Point-of-Care Ultrasound Psychomotor Learning Curves: A Systematic Review of the Literature.

OBJECTIVES: Use of point-of-care ultrasound (POCUS) in clinical medicine and inclusion in medical training is increasing. Some professional societies recommend that 25-50 POCUS examinations be completed for each application learned; however, the amount of practice required is not well studied. As such, a better understanding of the learning curves of POCUS psychomotor skills is needed. This systematic review characterizes the learning curves for POCUS psychomotor skill acquisition. METHODS: With the assistance of a research librarian, the available literature through August 28, 2023, was identified. The titles and abstracts, and then the full text were reviewed by two reviewers to screen for inclusion. All studies included after full-text review then underwent data extraction and analysis. RESULTS: The search identified 893 unique studies. Forty-five studies underwent full-text review, with 17 meeting full inclusion criteria. Substantial heterogeneity was noted in study design, duration of education, number and type of learners, and methods for statistical analysis. Clear and validated definitions for learning endpoints, such as plateau points or competency, are lacking. Learning curves and endpoints differ for different applications of POCUS. CONCLUSION: The results are overall supportive of the recommendations to complete 25-50 examinations per application of POCUS learned. However, specific applications require more practice than others. Certain applications, such as cardiac and the Focused Assessment with Sonography in Trauma (FAST) exams, are closer to 50; while others, such as soft tissue, airway, and eye require no more than 25.

Use of Gabapentin for Alcohol Withdrawal Syndrome in the Hospital Setting: A Randomized Open-Label Controlled Trial.

Background/objectives: Patients hospitalized with alcohol withdrawal syndrome (AWS) are typically treated with CIWA-directed benzodiazepines to prevent complications, such as seizures and delirium tremens. Gabapentin is an evidence-based alternative to benzodiazepines in the outpatient setting, but there is limited data for hospitalized patients with AWS. This study compared fixed-dose gabapentin to CIWA-directed benzodiazepines for AWS in the hospital setting. Methods: This open-label, randomized controlled trial enrolled 88 adults from February 1, 2017 to August 16, 2020 with a risk of complicated alcohol withdrawal as defined by the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) ≥4. Patients were randomized within 16 h of admission to either fixed-dose gabapentin taper or continued CIWA-directed benzodiazepine administration. The primary outcome was the length of stay (LOS). Secondary outcomes included seizure, delirium tremens, ICU transfer, and patient-reported symptoms (alcohol cravings, anxiety, sleepiness). Results: LOS was shorter, but not statistically different in the gabapentin group compared to the benzodiazepine group. Because benzodiazepines were received in both gabapentin and benzodiazepine groups before randomization, the mean amount of benzodiazepines received in each group was also not statistically different, although the amount received by the gabapentin group was less than half of that received by the benzodiazepine group (4.3 vs. 10.6 mg, p = 0.146 by per protocol analysis). There were no statistical differences in secondary measures. Conclusions: Fixed-dose gabapentin taper showed similar outcomes compared to CIWA-directed benzodiazepines for the treatment of hospitalized patients with mild/moderate AWS, but the interpretation of the results is limited due to under-enrollment and the use of benzodiazepines in both groups pre-enrollment.Clinical trial registration: NCT03012815.

Closer to or Farther away from an Ideal Model of Care? Lessons Learned from Geographic Cohorting.

Geographic "cohorting," "co-location," "regionalization," or "localization" refers to the assignation of a hospitalist team to a specific inpatient unit. Its benefits may be related to the formation of a team and the additional interventions like interdisciplinary rounding that the enhanced proximity facilitates. However, cohorting is often adopted in isolation of the bundled approach within which it has proven beneficial. Cohorting may also be associated with unintended consequences such as increased interruptions and increased indirect care time. Institutions may increase patient loads in anticipation of the efficiency gained by cohorting-leading to further increases in interruptions and time away from the bedside. Fragmented attention and increases in indirect care may lead to a perception of increased workload, errors, and burnout. As hospital medicine evolves, there are lessons to be learned by studying cohorting. Institutions and inpatient units should work in synergy to shape the day-to-day work which directly affects patient and clinician outcomes-and ultimately culminates in the success or failure of the parent organization. Such synergy can manifest in workflow design and metric selection. Attention to workloads and adopting the principles of continuous quality improvement are also crucial to developing models of care that deliver excellent care.

Characterizing Potentially Preventable Admissions: A Mixed Methods Study of Rates, Associated Factors, Outcomes, and Physician Decision-Making.

BACKGROUND: Potentially preventable admissions are a target for healthcare cost containment. OBJECTIVE: To identify rates of, characterize associations with, and explore physician decision-making around potentially preventable admissions. DESIGN: A comparative cohort study was used to determine rates of potentially preventable admissions and to identify associated factors and patient outcomes. A qualitative case study was used to explore physicians' clinical decision-making. PARTICIPANTS: Patients admitted from the emergency department (ED) to the general medicine (GM) service over a total of 4 weeks were included as cases (N = 401). Physicians from both emergency medicine (EM) and GM that were involved in the cases were included (N = 82). APPROACH: Physicians categorized admissions as potentially preventable. We examined differences in patient characteristics, admission characteristics, and patient outcomes between potentially preventable and control admissions. Interviews with participating physicians were conducted and transcribed. Transcriptions were systematically analyzed for key concepts regarding potentially preventable admissions. KEY RESULTS: EM and GM physicians categorized 22.2% (90/401) of admissions as potentially preventable. There were no significant differences between potentially preventable and control admissions in patient or admission characteristics. Potentially preventable admissions had shorter length of stay (2.1 vs. 3.6 days, p < 0.001). There was no difference in other patient outcomes. Physicians discussed several provider, system, and patient factors that affected clinical decision-making around potentially preventable admissions, particularly in the "gray zone," including risk of deterioration at home, the risk of hospitalization, the cost to the patient, and the presence of outpatient resources. Differences in provider training, risk assessment, and provider understanding of outpatient access accounted for differences in decisions between EM and GM physicians. CONCLUSIONS: Collaboration between EM and GM physicians around patients in the gray zone, focusing on patient risk, cost, and outpatient resources, may provide an avenues for reducing potentially preventable admissions and lowering healthcare spending.

Acute kidney injury in a patient with hemolytic anemia and thrombocytopenia.

Atypical hemolytic uremic syndrome (HUS) is clinically difficult to distinguish from HUS and thrombotic thrombocytopenic purpura. Atypical HUS results from dysregulation of complement activation causing thrombotic microangiopathy affecting multiple organ systems. Atypical HUS is associated with high morbidity and mortality, making early recognition and appropriate therapy necessary to improve patient outcomes.

Reversible cardiac dysfunction associated with hypocalcemia: a systematic review and meta-analysis of individual patient data.

Case reports have documented reversible cardiac dysfunction in the setting of severely depressed extracellular calcium concentrations. The present systematic review and meta-analyses of individual patient data were conducted to further characterize the cardiac dysfunction associated with low serum calcium levels in the clinical setting. We searched Ovid MEDLINE, Embase, PubMed databases and the Cochrane Library and the Registry of Clinical Trials from 1948 through August 2011. Studies that evaluated low serum calcium and cardiac dysfunction were identified and included for review. A total of 43 studies comprised of 47 individual cases met inclusion criteria. Univariate linear regression analysis showed a statistically significant correlation between corrected QT interval (QTc) length and corrected total serum calcium level (B = -23.19, SE = 8.04, P = 0.01), left ventricular ejection fraction and corrected total serum calcium (B = 5.16, SE = 1.29, P < 0.01) and ionized serum calcium (B = 5.48, SE = 2.04, P = 0.03). Hypocalcemia may be associated with reversible cardiac dysfunction including QTc interval prolongation and depressed left ventricular systolic function. The available evidence is very limited and does not provide a rationale for a certain threshold or a recommendation for calcium replacement. Future research is needed in this important and common metabolic disorder.

Evaluation of point-of-care ultrasound training among healthcare providers: a pilot study.

BACKGROUND: The use of Point-of-Care Ultrasound (POCUS) has become prevalent across a variety of clinical settings. Many healthcare professionals have started getting hands-on training. To evaluate the effectiveness of such training programs, this study aimed to assess a 4 day POCUS training course on healthcare providers' skills and knowledge acquisition. A secondary objective of this study is to gain valuable insights into the degree of perception, attitude, interest levels and perceived barriers of medical providers performing POCUS. METHODS: This is a prospective cohort study performed on healthcare providers in an integrated healthcare facility in Abu Dhabi undergoing the POCUS training course in February 2022. Course participants took a pre-course survey to evaluate their baseline knowledge, skills, confidence, perception, and interest in POCUS. The same survey was repeated immediately post-course. In total, seven healthcare professionals responded to the survey with a response rate of 53.8%. All data and information gathered were used to understand the effectiveness of POCUS training and gain insights into the degree of perception, interest and preparedness of POCUS among healthcare professionals in practice. RESULTS: Our results demonstrated that the brief POCUS course was effective in improving POCUS skills, knowledge and confidence amongst in-practice healthcare providers from varying medical specialties. The median skill score increased from 25% pre-course to 50% post-course. There is a notable increase in all skills scores after the POCUS training course with the greatest change in scores seen for adjusting 'gain and depth of image (54.84%), assessing VeXUS score (52.38%) and evaluating lung congestion (50%). The study also provided valuable insights into the perception, attitude, interest and potential barriers of POCUS implementation. Although significant barriers to POCUS are present including the lack of POCUS curriculum, what is challenging is lack of expertise and skills to perform POCUS. Therefore, medical providers must acquire prespecified skills to fully utilize POCUS effectively. CONCLUSION: The study confirmed the effectiveness of short POCUS training in improving the skills, knowledge and confidence of medical providers in practice. Healthcare professionals can master POCUS skills and techniques and gain confidence through brief training courses.

Barriers Preventing Medical Trainees from Active Participation in Research Activities.

Background: Research has increasingly become important to career progression and a compulsory component in most medical programs. While medical trainees are consistently urged to undertake research endeavors, they frequently encounter obstacles at both personal and organizational levels that impede the pursuit of high-quality research. This study aims to identify the barriers and recommend successful interventions to increase research productivity amongst medical trainees. Methods: A descriptive cross-sectional survey was carried out among interns, residents, and fellows within a single hospital located in the emirate of Abu Dhabi, UAE. The survey included inquiries regarding perceived obstacles hindering engagement in research activities, factors driving motivation for research involvement, and the assessment of how research participation relates to their job in terms of relevance. Results: Fifty-seven medical trainees participated in the survey, reflecting a response rate of 53%. The survey highlighted common obstacles, notably including time constraints, insufficient statistical and methodology training, the weight of other educational commitments, as well as inadequate incentives and rewards. While a majority of participants expressed interest in engaging in research activities, the consensus was that more incentives and increased funding opportunities would significantly encourage their involvement. Conclusion: Implementing successful interventions such as allocating dedicated time for research, facilitating access to research mentors, and organizing training sessions have the potential to be effective strategies in fostering a thriving research culture and subsequently elevating research productivity of medical trainees.

Impact of specialized renal technologists on optimizing delivery of continuous kidney replacement therapy in critical care areas a retrospective study.

BACKGROUND: Continuous renal replacement therapy (CKRT) is delivered to some of the most critically ill patients in hospitals. This therapy is expensive and requires coordination of multidisciplinary teams to ensure the prescribed dose is delivered. With increased demands on the critical care nursing staff and increased complexities of patients admitted to critical care units, we evaluated the role of specialized renal technologists in ensuring the prescribed dose is delivered. Therefore, the aim of this study is to investigate the impact of supporting intensive care unit nurses with specialized renal technologists on optimizing efficiency of CKRT sessions in the United Arab Emirates. METHODS: This is a retrospective study that compared critically ill patients on CKRT overseen by specialized renal technologists versus who are non-covered in the year 2021. RESULTS: A total of 331 sessions on 158 patients were included in the study. The mean filter life was longer in specialized renal technologists-covered patients compared to the non-covered group (66 vs. 59 h, p = 0.019). After adjustment by multiple regression analysis for risk factors (i.e., age, gender, mechanical ventilation, sepsis, mean arterial pressure, vasopressors, and SOFA) that may affect CKRT machines' filter life, presence of a specialized renal technologists resulted in significantly longer filter life (co-efficient 0.129; CI 95% 1.080, 11.970; p-value: 0.019). CONCLUSION: Our study suggests that specialized renal technologists play a vital role in prolonging CKRT machine's filter life span and optimizing CKRT machine's efficiency. Further research should focus on other potential benefits of having specialized renal technologists performing CKRT sessions, and to confirm the finding of this study. Additionally, a cost-benefit analysis could be conducted to determine the economic impact of having specialized teams performing CKRT.

Practice Changing Updates in Perioperative Medicine Literature 2022. A Systematic Review.

Perioperative medicine is a rapidly growing multidisciplinary field with significant advances published each year. In this review, we highlight important perioperative publications in 2022. A multi-database literature search from January to December of 2022 was undertaken. Original research articles, systematic reviews, meta-analyses, and guidelines were included. Abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature were excluded. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont, Canada). A modified Delphi technique was used to identify 8 practice-changing articles. We identified another 10 articles for tabular summaries. We highlight why these articles have the potential to change clinical perioperative practice and areas where more information is needed.

Successful recruitment and retention of academic physicians: hiring for longevity, productivity, and leadership in hospital medicine.

BACKGROUND: Considerable resources are expended by hospitals to recruit and retain physicians that will be successful. Healthcare managers lack data to guide these decisions. In that vacuum, suppositions regarding what attributes contribute to physician success predominate. OBJECTIVES: To evaluate the relationship between candidate factors known at the time of hiring and subsequent longevity and success of physicians in an academic division of hospital internal medicine. RESEARCH DESIGN: A retrospective review of all physicians hired in an academic hospital internal medicine division. Measures of longevity, research productivity, academic promotion and division leadership roles were compared to personal and professional characteristics at the time of hiring. Success was quantified in those four domains and associations explored for between success and hiring factors. RESULTS: Female physicians had greater longevity at the institution. Physicians from the hospital region were no more likely to stay long-term as compared to those from other regions. United States medical graduates were more likely to attain leadership positions than international graduates. There was an inverse relationship between research productivity and administrative leadership. CONCLUSIONS: Factors commonly sought by academic healthcare institutions were not associated with long term success in academic hospital medicine. Less research productivity was associated with greater divisional leadership involvement, suggesting that scholarship and administrative leadership may represent separate tracks for physicians at academic institutions.

Practice-Changing Updates in Perioperative Medicine Literature 2020-2021: A Systematic Review.

Recent literature published in a variety of multidisciplinary journals has significantly influenced perioperative patient care. Distilling and synthesizing the clinically important literature can be challenging. This review summarizes practice-changing articles in perioperative medicine from the years 2020 and 2021. Embase, Ovid, and EBM reviews databases were queried from January 2020 to December 2021. Inclusion criteria were original research, systematic review, meta-analysis, and important guidelines. Exclusion criteria were conference abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont., Canada). A modified Delphi technique was used to identify 9 practice-changing articles. We identified another 13 articles for tabular summaries, as they were relevant to an internist's perioperative evaluation of a patient. Articles were selected to highlight the clinical implications of new evidence in each field. We have also pointed out limitations of each study and clinical populations where they are not applicable.

Validation and Recalibration of Modified Mayo Delirium Prediction Tool in a Hospitalized Cohort.

BACKGROUND: Delirium prediction can augment and optimize care of older adults. Mayo Delirium Prediction (MDP) tool is a robust tool, developed from a large retrospective data set. The MDP tool predicts delirium risk for hospitalized older adults, within 24 hours of hospital admission, based on risk factor information available from electronic health record. OBJECTIVE: We intend to validate the prediction performance of this tool and optimize the tool for clinical use. METHODS: This is an observational cohort study conducted at Mayo Clinic Hospitals, Rochester, MN. All hospitalized older adults (age >50 years) from December 2019 to June 2020 were included. Patients with an admitting diagnosis of substance use disorder were excluded. The original MDP tool was modified to adjust for the fall risk variable as a binary variable that will facilitate broader applicability across different fall risk tools. The modified MDP tool was validated in the retrospective derivation and validation data set which yielded similar prediction capability (area under the receiver operating curve = 0.85 and 0.83, respectively). Diagnosis of delirium was captured by flowsheet diagnosis of delirium documented by nursing staff in the medical record. Predictive variable data were collected daily. RESULTS: A total of 8055 patients were included in the study (median age 71 y). Delirium prediction of the modified MDP tool compared to delirium occurrence was 4% in the low-risk group, 17.8% in the medium-risk group, and 45.3% in the high-risk group (area under receiver operating curve of 0.80). Recalibration of the tool was attempted to further optimize the tool which resulted in both simplification and increased performance (area under receiver operating curve 0.82). The simplified tool was able to predict delirium in hospitalized patients admitted to both medical and surgical services. CONCLUSIONS: Validation of the modified MDP tool revealed good prediction capabilities. Recalibration resulted in simplification with increased performance of the tool in both medical and surgical hospitalized patients.

The Effect of Bedside Rounds on Learning Outcomes in Medical Education: A Systematic Review.

PURPOSE: To determine if bedside rounds, compared with other forms of hospital ward rounds, improve learning outcomes in medical education. METHOD: For this systematic review, the authors searched Ovid MEDLINE, Embase, and Scopus from inception through February 20, 2020. Experimental studies were included if they (1) compared bedside rounds to any other form of rounds in a hospital-based setting, and (2) reported a quantitative comparison of a learning outcome (e.g., learner reaction, knowledge, skills, behavior, health care delivery) among physicians-in-training (medical students, residents, fellows). Extraction elements were summarized using descriptive statistics and a narrative synthesis of design, implementation, and outcomes. RESULTS: Twenty studies met inclusion criteria, including 7 randomized trials. All studies involved resident physicians, and 11 also involved medical students. The design and implementation of bedside rounds varied widely, with most studies (n = 13) involving cointerventions (e.g., staff education, real-time order entry).Of the 15 studies that reported learner satisfaction, 7 favored bedside rounds, 4 favored the control, and 4 were equivocal. Of the 4 studies reporting an outcome of learners' knowledge and skills, 2 favored bedside rounds and 2 were equivocal. Of the 8 studies that reported on learner behavior (e.g., bedside communication with patients), 5 favored bedside rounds, 1 favored the control, and 2 were equivocal. Finally, of the 14 studies that reported a health care delivery outcome (e.g., teamwork, rounding time), 8 favored bedside rounds and 6 were equivocal. Due to the high risk of bias and unexplained heterogeneity across studies, the overall strength of evidence was low. CONCLUSIONS: In hospital-based settings, learners' satisfaction with bedside rounds is mixed. However, bedside rounds appear to have a positive effect on learner behavior and health care delivery. Given their potential value, additional research is needed to identify barriers to and facilitators of educationally successful bedside rounds.

An Uncommon Cause of Acute Encephalopathy in Multiple Myeloma.

Multiple myeloma commonly presents with bone pain, pathological fractures, hypercalcemia, anemia, and acute kidney injury. Altered mental status due to multiple myeloma is generally attributed to uremia, hypercalcemia, and hyperviscosity. In this report, we present a rare case of altered mental status due to high serum ammonia levels in a patient with advanced multiple myeloma and with no liver dysfunction.