanisms by which elastic fiber damage may contribute to prolapse are poorly understood. Furthermore, the role of elastic fibers in normal vaginal wall mechanics has not been fully ascertained. Therefore, the objective of this study is to investigate the contribution of elastic fibers to murine vaginal wall mechanics. Vaginal tissue from C57BL/6 female mice was mechanically tested using biaxial extension-inflation protocols before and after intraluminal exposure to elastase. Elastase digestion induced marked changes in the vaginal geometry, and biaxial mechanical properties, suggesting that elastic fibers may play an important role in vaginal wall mechanical function. Additionally, a constitutive model that considered two diagonal families of collagen fibers with a slight preference toward the circumferential direction described the data reasonably well before and after digestion. The present findings may be important to determine the underlying structural and mechanical mechanisms of POP, and aid in the development of growth and remodeling models for improved assessment and prediction of changes in structure-function relationships with prolapse development.

Biaxial Mechanical Assessment of the Murine Vaginal Wall Using Extension-Inflation Testing.

Progress toward understanding the underlying mechanisms of pelvic organ prolapse (POP) is limited, in part, due to a lack of information on the biomechanical properties and microstructural composition of the vaginal wall. Compromised vaginal wall integrity is thought to contribute to pelvic floor disorders; however, normal structure-function relationships within the vaginal wall are not fully understood. In addition to the information produced from uniaxial testing, biaxial extension-inflation tests performed over a range of physiological values could provide additional insights into vaginal wall mechanical behavior (i.e., axial coupling and anisotropy), while preserving in vivo tissue geometry. Thus, we present experimental methods of assessing murine vaginal wall biaxial mechanical properties using extension-inflation protocols. Geometrically intact vaginal samples taken from 16 female C57BL/6 mice underwent pressure-diameter and force-length preconditioning and testing within a pressure-myograph device. A bilinear curve fit was applied to the local stress-stretch data to quantify the transition stress and stretch as well as the toe- and linear-region moduli. The murine vaginal wall demonstrated a nonlinear response resembling that of other soft tissues, and evaluation of bilinear curve fits suggests that the vagina exhibits pseudoelasticity, axial coupling, and anisotropy. The protocols developed herein permit quantification of biaxial tissue properties. These methods can be utilized in future studies in order to assess evolving structure-function relationships with respect to aging, the onset of prolapse, and response to potential clinical interventions.