Risk Factors and Emergency Department Outcomes in Methamphetamine-Associated Cardiomyopathy: A Case-Control Study.

BACKGROUND: Methamphetamine-associated cardiomyopathy (MACM) is a known complication of methamphetamine use; however, risk factors and outcomes of patients with MACM are not well understood. STUDY OBJECTIVES: This study aims to identify risk factors, emergency department (ED) interventions, and outcomes for MACM. METHODS: This case-control study was conducted between 2012 and 2020 at two academic EDs. ED patients ≥18 years with an index visit that included documented methamphetamine use were included. Patients with documented MACM during follow-up (3 months-3 years) were considered cases (MACM). A control group comprised of patients with documented methamphetamine use but no known MACM was matched at a 2:1 ratio. Logistic regression was used to model risk factors for MACM. RESULTS: A total of 9833 patients with methamphetamine use were identified. From this, 160 MACM patients were matched to 322 controls. The mean age was 48.4 years, and 143 patients (29.7%) were female. MACM patients were more likely to be admitted on their index visit (45.6% vs. 34.8%, p = 0.021). Significant variables associated with MACM included: admission at the index visit (odds ratio [OR] 1.51), diabetes (OR 3.02), kidney disease (OR 5.47), and pulmonary disease (OR 2.39). MACM patients had more ED visits in the follow-up period (10.1 vs. 7, p = 0.009) and were admitted at a higher rate across all visits (32.5% vs. 15.4%, p = 0.009). Additionally, MACM patients had significantly longer hospital stays than controls (mean 18 additional days, p = 0.009). CONCLUSION: Patients who developed MACM had traditional risk factors for heart failure and experienced significantly more ED visits, more hospitalizations, and longer hospital stays than matched controls.

Virtual interviewing for graduate medical education recruitment and selection: A BEME systematic review: BEME Guide No. 80.

BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient.

BACKGROUND: The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. METHODS: We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. RESULTS: Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. CONCLUSION: Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

The Depressed Frail Phenotype: The Clinical Manifestation of Increased Biological Aging.

Depression in later life is a severe public health problem, associated with higher rates of mortality, suicide, and dementia. Effectiveness of treatment is limited by the failure to deconstruct the heterogeneity of the illness and because diagnostic criteria, pathophysiological models, and treatment algorithms for depression are primarily based on studies of younger adults even though symptoms of the illness and physiology of the patient change with age. Thus, understanding how aging interacts with depressive illness may elucidate endophenotypes of late-life depression with different clinical manifestations and underlying mechanisms that can then be targeted with more personalized approaches to treatment. This paper proposes a model for the critical confluence between depression and frailty, a high-risk morbidity and mortality syndrome of later life. This model hypothesizes that characteristics of frailty in adults with late life depression represent the clinical manifestation of greater biological aging and their presence in the context of a depressive illness exposes elders to deleterious trajectories. Potential common biological substrates that may result in the manifestation of the depressed frail phenotype including mitochondrial functioning, dopaminergic neurotransmission, and inflammatory processes and implications for the assessment and treatment of adults with late-life depression are discussed. As society continues to live longer, the preservation of the quality of these added years becomes paramount, and the combined impact of depression and frailty on the preservation of this quality warrants the attention of clinical researchers and physicians.

INFLUENCE OF STUDY DESIGN ON TREATMENT RESPONSE IN ANXIETY DISORDER CLINICAL TRIALS.

OBJECTIVE: The influence of study design variables and publication year on response to medication and placebo was investigated in clinical trials for social anxiety disorder (SAD), generalized anxiety disorder (GAD), and panic disorder (PD). METHOD: Hierarchical linear modeling determined whether publication year, treatment assignment (medication vs. placebo), study type (placebo-controlled or active comparator), study duration, and the number of study visits affected the mean change associated with medication and placebo. RESULTS: In the 66 trials examined, the change associated with both medication and placebo increased over time (t = 4.23, df = 39, P < .001), but average drug-placebo differences decreased over time (t = -2.04, df = 46, P = .047). More severe baseline illness was associated with greater drug-placebo differences for serotonin norepinephrine reuptake inhibitors (SNRIs, t = 3.46, df = 106, P = .001) and selective serotonin reuptake inhibitors (SSRI, t = 10.37, df = 106, P < .001). Improvement with medication was significantly greater in active-comparator studies compared to placebo-controlled trials (t = 3.41, df = 39, P = .002). A greater number of study visits was associated with greater symptom improvement in PD trials relative to SAD (t = 2.83, df = 39, P = .008) and GAD (t = 2.16, df = 39, P = .037). CONCLUSIONS: Placebo response is substantial in SAD, GAD, and PD trials, and its rise over time has been associated with diminished drug-placebo differences. Study design features that influence treatment response in anxiety disorder trials include patient expectancy, frequency of follow-up visits, and baseline illness severity.

Percutaneous drainage for hinchey Ib and II acute diverticulitis with abscess improves outcomes.

BACKGROUND/AIMS: The role of percutaneous drainage in Hinchey Ib and II diverticulitis is controversial. The aim of the present study was to clarify the indications for percutaneous drainage in such circumstances. MATERIALS AND METHODS: This was a single-center retrospective review at an academic tertiary care hospital. All Hinchey Ib and II diverticulitis cases admitted from 2012 to 2014 were considered. RESULTS: Overall, 104 (78%) patients underwent successful conservative treatment, whereas 30 (22%) patients underwent surgery during admission. During the index admission, abscess drainage was performed in 21 patients, of which 19 patients were successfully managed without surgery on the index admission and two patients ultimately required surgery. Elective versus same-admission surgery resulted in an increase use of laparoscopy (p=0.01), higher rate of restoration of gastrointestinal continuity with the index operation (p=0.04), and lower rate of diverting stoma formation (p<0.01). CONCLUSION: Percutaneous drainage may diminish the need for emergent surgery for Hinchey Ib and II diverticulitis. Elective surgery following conservative management increases the use of laparoscopy and decreases the rates of stoma formation.

Early FAST Examinations during Resuscitation May Compromise Trauma Outcomes.

Focused assessment with Sonography for trauma (FAST) examination is essential to trauma triage. We sought to determine whether FASTs completed early in sequencing portend worse outcomes. A two-year review (2014-2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST times were compared. Outcomes included resuscitation time (RESUS-h), ventilation days (d), hospital length of stay (HLOS-d), ICU length of stay (LOS-d), survival (%), nosocomial infection rate (%), and venous thromboembolism complication rate (%). ED interventions included transfusions, crystalloid, antibiotics, central line placement, intubation, thoracostomy, thoracotomy, pelvic X-ray, and binder. One thousand, three hundred and twelve patients were included for analysis (mean age = 38 ± 19 years, mean Injury Severity Score = 12 ± 11, 21% penetrating). Compared with FASTs completed after the primary survey, early FASTs led to significantly more ventilation days (P < 0.01), longer ICU length of stay (P < 0.01), and a greater incidence of nosocomial infections (P = 0.03). In the ED, early FASTs led to significantly more intubations (P < 0.01) and transfusions (P < 0.01) compared with late FASTs. FASTs completed before primary survey portend worse outcomes, with more ED interventions and equivocal results. FAST as a true adjunct to primary survey is recommended.

Placebo response in antipsychotic clinical trials: a meta-analysis.

IMPORTANCE: Because increasing placebo response rates decrease drug-placebo differences and increase the number of failed trials, it is imperative to determine what is causing this trend. OBJECTIVES: To investigate the relationship between antipsychotic medication and placebo response by publication year, and to identify associated study design and implementation variables. DATA SOURCES: MEDLINE, PsycINFO, and PubMed were searched to identify randomized clinical trials of antipsychotic medications published from 1960 to July 2013. STUDY SELECTION: Included were randomized clinical trials lasting 4 to 24 weeks, contrasting antipsychotic medication with placebo or an active comparator, and enrolling patients 18 years of age or older with schizophrenia or schizoaffective disorder. DATA EXTRACTION AND SYNTHESIS: Standardized mean change scores were calculated for each treatment arm, plotted against publication year, and tested with Spearman rank correlation coefficients. Hierarchical linear modeling identified factors associated with the standardized mean change across medication and placebo treatment arms. MAIN OUTCOMES AND MEASURES: We hypothesized that the mean change in placebo-treated patients would significantly increase from 1960 to the present, that a greater change would be observed in active comparator vs placebo-controlled trials, and that more protocol visits would increase the symptom change observed. RESULTS: In the 105 trials examined, the mean change observed in placebo arms increased significantly with year of publication (n=39, r=0.52, P=.001), while the mean change in effective dose medication arms decreased significantly (n=208, r=-0.26, P<.001). Significant interactions were found between assignment to effective dose medication and publication year (t260=-5.55, P<.001), baseline severity (t260=5.08, P<.001), and study duration (t260=-3.76, P<.001), indicating that the average drug-placebo difference significantly decreased over time, with decreasing baseline severity and with increasing study duration. Medication treatment in comparator studies was associated with significantly more improvement than medication treatment in placebo-controlled trials (t93=2.73, P=.008). CONCLUSIONS AND RELEVANCE: The average treatment change associated with placebo treatment in antipsychotic trials increased since 1960, while the change associated with medication treatment decreased. Changes in randomized clinical trials leading to inflation of baseline scores, enrollment of less severely ill participants, and higher expectations of patients may all be responsible.