Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians.

For more than 20 years, the American College of Physicians (ACP) has advocated for the need to address firearm-related injuries and deaths in the United States. Yet, firearm violence continues to be a public health crisis that requires the nation's immediate attention. The policy recommendations in this paper build on, strengthen, and expand current ACP policies approved by the Board of Regents in April 2014, based on analysis of approaches that the evidence suggests will be effective in reducing deaths and injuries from firearm-related violence.

Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper.

Social determinants of health are nonmedical factors that can affect a person's overall health and health outcomes. Where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy. In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.

Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians.

Women comprise more than one third of the active physician workforce, an estimated 46% of all physicians-in-training, and more than half of all medical students in the United States. Although progress has been made toward gender diversity in the physician workforce, disparities in compensation exist and inequities have contributed to a disproportionately low number of female physicians achieving academic advancement and serving in leadership positions. Women in medicine face other challenges, including a lack of mentors, discrimination, gender bias, cultural environment of the workplace, imposter syndrome, and the need for better work-life integration. In this position paper, the American College of Physicians summarizes the unique challenges female physicians face over the course of their careers and provides recommendations to improve gender equity and ensure that the full potential of female physicians is realized.

Women's Health Policy in the United States: An American College of Physicians Position Paper.

In this position paper, the American College of Physicians (ACP) examines the challenges women face in the U.S. health care system across their lifespans, including access to care; sex- and gender-specific health issues; variation in health outcomes compared with men; underrepresentation in research studies; and public policies that affect women, their families, and society. ACP puts forward several recommendations focused on policies that will improve the health outcomes of women and ensure a health care system that supports the needs of women and their families over the course of their lifespans.

Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper.

Substance use disorders involving illicit and prescription drugs are a serious public health issue. In the United States, millions of individuals need treatment for substance use disorders but few receive it. The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.

In-Hospital Management and Follow-Up Treatment of Venous Thromboembolism: Focus on New and Emerging Treatments.

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major cause of morbidity and mortality of particular relevance for intensivists and hospitalists. Acute VTE is usually managed with parenteral unfractionated heparin or low-molecular-weight heparin, followed by an oral vitamin K antagonist. Data are lacking for optimal treatment of less common occurrences, such as upper extremity DVT, and for approaches such as thrombolysis for PE associated with early signs of hemodynamic compromise or inferior vena cava filters when anticoagulation is contraindicated. Direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are now added to the armamentarium of agents available for acute management of VTE and/or reducing the risk of recurrence. This review outlines an algorithmic approach to acute VTE treatment: from aggressive therapies when anticoagulation may be inadequate, to alternative choices when anticoagulation is contraindicated, to anticoagulant options in the majority of patients in whom anticoagulation is appropriate. Evidence-based guidelines and the most recent DOAC clinical trial data are discussed in the context of the standard of care. Situations and treatment approaches for which data are unavailable or insufficient are identified. VTE therapy in care transitions is discussed, as are choices for secondary prevention.

Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections.

OBJECTIVE: Determine the impact of three stepwise interventions on the rate of central catheter-associated bloodstream infections. DESIGN: Quasi-experimental study. SETTING: Three surgical intensive care units (general surgery, trauma, and neurosurgery) at a 1500-bed county teaching hospital in the Miami metro area. PATIENTS: All consecutive central catheter-associated bloodstream infection cases as determined by the Infection Control Department. INTERVENTIONS: Three interventions aimed at catheter maintenance were implemented at different times in the units: chlorhexidine "scrub-the-hub," chlorhexidine daily baths, and daily nursing rounds aimed at assuring compliance with an intensive care unit goal-oriented checklist. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the monthly intensive care unit rate of central catheter-associated bloodstream infections (infections per 1000 central catheter days). Over 33 months of follow-up (July 2008 to March 2011), we found decreased rates in each of the three intensive care units evaluated during the interventions, especially after implementation of chlorhexidine daily baths. Rates in unit A decreased from a rate of 8.6 to 0.5, unit B from 6.9 to 1.6, and unit C from 7.8 to 0.6. Secondary bloodstream infection rates remained unchanged throughout the observation period in units A and B; however, unit C had a decrease in its rates over time. CONCLUSIONS: We report the progressive reduction of central catheter-associated bloodstream infection rates after the stepwise implementation of chlorhexidine "scrub-the-hub" and daily baths in surgical intensive care units, suggesting effectiveness of these interventions.

Sexual assault forensic examiners' training and assessment using simulation technology.

INTRODUCTION: More than 190,000 sexual assaults involving persons aged 12 years or older occur annually in the United States. For these victims, a forensic examination is the first step in the process to justice. Assessment and treatment of victims, as well as the meticulous collection and documentation of evidence, are vital for a strong case. Providing timely services 24/7 by qualified professionals can be taxing on schedules and budgets. Using in-house resources to cross-train ED personnel, we developed a program that introduced novice forensic examiners to common clinical scenarios encountered in the treatment of victims and provided a framework for the evaluation and management of each case. METHODS: Seventeen ED personnel attended statewide sexual assault nurse examination training and participated in four simulation scenarios and debriefings. Pre-tests and post-tests were administered, and a checklist was used to assess competence in performing examinations independently. RESULTS: The majority of participants achieved competence (≥85% on the checklist) with their first case and had statistically significant gains in knowledge between pre-test and post-test (pre-test mean score [±SE] of 69.1 ± 1.7 vs. post-test mean score of 84.4 ± 2.6, P < .001). Course evaluations were favorable, with a mean score of 91.3%. DISCUSSION: Our results validated the use of simulation technology and in-house resources for cross-training in a sexual assault forensic examination program, together with a checklist to assess competence in performing examinations independently. Benefits of having a sexual assault forensic examination program in the emergency department are standardized and timely care for victims, as well as enhanced evidence collection and increased reporting and prosecution of crimes.

A blended approach to invasive bedside procedural instruction.

OBJECTIVE: This study assessed the impact of a blended, standardized curriculum for invasive bedside procedural training on medical knowledge and technical skills for Internal Medicine residents. METHODS: The investigators developed a curriculum in procedural instruction and performance for Internal Medicine house staff, and implemented the program at a tertiary care academic medical center with a primary affiliation with a US medical school. The investigators chose procedures recommended for technical competence by the American Board of Internal Medicine: lumbar puncture, thoracentesis, paracentesis, central venous catheter insertion, and knee arthrocentesis. The program included: (1) assessment of baseline medical knowledge and technical proficiency on mannequins, (2) video instruction of procedure, (3) faculty-led discussion of critical concepts, (4) faculty demonstration of the procedure on mannequin, (5) individual practice on simulators, (6) post-intervention knowledge evaluation, and (7) post-intervention skills evaluation. The performance achieved during the initial skills evaluation on a mannequin was compared to the performance achieved on the first patient subsequent to the instructional portion. RESULTS: All participants with complete data demonstrated a statistically significant pre-intervention to post-intervention improvement (p < 0.05) in comprehensive medical knowledge and procedural skills. CONCLUSION: A blended, standardized curriculum in invasive bedside procedural instruction can significantly improve performance in participants' medical knowledge and technical skills.

Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine.

EXECUTIVE SUMMARY: When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks. We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients. We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients. We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.

Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine.

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

A novel cognitive assessment paradigm to detect Pre-mild cognitive impairment (PreMCI) and the relationship to biological markers of Alzheimer's disease.

OBJECTIVE: A number of older adults obtain normal scores on formal cognitive tests, but present clinical concerns that raise suspicion of cognitive decline. Despite not meeting full criteria for Mild Cognitive Impairment (MCI), these PreMCI states confer risk for progression to Alzheimer's disease (AD). This investigation addressed a pressing need to identify cognitive measures that are sensitive to PreMCI and are associated with brain biomarkers of neurodegeneration. METHOD: Participants included 49 older adults with a clinical history suggestive of cognitive decline but normal scores on an array of neuropsychological measures, thus not meeting formal criteria for MCI. The performance of these PreMCI participants were compared to 117 cognitively normal (CN) elders on the LASSI-L, a cognitive stress test that uniquely assesses the failure to recover from proactive semantic interference effects (frPSI). Finally, a subset of these individuals had volumetric analyses based on MRI scans. RESULTS: PreMCI participants evidenced greater LASSI- L deficits, particularly with regards to frPSI and delayed recall, relative to the CN group. No differences on MRI measures were observed. Controlling for false discovery rate (FDR), frPSI was uniquely related to increased dilatation of the inferior lateral ventricle and decreased MRI volumes in the hippocampus, precuneus, superior parietal region, and other AD prone areas. In contrast, other LASSI-L indices and standard memory tests were not related to volumetric findings. CONCLUSIONS: Despite equivalent performance on traditional memory measures, the frPSI distinguished between PreMCI and CN elders and was associated with reductions in brain volume in numerous AD-relevant brain regions.

Effectiveness of a Perioperative Transthoracic Ultrasound Training Program for Students and Residents.

OBJECTIVE: Focused ultrasound (US) is being incorporated across all levels of medical education. Although many comprehensive US courses exist, their scope is broad, requiring expert instructors, access to simulation, and extensive time commitment by the learner. We aim to compare learning across levels of training and specialties using a goal-directed, web-based course without live skills training. DESIGN: A prospective observational study of students and residents from medicine, surgery, and anesthesiology. Analysis compared pretests and posttests assessing 3 competencies. Individual mean score improvement (MSI) was compared by paired-sample t-tests and MSI among cohorts by analysis of variance, with significance set at p ≤ 0.05. McNemar test compared those who agreed or strongly agreed with survey items with those who did not before and after intervention. SETTING: Jackson Memorial Hospital, Miami, FL residency training programs in Medicine, Surgery, and Anesthesiology. RESULTS: A total of 180 trainees participated. A significant MSI was noted in each of 3 competencies in all 3 cohorts. Students' (S) MSI was significantly higher than residents' (R) and interns' (I) in US "knobology" and window recognition [S = 2.28 ± 1.29/5 vs R = 1.63 ± 1.21/5 (p = 0.014); vs I = 1.59 ± 1.12/5 (p = 0.032)]; students' total score MSI was significantly higher than residents [7.60 ± 3.43/20 vs 5.78 ± 3.08/20 (p < 0.008)]. All cohorts reported improved comfort in using transthoracic US and improved ability to recognize indications for use. More than 81% of all participants reported improved confidence in performing transthoracic US; more than 91% reported interest in additional training; and more than 88% believed course length was appropriate. CONCLUSIONS: Learners across levels of medical training and specialties can benefit from a brief, goal-directed, web-based training with early incorporation producing maximal yield.

Systemic bevacizumab (Avastin) therapy for neovascular age-related macular degeneration: twenty-four-week results of an uncontrolled open-label clinical study.

PURPOSE: To evaluate the safety, efficacy, and durability of bevacizumab for the treatment of subfoveal choroidal neovascularization (CNV) in patients with neovascular age-related macular degeneration (AMD). DESIGN: Open-label, single-center, uncontrolled clinical study. PARTICIPANTS: Age-related macular degeneration patients with subfoveal CNV (n = 18) and best-corrected visual acuity (VA) letter scores of 70 to 20 (approximate Snellen equivalent, 20/40-20/400). METHODS: Patients were treated at baseline with an intravenous infusion of bevacizumab (5 mg/kg) followed by 1 or 2 additional doses given at 2-week intervals. Safety assessments were performed at all visits. Ophthalmologic evaluations included protocol VA measurements, ocular examinations, and optical coherence tomography (OCT) imaging at each visit. Retreatment with bevacizumab was performed if there was evidence of recurrent CNV. MAIN OUTCOME MEASURES: Assessments of safety and changes from baseline in VA scores and OCT measurements were performed through 24 weeks. RESULTS: No serious ocular or systemic adverse events were identified through 24 weeks. The only adverse event identified was a mild elevation of mean systolic and diastolic blood pressure measurements (+11 mmHg, P = 0.004; +8 mmHg, P<0.001) evident by 3 weeks and easily controlled with antihypertensive medications. By 24 weeks, the systolic and diastolic mean blood pressures were at or below baseline measurements. Visual acuity in the study eyes improved within the first 2 weeks, and by 24 weeks, the mean VA letter score increased by 14 letters in the study eyes (P<0.001), and the mean OCT central retinal thickness measurement decreased by 112 microm (P<0.001). By 24 weeks, retreatment was needed for only 6 of the 18 study eyes, and after retreatment, the recurrent leakage was eliminated, with restoration of any lost VA. CONCLUSIONS: Systemic bevacizumab therapy for neovascular AMD was well tolerated and effective for all 18 patients through 24 weeks. By 6 months, most patients did not require any additional treatment beyond the initial 2 or 3 infusions. Despite these impressive results, it is unlikely that systemic bevacizumab will be studied in a large clinical trial because of the potential risks associated with systemic anti-VEGF therapy and the perception that intravitreal therapy is safer.

Transitions in the Prophylaxis, Treatment and Care of Patients with Venous Thromboembolism.

INTRODUCTION: Patients experience numerous transitions, including changes in clinical status, pharmacologic treatment and prophylaxis, and progression through the physical locations of their healthcare setting as they advance through a venous thromboembolism (VTE) clinical experience. This review provides an overview of these transitions and highlights how they can impact clinical care. METHODS: Major public resources (PubMed, MEDLINE, and Google Scholar) were searched using various combinations of the terms: "venous thromboembolism", "deep vein thromboses", "pulmonary embolism", "transitions in care", and "hospital protocols" to identify narrative reviews, professional guidelines, or primary manuscripts reporting protocol development strategies and/or clinical data, published in English from 2010 through January 2015. The studies included in this review were selected on the basis of extensive reading of the literature and the author's clinical expertise. RESULTS: VTE treatment and prophylaxis is a dynamic process requiring ongoing patient assessments and adjustments to therapeutic strategies as the patient progresses through various hospital and outpatient settings. Throughout these transitions in care, physicians need to be vigilant of any changes in the patient's clinical condition which may impact the patient's risk of VTE, and re-evaluate the intervention(s) employed when such changes occur. A standardized, interdisciplinary VTE clinical pathway developed for medical patients with acute VTE resulted in decreased utilization of hospital resources and healthcare costs, suggesting that further research is warranted in this area. CONCLUSION: The prevention and management of VTE can be optimized by the development and local implementation of standardized evidence-based clinical pathways.

Recent advances in antithrombotic therapy for stroke prevention in patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia and patients with AF have a higher risk for stroke than the general population. The prevalence of AF is increasing, which underscores the importance of understanding the therapeutic options available for stroke prevention in the primary care setting. This article examines evidence for the use of novel oral anticoagulant (OAC) therapy, including the direct thrombin inhibitor dabigatran and the activated factor X inhibitors rivaroxaban and apixaban for stroke prevention in patients with AF. Although warfarin therapy is the gold standard for prevention of stroke, its use is associated with significant challenges related to drug-drug and food-drug interactions. Warfarin use also requires frequent blood monitoring to maintain anticoagulation within a narrow therapeutic window. Overall, the novel OACs are as good as, or better than, warfarin therapy for stroke prevention in patients with AF, and they have a comparable or reduced risk of associated major bleeding. In addition, the novel OACs have fewer drug-drug and food-drug interactions and do not require continuous blood monitoring. Integration of the novel OACs into clinical practice offers patients with AF new treatment options, and as therapeutic use of the novel OACs increases, real-world experience will add to our understanding of the value of these agents.