How Medical Students Benefit from Participating in a Longitudinal Resource Stewardship Medical Education Program (STARS): An International Descriptive Evaluation.

BACKGROUND: STARS (Students and Trainees Advocating for Resource Stewardship) is a medical student leadership program that promotes integration of resource stewardship (RS) into medical education in at least seven countries. Little is known about how participation affects student leaders. AIM: To understand how partaking in STARS impacted participants' knowledge, skills, and influenced career plans, and aspirations. SETTING AND PARTICIPANTS: We conducted qualitative semi-structured interviews with STARS participants (n = 27) from seven countries. PROGRAM DESCRIPTION: STARS was designed to facilitate grassroots efforts that embed RS principles into medical education. STARS programs globally share common features: participation from several medical schools, centralized organizing hubs and leadership summits, and support from faculty mentors. Students take lessons learnt from centralized programming to implement changes that advance RS initiatives at their schools. PROGRAM EVALUATION: Students finished STARS with better RS knowledge, enhanced change management skills (leadership, advocacy, collaboration), and a commitment to incorporate RS into future practice. Nearly all respondents hoped to pursue leadership activities in medicine, but most were unclear if they would focus efforts to advance RS. DISCUSSION: STARS participants gained knowledge as it relates to RS, change management skills, and catalyzed a commitment to incorporate high-value care into future practice. Medical education initiatives should be leveraged as a key strategic approach to build RS capacity.

"4 E's" Ways That Clinicians Can Reduce Low-Value Care on Medical Wards.

This JAMA Network Insight demonstrates examples of how clinicians can implement stepwise changes to reduce unnecessary patient harms, using the 4 E's.

Effect of Ward-Based High-Flow Nasal Cannula (HFNC) Oxygen Therapy on Critical Care Utilization During the COVID-19 Pandemic: A Retrospective Cohort Analysis.

BACKGROUND: Hospitals expanded critical care capacity during the COVID-19 pandemic by treating COVID-19 patients with high-flow nasal cannula oxygen therapy (HFNC) in non-traditional settings, including general internal medicine (GIM) wards. The impact of this practice on intensive care unit (ICU) capacity is unknown. OBJECTIVE: To describe how our hospital operationalized the use of HFNC on GIM wards, assess its impact on ICU capacity, and examine the characteristics and outcomes of treated patients. DESIGN: Retrospective cohort study of all patients treated with HFNC on GIM wards at a Canadian tertiary care hospital. PARTICIPANTS: All patients admitted with COVID-19 and treated with HFNC on GIM wards from December 28, 2020, to June 13, 2021, were included. MAIN MEASURES: We combined administrative data on critical care occupancy daily with chart-abstracted data for included patients to establish the total number of patients receiving ICU-level care at our hospital per day. We also collected data on demographics, medical comorbidities, illness severity, COVID-19 treatments, HFNC care processes, and patient outcomes. KEY RESULTS: We treated 124 patients with HFNC on the GIM wards (median age 66 years; 48% female). Patients were treated with HFNC for a median of 5 days (IQR 3 to 8); collectively, they received HFNC for a total of 740 hospital days, 71% of which were on GIM wards. At peak ICU capacity strain (144%), delivering HFNC on GIM wards added 20% to overall ICU capacity by managing up to 14 patients per day. Patients required a median maximal fraction of inspired oxygen of 80% (IQR 60 to 95). There were 18 deaths (15%) and 85 patients (69%) required critical care admission; of those, 40 (47%) required mechanical ventilation. CONCLUSIONS: With appropriate training and resources, treatment of COVID-19 patients with HFNC on GIM wards appears to be a feasible strategy to increase critical care capacity.

Don't Interrupt! A Case Report of Continuing Peritoneal Dialysis After Endoscopic Gastric Tumor Resection.

RATIONALE: The evidence supporting the safety of restarting peritoneal dialysis (PD) immediately after abdominal surgery and interventions is scant. In particular, there are no reported cases characterizing periprocedural management of PD for patients undergoing endoscopic submucosal dissection for gastric intramucosal tumor removal. PRESENTING CONCERNS OF THE PATIENT: A 66-year-old female with end-stage kidney disease secondary to diabetic nephropathy, currently on nocturnal automatic PD, presented with new iron-deficiency anemia. Workup revealed an intramucosal gastric lesion proximal to the pylorus, without surrounding lymph node involvement. Endoscopic submucosal dissection was performed with en bloc endoscopic resection of a 5-cm, partially flat, partially sessile mass along the posterior wall and lesser curvature of the gastric antrum. Pathology revealed low-grade dysplasia without features of malignancy. There was no evidence of hemorrhage or leak post-dissection. DIAGNOSES: The clinical presentation was consistent with an uncomplicated endoscopic submucosal dissection. INTERVENTIONS: Peritoneal dialysis was held for 48 hours and restarted thereafter with no complications. The patient did not require bridging with hemodialysis. OUTCOMES: The patient had an uncomplicated post-endoscopic course, with no subsequent episodes of PD-associated peritonitis after at least 6-month follow-up. NOVEL FINDING: This is the first reported case of PD reinitiation after endoscopic submucosal dissection of a gastric tumor.

JUSTIFICATION: Les données probantes soutenant l'innocuité de la reprise de la dialyse péritonéale (DP) immédiatement après une procédure ou une chirurgie abdominale sont rares. Surtout, il n'existe aucun cas signalé caractérisant la prise en charge périprocédurale de la dialyse péritonéale chez les patients subissant une dissection sous-muqueuse endoscopique pour l'ablation d'une tumeur de la muqueuse gastrique. PRÉSENTATION DU CAS: Une patiente de 66 ans atteinte d'insuffisance rénale terminale consécutive à une néphropathie diabétique. La patiente était traitée par dialyse péritonéale nocturne automatique et présentait une anémie ferriprive. Le bilan a révélé une lésion gastrique intramucosale à proximité du pylore, sans atteinte des ganglions lymphatiques environnants. Une dissection sous-muqueuse endoscopique a été pratiquée, avec exérèse endoscopique en monobloc d'une tumeur de 5-cm, partiellement plate et partiellement sessile, le long de la paroi postérieure et de la petite courbure de l'antre pylorique. L'examen pathologique a révélé une dysplasie de bas grade sans caractères de malignité. Aucun signe d'hémorragie ou de fuite n'a été observé après l'intervention. DIAGNOSTIC: Le tableau clinique était typique d'une dissection sous-muqueuse endoscopique sans complication. INTERVENTION: La dialyse péritonéale a été interrompue pour 48 heures, puis redémarrée sans complication. La patiente n'a pas eu besoin d'hémodialyse entre temps. RÉSULTATS: Le parcours post-endoscopique de la patiente s'est avéré simple, aucun épisode subséquent de péritonite associée à la DP n'a été rapporté après au moins six mois de suivi. CONCLUSION: Il s'agit du premier cas rapporté de reprise d'une dialyse péritonéale après la dissection sous-muqueuse endoscopique d'une tumeur gastrique.