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BACKGROUND: Bronchopulmonary dysplasia (BPD) is associated with neurodevelopmental impairment (NDI). METHODS: To compare the ability of NICHD 2001 and Jensen 2019 definitions of BPD and respiratory support at 40 weeks postmenstrual age (PMA) to predict NDI, a retrospective study (1/2010-12/2020) was conducted in infants with gestational age <32 weeks and birth weight <1500 g. The primary outcome measure was NDI at 18-24 months corrected age. RESULTS: Of 1119 infants, 227 (20.7%) met the inclusion criteria and had adequate follow-up data. Multivariate regression analysis showed that the NICHD 2001 definition was not predictive of NDI. Infants with Grade 2 or 3 BPD (Jensen 2019) had 4.75 (95% CI: 1.282-17.563) times greater odds of having NDI than infants without BPD. Infants requiring respiratory support at 40 weeks PMA had 4.95 (95% CI: 1.490-16.47) times greater odds of having NDI. Receiver operating characteristic curves demonstrated that the 2 definitions of BPD and the need for respiratory support at 40 weeks PMA were similar in their ability to predict NDI. CONCLUSION: There is no significant difference in the ability of the NICHD 2001 and Jensen 2019 BPD definitions, as well as the need for respiratory support at 40 weeks, for predicting NDI. IMPACT STATEMENT: Current bronchopulmonary dysplasia (BPD) definitions may not effectively predict neurodevelopmental impairment (NDI) in preterm infants. Grades 2/3 BPD (Jensen 2019 criteria) significantly associate with NDI. Infants requiring respiratory support at 40 weeks post-menstrual age (PMA) have 5 times higher odds of NDI than those on room air at 40 weeks PMA. The NICHD 2001, Jensen 2019 definitions, and the requirement for respiratory support at 40 weeks PMA, do not differ in their ability to predict NDI. Future studies should include multiple centers, with level III-IV NICUs, catering to socioeconomic, culturally, and racially diverse populations.
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INTRODUCTION: Older trauma patients are at risk for worse outcomes compared to younger patients. We hypothesized that early initiation of palliative care (EPC) evaluations, within 72 h of trauma intensive care unit (ICU) admission, would be associated with reduced invasive procedures without a change in hospital mortality. METHODS: A retrospective cohort review was performed of all trauma patients aged ≥65 y admitted to the trauma (ICU) from January 1, 2016, to December 31, 2021. Patients who received formal palliative care assessments were included. Patient demographics and injury characteristics were evaluated. The primary outcome was ICU length of stay (LOS). Secondary outcomes included code status change, tracheostomy or percutaneous endoscopic gastrostomy placement, use and length of mechanical ventilation, in-hospital mortality, and withdrawal of life-sustaining care. RESULTS: Two hundred twenty-five patients met inclusion. One hundred and six had EPC while 119 had late palliative care. EPC was associated with decreased ICU LOS (3 versus 9 d, P < 0.001), hospital LOS (3 versus 11 d, P < 0.001), and days on mechanical ventilation (P < 0.001), and fewer tracheostomy (P = 0.007) and percutaneous endoscopic gastrostomy tubes (P = 0.049). There was no difference in withdrawal of life-sustaining care (P = 0.581) or in-hospital mortality (P = 0.172). Pre-existing code status or code status clarification early in admission was associated with EPC (P = 0.003) and decreased interventions. CONCLUSIONS: EPC is associated with decreased LOS and fewer invasive procedures without a change in hospital mortality. Early discussions regarding code status are helpful in decreasing hospital costs and futile interventions. Further investigation is required to standardize palliative care in this population.
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INTRODUCTION: Our previous work demonstrated that use of ShotSpotter (SS), a gunfire detection system, and use of police department (PD) transport decreased response and transport time for gunshot wound (GSW) victims versus events with non-ShotSpotter (NSS). The purpose of this study was to evaluate transport trends and how they are linked to SS in the period of 2016-2021 in Camden, NJ. METHODS: This was a single-center, retrospective observational study. Demographics, response time, transport time, and clinical data were collected. Independent t-test, Mann-Whitney U test, chi-squared test, and linear regression to correct for transport time and method of transport were used to compare outcomes (P < 0.05). RESULTS: A total of 267 GSWs were included: 77 emergency medical technicians (EMS)-SS, 41 EMS-NSS, 116 PD-SS, and 33 PD-NSS. When comparing response from 2016 to 2021, PD improved from 4 to 2 min (P = 0.001). EMS improved from 6.4 min (EMS-NSS) and 4.5 min (EMS-SS) to 5 min (EMS- NSS) and 4 min (EMS-SS) (P = 0.281). In addition, PD transport times, 5 min (SS) and 4 min (NSS), were faster than EMS, 9 min (SS and NSS) (P < 0.001). Overall PD transport volume increased with a peak in 2020 (68.3%). There was also an increase in PD-NSS transport 4% to 37.9% (P < 0.001). EMS-SS transport decreased from 54.7% to 6.9% (P < 0.001). CONCLUSION: The presence of SS technology in a small urban setting continues to be associated with a higher rate of PD transport of GSW victims. The critical time of dispatch and transport for both PD and EMS has shown durable improvement.
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Transporte de Pacientes , Ferimentos por Arma de Fogo , Estudos Retrospectivos , Humanos , Masculino , Transporte de Pacientes/estatística & dados numéricos , Transporte de Pacientes/métodos , Adulto , Feminino , Pessoa de Meia-Idade , Polícia/estatística & dados numéricos , Fatores de Tempo , Serviços Médicos de Emergência/estatística & dados numéricosRESUMO
INTRODUCTION: Gun violence is a pervasive and dynamic public health crisis causing substantial burden on communities and healthcare systems in the United States. Risk factor and outcome analyses are crucial to develop effective interventions. The aim of this study was to assess firearm injury in a diverse community setting as it relates to neighborhood socioeconomic disadvantage and changes over time following large-scale local interventions. METHODS: All county residents with firearm injury presenting to a Level 1 Trauma Center from January 2012 to December 2021 were retrospectively reviewed. Area Deprivation Index (ADI) was used to measure neighborhood socioeconomic disadvantage based on a nine-digit zip code at patients' home address. Injuries were also stratified by 5-year time periods, 2012-2016 and 2017-2021. Demographics and clinical data were analyzed including injury severity, hospital course, and discharge location. Data were compared by ADI quintile and between time periods using chi-squared, one-way analysis of variance, and Cochran-Armitage test. RESULTS: A total of 1044 injuries were evaluated. Patients were 93% male with mean age of 29 y (standard deviation 10.2) and were concentrated in the most disadvantaged neighborhoods (74% ADI Q5). Black or African American race was greater in the most disadvantaged ADI groups (76% versus 47%-66%; P <0.001). Percentage of total injuries in the most disadvantaged ADI group rose from 71% to 78% over time (P = 0.006). Mortality occurred in 154 (15%) patients overall, while most (71%) were discharged to home. Mortality declined from 18% to 11% over time (P <0.001). Medicaid utilization rose from 42% to 77% alongside a decrease in self-pay status from 44% to 4% (P <0.001). There were no clinically significant group differences in injury severity or clinical characteristics. CONCLUSIONS: Firearm injury remains concentrated in the most socioeconomically disadvantaged neighborhoods, and this disparity is increasing over time. Medicaid utilization rose and mortality decreased in this population over time. This research presents a method to inform and monitor local gun violence interventions using ADI to address public health equity.
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Armas de Fogo , Violência com Arma de Fogo , Ferimentos por Arma de Fogo , Humanos , Masculino , Estados Unidos/epidemiologia , Adulto , Feminino , Violência com Arma de Fogo/prevenção & controle , Estudos Retrospectivos , Ferimentos por Arma de Fogo/epidemiologia , Características de ResidênciaRESUMO
The purpose of this study was to evaluate disparities in urine drug testing (UDT) during perinatal care at a single academic medical center. This retrospective cohort study included patients who had a live birth and received prenatal care at our institution between 10/1/2015 and 9/30/2020. The primary outcomes were maternal UDT during pregnancy (UDTPN) and UDT only at delivery (UDTDEL). Secondary outcomes included the number of UDTs (UDTNUM) and the association between a positive UDT test result and race/ethnicity. Mixed model logistic regression and negative binomial regression with clustering based on prenatal care locations were used to control for confounders. Of 6,240 live births, 2,265 (36.3%) and 167 (2.7%) received UDTPN and UDTDEL, respectively. Black (OR 2.09, 95% CI 1.54-2.84) and individuals of Other races (OR 1.64, 95% CI 1.03-2.64) had greater odds of UDTPN compared to non-Hispanic White individuals. Black (beta = 1.12, p < 0.001) and Hispanic individuals (beta = 0.78, p < 0.001) also had a positive relationship with UDTNUM. Compared to individuals with non-Medicaid insurance, those insured by Medicaid had greater odds of UDTPN (OR 1.66, 95% CI 1.11-2.49) and had a positive relationship with UDTNUM (beta = 0.89, p < 0.001). No significant associations were found for UDTDEL and race/ethnicity. Despite receiving more UDT, Black individuals were not more likely to have a positive test result compared to non-Hispanic White individuals (OR 0.95, 95% CI 0.72-1.25). Our findings demonstrate persistent disparities in substance use testing during the perinatal period.
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Centros Médicos Acadêmicos , Disparidades em Assistência à Saúde , Detecção do Abuso de Substâncias , Humanos , Estudos Retrospectivos , Feminino , Gravidez , Centros Médicos Acadêmicos/estatística & dados numéricos , Adulto , Detecção do Abuso de Substâncias/métodos , Detecção do Abuso de Substâncias/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Assistência Perinatal/estatística & dados numéricos , Assistência Perinatal/métodos , Estudos de Coortes , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/urina , Cuidado Pré-Natal/estatística & dados numéricos , Cuidado Pré-Natal/métodos , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/urinaRESUMO
BACKGROUND: Opioid-associated out-of-hospital cardiac arrest (OA-OHCA) is a subset of cardiac arrests that could benefit from measures outside of standard Advanced Cardiac Life Support (ACLS), such as naloxone. STUDY OBJECTIVES: In this study, we sought to examine whether OHCA patients chosen for naloxone therapy by emergency medical services (EMS) clinicians in a system with high rates of opioid overdose would have increased rates of return of spontaneous circulation (ROSC) and survival to hospital discharge. METHODS: The study took place in an urban EMS system with a high prevalence of opioid overdose. Paramedics could administer naloxone in cardiac arrest in addition to ACLS. It was often administered based on clinical gestalt for suspected OA-OHCA. The outcomes of OHCA patients who received naloxone were compared against those who received usual care in both an adjusted and unadjusted fashion. Lastly, we created a logistic regression model to test for an independent association of naloxone administration on ROSC and survival to hospital discharge. RESULTS: A consecutive sample of 769 OHCA patients was obtained, of which 175 (23%) received naloxone. On average, patients who received naloxone had significantly fewer comorbidities and were younger. There was no difference in ROSC, survival to hospital discharge, or modified Rankin Scores. Using logistic regression modeling, there was no statistically significant effect of naloxone administration on these outcomes. CONCLUSION: OHCA patients who received naloxone, despite being younger and having fewer comorbidities, had similar outcomes compared to those who received usual care. The difference in baseline characteristics suggests that paramedic gestalt reasonably selected for OA-OHCA.
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INTRODUCTION: Given the early surge of COVID-19 in New Jersey (NJ), a statewide executive order (EO) to stay-at-home was instituted on March 22, 2020. We hypothesized that the EO would result in a decreased number of trauma admissions, length of stay, and resources utilized in trauma patients at NJ trauma centers. METHODS: In an institutional review board-approved, retrospective, multicenter study, trauma registries at three level one trauma centers in NJ were queried from March 22 to June 14 in 2020 and compared to the same timeframe the year prior. Epidemiological and clinical data were obtained including demographics, select preexisting conditions, mechanism of injury, injury severity score, resources utilized, and outcomes. RESULTS: 1859 trauma patients were evaluated during the EO versus 2201 the year prior. During the EO, trauma patients were less likely to be transferred from another hospital (21% versus 29% P < 0.05), more likely to have a penetrating mechanism (16% versus 12% P < 0.05), were equally likely to require a procedure (P = 0.44) and had similar injury severity score (5 [interquartile range [IQR] 1-9] versus 5 [IQR 1-9], P = 0.73). There was no significant difference in ventilator days (0 [IQR 0-1] versus 0 [IQR 0-2] P = 0.08), intensive care unit days (2 [IQR 0-4] versus 2 [IQR 0-3] P = 0.99), or length of stay (2 [IQR 1-5] versus 2 [IQR 1-6] P = 0.73). Patients were more likely to be sent home than to rehabilitation or long-term acute care hospital during the EO (81% versus 78%, P = 0.02). CONCLUSIONS: The 2020 COVID-19 EO was associated with a significantly different epidemiology with a higher rate of penetrating injury during the EO, and similar volume of injured patients evaluated.
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COVID-19 , Humanos , Estudos Retrospectivos , New Jersey/epidemiologia , Incidência , COVID-19/epidemiologia , Escala de Gravidade do Ferimento , Centros de Traumatologia , Tempo de InternaçãoRESUMO
Regional lymph node metastasis is a well-established negative predictive prognostic factor in endometrial carcinomas. Recently, our approach to the pathologic evaluation of lymph nodes in endometrial carcinomas has changed, mainly due to the utilization of immunohistochemical stains in the assessment of sentinel lymph nodes, which may result in the identification of previously unrecognized disease [particularly isolated tumor cells (ITCs)] on hematoxylin and eosin stained slides. However, the clinical significance of this finding is not entirely clear. Following the experience in other organs systems such as breast, the Eight Edition of the American Joint Committee on Cancer's Cancer Staging Manual has recommended utilizing the N0(i+) terminology for this finding, without impact in the final tumor stage. We performed a comparative retrospective multi-institutional survival analysis of 247 patients with endometrial carcinoma with regional lymph node metastasis of various sizes identified in nonsentinel lymphadenectomy, demonstrating that the cumulative survival of patients with isolated tumor cells in regional lymph nodes is not statistically different from patient with negative lymph nodes, and is statistically different from those with lymph nodes showing micrometastasis or larger metastatic deposits. In addition, we evaluated the prognostic implications of the number of involved regional lymph nodes, demonstrating a worsening prognosis as the number of involved lymph nodes increases from none to one, and from one to more than one. Our data suggests that regional lymph nodes with isolated tumor cells in patients with endometrial carcinoma should likely be considered, for staging purposes, as negative lymph nodes, simply indicating their presence with the (i+) terminology.
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Neoplasias do Endométrio , Linfonodos , Feminino , Humanos , Neoplasias do Endométrio/patologia , Excisão de Linfonodo , Linfonodos/patologia , Metástase Linfática/patologia , Estadiamento de Neoplasias , Prognóstico , Estudos RetrospectivosRESUMO
The goals of this study were to determine the completion rates of patient order forms at the Cooper Rowan Clinic, a student-run free clinic, and to implement the use of a post-encounter phone call to improve completion rates, preventive medicine, and medical student clinical involvement. 151 patients completed a pre-intervention questionnaire before their visit. The questionnaire collected information regarding successfully completed order forms. First-year students were trained to perform phone calls and called their patients for five months. 205 patients then completed a post-intervention questionnaire. Dependent variables included completion rates for laboratory studies, specialty referrals, imaging studies and miscellaneous tests. Chi-squared tests were performed. Although the completion rates for laboratory testing (pre = 73.7% vs post = 81.1%), referrals (pre = 50.0% vs post = 65.1%) and imaging studies (pre = 60.9% vs post = 71.7%) increased, the results were not statistically significant. The completion rate of miscellaneous testing (pre = 41.7% vs post = 100.0%) increased following the implementation and was statistically significant. When patients were stratified to those who received a phone call, completion rates of referrals (73.0%), laboratory testing (86.1%), imaging studies (80.5%), and miscellaneous studies (100.0%) substantially increased. Although not statistically significant except for miscellaneous studies, there was an overall increase in completion in all categories. Further evidence to suggest that phone calls improved order completion was the substantial increase in completion rates in patients who received a call. The implementation improves completion of orders which could enhance preventive measures within the clinic. Additionally, it provides an opportunity for earlier student clinical exposure through direct patient contact.
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Clínica Dirigida por Estudantes , Estudantes de Medicina , Humanos , Telefone , Instituições de Assistência AmbulatorialRESUMO
OBJECTIVE: Extremely low birth weight (ELBW) infants often receive transfusions of packed red blood cells (PRBCs). Long-term outcomes of infants treated with liberal versus restricted transfusion criteria have been evaluated with conflicting results. Clinicians incorporate a reticulocyte count (RC) in their transfusion decisions. There is a lack of information on reference ranges for RCs in growing ELBW infants and whether infant's chronologic age or corrected gestational age (GA) generates a specific trend in the RCs. Our aim was to evaluate the levels of RCs obtained from ELBW infants over the course of the initial hospitalization. STUDY DESIGN: A retrospective chart review of ELBW infants treated in the neonatal intensive care unit (NICU) and had RCs performed. We analyzed the RCs to observe trends based on the chronologic age and corrected GA. RESULTS: A total of 738 RCs were analyzed. A positive trend in RCs that reached a peak at 32 to 34 weeks' corrected GA and then experienced a downward trend was observed. CONCLUSION: Our report examines a very common hematologic test that is theoretically helpful but is in need of guidelines concerning the appropriate frequency of testing and its utility in making transfusion decisions in ELBW infants. KEY POINTS: · RCs should help in making transfusion decisions for ELBW infants.. · No current reference ranges for RC in this population.. · No current reference ranges for RC based on GA and postnatal age..
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Recém-Nascido de Peso Extremamente Baixo ao Nascer , Reticulócitos , Recém-Nascido , Lactente , Humanos , Estudos Retrospectivos , Terapia Intensiva Neonatal , Unidades de Terapia Intensiva Neonatal , Peso ao NascerRESUMO
PURPOSE: To evaluate and quantify the character and amount of lesbian, gay, bisexual, transgender, and queer (LGBTQ +) content on sperm, oocyte, and embryo provider websites in the USA. METHODS: Websites with LGBTQ + information were categorized into "minimal," "moderate," and "significant" content. The presence and type (category) of LGBTQ + content were assessed in its relationship to geographic regions, in vitro fertilization (IVF) cycles/year, and website types. Interobserver reliability was assessed for the categorization system created. RESULTS: Out of 373 unique websites, 191 (51.2%) had LGBTQ + content of any kind. Regarding the amount of content, websites were categorized as "none" (48.8%), "minimal" (8.0%), "moderate" (28.4%), and "significant" (14.8%). "Private fertility clinic" websites were more likely to have LGBTQ + content and a significantly increased amount of content compared to other website types ("academic hospital" and "sole sperm, oocyte, and embryo provider" websites) (p < 0.0001). Fertility clinics with more IVF cycles/year were more likely to have increased amount of LGBTQ + content compared to those with fewer IVF cycles/year (OR = 4.280; 95% CI, 1.952-9.388). Northeast, West, South, and Midwest regions showed no statistically significant difference in presence and type of content (p = 0.06 and p = 0.13, respectively). CONCLUSION: Approximately half of websites had LGBTQ + content. Private fertility clinics and fertility clinics with increased IVF cycles/year show a positive relationship to the presence and type of LGBTQ + content, while LGBTQ + website content was similar across four geographic regions.
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Minorias Sexuais e de Gênero , Pessoas Transgênero , Masculino , Humanos , Reprodutibilidade dos Testes , Sêmen , OócitosRESUMO
BACKGROUND: Rotator cuff tear arthropathy (CTA) carries a significant symptomatic burden for patients. Reverse shoulder arthroplasty (RSA) is an effective treatment intervention for CTA. Disparities in musculoskeletal medicine are well documented; however, there is a paucity of literature on how social determinants of health affect utilization rates. The purpose of this study is to determine how social determinants of health affect the utilization rates of RSA. METHODS: A single-center retrospective review was conducted for adult patients diagnosed with CTA between 2015 and 2020. Patients were divided by those who underwent RSA and those who were offered RSA but did not undergo surgery. Each patient's zip code was used to determine the most specific median household income in the US Census Bureau database and compared to the multistate metropolitan statistical area median income. Income levels were defined by the US Department of Housing and Urban Development's (HUD's) 2022 Income Limits Documentation System and the Federal Reserve's (FED's) Community Reinvestment Act. Because of numeric restrictions, patients were grouped into racial cohorts of Black, White, and all other races. RESULTS: Patients of other races had significantly lower odds of continuing to surgery compared with White patients in models controlled for median household income (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.18-0.81, P = .01), HUD's 3 income levels (OR 0.36, 95% CI 0.18-0.74, P = .01), and FED's income levels (OR 0.37, 95% CI 0.17-0.79, P = .01). There was no significantly different odds of going on to surgery between FED income levels and median household income levels, but when compared with those with low HUD income, those below median had significantly lower odds of going on to surgery (OR 0.43, 95% CI 0.23-0.80, P = .01). CONCLUSION: Although contradictory to reported health care utilization for Black patients, our study supports reported disparities in utilization for other ethnic minorities. These findings may suggest that improvements in utilization efforts targeted Black-identifying patients but not necessarily other ethnic minorities. The findings of this study can help providers understand how social determinants of health play a role in the utilization of care for CTA and direct mitigation efforts to reduce disparities in access to adequate orthopedic care.
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Artroplastia do Ombro , Lesões do Manguito Rotador , Artropatia de Ruptura do Manguito Rotador , Articulação do Ombro , Adulto , Humanos , Artropatia de Ruptura do Manguito Rotador/cirurgia , Articulação do Ombro/cirurgia , Artroplastia do Ombro/efeitos adversos , Resultado do Tratamento , Artroplastia , Estudos Retrospectivos , Lesões do Manguito Rotador/cirurgia , Lesões do Manguito Rotador/etiologiaRESUMO
INTRODUCTION: The current treatment paradigm of abdominal aortic aneurysms (AAA) focuses on observing patients until their disease reaches certain thresholds for intervention, with no preceding treatment available. There is an opportunity to develop novel therapies to prevent further aneurysmal growth and decrease the risk of a highly morbid rupture. We used a porcine model of aortic dilation to assess the ability of human adipose-derived mesenchymal stem cells (MSCs) to attenuate aortic dilation. MATERIALS AND METHODS: Twelve Yorkshire pigs received periadventitial injections (collagenase and elastase) into a 4-cm segment of infrarenal aorta. Animals were treated with either 1 × 106 MSCs placed onto Gelfoam or treated with media as a control. Aortic diameters were measured at the time of surgery and monitored at postoperative day (POD) 7 and 14 with ultrasound. Animals were sacrificed on POD 21. Aortic tissue was harvested for histopathological analyses and immunohistochemistry. Groups were compared with paired t-tests or Mann-Whitney U-tests. RESULTS: All animals survived until POD 21. The mean aortic diameter was reduced in the aortic dilation + MSC treatment group compared to aortic dilation control animals (1.10 ± 0.126 versus 1.48 cm ± 0.151, P < 0.001). Aortic media thickness was reduced in the aortic dilation group compared to the aortic dilation + MSC group (609.14 IQR 445.21-692.93 µm versus 643.55 IQR 560.91-733.88 µm, P = 0.0048). There was a significant decrease in the content of collagen and alpha-smooth muscle actin and elastin perturbation in the aortic dilation group as compared to the aortic dilation + MSC group. Immunohistochemistry demonstrated an increased level of vascular endothelial growth factor, tissue inhibitor of matrix metalloproteinase 1, and tissue inhibitor of matrix metalloproteinase 3 expression in the aorta of aortic dilation + MSC animals. CONCLUSIONS: Stem cell therapy suppressed the aortic dilation in a porcine model. Animals from the aortic dilation group showed more diseased gross features, histologic changes, and biochemical properties of the aorta compared to that of the aortic dilation + MSC treated animals. This novel finding should prompt further investigation into translatable drug and cell therapies for aneurysmal disease.
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Aneurisma da Aorta Abdominal , Células-Tronco Mesenquimais , Animais , Aorta Abdominal/metabolismo , Aneurisma da Aorta Abdominal/metabolismo , Modelos Animais de Doenças , Humanos , Células-Tronco Mesenquimais/metabolismo , Suínos , Fator A de Crescimento do Endotélio Vascular/metabolismoRESUMO
BACKGROUND: The subspecialty of Hospital Medicine (HM) has grown rapidly since the mid-1990s. Diversity and inclusion are often studied in the context of healthcare equity and leadership. However, little is known about the factors potentially associated with choosing this career path among US medical students. METHODS: We analyzed the results of the Annual Association of American Medical Colleges Survey administered to Graduating medical students from US medical schools from 2018 to 2020. RESULTS: We analyzed 46,614 questionnaires. 19.3% of respondents (N = 8,977) intended to work as a Hospital Medicine [HM] (unchanged from 2018 to 2020), mostly combined with specialties in Internal medicine (31.5%), Pediatrics (14.6%), and Surgery (9.1%). Students interested in HM were significantly more likely to identify as female, sexual orientation minorities (Lesbian/Gay or Bisexual), Asian or Black/African-American, or Hispanic. Role models and the ability to do a fellowship were strong factors in choosing HM, as was higher median total debt ($170,000 vs. $155,000). Interest in higher salary and work/life balance negatively impacted the likelihood of choosing HM. There were significant differences between students who chose IM/HM and Pediatrics/HM. CONCLUSION: About one in five US medical students is interested in HM. The probability of choosing future HM careers is higher for students who identify as sexual or racial minorities, with a higher amount of debt, planning to enter a loan forgiveness program, or are interested in doing a fellowship.
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Médicos Hospitalares , Estudantes de Medicina , Feminino , Humanos , Masculino , Criança , Escolha da Profissão , Medicina Interna/educação , Inquéritos e Questionários , Demografia , Fatores EconômicosRESUMO
Aims: In 2012, the first totally Subcutaneous Implantable Cardioverter-Defibrillator (S-ICD) was approved by the Food and Drug Administration (FDA) in the United States. A possible benefit of this device is that it does not involve placing leads 'in' or 'on' the heart, potentially reducing complications. Methods amd results: Ninety-one S-ICD and 182 single chamber TV-ICD implants were performed between 10/22/2012 and 9/22/2015. During this period of time, 91 patients with S-ICD were matched to TV-ICD patients using single centre NCDR ICD Registry Data based on dialysis status, gender, and age. Intra- and post-operative complications and deaths were examined within the first 180 days following implantation. Patients with S-ICDs had higher creatinine (2.3 ± 2.5 vs. 1.1 ± 0.7, P < 0.001) and were more likely to be on chronic dialysis (20.9% vs. 5.5%, P < 0.001) than TV-ICD patients. Patients in the S-ICD group were more likely to have had prior device infections (14.3% vs. 3.3%, P = 0.021) as well as prior TIA/CVA (14.3% vs. 4.4%, P = 0.049) compared to patients in the TV-ICD group. Seven patients experienced 7 complications or death in TV-ICD group and 5 patients experienced 7 complications or death in SQ-ICD group, P = 0.774. Conclusion: In this retrospective matched single centre cohort study, there was no significant difference in implantation complications or death in patients receiving single chamber TV-ICDs compared to S-ICDs within 6 months following implantation. This occurred despite more severe preexisting illness in the S-ICD group. Further investigation is needed to determine outcomes after longer-term follow-up.
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Arritmias Cardíacas/terapia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Implantação de Prótese/métodos , Adulto , Idoso , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/mortalidade , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Implantação de Prótese/efeitos adversos , Implantação de Prótese/mortalidade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
In sepsis, an overwhelming immune response, as mediated by the release of various inflammatory mediators, can lead to shock, multiple organ damage, and even death. Pneumonia is the leading cause of sepsis. In animal septic models, sepsis could induce uncontrolled calcium (Ca) leaking, raising cytosolic Ca to a toxic level, causing irreversible cellular injuries and organ failure. All types of calcium channel blockers (CCBs), by inhibiting Ca influx, have been shown to decrease overall mortality in various septic animal models. However, to our best knowledge, no clinical study had been conducted to investigate the beneficial effect(s) of CCBs in sepsis. We conducted a retrospective propensity-matched cohort study after screening 2214 patients hospitalized for pneumonia from year 2012 to 2014 at our institution. We identified 387 preadmission CCB users and 387 nonusers by propensity score matching. Logistic regression analysis was then used to determine the association between preadmission CCB use and outcomes in pneumonia. Our study showed that the odds for development of severe sepsis was significantly lower in the CCB user group [odds ratio (OR), 0.466; 95% confidence interval (CI), 0.311-0.697; P = 0.002]. Preadmission CCB use was associated with a lower risk of contracting bacteremia (OR, 0.498; 95% CI, 0.262-0.99; P = 0.0327), lower risk of acute respiratory insufficiency (OR, 0.573; 95% CI, 0.412-0.798; P = 0.001), lower risk of intensive care unit admission (OR, 0.602; 95% CI, 0.432-0.840; P = 0.0028). In conclusion, our study suggested preadmission CCB use was associated with a reduction in the risks of development of respiratory insufficiency, bacteremia, and severe sepsis in patients admitted to the hospital with pneumonia.
Assuntos
Bacteriemia/epidemiologia , Bloqueadores dos Canais de Cálcio/uso terapêutico , Hospitalização , Unidades de Terapia Intensiva/estatística & dados numéricos , Pneumonia/terapia , Insuficiência Respiratória/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pontuação de Propensão , Fatores de Proteção , Estudos Retrospectivos , Sepse/epidemiologiaRESUMO
BACKGROUND: A consensus statement recommends initial intravenous (IV) vancomycin dosing of 15-20 mg/kg every 8- 24 hours, with an optional 25- to 30-mg/kg loading dose. Although some studies have shown an association between weight and the development of vancomycin-associated nephrotoxicity, results have been inconsistent. OBJECTIVE: To evaluate the correlation between incidence of nephrotoxicity associated with weight-based IV vancomycin dosing strategies in nonobese and obese patients. METHODS: This retrospective cohort study evaluated hospitalized adult patients admitted who received IV vancomycin. Patients were stratified into nonobese (body mass index [BMI] <25 kg/m2), obesity class I and II (BMI 30-39.9kg/m2), and obesity class III (BMI≥40 kg/m2) groups; patients who were overweight but not obese were excluded. Incidence of nephrotoxicity and serum vancomycin trough concentrations were evaluated. RESULTS: Of a total of 62 documented cases of nephrotoxicity (15.1%), 13 (8.7%), 23 (14.3%), and 26 (26.3%) cases were observed in nonobese, obesity class I and II, and obesity class III groups, respectively ( P=0.002). Longer durations of therapy ( P<0.0001), higher initial maintenance doses in both total milligrams/day ( P=0.0137) and milligrams/kilogram ( P=0.0307), and any trough level >20 mg/L ( P<0.0001) were identified as predictors of development of nephrotoxicity. Concomitant administration of piperacillin/tazobactam, diuretics, and IV contrast were associated with development of nephrotoxicity ( P<0.005, all). Patients with class III obesity were 3-times as likely to develop nephrotoxicity when compared with nonobese patients (odds ratio [OR]=2.99; CI=1.12-7.94) and obesity class I and II patients (OR=3.14; CI=1.27-7.75). CONCLUSIONS: Obesity and other factors are associated with a higher risk of vancomycin-associated nephrotoxicity.
Assuntos
Antibacterianos/efeitos adversos , Nefropatias/induzido quimicamente , Obesidade/fisiopatologia , Vancomicina/efeitos adversos , Administração Intravenosa , Adulto , Idoso , Antibacterianos/uso terapêutico , Índice de Massa Corporal , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Razão de Chances , Ácido Penicilânico/administração & dosagem , Ácido Penicilânico/análogos & derivados , Piperacilina/administração & dosagem , Combinação Piperacilina e Tazobactam , Estudos Retrospectivos , Vancomicina/administração & dosagemRESUMO
A common side effect of levetiracetam is the onset of neuropsychiatric symptoms such as mood changes including depression, anxiety, agitation, and sometimes psychosis. We performed a retrospective analysis to examine the effect of sleep pattern and chronotype on individual susceptibility to levetiracetam-induced mood changes. We reviewed records of 110 adults with epilepsy presenting to our clinic during a 3-month period, and categorized them into those currently on levetiracetam, and those no longer taking it because of mood-related adverse effects. Patients were administered Morningness-Eveningness Questionnaire (MEQ), Beck's Depression Inventory-II, and Neurological Disorders Depression Inventory in Epilepsy. Using various statistical methods, we analyzed the comparison of these 3 different scales amongst one another and between those subjects who tolerated levetiracetam and those who did not. Of 110 patients, 74 (67%) tolerated levetiracetam and 36 (33%) did not tolerate it because of mood changes with chronotype being a significant determining factor. Of those who tolerated the drug, 62% were intermediate chronotypes and 20.3% and 17.6% were morning and evening chronotypes, respectively. For those intolerant, 86.1% were morning chronotypes, 13.9% were intermediate chronotypes, and none were evening chronotypes (p<0.001). Thirty-two percent of morning chronotypes, 100% of evening chronotypes, and 90.2% of intermediate chronotypes were tolerant of levetiracetam (p<0.001). Chronotype significantly affected toleration of levetiracetam. Chronotype, but not depression, was a significant factor in determining tolerability of mood-altering side effects of levetiracetam, via statistically significant trend for an increasing ability to tolerate levetiracetam as chronotype would shift from morning to intermediate to evening. Additional research may help establish if this is related to possible underreporting of poor mood with evening chronotypes, and morning chronotypes having more stringent sleep schedules, genetic factors, or other reasons.