Medical Professionalism in the Provision of Clinical Care in Healthcare Organizations.

Medical professionalism is critical toward provision of safe, effective, patient-centered, timely, efficient, and equitable clinical care delivery. The basic tenets of medical professionalism are deeply embedded in the historical context via oaths and expectations. However, standardization of professional conduct and its integration by providers have been a challenge due to the evolving complexity of healthcare organizations (HCOs) and academic medical institutions (AMIs). Increasing heterogeneity of the workforce leads to greater complexity in collaborative teamwork. In this evolving landscape, violations of professional conduct demand closer scrutiny along professional and personal lines. Likewise, actions among minority groups pose challenges between integration and inclusion of certain professional interactions and conduct. Recently, in American HCOs and AMIs, there has been a renewed emphasis on accountability and managing unprofessional behaviors in the delivery of clinical care. This descriptive literature-based treatise explicates the professionalism construct in its historical milieu, underscores key facets of professionalism, highlights principal drivers of unprofessional behaviors, and posits solutions for enhancing and nurturing professionalism in the delivery of clinical care in HCOs and AMIs by a diverse workforce of healthcare providers.

Promise and Provisos of Artificial Intelligence and Machine Learning in Healthcare.

Artificial Intelligence (AI) and Machine Learning (ML) promise to transform all facets of medicine. Expected changes include more effective clinical triage, enhanced accuracy of diagnostic interpretations, improved therapeutic interventions, augmented workflow algorithms, streamlined data collection and processing, more precise disease prognostication, newer pharmacotherapies, and ameliorated genome interpretation. However, many caveats remain. Reliability of input data, interpretation of output data, data proprietorship, consumer privacy, and liability issues due to potential for data breaches will all have to be addressed. Of equal concern will be decreased human interaction in clinical care, patient satisfaction, affordability, and skepticism regarding cost-benefit. This descriptive literature-based treatise expounds on the promise and provisos associated with the anticipated import of AI and ML into all domains of medicine and healthcare in the very near future.

COVID-19 Pandemic and Physician Burnout: Ramifications for Healthcare Workforce in the United States.

Across the United States, physician burnout is progressively escalating, with accompanying negative sequelae for myriad stakeholders in healthcare, including communities, patients, physicians, and Healthcare Organizations (HCOs) with essential manpower implications. This ubiquitous trend is due to complex and multifactorial elements, including individual physician-related influences, generational perspectives, sociocultural communal effects, HCOs, and more recently the mounting challenges accompanying the COVID-19 pandemic. To achieve the overarching goals of US healthcare provision (ie, safe, effective, patient-centered, timely, efficient, and equitable patient care), proposed solutions should focus on longitudinal actionable data acquisition to meet workforce needs preemptively, resource allocation for wellness programs geared towards enhancing recruitment and retention, and shared responsibility at the level of individual physician and HCO. This descriptive literature-based treatise expounds on the underlying causality for physician burnout, its consequences for the healthcare workforce in the US, and provides individual- and institution-based solutions for its mitigation.

Organizational Culture and Effective Leadership in Academic Medical Institutions.

In the US, a heterogeneity in archetypes of leadership augments the success of an Academic Medical Institution (AMI) in fulfilling its key missions of clinical service, teaching, training, mentoring, research and scholarship, community engagement, inclusion, and diversity. Effective leadership is profoundly influenced by organizational culture with its dominant foundations in shared attitudes, beliefs, mores, behaviors-scripted and unscripted, as well as explicit and tacit rules and policies that become entrenched in the operational repertoire over time. Modulating organizational culture are an AMI's mission, vision, core and affirmed values, formal governance and its complexity, informal influencers, historical precedent, the rapidly evolving landscape of healthcare, regional and institutional socioeconomics, and faculty prototypes. It is paramount that AMIs endeavor to recruit and position leaders whose values align with those of the institution ("cultural fit"). This treatise highlights the crucial influences that affect organizational culture and its interface with AMI leadership and ensure the success of the organization and its leaders.

Impact of Acute Confusional State in Patients With COVID-19 and a Predictive Score.

BACKGROUND: Acute confusional state (ACS) in COVID-19 is shown to be associated with poor clinical outcomes. METHODS: We assessed the impact of ACS - defined as a documented deterioration of mental status from baseline on the alertness and orientation to time, place, and person - on inpatient mortality and the need for intensive care unit (ICU) transfer in inpatient admissions with active COVID-19 infection in a single-center retrospective cohort of inpatient admissions from a designated COVID-19 tertiary care center using an electronic health record system. Furthermore, we developed and validated a neurological history and symptom-based predictive score of developing ACS. RESULTS: Thirty seven out of 245 (15%) patients demonstrated ACS. Nineteen (51%) patients had multifactorial ACS, followed by 11 (30%) patients because of hypoxemia. ACS patients were significantly older (80 [70-85] years vs 50.5 [38-69] years, p < 0.001) and demonstrated more frequent history of dementia (43% vs 9%, p < 0.001) and epilepsy (16% vs 2%, p = 0.001). ACS patients observed significantly higher in-hospital mortality (45.9% vs 1.9%, aOR [adjusted odds ratio]: 15.7, 95% CI = 3.6-68.0, p < 0.001) and need for ICU transfer (64.9% vs 35.1%, aOR: 2.7, 95% CI = 1.2-6.1, p = 0.015). In patients who survived hospitalization, ACS was associated with longer hospital stay (6 [3.5-10.5] days vs 3 [2-7] day, p = 0.012) and numerically longer ICU stay (6 [4-10] days vs 3 [2-6] days, p = 0.078). A score to predict ACS demonstrated 75.68% sensitivity and 81.73% specificity at a cutoff of ≥3. CONCLUSION: A high prevalence of ACS was found in patients with COVID-19 in our study cohort. Patients with ACS demonstrated increased mortality and need for ICU care. An internally validated score to predict ACS demonstrated high sensitivity and specificity in our cohort.

A Rare Case of Disseminated Coccidioidomycosis Presenting as Brachial Plexopathy.

Coccidioidomycosis, a fungal infection caused by inhaling spores of Coccidioides immitis/posadasii, is endemic to the southwestern states of the United States, Northern Mexico and some parts of Central and South America. It is primarily a pulmonary infection with less than 0.5% of symptomatic cases showing dissemination. Skin, lymph nodes and bone are the commonest sites. Neurological involvement is rare and commonly presents as strokes, abscesses or meningoencephalitis. We present the case of a previously healthy 23-year-old African American male, presented with a four-month history of progressive right upper extremity weakness that initially started with right shoulder pain followed by worsening weakness and loss of muscle mass. Electromyography (EMG) demonstrated right brachial plexopathy with moderate-to-severe active denervation changes. MRI cervical spine revealed a 9-cm contrast enhancing extradural mass extending through the neural foramen from C4-T1 roots and forming a 4-cm right apical lung mass subsequently seen on MRI of the brachial plexus. All trunks, divisions and cords were thickened, hyperintense and showed contrast enhancement on MRI. Neuromuscular ultrasound (NUS) demonstrated enlargement of peripheral nerves. Differentials prior to biopsy of the mass ranged from neurofibromas to pancoast lung tumors. Coccidioidomycosis did not figure on the initial list of differentials. Patient underwent subsequent biopsy of the extradural and lung masses that showed coccidiodes. Serum coccidioides antibody titers were elevated. The patient was treated with high-dose intravenous fluconazole and aggressive mass debridement. His weakness improved on four months follow-up evaluation with significant resolution of EMG abnormalities and decreased swelling on NUS.

Neurocognitive sequela of burn injury in the elderly.

Elderly individuals are a fast-rising segment of the US population and are at high risk of permanent disability and premature death secondary to traumatic injuries such as burn injury. The current paper will review the extant literature to understand the prevalence of burn injury in the elderly, the neurocognitive complications unique to the aged that places this cohort at risk, and evidence-based recommendations to reduce the early and late neurocognitive effects of burn injury in the aged. The elderly are a high-risk population for burn injury and its neurological sequela. This risk, at least in part, reflects multiple factors: age-related changes in the central and peripheral nervous system; multiple pre-existing co-morbidities (such as dementia and COPD); polypharmacy; suboptimal social support; and increased susceptibility to hypothermia, burn-related infections, and electrolyte and metabolic dysregulations.

Alignment between physicians and hospital administrators: historical perspective and future directions.

Unfortunately, the working relationship between physicians and hospital administrators is often not congruent and can even become contentious, resulting in antagonism across many Healthcare Organizations (HCOs). This treatise provides a broad, literature-based, descriptive overview in an evolving historical context, coupled with observations based on extensive professional experience. It highlights the root causes of the nonalignment between physicians and hospital administrators. Most importantly, this manuscript proposes a framework for short and long-term solutions toward a more cohesive and collaborative team approach, based on understanding the respective roles, as well as the strengths, and contributions of the two groups.

Osmotherapy With Hypertonic Saline Attenuates Global Cerebral Edema Following Experimental Cardiac Arrest via Perivascular Pool of Aquaporin-4.

OBJECTIVES: We tested the hypothesis that osmotherapy with hypertonic saline attenuates cerebral edema following experimental cardiac arrest and cardiopulmonary resuscitation by exerting its effect via the perivascular pool of aquaporin-4. We used mice with targeted disruption of the gene encoding α-syntrophin (α-Syn) that demonstrate diminished perivascular aquaporin-4 pool but retain the non-endfoot and ependymal pools. DESIGN: Laboratory animal study. SETTING: University animal research laboratory. INTERVENTIONS: Isoflurane-anesthetized adult male wild-type C57B/6 or α-Syn mice were subjected to cardiac arrest/cardiopulmonary resuscitation and treated with either a continuous IV infusion of 0.9% saline or various concentrations of hypertonic saline. Serum osmolality, regional brain water content, blood-brain barrier disruption, and aquaporin-4 protein expression were determined at 24 hours after cardiac arrest/cardiopulmonary resuscitation. MEASUREMENTS AND MAIN RESULTS: Hypertonic saline (7.5%) treatment significantly attenuated water content in the caudoputamen complex and cortex compared with 0.9% saline treatment in wild-type mice subjected to cardiac arrest/cardiopulmonary resuscitation. In contrast, in α-Syn mice subjected to cardiac arrest/cardiopulmonary resuscitation, 7.5% hypertonic saline treatment did not attenuate water content. Treatment with 7.5% hypertonic saline attenuated blood-brain barrier disruption at 24 hours following cardiac arrest/cardiopulmonary resuscitation in wild-type mice but not in α-Syn mice. Total aquaporin-4 protein expression was not different between 0.9% saline and hypertonic saline-treated wild-type mice. CONCLUSIONS: Following experimental cardiac arrest/cardiopulmonary resuscitation: 1) continuous hypertonic saline therapy maintained to achieve serum osmolality of ≈ 350 mOsm/L is beneficial for the treatment of cerebral edema; 2) perivascular pool of aquaporin-4 plays a critical role in water egress from brain; and 3) hypertonic saline attenuates blood-brain barrier disruption via perivascular aquaporin-4 pool.

Conivaptan, a Selective Arginine Vasopressin V1a and V2 Receptor Antagonist Attenuates Global Cerebral Edema Following Experimental Cardiac Arrest via Perivascular Pool of Aquaporin-4.

BACKGROUND: Cerebral edema is a major cause of mortality following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). Arginine vasopressin (AVP) and water channel aquaporin-4 (AQP4) have been implicated in the pathogenesis of CA-evoked cerebral edema. In this study, we examined if conivaptan, a V1a and V2 antagonist, attenuates cerebral edema following CA/CPR in wild type (WT) mice as well as mice with targeted disruption of the gene encoding α-syntrophin (α-syn(-/-)) that demonstrate diminished perivascular AQP4 pool. METHODS: Isoflurane-anesthetized adult male WT C57Bl/6 and α-syn(-/-) mice were subjected to 8 min CA/CPR and treated with either bolus IV injection (0.15 or 0.3 mg/kg) followed by continuous infusion of conivaptan (0.15 mg/kg/day or 0.3 mg/kg/day), or vehicle infusion for 48 h. Serum osmolality, regional brain water content, and blood-brain barrier (BBB) disruption were determined at the end of the experiment. Sham-operated mice in both strains served as controls. RESULTS: Treatment with conivaptan elevated serum osmolality in a dose-dependent manner. In WT mice, conivaptan at 0.3 mg dose significantly attenuated regional water content in the caudoputamen (81.0 ± 0.5 vs. 82.5 ± 0.4% in controls; mean ± SEM) and cortex (78.8 ± 0.2 vs. 79.4 ± 0.2% in controls), while conivaptan at 0.15 mg was not effective. In α-syn(-/-) mice, conivaptan at 0.3 mg dose did not attenuate water content compared with controls. Conivaptan (0.3 mg/kg/day) attenuated post-CA BBB disruption at 48 h in WT mice but not in α-syn(-/-) mice. CONCLUSIONS: Continuous IV infusion of conivaptan attenuates cerebral edema and BBB disruption following CA. These effects of conivaptan that are dependent on the presence of perivascular pool of AQP4 appear be mediated via its dual effect on V1 and V2 receptors.

Chronic traumatic encephalopathy: a critical appraisal.

Chronic traumatic encephalopathy (CTE) formerly known as dementia pugilistica is a long-term neurodegenerative disorder associated with repeated subconcussive head injuries in high-contact sports. We reviewed the existing literature on CTE and examined epidemiological trends, risk factors, and its temporal progression, and proposed the underlying pathophysiological mechanisms that may provide unique insights to clinicians with an in-depth understanding of the disease to aid in the diagnosis and prevention, and provide future perspectives for research via search of Medline and Cochrane databases as well as manual review of bibliographies from selected articles and monographs. The prevalence of CTE in recent years is on the rise and almost exclusively affects men, with pathologic signs characterized by progressive memory loss, behavioral changes, and violent tendencies with some patients demonstrating Parkinsonian-like symptoms and signs. Many patients with CTE die following suicide, accident, or complications of drug or alcohol use. Postmortem pathologic analysis is characterized by neurofibrillary tangles and Aß plaques in 50 % of cases. Currently, there are no ante-mortem diagnostic criteria, but modern imaging techniques such as functional magnetic resonance (MR) imaging, MR spectroscopy, and diffusion tension imaging hold promise for delineating the future diagnostic criteria. Further long-term longitudinal studies are warranted to investigate risk factors that will enhance understanding of the disease progression and its pathogenesis.

Gastrointestinal prophylaxis in neurocritical care.

The aim of this study is to review and summarize the relevant literature regarding pharmacologic and non-pharmacologic methods of prophylaxis against gastrointestinal (GI) stress ulceration, and upper gastrointestinal bleeding in critically ill patients. Stress ulcers are a known complication of a variety of critical illnesses. The literature regarding epidemiology and management of stress ulcers and complications thereof, is vast and mostly encompasses patients in medical and surgical intensive care units. This article aims to extrapolate meaningful data for use with a population of critically ill neurologic and neurosurgical patients in the neurological intensive care unit setting. Studies were identified from the Cochrane Central Register of controlled trials and NLM PubMed for English articles dealing with an adult population. We also scanned bibliographies of relevant studies. The results show that H(2)A, sucralfate, and PPI all reduce the incidence of UGIB in neurocritically ill patients, but H(2)A blockers may cause encephalopathy and interact with anticonvulsant drugs, and have been associated with higher rates of nosocomial pneumonias, but causation remains unproven and controversial. For these reasons, we advocate against routine use of H(2)A for GI prophylaxis in neurocritical patients. There is a paucity of high-level evidence studies that apply to the neurocritical care population. From this study, it is concluded that stress ulcer prophylaxis among critically ill neurologic and neurosurgical patients is important in preventing ulcer-related GI hemorrhage that contributes to both morbidity and mortality. Further, prospective trials are needed to elucidate which methods of prophylaxis are most appropriate and efficacious for specific illnesses in this population.

Neurological complications of transplantation.

Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders-often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.

Evaluation of coma: a critical appraisal of popular scoring systems.

Numerous scoring scales have been proposed and validated to evaluate coma for rapid pre-hospital assessment and triage, disease severity, and prognosis for morbidity and mortality. These scoring systems have been predicated on core features that serve as a basis for this review and include ease of use, inter-rater reliability, reproducibility, and predictive value. Here we review the benefits and limitations of the most popular coma scoring systems. The methods include search of Medline, databases, and manual review of article bibliographies. Few of the many available coma scales have gained widespread approval and popularity. The best known and widely accepted scale is the Glasgow Coma Scale (GCS). The Reaction Level Scale (RLS85) has utility and proven benefit, but little acceptance outside of Scandinavia. The newer Full Outline of UnResponsiveness (FOUR) score provides an attractive replacement for all patients with fluctuating levels of consciousness and is gradually gaining wide acceptance.

Na(+)-K (+)-2Cl (-) cotransport inhibitor attenuates cerebral edema following experimental stroke via the perivascular pool of aquaporin-4.

INTRODUCTION: The Na(+)-K(+)-2Cl(-) cotransporter localized in the brain vascular endothelium has been shown to be important in the evolution of cerebral edema following experimental stroke. Previous in vivo studies have demonstrated that bumetanide, a selective Na(+)-K(+)-2Cl(-) cotransport inhibitor, attenuates ischemia-evoked cerebral edema. Recently, bumetanide has been shown to also inhibit water permeability via aquaporin-4 (AQP4) expressed in Xenopus laevis oocytes. We tested the hypothesis that the perivascular pool of AQP4 plays a significant role in the anti-edema effect of bumetanide by utilizing wild-type (WT) mice as well as mice with targeted disruption of alpha-syntrophin (alpha-Syn(-/-)) that lack the perivascular pool of AQP4. METHODS: Isoflurane-anesthetized adult male WT C57Bl6 and alpha-Syn(-/-) mice were subjected to 90 min middle cerebral artery occlusion (MCAO) followed by 24 or 48 h of reperfusion. Adequacy of MCAO and reperfusion was monitored with laser-Doppler flowmetry over the ipsilateral parietal cortex. Infarct volume (tetrazolium staining), cerebral edema (wet-to-dry ratios), and AQP4 protein expression (immunoblotting) were determined in different treatment groups in separate sets of experiments. RESULTS: Bumetanide significantly attenuated infarct volume and decreased ipsilateral hemispheric water content in WT mice compared to vehicle treatment. In alpha-Syn(-/-) mice, bumetanide treatment had no effect on infarct volume or ischemia-evoked cerebral edema. Bumetanide-treated WT mice had a significant attenuation of AQP4 protein expression at 48 h post-MCAO compared to vehicle-treated WT mice. CONCLUSIONS: These data suggest that bumetanide exerts its neuroprotective and anti-edema effects partly via blockade of the perivascular pool of AQP4 and may have therapeutic potential for ischemic stroke in the clinical setting.

Pneumocephalus: case illustrations and review.

BACKGROUND: Pneumocephalus is commonly encountered after neurosurgical procedures but can also be caused by craniofacial trauma and tumors of the skull base and rarely, can occur spontaneously. Contributing factors for the development of pneumocephalus include head position, duration of surgery, nitrous oxide (N(2)O) anesthesia, hydrocephalus, intraoperative osmotherapy, hyperventilation, spinal anesthesia, barotauma, continuous CSF drainage via lumbar drain, epidural anesthesia, infections, and neoplasms. Clinical presentation includes headaches, nausea and vomiting, seizures, dizziness, and depressed neurological status. In this article, we review the incidence, mechanisms, precipitating factors, diagnosis, and management of pneumocephalus. Search of Medline, databases, and manual review of article bibliographies. Considering four case illustrations that typify pneumocephalus in clinical practice, we discuss the common etiologies, and confirm the diagnosis with neuroimaging and management strategies. Avoidance of contributing factors, high index of suspicion, and confirmation with neuroimaging are important in attenuating mortality and morbidity. A significant amount of pneumocephalus can simulate a space-occupying lesion. Supplemental oxygen increases the rate of absorption of pneumocephalus.