Longitudinal characterization of pain interference and influential factors in former National Football League (NFL) players over a 19-year period: an NFL-LONG Study.

Previous studies on pain experiences in retired contract sport athletes have been cross-sectional, leaving gaps in our understanding of the evolution of pain interference (PI) and factors that influence trajectories decades after sport discontinuation. This study investigated the longitudinal course of PI in former male NFL players over a 19-year period following sport discontinuation and examined factors influencing overall levels and trajectories of PI. Former NFL players completed health surveys in 2001, 2010, and 2019, with PI ratings measured using the 36-Item Short Form Health Survey (2001 and 2010) and the Patient-Reported Outcomes Measurement Information System (2019). Unconditional latent growth curve models analyzed overall PI severity and trajectories. Conditional LGCMs explored the influence of musculoskeletal injuries, osteoarthritis (OA), and depression diagnosis on PI. Over 19 years (N=338; mean age=48.96±9.35), PI significantly increased (slope=0.179, p<0.001; mean PROMIS PI t-scores 2001=54.19, 2010=54.64, 2019=57.38). Cumulative musculoskeletal injuries (B=0.092, p<0.001) and baseline depression diagnosis (B=4.463, p<0.001) were associated with overall PI levels, but not change over time. OA was significantly associated with overall PI levels (B=6.536, p<0.001) and trajectory (B=-0.253, p<0.001); those endorsing OA in 2001 had lower PI increases over 19 years. Body region of injury and level of play during injuries mirrored overall injury effects. PI mildly increased over 19 years, with multiple factors independently influencing overall PI levels. Enhancing former contact sport athlete daily functionality may be achieved through holistic biopsychosocial interventions addressing musculoskeletal injuries, OA, and depression. Future research should identify factors influencing elevated trajectories of long-term PI post-sport discontinuation. PERSPECTIVE: This study assessed pain interference (PI) in former NFL athletes over two-decades, revealing notable inter-individual variability in trajectories over time. Musculoskeletal injuries, depression, and osteoarthritis correlated with overall PI. Prevention and intervention in these three areas presents potential to improve disruptions in daily living due to pain in former athletes.

Resident-Driven Clinical Decision Support Governance to Improve the Utility of Clinical Decision Support.

OBJECTIVES: This resident-driven quality improvement project aimed to better understand the known problem of a misaligned clinical decision support (CDS) strategy and improve CDS utilization. METHODS: An internal survey was sent to all internal medicine (IM) residents to identify the most bothersome CDS alerts. Survey results were supported by electronic health record (EHR) data of CDS firing rates and response rates which were collected for each of the three most bothersome CDS tools. Changes to firing criteria were created to increase utilization and to better align with the five rights of CDS. Findings and proposed changes were presented to our institution's CDS Governance Committee. Changes were approved and implemented. Postintervention firing rates were then collected for 1 week. RESULTS: Twenty nine residents participated in the CDS survey and identified sepsis alerts, lipid profile reminders, and telemetry renewals to be the most bothersome alerts. EHR data showed action rates for these CDS as low as 1%. We implemented changes to focus emergency department (ED)-based sepsis alerts to the right provider, better address the right information for lipid profile reminders, and select the right time in workflow for telemetry renewals to be most effective. With these changes we successfully eliminated ED-based sepsis CDS reminders for IM providers, saw a 97% reduction in firing rates for the lipid profile CDS, and noted a 55% reduction in firing rates for telemetry CDS. CONCLUSION: This project highlighted that alert improvements spearheaded by resident teams can be completed successfully using robust CDS governance strategies and can effectively optimize interruptive alerts.

Clinical Reasoning: A 24-Year-Old Woman With Penetrating Neck Injury From a Needlefish.

Evaluating patients with a traumatic spinal cord injury can be complicated by other injuries. In this case, a 24-year-old woman injured by a needlefish presented with combined motor and sensory defects, cranial nerve deficits, and a blunt vascular injury. This case highlights the importance of neurologic and vascular localizations and an understanding of spinal cord injuries involving various ascending and descending tracts. Appreciation of these anatomical considerations through this case illustrates the diagnostic approach to neurologic evaluation. While we present a traumatic etiology for multiple neurologic syndromes, this case gives readers an opportunity to develop a comprehensive differential diagnosis and tailor investigations for other relevant etiologies. Readers walking through this stepwise process will ultimately arrive at several distinct but related diagnoses.

Survey on the Perceptions of Pregnancy and Parenthood in Trainees: Advances, Obstacles, and Growth Opportunities.

INTRODUCTION: Despite national policy changes, perspective changes on pregnancy and parenting in training are often lacking. We evaluated current viewpoints regarding pregnancy, parenthood, leave needs, and perceptions of support across trainees at our institution. METHODS: A cross-sectional survey was sent to all residents and fellows at a tertiary care academic center with >700 trainees. Demographic information, opinions on maternity and paternity leave, and opinions on institutional support and career goals were collected. The survey was sent via the Graduate Medical Education Office listserv -- 66 Accreditation Council for Graduate Medical Education (ACGME) programs and 40 non-ACGME programs. RESULTS: Seven hundred and forty-seven house officers received the survey with a response rate of 21.9% (n = 164). Of respondents, 81% were residents and 99 respondents were female (representing 31% of female trainees at our institution). Thirty-seven point two percent of respondents reported being parents. Twenty-five point three percent of respondents had been pregnant while a trainee with no statistical difference by specialty type (P = 0.0817). Statistically significant difference was noted in having children based on sex with men becoming parents at twice the rate of women (56% vs 26%, P < 0.001). No difference was noted between specialties on perceived support while pregnant and peripartum. Thirty percent of parent respondents reported thinking about leaving medical training after having children given family stressors. Statistical difference in thoughts of leaving medicine overall between females (46%) and males (17.6%; P = 0.0238). CONCLUSIONS: Men and women need support as they navigate becoming parents at a naturally stressful transition period. Females consider leaving medicine at twice the rate of males after becoming parents. Our institution and other ACGME programs need greater transparency and consistent leave practices that reflect changing times.

The Future of Community Outreach: Using Patient Portals to Provide Voter Resources during the Coronavirus Disease 2019 Pandemic.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, there was a concern for the 2020 general election becoming a superspreader event due to in-person voting. OBJECTIVES: Our project addressed this concern by disseminating nonpartisan websites detailing safe voter options in the state of North Carolina to prevent community spread of the virus as much as possible. METHODS: In this study, patient portals were used to disseminate a Research Electronic Data Capture survey containing embedded links to voter resources including nonpartisan websites discussing voting options. The survey also asked for demographic data and sentiments regarding the resources provided. Quick response (QR) codes with the survey link were also placed in the clinics during the study period. RESULTS: The survey was sent to 14,842 patients who had at least one patient encounter in the past 12 months at one of three General Internal Medicine clinics at Atrium Health Wake Forest Baptist. Survey participation through both the patient portals and QR codes was assessed. Patient sentiments toward the voter resources in regard to (1) interest and (2) perceived helpfulness were collected in the survey. In total, 738 (4.99%) patients filled out the survey. Eighty-seven percent of survey respondents reported that the voter resources were helpful. Significantly more black patients than white (29.3 vs. 18.2, p < 0.05) voiced interest in voter resources. There was no statistical significance across gender or reported comorbidities. CONCLUSION: Multicultural, underserved, and underinsured patients perceived the most benefit. During public health crises, patient portal messages can be used to bridge information gaps and promote better health outcomes in a timely and effective manner.

Femoral head osteochondritis dissecans in a child.

This case report describes an early-adolescent boy with an osteochondritis dissecans (OCD) lesion of the left femoral head secondary to significant acetabular dysplasia and coxa valga of the proximal femur. Patient underwent left proximal femur varus osteotomy. Follow-up imaging demonstrates healing and resolution of the OCD lesion. Future plan for left hip is periacetabular osteotomy, following triradiate cartilage closure, to correct acetabular dysplasia. The aim of this case report is to support clinicians in the assessment and treatment of this rare condition.

Active Bystander Training: Using Standardized Patient Methodology to Teach Residents to Navigate Microaggressions in Patient Encounters.

Introduction: Studies show that physicians and medical trainees who identify as underrepresented in medicine or as women experience higher rates of microaggressions during patient encounters. We designed, implemented, and evaluated an active bystander training workshop focused on mitigating microaggressions using standardized patient (SP) methodology. Methods: Internal medicine faculty members and chief residents led the workshop. Participants included 31 PGY 1 categorical and preliminary internal medicine residents. They participated in three case simulations with SPs involving microaggressions from patients toward a member of the health care team. Prior to the case simulations, a brief presentation outlined examples of microaggressions and reviewed the behavioral response framework WAKE (work with who you are, ask questions/make direct statements, involve key people, and employ distraction techniques). After each encounter, residents debriefed with an internal medicine faculty member and discussed questions related to each scenario. Results: All 31 residents participated in the workshop and, before and after the activity, completed a survey that asked them to rank their agreement with statements via a Likert scale. Participants reported statistically significant improvement in recognizing microaggressions (12% reported increase, p = .002), the ability to respond to patients who exhibit microaggressions (23% reported increase, p < .001), and the ability to debrief with team members (20% reported increase, p < .001). Discussion: SP simulations can be an effective teaching modality for microaggression response strategies during patient encounters. Additional studies are needed to further characterize the workshop's effect on other medical workforce trainees and retention of skills over time.

Applying FHIR Genomics for Research - From Sequencing to Database.

The availability of next-generation sequencing (NGS) technologies and their continually declining costs have resulted in the accumulation of large genomic data sets. NGS results have traditionally been delivered in PDF format, and in some cases, structured data, e.g., XML or JSON formats, are also made available, but there is a lack of uniformity around the profiling of external vendor testing platforms. Atrium Health Wake Forest Baptist and TriNetX have harmonized and mapped genomic data to FHIR Genomic standards and imported it into the TriNetX database through a data pipeline. This process is translatable to other sequencing platforms and to other institutions. The addition of genotypic data to the TriNetX database to the reservoir of phenotypic data will promote enhanced industry trial recruitment, (ii) comprehensive intra-institutional genomic benchmarking/quality improvement, and eventually (iii) sweeping inter-institutional genomic research and treatment paradigm shifts.

Clinical Decision Support Stewardship: Best Practices and Techniques to Monitor and Improve Interruptive Alerts.

Interruptive clinical decision support systems, both within and outside of electronic health records, are a resource that should be used sparingly and monitored closely. Excessive use of interruptive alerting can quickly lead to alert fatigue and decreased effectiveness and ignoring of alerts. In this review, we discuss the evidence for effective alert stewardship as well as practices and methods we have found useful to assess interruptive alert burden, reduce excessive firings, optimize alert effectiveness, and establish quality governance at our institutions. We also discuss the importance of a holistic view of the alerting ecosystem beyond the electronic health record.

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

BACKGROUND: Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden. OBJECTIVE: (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics. MATERIALS AND METHODS: We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric. RESULTS: Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden. CONCLUSION: Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used.

Sab concentrations indicate chemotherapeutic susceptibility in ovarian cancer cell lines.

The occurrence of chemotherapy-resistant tumors makes ovarian cancer (OC) the most lethal gynecological malignancy. While many factors may contribute to chemoresistance, the mechanisms responsible for regulating tumor vulnerability are under investigation. Our analysis of gene expression data revealed that Sab, a mitochondrial outer membrane (MOM) scaffold protein, was down-regulated in OC patients. Sab-mediated signaling induces cell death, suggesting that this apoptotic pathway is diminished in OC. We examined Sab expression in a panel of OC cell lines and found that the magnitude of Sab expression correlated to chemo-responsiveness; wherein, OC cells with low Sab levels were chemoresistant. The Sab levels were reflected by a corresponding amount of stress-induced c-Jun N-terminal kinase (JNK) on the MOM. BH3 profiling and examination of Bcl-2 and BH3-only protein concentrations revealed that cells with high Sab concentrations were primed for apoptosis, as determined by the decrease in pro-survival Bcl-2 proteins and an increase in pro-apoptotic BH3-only proteins on mitochondria. Furthermore, overexpression of Sab in chemoresistant cells enhanced apoptotic priming and restored cellular vulnerability to a combination treatment of cisplatin and paclitaxel. Contrariwise, inhibiting Sab-mediated signaling or silencing Sab expression in a chemosensitive cell line resulted in decreased apoptotic priming and increased resistance. The effects of silencing on Sab on the resistance to chemotherapeutic agents were emulated by the silencing or inhibition of JNK, which could be attributed to changes in Bcl-2 protein concentrations induced by sub-chronic JNK inhibition. We propose that Sab may be a prognostic biomarker to discern personalized treatments for OC patients.