A Multicenter Curricular Intervention to Address Resident Knowledge and Perceptions of Personal Finance.

OBJECTIVES: We evaluated internal medicine residents' confidence and knowledge of personal finance, perceptions of burnout, and relations between these issues before and after an educational intervention. METHODS: We surveyed internal medicine residents at two university-based training programs in 2018. We developed and implemented a curriculum at both sites, covering topics of budgeting, saving for retirement, investment options, and the costs of investing. Each site used the same content but different strategies for dissemination. One used a condensed-form lecture series (two 1-hour sessions) and the other used a microlecture series (four 30-minute sessions) series. Residents were resurveyed following the intervention for comparison. RESULTS: The preintervention survey response rate was 41.2% (122/296) and the postintervention response rate was 44.3% (120/271). Postintervention mean scores for personal finance knowledge improved for basic concepts (52.6% vs 39.4%, P < 0.001), mutual fund elements (30.8% vs 19.7%, P < 0.001), investment plans (68.5% vs. 49.2%, P < 0.001), and overall knowledge (50.1% vs 36.1%, P < 0.001). A significantly smaller proportion of residents reported feelings of burnout following the intervention (23.3% vs 36.9%, P = 0.022). CONCLUSIONS: Our findings show that residents want to learn about finances. Our brief educational intervention is a practical way to improve overall knowledge. Our intervention suggests that improving knowledge of finance may be associated with decreased feelings of burnout.

Racial/ethnic differences in multiple diabetes outcomes in patients with type 2 diabetes in the southeastern United States.

OBJECTIVE: To determine racial/ethnic differences in control of multiple diabetes outcomes in a large, diverse primary care sample. METHODS: 661 adults with type 2 diabetes (T2DM) were recruited from three primary care settings. The primary outcomes were individual and composite control of multiple diabetes outcomes. Control of individual diabetes outcomes were defined as hemoglobin A1c (HbA1c) < 7%, blood pressure (BP) < 130/80 mmHg and low-density lipoprotein (LDL)-cholesterol < 100 mg/dL. Composite control was defined as having all three outcomes under control. Linear and logistic regression models were used to assess differences in individual means and individual and composite outcomes control between non-Hispanic Blacks (NHB) and Whites (NHW) adjusting for relevant covariates. RESULTS: NHBs were 67% of the sample, -61% earned < $20,000, and 78% earned < $35,000. Unadjusted mean HbA1c (8.0 vs 7.6, P = .024), SBP (134 vs 126 P < .001), DBP (76 vs 69, P < .001) and LDL (96 vs 87, P = .003) levels were significantly higher in NHBs. Adjusted linear regression showed that SBP (beta = 9.4; 4.5-8.6) and DBP (beta = 5.7; 3.5-7.9) were significantly higher in NHBs. 12.6% had composite control and NHBs had lower composite control (10.0% vs 17.6%). Adjusted logistic models showed that BP control (OR .45; .30-.67) and composite control (OR .57; .33-.98) were significantly lower in NHBs. CONCLUSIONS: In this diverse sample of primary care patients with T2DM, NHBs had significantly lower BP control and composite outcome control compared to NHWs adjusting for relevant confounding factors. Strategies are needed to optimize control of multiple outcomes and reduce disparities in patients with T2DM.

Patterns of gastroenterology specialty referral for primary care patients with metabolic dysfunction-associated steatotic liver disease.

BACKGROUND: As metabolic dysfunction-associated steatotic liver disease (MASLD) management extends into primary care, little is known about patterns of specialty referral for affected patients. We determined the proportion of primary care patients with MASLD that received a gastroenterology (GI) consultation and compared advanced fibrosis risk between patients with and without a referral. METHODS: This retrospective study of electronic health record data from a primary care clinic included patients with MASLD, no competing chronic liver disease diagnoses, and no history of cirrhosis. Referral to GI for evaluation and management (E/M) any time after MASLD ascertainment was the outcome. Fibrosis-4 Index (FIB-4) scores were calculated, categorized by advanced fibrosis risk, and compared by receipt of a GI E/M referral. Logistic regression models were developed to determine the association of FIB-4 risk with receipt of a GI referral. RESULTS: The cohort included 652 patients of which 12% had FIB-4 scores (≥2.67) at high-risk for advanced fibrosis. Overall, 31% of cohort patients received a GI referral for E/M. There was no difference in the proportion of patients with high (12% vs. 12%, p=0.952) risk FIB-4 scores by receipt of a GI E/M referral. In adjusted logistic regression models, high-risk FIB-4 scores (OR 1.01; 95% CI 0.59 - 1.71) were not associated with receipt of a referral. CONCLUSIONS: Only 30% of patients in this primary care MASLD cohort received a GI E/M referral during the study period, and those patients with a referral did not differ by FIB-4 advanced fibrosis risk.

Southern tick-associated rash illness: erythema migrans is not always Lyme disease.

Southern tick-associated rash illness (STARI) is a rash occurring after a tick bite. It is a form of erythema migrans, an annular rash with central clearing that is almost identical with the erythema migrans seen in Lyme disease. The etiologic agent is not known but may be a Borrelia species. The tick vector is different in the two diseases. Serious systemic complications are not currently recognized with STARI but treatment with doxycycline is prudent. Differentiating STARI from Lyme disease is discussed.

The Structure of Medical Intensive Care Units at Training Institutions.

BACKGROUND: As a result of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour guideline implementation, the structure of intensive care unit (ICU) teams at training institutions has been affected. The impact these changes have had on the current work environment has not been well described. METHODS: The authors conducted an online survey of internal medicine program directors in 2016. The survey investigated how training institutions structure their intensive care units in reference to volume, resident housestaff and alternative coverage options, with a focus on changes made after the implementation of the 2011 ACGME duty hour restrictions. RESULTS: Notable differences were found in program director responses to coverage of patients in the ICUs. A total of 62 of the 132 (48%) responding program directors describe coverage of all patients solely by resident housestaff. Since 2011, 54 (41%) programs have increased the number of resident physicians rotating in the ICU per month and initiated or increased the use of nonresident coverage of patients. Use of non-resident providers is not associated with a decrease in the number of total ICU months per resident or a decrease in educational value. CONCLUSIONS: Since the 2011 ACGME duty hour implementation, there is wide variability in the learning environment of medical intensive care units in training institutions.

Long-Term, Competitive Swimming and the Association with Atrial Fibrillation.

BACKGROUND: Endurance exercise plays a role in cardiovascular risk reduction, but may also be a risk factor for atrial fibrillation. This study was performed to assess the prevalence of atrial fibrillation in a population of long-term, competitive swimmers compared with patients within an internal medicine clinic with known risk factors for atrial fibrillation such as diabetes mellitus and hypertension. METHODS: This cross-sectional study utilized survey data comparing the prevalence of atrial fibrillation in swimmers to a general internal medicine population. A multi-national group of swimmers over the age of 60 were surveyed, and a chart review was performed on a random sample of age-matched internal medicine patients. The primary outcome was the diagnosis of atrial fibrillation. Univariate analysis was used for means of proportions of the responses, and a multivariate logistic regression analysis was performed with diagnosis of atrial fibrillation as the dependent variable. RESULTS: Forty-nine swimmers completed surveys and 100 age-matched internal medicine patients underwent chart review. Swimmers reported atrial fibrillation in 13 cases (26.5 %) compared to 7 (7 %) in the comparison group (p = 0.001). A diagnosis of hypertension or diabetes mellitus was present in 23 (46.9 %) and 1 (2 %) of the swimmers, respectively, as compared to 72 (72 %, p = 0.003) and 32 (32 %, p < 0.001) in the comparison group. Age, presence of diabetes mellitus, and swimming history were variables included in the logistic regression, in relation to atrial fibrillation. Swimming was associated with an odds ratio of 8.739 (95 % CI 2.290 to 33.344, p = 0.015). CONCLUSIONS: Long-term, competitive swimmers have an increased prevalence of atrial fibrillation compared to internal medicine patients, despite the higher burden of diabetes mellitus and hypertension in the internal medicine group.

Gender differences in composite control of cardiovascular risk factors among patients with type 2 diabetes.

OBJECTIVE: Disparities in outcomes for cardiovascular disease (CVD) exist between men and women with type 2 diabetes mellitus (T2DM). We examined gender differences in composite control of cardiovascular risk factors in a sample of adults with T2DM. SUBJECTS AND METHODS: This was a cross-sectional study of 680 people recruited from three primary care settings. Primary outcomes were individual and composite control of CVD risk factors. Control of individual risk outcomes was defined as glycosylated hemoglobin A1c (HbA1c) level of <7%, blood pressure (BP) of <130/80 mm Hg, and low-density lipoprotein (LDL) cholesterol level of <100 mg/dL. Composite control was defined as having all three outcomes under control simultaneously. Linear and logistic regression models were used to assess differences in individual means and individual and composite outcomes control between men and women, while adjusting for relevant covariates. RESULTS: Men made up 56% of the sample, approximately 67% were non-Hispanic black, and 78% made less than $35,000 annually. Unadjusted mean systolic BP (134 mm Hg vs. 130 mm Hg, P=0.005) and LDL cholesterol (99.7 mg/dL vs. 87.6 mg/dL, P<0.001) levels were significantly higher in women than in men. Adjusted linear regression showed mean diastolic BP (ß=3.09; 95% confidence interval 0.56, 5.63) was significantly higher in women. Overall, 12.4% of the sample had composite control, and women had poorer composite control compared with men (5.9% vs. 17.3%). Adjusted logistic models showed that men were significantly more likely to have composite risk factor control (odds ratio 2.90; 95% confidence interval 1.37, 6.13) compared with women. CONCLUSIONS: In this sample of adults with T2DM, women had significantly lower composite control compared with men, when adjusting for relevant confounders. It is imperative that women are informed about CVD risk factors, educated on how to reduce them, and aggressively treated to avoid adverse outcomes. Additional research involving women is needed to explore and reduce disparities in CVD risk between men and women with T2DM.