Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.

OBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING: An urban safety-net hospital ICU. PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.

Hypothyroidism: Diagnosis and Treatment.

Clinical hypothyroidism affects one in 300 people in the United States, with a higher prevalence among female and older patients. Symptoms range from minimal to life-threatening (myxedema coma); more common symptoms include cold intolerance, fatigue, weight gain, dry skin, constipation, and voice changes. The signs and symptoms that suggest thyroid dysfunction are nonspecific and nondiagnostic, especially early in disease presentation; therefore, a diagnosis is based on blood levels of thyroid-stimulating hormone and free thyroxine. There is no evidence that population screening is beneficial. Symptom relief and normalized thyroid-stimulating hormone levels are achieved with levothyroxine replacement therapy, started at 1.5 to 1.8 mcg per kg per day. Adding triiodothyronine is not recommended, even in patients with persistent symptoms and normal levels of thyroid-stimulating hormone. Patients older than 60 years or with known or suspected ischemic heart disease should start at a lower dosage of levothyroxine (12.5 to 50 mcg per day). Women with hypothyroidism who become pregnant should increase their weekly dosage by 30% up to nine doses per week (i.e., take one extra dose twice per week), followed by monthly evaluation and management. Patients with persistent symptoms after adequate levothyroxine dosing should be reassessed for other causes or the need for referral. Early recognition of myxedema coma and appropriate treatment is essential. Most patients with subclinical hypothyroidism do not benefit from treatment unless the thyroid-stimulating hormone level is greater than 10 mIU per L or the thyroid peroxidase antibody is elevated.

TACI is mutant in common variable immunodeficiency and IgA deficiency.

The tumor necrosis factor receptor family member TACI (transmembrane activator and calcium-modulator and cyclophilin ligand interactor) mediates isotype switching in B cells. We found that 4 of 19 unrelated individuals with common variable immunodeficiency (CVID) and 1 of 16 individuals with IgA deficiency (IgAD) had a missense mutation in one allele of TNFRSF13B (encoding TACI). One of the four individuals with CVID had a single nucleotide insertion in the other TNFRSF13B allele. None of these mutations were present in 50 healthy subjects. TNFRSF13B mutations cosegregated with the phenotype of CVID or IgAD in family members of four index individuals that we studied. B cells from individuals with TACI mutations expressed TACI but did not produce IgG and IgA in response to the TACI ligand APRIL, probably reflecting impaired isotype switching. These results suggest that TACI mutations can result in CVID and IgAD.

Racial Justice Curricula in Family Medicine Residency Programs: A CERA Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Structural racism is a cause of health disparities. Graduate medical education is tasked with training physicians who understand and address disparities. Addressing health disparities includes education on racism, such as racial justice curricula (RJC). We surveyed program directors (PDs) about the prevalence and characteristics of RJC in family medicine residency programs (FMRPs). METHODS: RJC questions were included in the 2020 Council of Academic Family Medicine Educational Research (CERA) survey of FMRP PDs. We calculated univariate and bivariate statistics to describe respondent characteristics and attitudes, program characteristics, curriculum characteristics, and barriers to implementation. RESULTS: Of 624 PDs, 312 (50%) responded and 283/312 (90.7%) completed RJC questions. Less than one-third of FMRPs reported RJC, of which 98.9% focused on implicit/unconscious bias. Program characteristics associated with RJC included location, percent underrepresented minorities in medicine (URMM) residents and faculty, and percent patients identifying as Black, Latino/a, and Native American. FMRPs with RJC were more likely to have PDs who reported favorable attitudes toward including RJC and believed it is important for family physicians to understand structural racism. The greatest barrier to implementation of RJC was lack of faculty training. CONCLUSIONS: In this national survey, most FMRPs reported no RJC. Most respondent PDs endorsed that it is important for family physicians to understand structural racism and that RJC should be included in residency. Lack of faculty training was the greatest barrier to implementation. Research is needed to evaluate existing RJC and explore strategies for overcoming barriers to implemention.

TACI and BAFF-R mediate isotype switching in B cells.

The tumor necrosis factor family members BAFF and APRIL induce Ig isotype switching in human B cells. We analyzed the ability of BAFF and APRIL to induce isotype switching in murine B cells to IgG1, IgA, and IgE. APRIL and BAFF each engage two receptors, transmembrane activator and calcium-modulator and cytophilin ligand interactor (TACI) and B cell maturation antigen (BCMA), on B cells. In addition, BAFF engages a third receptor on B cells, BAFF-R. To determine the role of these receptors in isotype switching, we examined B cells from mice deficient in TACI, BCMA, and BAFF-R. The results obtained indicate that both TACI and BAFF-R are able to transduce signals that result in isotype switching.

Resident Remediation in Family Medicine Residency Programs: A CERA Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Identifying underperforming residents and helping them become fully competent physicians is an important faculty responsibility. The process to identify and remediate these learners varies greatly between programs. The objective of this study was to evaluate the remediation landscape in family medicine residency programs by investigating resident remediation characteristics, tools to improve the process, and remediation challenges. METHODS: This study analyzed responses from the Council of Academic Family Medicine Educational Research Alliance (CERA) national survey of family medicine program directors in 2017. Survey questions included topics on faculty remediation training, remediation prevalence, tools for remediation, and barriers to remediation. RESULTS: Two hundred sixty-seven of 503 program directors completed our survey (53% response rate). Most residency programs (245/264, 93%) had at least one resident undergoing remediation in the last 3 years. A majority (242/265, 91%) of residents undergoing remediation were successful within 12 months. The three most important tools to improve remediation were an accessible remediation toolkit (50%), formal remediation recommendations from national family medicine organizations (20%), and on-site faculty development and training (19%). The top-two challenges to the remediation process were a lack of documented evaluations to trigger remediation and a lack of faculty knowledge and skills with effective remediation strategies. CONCLUSIONS: Residents needing remediation are common, but most were successfully remediated within 12 months. Program directors wanted access to a standardized toolkit to help guide the remediation process.

Continuity of Specialty Pharmacy Practice: A Survey of PGY-2 Pharmacy Residency Graduates.

BACKGROUND: Literature regarding career trajectory for postgraduate year 2 (PGY-2) pharmacy residency specialty-trained pharmacists is limited. OBJECTIVE: The objective of our study is to describe PGY-2 pharmacy residency training on career practice and satisfaction. METHODS: A cross-sectional study surveyed graduates of PGY-2 pharmacy residency programs. Respondents were identified by current PGY-2 residency program directors requesting participation from their program alumni. The primary outcome was whether PGY-2 residency-trained pharmacists continued working within their specialty or not. Secondary outcomes included alternative specialty areas, current satisfaction with their specialty, and the necessity of completing a PGY-2. RESULTS: Among 647 respondents, 84% completed their program in the past 6 years. The top 3 represented pharmacy specialties were critical care (19%), ambulatory care (14%), and oncology (13%). Most respondents continue to practice in the same specialty as their PGY-2 residency program (n = 572, 87%) compared with pharmacists who currently practice in other clinical specialties or areas of pharmacy (n = 83, 13%). Critical care (n = 28, 33%) had the largest specialty response no longer practicing in their PGY-2 residency program specialty with 42% (n = 12) now practicing within the emergency medicine specialty. The average satisfaction for their current specialty was 4.7 ± 0.82 (Likert scale of 1 = extremely dissatisfied to 5 = extremely satisfied). CONCLUSIONS: The vast majority PGY-2 pharmacy residency-trained pharmacists experienced training-practice concordance and are satisfied with their trained specialty. Among those with specialty training practice discordance, critical care training was most prevalent.

Using quantitative and qualitative approaches to understand racial disparities in adult vaccination.

BACKGROUND: One proposed explanation for the persistence of racial disparities in adult immunizations is that minority patients receive primary care at practices that differ substantively from practices where white patients receive care. This study used both quantitative and qualitative methods to assess physician and practice factors contributing to disparities in a sample of inner-city, urban, and suburban practices in low to moderate income neighborhoods. METHODS: Pneumococcal polysaccharide vaccine (PPV) and influenza vaccination rates were determined from medical record review in a sample of 2021 elderly (aged > or = 65 years) patients. Their physicians were surveyed about office systems for adult immunizations and structured observations of practice physical features, and operations were conducted. Case studies of practices with lowest and highest rates and the largest racial disparities are presented. RESULTS: Overall, weighted PPV vaccination rate was 60%, but rates differed significantly by race (65.8% for whites vs 36.5% for minorities, P < .001 by stratified Cochran-Mantel-Haenszel test). Two of 6 minority panels had PPV rates less than 20%. Overall, weighted influenza vaccination rate, as measured by receipt of the vaccine in 3 of the 5 most recent seasons, was 51.9%, but rates also differed significantly by race (55.6% for whites vs 36.2% for minorities, P < .03, by stratified Cochran-Mantel-Haenszel test). CONCLUSIONS: Low rates in 2 minority panels, racial disparity between minorities and whites in mixed panels, and between-panel variation in rates contributed to the overall differences in vaccination rates by race.

Overview and Assessment of a Full-time Family Medicine Faculty Development Fellowship.

BACKGROUND AND OBJECTIVES: Part-time faculty development (FD) fellowships help faculty become successful and effective teachers in medicine. Fulltime FD fellowships provide a unique and promising model to train and retain high-quality faculty. This article presents an overview of a well-established, fulltime FD fellowship at the University of Pittsburgh and the results from a survey of its graduates regarding fellowship experiences and their career trajectories. METHODS: A 29-item questionnaire was sent to all graduates who completed the University of Pittsburgh St Margaret Faculty Development Fellowship from 1982 and 2014. Questions covered motivation for pursuing the fellowship, explored fellowship experiences, and examined its impact on career and professional development. We present descriptive frequencies and common themes identified from qualitative data from physician respondents. RESULTS: Fifty-two of the 69 physicians surveyed responded (75.2% response rate). Many completed a 2-year fellowship (n=32, 61.5%). Nearly two-thirds of graduates had an educator position as their first (n=34, 65.4%) and current (n=30, 62.5%) job. Graduates reported a mean fellowship satisfaction score of 8.83 (SD 1.74) on a 10-point scale. Research-related activities and professional development skills were identified as being the most useful/valuable aspects of the fellowship. CONCLUSIONS: Fellowship graduates were highly satisfied with their training and had a high retention rate in academic positions. Our findings can guide FD fellowship program design and address the needs of future and current educators in medicine.

An innovative, residency-based, interprofessional faculty development program.

PURPOSE: The impact of an interprofessional faculty development fellowship (FDF) on pharmacy graduates' careers is described. SUMMARY: The FDF instructional approach is a longitudinal acquisition and application of knowledge, skills, and attitudes fostered by clinical care delivery, teaching experiences, structured reflection, the giving and receiving of feedback, research and scholarly projects, and leadership development and exercises. Interprofessional FDF fellows teach, learn, and provide care together in both inpatient and outpatient clinical settings as a part of the evidence-based medicine curriculum, providing educational sessions for medical students, pharmacy students, medical residents, attending family medicine physicians, and clinical pharmacy faculty throughout the year. Twenty-seven of the 30 pharmacist graduates of the fellowship (90% response rate) responded to an electronic survey about the influence of the FDF on their careers. Overall, pharmacy graduates were very satisfied with the fellowship. The fellowship fostered a clear pattern of continued, collaborative learning. While additional training beyond a pharmacy residency program is not necessary for a successful clinical career, 41% of graduates pursued additional training after completing the fellowship. Open-ended responses for motivations for completing the FDF and influences the FDF had on their careers fell unforced into the FDF curriculum domains, which reinforced the belief that these are the right areas to target for development. CONCLUSION: Pharmacy residents participated in a broad, interprofessional faculty development curriculum, which fostered teaching, scholarship, leadership, professional development, and clinical skills. Pharmacist graduates indicated that the experience significantly influenced their careers and professional development.

Training Family Medicine Residents to Perform Home Visits: A CERA Survey.

BACKGROUND: Home visits have been shown to improve quality of care, save money, and improve outcomes. Primary care physicians are in an ideal position to provide these visits; of note, the Accreditation Council for Graduate Medical Education no longer requires home visits as a component of family medicine residency training. OBJECTIVE: To investigate changes in home visit numbers and expectations, attitudes, and approaches to training among family medicine residency program directors. METHODS: This research used the Council of Academic Family Medicine Educational Research Alliance (CERA) national survey of family medicine program directors in 2015. Questions addressed home visit practices, teaching and evaluation methods, common types of patient and visit categories, and barriers. RESULTS: There were 252 responses from 455 possible respondents, representing a response rate of 55%. At most programs, residents performed 2 to 5 home visits by graduation in both 2014 (69% of programs, 174 of 252) and 2015 (68%, 172 of 252). The vast majority (68%, 172 of 252) of program directors expect less than one-third of their graduates to provide home visits after graduation. Scheduling difficulties, lack of faculty time, and lack of resident time were the top 3 barriers to residents performing home visits. CONCLUSIONS: There appeared to be no decline in resident-performed home visits in family medicine residencies 1 year after they were no longer required. Family medicine program directors may recognize the value of home visits despite a lack of few formal curricula.

Physician Factors Associated with Polypharmacy and Potentially Inappropriate Medication Use.

BACKGROUND: Despite accumulating evidence about the harm of polypharmacy in family medicine, few studies have investigated factors related to polypharmacy. The objective of this study was to explore factors related to physicians' prescribing behavior. METHODS: We conducted a survey of physicians at 5 family medicine residency practices and a linked health record review of their patients ≥65 years old. The determinants of physicians' mean number of prescriptions and potentially inappropriate medications (PIMs) were examined using a generalized linear model. RESULTS: A total of 61 physicians (38 residents, 23 fellows/faculty) completed the survey, and 2103 visits by 932 patients seen by these physicians were analyzed. The mean numbers of prescriptions and PIMs per visit per physician were 9.50 and 0.46, respectively. After controlling for patient race and age, low prescribers were more likely to consider the number of medications (P = .007) and benefit/risk information for deprescribing (P = .017) when making prescribing decisions. Use of the Beers List was marginally significant in lower PIM prescribing (P = .05). Physicians' sex, duration of experience, and perceived confidence were not associated with prescribing patterns. CONCLUSIONS: Conscious consideration concerning the number of medications and benefit/risk information, as well as using the Beers List, were associated with less polypharmacy and fewer PIMs.

Integration of Clinical Pharmacists in Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: Clinical pharmacists are valued educators and practitioners within family medicine residency programs (FMRPs). Since the last survey of clinical pharmacists within FMRPs, there have been significant advancements to pharmacy education and training as well as growth of interprofessional education and collaborative practice within family medicine. The objective of this study is to describe the integration of clinical pharmacists within FMRPs. METHODS: All 480 Accreditation Council for Graduate Medical Education (ACGME)-approved FMRPs were contacted to identify clinical pharmacists involved with their programs. An electronic survey was distributed to these 253 pharmacists. Questions addressed educational, clinical, scholarly, and administrative activities. RESULTS: Of 396 FMRPs reached, 208 (52.5%) reported 253 clinical pharmacists within their programs. Survey responses were received from 142 (56.1%) pharmacists. Academic appointments in colleges/schools of pharmacy and medicine were held by 105 (75.5%) and 69 (50.0%) respondents, respectively. Eighty-nine (64.0%) pharmacists reported a single source of salary, 19.1% of which received full support from the FMRP. Clinical pharmacists dedicated an average of 50.4% of their overall time to the FMRP, and 14.5% of pharmacists dedicated all of their time to the FMRP. Time within the FMRP was spent on patient care (52.9%), teaching (31.6%), research/scholarship (7.5%), administrative activities (5.9%), and drug dispensing (0.7%). DISCUSSION: Prevalence of clinical pharmacists within FMRPs has increased since 2000, from 27.9% to 52.5%. However, the amount of time dedicated to the FMRPs has decreased. This shift from teaching to a more clinical role may reflect both a growth of patient-centered, interprofessional care and a needed mechanism to assist funding these positions.

Clinical Inquiry: Do ACE inhibitors or ARBs help prevent kidney disease in patients with diabetes and normal BP?

Yes for angiotensin-converting enzyme (ACE) inhibitors, no for angiotensin receptor blockers (ARBs). A 2011 meta-analysis of 5 RCTs (total 2975 patients) that compared ACE inhibitor therapy with placebo in diabetic patients without hypertension and albuminuria found that ACE inhibitors reduced the risk of new-onset microalbuminuria or macroalbuminuria by 18% (relative risk [RR]=0.82; 95% confidence interval [CI], 0.73-0.92).

Racial differences in beliefs about genetic screening among patients at inner-city neighborhood health centers.

BACKGROUND: Genetic testing has the potential to identify persons at high risk for disease. Given the history of racial disparities in screening, early detection and accessing treatment, understanding racial differences in beliefs about genetics is essential to preventing disparities in some conditions. METHODS: In 2004, a sample of older adult patients from four inner-city health centers was surveyed to assess beliefs about genetic determinants of disease, genetic testing and religion. Logistic regression determined which beliefs were associated with race. RESULTS: Of the 314 respondents, 50% were African Americans. Most respondents thought that sickle cell disease, cystic fibrosis and diabetes are primarily genetic. African Americans were more likely than Caucasians to believe that genetic testing will lead to racial discrimination (Odds ratio (OR): 3.02, 95% confidence interval (CI): 1.5-6.0) and to think that all pregnant women should have genetic tests (OR=3.8, 95% CI: 1.7-8.6). African Americans were more likely to believe that God's Word is the most important source for moral decisions (OR: 3.6, 95% CI :1.5-8.7). CONCLUSION: African Americans and Caucasians differ in beliefs about genetic testing and the basis for moral decision-making. Acknowledging and understanding these differences may lead to better medical care.

Flextensional ultrasonic piezoelectric micro-motor.

This paper presents the experimental design, construction, and operational characteristics of a new type of standing wave piezoelectric ultrasonic micro-motor. The motor uses a composite stator, consisting of a metallic flex-tensional mode converter, or "cymbal", bonded to a 2-mm-square piezoelectric plate. The cymbal converts contour-mode vibrations of the plate into oscillations in the cymbal, perpendicular to the stator plane. These are further converted into rotational movement in a rotor pressed against the cymbal by means of an elastic-fin friction drive to produce the required rotary actuation. The motor operates on a single-phase electrical supply, and direct control of the output speed and torque can be achieved by adjusting the amplitude and frequency of the supply voltage. Noncontact optical techniques were used to assess the performance of the developed micro-motor. The operational characteristics were developed from the acceleration and deceleration characteristics. No-load output speed (11 rev s(-1)) and stall torque (27 nNm) were derived using high-speed imaging and image analysis. Maximum efficiency was 0.6%.