Geriatrics fellowship during COVID-19: expanding impact, using innovation and maintaining balance.

The COVID-19 pandemic provided an opportunity for geriatricians, especially geriatrics fellows, to demonstrate leadership in a crisis that has significantly affected the 65 and older demographic. Given their expertise in care delivery to complex, multimorbid patients, as well as their ability to navigate different healthcare settings, geriatrics fellows became a valuable resource during the pandemic, particularly at one large, urban academic health system. Their training in patient-centered, value-based care helped determine the best course of action for patients not only in the hospital, but also in the community. Utilizing innovative strategies such as a newly developed Palliative Care Hotline (PATCH-24 line), telehealth, and community paramedicine, fellows delivered services to complex patients in community settings. In addition to providing direct patient care, geriatrics fellows also taught their skills to frontline physicians of other specialties. Strong support from the fellowship program's leadership, as well as an ongoing focus on clinician wellbeing and resilience, have been central factors in the success of geriatrics fellows during the COVID-19 crisis.

Value of computerized shunt infusion study in assessment of pediatric hydrocephalus shunt function-a two center cross-sectional study.

BACKGROUND: Hydrocephalus shunt malfunction can-also in children-occur insidiously without clear symptoms of raised intracranial pressure (ICP) or changes in ventricular size, imposing a diagnostic challenge. Computerized shunt infusion studies enable quantitative shunt function assessment. We report on feasibility and results of this technique in children in a two center cross-sectional study. MATERIAL AND METHODS: Shunt infusion study (SIS) is performed with two needles inserted into a pre-chamber for ICP recording and CSF infusion. After baseline ICP recording, constant rate infusion is started until a new ICP plateau (ICPpl) is reached. Dedicated software containing the shunt's resistance characteristics calculates ICP and its amplitude outflow resistance and critical shunt pressure (CSP). Overall, 203 SIS were performed in 166 children. Shunts were defined as functional if ICPpl was 5 mmHg above CSP and borderline in between. RESULTS: Forty-one shunts (20.2%) were found obstructed, 26 (12.8%) had borderline characteristics, and 136 (67%) were functional. Baseline ICP in obstructed shunts was significantly above shunt operating pressure. CSF outflow resistance (Rout) and ∆ICP plateau were significantly elevated in obstructed shunts, with cut-off thresholds of 8.07 mmHg min/ml and 11.74 mmHg respectively. Subgroup analysis showed smaller ventricles in 69% of revised cases. CONCLUSION: SIS is a feasible, reliable, and radiation-free technique for quantitative shunt assessment to rule out or prove shunt malfunction. Dedicated software containing shunt hydrodynamic characteristics is necessary and small children may need short-term sedation. Due to the clinical and inherent economic advantages, SIS should be more frequently used in pediatric neurosurgery.

Methods for the Evaluation of Industrial Mechanical Pretreatments before Anaerobic Digesters.

Different methods were tested to evaluate the performance of a pretreatment before anaerobic digestion. Besides conventional biochemical parameters, such as the biochemical methane potential (BMP), the methane production rate, or the extent of solubilization of organic compounds, methods for physical characterization were also developed in the present work. Criteria, such as the particle size distribution, the water retention capacity, and the rheological properties, were thus measured. These methods were tested on samples taken in two full-scale digesters operating with cattle manure as a substrate and using hammer mills. The comparison of samples taken before and after the pretreatment unit showed no significant improvement in the methane potential. However, the methane production rate increased by 15% and 26% for the two hammer mills, respectively. A relevant improvement of the rheological properties was also observed. This feature is likely correlated with the average reduction in particle size during the pretreatment operation, but these results needs confirmation in a wider range of systems.

Rapid Molecular Diagnostics, Antibiotic Treatment Decisions, and Developing Approaches to Inform Empiric Therapy: PRIMERS I and II.

BACKGROUND: Rapid molecular diagnostic (RMD) platforms may lead to better antibiotic use. Our objective was to develop analytical strategies to enhance the interpretation of RMDs for clinicians. METHODS: We compared the performance characteristics of 4 RMD platforms for detecting resistance against ß-lactams in 72 highly resistant isolates of Escherichia coli and Klebsiella pneumoniae (PRIMERS I). Subsequently, 2 platforms were used in a blinded study in which a heterogeneous collection of 196 isolates of E. coli and K. pneumoniae (PRIMERS II) were examined. We evaluated the genotypic results as predictors of resistance or susceptibility against ß-lactam antibiotics. We designed analytical strategies and graphical representations of platform performance, including discrimination summary plots and susceptibility and resistance predictive values, that are readily interpretable by practitioners to inform decision-making. RESULTS: In PRIMERS I, the 4 RMD platforms detected ß-lactamase (bla) genes and identified susceptibility or resistance in >95% of cases. In PRIMERS II, the 2 platforms identified susceptibility against extended-spectrum cephalosporins and carbapenems in >90% of cases; however, against piperacillin/tazobactam, susceptibility was identified in <80% of cases. Applying the analytical strategies to a population with 15% prevalence of ceftazidime-resistance and 5% imipenem-resistance, RMD platforms predicted susceptibility in >95% of cases, while prediction of resistance was 69%-73% for ceftazidime and 41%-50% for imipenem. CONCLUSIONS: RMD platforms can help inform empiric ß-lactam therapy in cases where bla genes are not detected and the prevalence of resistance is known. Our analysis is a first step in bridging the gap between RMDs and empiric treatment decisions.

Complexity in graduate medical education: a collaborative education agenda for internal medicine and geriatric medicine.

Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.

A longitudinal, experiential quality improvement curriculum meeting ACGME competencies for geriatrics fellows: lessons learned.

Quality improvement (QI) initiatives are critical in the care of older adults who are more vulnerable to substandard care. QI education meets aspects of core Accreditation Council of Graduate Medical Education competencies and prepares learners for the rising focus on performance measurement in health care. The authors developed, implemented, and evaluated a QI curriculum for geriatrics fellows. The evidence-based curriculum included didactics and a fellow-led QI intervention based on audit and feedback through the Practice Improvement Module in Care of the Vulnerable Elderly. QI knowledge, attitudes, and behaviors were assessed before and after the improvement project. Fellows' knowledge of QI improved (p = .0156), but behavior did not change significantly across a short-term improvement project. A structured focus group with fellows revealed themes of accountability and the importance of interprofessional teamwork in QI. QI education for geriatrics fellows can be feasible, well received, and prepare future physician leaders for patient-centered care, performance measurement, and effecting systems change.

Looking back, moving forward: A practical guide to implementing the updated ACGME geriatric medicine Milestones 2.0.

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones as a tool to aid trainee assessment based on the framework of the six core competencies of practice. Variability in the interpretation and application of the original Milestones prompted the ACGME to convene work groups within the different specialties and subspecialties to update the Milestones. The Geriatric Medicine work group was convened in 2019 with the goal of clarifying and simplifying the language of the Milestones, revising content to be specific to geriatrics, and developing supplemental resources to aid in implementation and use. We suggest using a practical, four-step process to implement the updated Milestones, called the Milestones 2.0, in fellowship programs by: (1) training faculty in the use of the Milestones 2.0, including an overview of the background and updates, (2) mapping the Milestones 2.0 to existing assessments, (3) educating fellows about the Milestones 2.0 and (4) presenting and discussing the Milestones 2.0 at Clinical Competency Committee meetings. This systematic approach promotes the development of a shared mental model for trainee assessments.

Geriatrics and palliative medicine leadership is needed now more than ever: What are the training gaps?

BACKGROUND: Geriatrics and palliative medicine specialists are uniquely trained to provide expert coordinated care for older adults and seriously ill and complex patients. Health system leadership geared towards this patient population is critically important as society ages. Currently, there is no standardized approach to teaching core leadership skills. To assess the leadership training needs of geriatrics and palliative medicine fellowship graduates, we conducted a needs assessment to identify (1) early career leadership trajectories and challenges and (2) knowledge and skills deemed essential for effective leadership. METHODS: Individuals identified as leaders in geriatrics and/or palliative medicine completed an electronic survey and a semi-structured qualitative interview. These leaders were divided into two categories: Icahn School of Medicine at Mount Sinai (ISMMS) trained leaders or non-ISMMS trained leaders. The semi-structured interviews were recorded, transcribed, and reviewed using thematic analysis. RESULTS: Within 1 year of fellowship graduation, 50% of ISMMS trained leaders had leadership positions; within 6 years, 100% had a leadership role. Based on qualitative interviews, both ISMMS trained leaders and non-ISMMS trained leaders perceived leadership training gaps in two domains: (1) knowledge and (2) skills. Knowledge and skill gap themes included communication and management, mentorship and negotiation, program development, knowledge, and apprenticeship. CONCLUSION: Geriatrics and palliative medicine physicians obtained leadership roles quickly after fellowship. Both ISMMS trained leaders and non-ISMMS trained leaders often felt unprepared, learned "on the job," and sought out additional leadership training. Early leadership training is needed to prepare fellowship graduates for the pressing demands of accelerated leadership.

House staff member awareness of older inpatients' risks for hazards of hospitalization.

BACKGROUND: Many hospitalized older adults develop iatrogenic complications unrelated to their presenting diagnoses that can result in longer hospitalizations, functional impairment, or unanticipated medical or surgical interventions. These complications are often referred to as "hazards of hospitalization" and include delirium, malnutrition, urinary incontinence, pressure ulcers, depression, falls, restraint use, infection, functional decline, adverse drug effects, and death. The aims of this study were to assess house staff member awareness of older patients' risk factors for developing hazards of hospitalization and to determine areas in which interventions may help improve recognition. METHODS: A cross-sectional study was performed, from December 1, 1999, through August 31, 2002, of internal medicine and medicine or pediatric house staff members and their patients from 4 medical units at Mount Sinai Medical Center. Each house staff member completed a 23-item survey on 3 of their recently admitted patients. These patients and, if appropriate, their surrogates were interviewed by the study investigator within 2 hours of the completion of the house staff survey. House staff member responses are compared with those obtained by the study investigator. The completed house staff surveys were compared with the reference standard, and areas of agreement and disagreement were noted. RESULTS: Eighty-six house staff teams, consisting of 1 intern and 1 resident (in either the second or third postgraduate year), and 105 patients were enrolled in the study. The house staff members were in frank disagreement or poor agreement with the reference standard in knowing the following: how well their patients were oriented to place or how long they had been hospitalized; patients' quality of sleep, presence of pain, history of falls, mood, quantity of food intake, and use of hearing aids, glasses, or an ambulation assistive device when at home; and the name of their patients' primary care physicians. CONCLUSIONS: This study showed that internal medicine house staff members are not aware of many of their patients' risk factors for developing the hazards of hospitalization. Some of these deficits are glaring, particularly the lack of awareness of patients' orientation to place and time (duration of hospitalization), presence of pain, and the identity of their primary care physician. It will likely take education and cultural change to improve this performance. Such improvement could be accomplished as part of 3 of the Accreditation Council for Graduate Medical Education competencies: interpersonal communication, patient care, and systems-based practice. Such a process might improve not only house staff member awareness but also patient outcomes, since interdisciplinary communication and interventions are key to preventing the hazards of hospitalization.

American Geriatrics Society/Association of Directors of Geriatric Academic Programs curricular milestones for graduating geriatric fellows.

This article describes the curricular milestones for geriatric fellows and the process used to develop them. The curricular milestones were developed to determine what every graduating geriatric fellow should be able to demonstrate to ensure that they will be able to practice effectively and safely in all care settings and with different older adult populations. Three major domains were identified: Caring for the Elderly Patient, Systems-Based Care for Elder Patients, and Geriatric Syndromes. Six hundred thirty-five geriatricians each reviewed and commented on one domain. These geriatricians represented important stakeholder groups: geriatric fellowship program directors; Association of Directors of Geriatric Academic Programs (ADGAP) members, who are primarily geriatric program and fellowship directors; the American Geriatrics Society (AGS) and ADGAP Education Committee; the AGS Teacher's Section; Geriatric Academic Career Award awardees; and through the American Board of Internal Medicine and the American Board of Family Medicine, board-certified geriatricians who spend more than 50% of their time in clinical practice. The AGS and ADGAP boards approved the final set of 76 Geriatric Curricular Milestones, which were posted on the Portal of Geriatric Online Education in December 2012. These curricular milestones are intended to assist geriatric fellowship directors as they develop curricula and assessments to inform program director reporting to the Accreditation Council for Graduate Medical Education in the Next Accreditation System, which begins in July 2014.

The effectiveness of the Geritalk communication skills course: a real-time assessment of skill acquisition and deliberate practice.

BACKGROUND: Communication skills are critical in Geriatrics and Palliative Medicine because these patients confront complex clinical scenarios. We evaluated the effectiveness of the Geritalk communication skills course by comparing pre- and post-course real-time assessment of the participants leading family meetings. We also evaluated the participants' sustained skills practice. MEASURES: We compare the participants' skill acquisition before and after Geritalk using a direct observation Family Meeting Communication Assessment Tool and assess their deliberate practice at follow-up. INTERVENTION: First-year Geriatrics or Palliative Medicine fellows at Mount Sinai Medical Center and the James J. Peters Bronx VA Medical Center participated in Geritalk. OUTCOMES: Pre- and post-course family meeting assessments were compared. An average net gain of 6.8 skills represented a greater than 20% improvement in use of applicable skills. At two month follow-up, most participants reported deliberate practice of fundamental and advanced skills. CONCLUSIONS/LESSONS LEARNED: This intensive training and family meeting assessment offers evidence-based communication skills training.

What is a geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs end-of-training entrustable professional activities for geriatric medicine.

Entrustable professional activities (EPAs) describe the core work that constitutes a discipline's specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end-of-training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatrician's fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.

The Donald W. Reynolds Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE): a model for dissemination of subspecialty educational expertise.

PURPOSE: Most U.S. medical schools and training programs lack sufficient faculty expertise in geriatrics to train future physicians to care for the growing population of older adults. Thus, to reach clinician-educators at institutions and programs that have limited resources for enhancing geriatrics curricula, the Donald W. Reynolds Foundation launched the Faculty Development to Advance Geriatrics Education (FD~AGE) program. This consortium of four medical schools disseminates expertise in geriatrics education through support and training of clinician-educators. The authors conducted this study to measure the effects of FD~AGE. METHOD: Program leaders developed a three-pronged strategy to meet program goals: FD~AGE offers (1) advanced fellowships in clinical education for geriatricians who have completed clinical training, (2) mini-fellowships and intensive courses for faculty in geriatrics, teaching skills, and curriculum development, and (3) on-site consultations to assist institutions with reviewing and redesigning geriatrics education programs. FD~AGE evaluators tracked the number and type of participants and conducted interviews and follow-up surveys to gauge effects on learners and institutions. RESULTS: Over six years (2004-2010), FD~AGE trained 82 fellows as clinician-educators, hosted 899 faculty scholars in mini-fellowships and intensive courses, and conducted 65 site visits. Participants taught thousands of students, developed innovative curricula, and assumed leadership roles. Participants cited as especially important to program success expanded knowledge, improved teaching skills, mentoring, and advocacy. CONCLUSIONS: The FD~AGE program represents a unique model for extending concentrated expertise in geriatrics education to a broad group of faculty and institutions to accelerate progress in training future physicians.

Audit and feedback: an intervention to improve discharge summary completion.

Discharge summaries (DS) communicate important clinical information from inpatient to outpatient settings. Previous studies noted increased adverse events and rehospitalization due to poor DS quality. We postulated that an audit and feedback intervention of DS completed by geriatric medicine fellows would improve the completeness of their summaries. We conducted a preintervention post intervention study. In phase 1 (AUDIT #1 and FEEDBACK) we scored all DS (n = 89) completed by first year fellows between July 2006 to December 2006 using a 21-item checklist. Individual performance scores were reviewed with each fellow in 30-minute feedback sessions. In phase 2 (AUDIT #2) we scored all DS (n = 79) completed after the first phase between February 2007 to July 2007 using the same checklist. Data were analyzed using generalized estimating equations. Fellows were more likely to complete all required DS data after feedback when compared with prior to feedback (91% vs. 71%, P < 0.001). Feedback was also associated with improved admission (93% vs. 70%, P < 0.001), duration of hospitalization (93% vs 78%, P < 0.001), discharge planning (93% vs. 18%, P < 0.02) and postdischarge care (83% vs. 57%., P < 0.001) section-specific information. In conclusion, audit and feedback sessions were associated with better DS completeness in areas of particular importance to geriatric care.

In vitro activities of doripenem and six comparator drugs against 423 aerobic and anaerobic bacterial isolates from infected diabetic foot wounds.

Against 182 anaerobe and 241 aerobe strains obtained from diabetic foot infections, doripenem was the most active carbapenem against Pseudomonas aeruginosa (MIC(90), 2 microg/ml), more active than imipenem against Proteus mirabilis, and ertapenem was more active against Escherichia coli and Klebsiella spp. The MIC(50) and MIC(90) values were < or =0.125 microg/ml for methicillin-sensitive Staphylococcus aureus and all streptococci and 0.25/1 for Bacteroides fragilis.

Comparative in vitro activities of retapamulin (SB-275833) against 141 clinical isolates of Propionibacterium spp., including 117 P. acnes isolates.

Using the NCCLS agar dilution method, we studied the in vitro activity of retapamulin (SB-275833) against 141 clinical isolates of Propionibacterium species, including seven multiresistant strains, and found retapamulin to be the most active agent among those tested with MICs of < or = 1 microg/ml against all isolates.

In vitro activity of moxifloxacin against 923 anaerobes isolated from human intra-abdominal infections.

The in vitro activity of moxifloxacin against 923 recent anaerobic isolates obtained from pretreatment cultures in patients with complicated intra-abdominal infections was studied using the CLSI M11-A-6 agar dilution method. Moxifloxacin was active against 87% (96 of 110) Bacteroides fragilis strains at < or = 1 microg/ml and 87% (79 of 90) B. thetaiotaomicron strains at < or = 2 microg/ml. Species variation was seen, with B. uniformis, B. vulgatus, Clostridium clostridioforme, and C. symbiosum being least susceptible and accounting for most of the resistant isolates; excluding the aforementioned four resistant species, 86% (303 of 363) of Bacteroides species isolates and 94% (417 of 450) of all other genera and species were susceptible to < or = 2 microg/ml of moxifloxacin. Overall, moxifloxacin was active against 763 of 923 (83%) of strains at < or = 2 microg/ml, supporting its use as a monotherapy for some community-acquired intra-abdominal infections.

In vitro activities of daptomycin, vancomycin, and penicillin against Clostridium difficile, C. perfringens, Finegoldia magna, and Propionibacterium acnes.

Daptomycin has in vitro activity against gram-positive anaerobic bacteria, although limited numbers of species have been tested. We studied the in vitro activities of daptomycin, vancomycin, and penicillin against more than 100 strains each of Clostridium difficile, C. perfringens, Finegoldia magna, and Propionibacterium acnes. Daptomycin Etest MICs and results from time-kill studies were determined for selected strains. For 392 of 421 strains (93%), daptomycin was inhibitory at < or =1 microg/ml, including 15 of 16 strains of C. difficile with elevated linezolid MICs of 8 and 16 microg/ml, all 32 strains with moxifloxacin MICs of > or =4 microg/ml, and all 16 strains resistant to clindamycin. Daptomycin MICs were also < or =1 microg/ml for all 16 F. magna strains resistant to clindamycin and all 32 strains resistant to tetracycline. Only one strain, a C. perfringens strain, had a MIC of >2 microg/ml to daptomycin. Eighty-five and 92.5% of the Etest MICs were within 1 dilution of the agar dilution method for all drugs at 24 and 48 h, respectively. In time-kill studies, a C. difficile strain was inhibited by both daptomycin and vancomycin at 1, 2, 4, 8, and 24 h; colony counts were decreased by 2.3 to 2.9 log at 24 h. Vancomycin was not bactericidal for C. perfringens; however, daptomycin showed bactericidal activity as early as 1 h at four and eight times the MIC and at 2 and 4 h at two and four times the MIC.