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BACKGROUND AND AIMS: Female representation among gastroenterology (GI) fellows has remained around 30%, yet women comprise over 50% of internal medicine (IM) residents. We aim to identify the gender-specific barriers of IM residents toward pursuing GI. METHODS: We surveyed IM residents in the Northeast by emailing 168 IM programs a survey link to be distributed to their residents. A 4-point Likert barrier scale and bivariate analysis were performed with "yes" and "no," where "yes" was analyzed as "somewhat of a barrier" and above. Females received a third table assessing female-specific barriers. Significance was set at < 0.05. RESULTS: Of 215 survey responses, 56.3% (n = 121) were female. Response rate could not be determined due to resident identity protection and inconsistent responses of survey dissemination from programs. Females had significantly greater concerns about fertility, maternity leave, radiation exposure, work-life balance, stress, and burnout compared to males (p < 0.05). For females, 48.7% felt a lack of gender diversity in GI, 54.6% felt a lack of female GI mentors, and 43.7% felt there is a lack of respect as a female in GI. No gender differences existed in motivation to pursue GI, exposure to GI, and access to GI mentors, or GI-related research. CONCLUSIONS: Our study reveals that female IM trainees had greater concerns surrounding fertility, radiation exposure, and maternity leave compared to male IM trainees. Lack of gender diversity and lack of female GI mentors were noted barriers for female IM trainees. Addressing these barriers may help increase female representation in GI.
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Agotamiento Profesional , Gastroenterología , Internado y Residencia , Embarazo , Femenino , Masculino , Humanos , Gastroenterología/educación , Actitud del Personal de Salud , MentoresRESUMEN
GOALS: We aim to determine the incidence of esophagogastroduodenoscopies (EGDs) primarily performed for imaging findings of distal esophageal thickening (DET). We also aim to determine if patients with imaging findings of DET have a higher incidence of cancer, and to evaluate the risk factors associated with findings of malignancy. BACKGROUND: The growth of diagnostic imaging has led to an increase in incidental findings of DET. This nonspecific finding frequently prompts an EGD for evaluation-many of which demonstrate benign conditions. There may be a misuse of valuable resources. STUDY: We performed a retrospective chart review of 1080 EGDs from January 2016 to July 2018 at the Veterans Affairs Medical Center, comparing EGDs for the indication of imaging report of DET with EGDs for other indications. Patient demographics, clinical history, imaging, procedure, and pathology reports were collected. Descriptive analysis and biostatistical analysis with χ2, Fisher exact, Wilcoxon rank sum, and Kruskal-Wallis tests were utilized in analyzing the data. RESULTS: Of the 1080 total endoscopies, 8.2% (n=88) were done specifically because of the imaging findings of DET. Those who had EGDs performed because of DET had a higher percentage of abnormal esophageal findings and of cancer. A history of Barrett's esophagus, tobacco use, and having gastrointestinal symptoms were not significant predictors of abnormal findings or of cancer for EGDs done for DET. CONCLUSIONS: There may be a role for EGDs performed for radiologic findings of DET. Even those without risk factors for malignancy should have EGDs performed for DET. Radiologists should consider reporting the DET size in order to determine if significant endoscopic findings correlate with wall thickness.
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Esófago de Barrett , Neoplasias Esofágicas , Endoscopía del Sistema Digestivo , Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Esofágicas/epidemiología , Humanos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Diabetes mellitus (DM) and inflammatory bowel diseases (IBD) are chronic systemic illnesses associated with chronic inflammation, dysbiosis, impaired immune function, and infection risk. The impact of DM in modifying disease activity in patients with IBD remains largely unknown. AIM: To investigate the impact of DM on IBD-related disease outcomes, mortality, and infections in patients with IBD. METHODS: We performed a longitudinal cohort analysis. Using a large institutional database, patients with concurrent IBD and DM (IBD-DM), and IBD without DM (IBD cohort), were identified and followed longitudinally to evaluate for primary (IBD-related) and secondary (mortality and infections) outcomes. Cox proportional hazards models were used to determine the independent effect of DM on each outcome, adjusting for confounding effects of covariates. RESULTS: A total of 901 and 1584 patients were included in the IBD-DM and DM cohorts. Compared with IBD, IBD-DM had significantly higher risk of IBD-related hospitalization [adjusted hazard ratio (HR) 1.97, 95% confidence interval (1.71-2.28)], disease flare [HR 2.05 (1.75-2.39)], and complication [HR 1.54 (1.29-1.85)]. No significant difference was observed in the incidence of IBD-related surgery. All-cause mortality, sepsis, Clostridioides difficile infection (CDI), pneumonia, urinary tract infection, and skin infection were also more frequent in the IBD-DM than the IBD cohort (all p ≤ 0.05). Subgroup analysis of Crohn's disease (CD) and ulcerative colitis patients showed similar associations, except with an additional risk of surgery and no association with CDI in the CD-DM cohort. CONCLUSION: Comorbid diabetes in patients with IBD is a predictor of poor disease-related and infectious outcomes.
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Enfermedades Transmisibles/diagnóstico , Enfermedades Transmisibles/epidemiología , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Enfermedades Inflamatorias del Intestino/diagnóstico , Enfermedades Inflamatorias del Intestino/epidemiología , Anciano , Infecciones por Clostridium/diagnóstico , Infecciones por Clostridium/epidemiología , Estudios de Cohortes , Comorbilidad , Femenino , Predicción , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Infecciones Cutáneas Estafilocócicas/diagnóstico , Infecciones Cutáneas Estafilocócicas/epidemiologíaRESUMEN
BACKGROUND: Early morning patient discharge from the hospital is increasingly being recognized as a key dimension of quality of care. At our institution, there is a significantly lower early discharge rate on the teaching hospitalist teams in comparison with the non-teaching teams. OBJECTIVE: To implement a resident-driven intervention in the teaching medical services to increase overall discharge order rate before 11 am (DOB-11) and assess the effect of this intervention on hospital length of stay (LOS), 30-day readmission rates (RR), and resident perception. DESIGN: Interrupted time series as well as controlled before-after designs. PARTICIPANTS: All inpatients discharged from general medicine units. INTERVENTIONS: We implemented an educational didactic in conjunction with resident-attending daily walk rounds followed by resident-led multidisciplinary discharge huddles to identify next-day discharges. MAIN MEASURES: The primary outcome was DOB-11 rates 18 months pre- and 12 months post-intervention. SECONDARY OUTCOMES: LOS and RR. Additionally, we assessed residents' perception of the early discharge protocol. KEY RESULTS: The DOB-11 rate increased from 12 to 29% (p < 0.001), LOS increased by 1.47 days (P < 0.001), and RR increased by 0.32% (P = 0.84), respectively, on the teaching teams. Compared with the non-teaching (control) teams, the teaching teams registered a greater increase in DOB-11 rate (by 17%, p < 0.001; ratio of adjusted ORs 2.16; 95% CI, 1.65, 2.85; p value < 0.001), small increase in LOS (by 0.74 day, p = 0.39; ratio of adjusted post-/pre-intervention ratio [teaching] and post-/pre- intervention ratio [non-teaching] = 1.05, 95% CI, 0.97, 1.14, p = 0.23), and relative increase in RR (by 3.98%, p = 0.07, and ratio of ORs = 1.35, 95% CI, 1.03, 1.8), p = 0.03). Approximately 55% (16/29) of the residents agreed that the early discharge initiative helped in understanding the importance of prioritizing patients for early discharge. Additionally, 55% (20/36) of the residents "agreed" that the early discharge initiative compromised their learning during teaching rounds. CONCLUSION: Our study demonstrates that DOB-11 is an achievable goal, not only for non-teaching teams but also for resident-run teaching teams.
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Médicos Hospitalarios , Internado y Residencia , Hospitales de Enseñanza , Humanos , Tiempo de Internación , Alta del Paciente , Readmisión del PacienteRESUMEN
INTRODUCTION: Acute kidney injury (AKI) is strongly associated with poor outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19), but data on the association of proteinuria and hematuria are limited to non-US populations. In addition, admission and in-hospital measures for kidney abnormalities have not been studied separately. METHODS: This retrospective cohort study aimed to analyze these associations in 321 patients sequentially admitted between March 7, 2020 and April 1, 2020 at Stony Brook University Medical Center, New York. We investigated the association of proteinuria, hematuria, and AKI with outcomes of inflammation, intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), and in-hospital death. We used ANOVA, t test, χ2 test, and Fisher's exact test for bivariate analyses and logistic regression for multivariable analysis. RESULTS: Three hundred patients met the inclusion criteria for the study cohort. Multivariable analysis demonstrated that admission proteinuria was significantly associated with risk of in-hospital AKI (OR 4.71, 95% CI 1.28-17.38), while admission hematuria was associated with ICU admission (OR 4.56, 95% CI 1.12-18.64), IMV (OR 8.79, 95% CI 2.08-37.00), and death (OR 18.03, 95% CI 2.84-114.57). During hospitalization, de novo proteinuria was significantly associated with increased risk of death (OR 8.94, 95% CI 1.19-114.4, p = 0.04). In-hospital AKI increased (OR 27.14, 95% CI 4.44-240.17) while recovery from in-hospital AKI decreased the risk of death (OR 0.001, 95% CI 0.001-0.06). CONCLUSION: Proteinuria and hematuria both at the time of admission and during hospitalization are associated with adverse clinical outcomes in hospitalized patients with COVID-19.
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Lesión Renal Aguda/orina , Lesión Renal Aguda/virología , COVID-19/orina , Hematuria/virología , Proteinuria/virología , Lesión Renal Aguda/mortalidad , Anciano , COVID-19/mortalidad , COVID-19/virología , Estudios de Cohortes , Femenino , Hematuria/mortalidad , Humanos , Masculino , Persona de Mediana Edad , New York/epidemiología , Proteinuria/mortalidad , Estudios Retrospectivos , SARS-CoV-2/aislamiento & purificación , Análisis de SupervivenciaRESUMEN
Objective Chronic pain and opioid management are challenging in primary care, especially for trainees with discontinuous ambulatory schedules and less practice experience. The study objective was to improve adherence to quality metrics and office visit utilization in a resident clinic. Design Before-after quality improvement intervention over two Plan-Do-Study-Act cycles. Setting Suburban, university-affiliated Internal Medicine resident clinic. Methods During the 2015-2017 academic years, two sequential interventions were implemented: 1) use of electronic pain and opioid management templates and workflow redesign routing opioid renewals through a registered nurse (RN); 2) RN previsit planning and daily nurse-physician huddles before patient visits. Outcomes included adherence to annual toxicology screening, risk assessment and opioid agreements, opioid dose prescribed, and office visit utilization. Results The template and workflow redesign intervention increased annual toxicology from 53% to 81% (P < 0.0015), annual opioid agreement from 13.8% to 53.5% (P < 0.0001), and risk assessment from 0% to 75.9% (P < 0.0001). Average daily morphine milligram equivalents (MME) decreased from 96.6 MME to 67.7 MME (P < 0.0001), and annual office visits decreased from 11.1 to 8.9 (P = 0.0004). Previsit planning and huddles did not show incremental increases in adherence to quality measures but did improve clinic utilization and maintained high levels of adherence to quality measures. Conclusions Quality improvement interventions can improve adherence to quality measures and clinic utilization. A critical role is served by midlevel nursing providers to provide continuity to patients and trainees. Teaching clinics need to develop sustainable systems of care to moderate quality assurance in opioid prescribing.
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Analgésicos Opioides/economía , Analgésicos Opioides/uso terapéutico , Recursos en Salud/economía , Medicina Interna/economía , Medicina Interna/estadística & datos numéricos , Manejo del Dolor/economía , Manejo del Dolor/métodos , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Continuidad de la Atención al Paciente , Estudios Controlados Antes y Después , Prescripciones de Medicamentos/normas , Registros Electrónicos de Salud , Femenino , Humanos , Internado y Residencia , Masculino , Persona de Mediana Edad , Enfermería , Cooperación del Paciente , Mejoramiento de la Calidad , Medición de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: To investigate the association between stages of QTc prolongation and the risk of cardiac events among patients on TKIs. METHODS: This was a retrospective cohort study performed at an academic tertiary care center of cancer patients who were taking TKIs or not taking TKIs. Patients with two recorded ECGs between January 1, 2009, and December 31, 2019, were selected from an electronic database. The QTc duration > 450ms was determined as prolonged. The association between QTc prolongation progression and events of cardiovascular disease were compared. RESULTS: This study included a total of 451 patients with 41.2% of patients taking TKIs. During a median follow up period of 3.1 years, 49.5% subjects developed CVD and 5.4% subjects suffered cardiac death in patient using TKIs (n = 186); the corresponding rates are 64.2% and 1.2% for patients not on TKIs (n = 265), respectively. Among patient on TKIs, 4.8% of subjects developed stroke, 20.4% of subjects suffered from heart failure (HF) and 24.2% of subjects had myocardial infarction (MI); corresponding incidence are 6.8%, 26.8% and 30.6% in non-TKIs. When patients were regrouped to TKIs versus non-TKIs with and without diabetes, there was no significant difference in the incidence of cardiac events among all groups. Adjusted Cox proportional hazards models were applied to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). There is a significant increased risk of HF events (HR, 95% CI: 2.12, 1.36-3.32) and MI events (HR, 95% CI: 1.78, 1.16-2.73) during the 1st visit. There are also trends for an increased incidence of cardiac adverse events associated with QTc prolongation among patient with QTc > 450ms, however the difference is not statistically significant. Increased cardiac adverse events in patients with QTc prolongation were reproduced during the 2nd visit and the incidence of heart failure was significantly associated with QTc prolongation(HR, 95% CI: 2.94, 1.73-5.0). CONCLUSION: There is a significant increased QTc prolongation in patients taking TKIs. QTc prolongation caused by TKIs is associated with an increased risk of cardiac events.
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The prevalence of soil-transmitted helminths (STH) is high in communities within the Peruvian Amazon despite repeated mass-drug administration, demanding alternative strategies of control. Smartphone-attached microscopy (SAM) permits visualization of STH from a small portable microscope through a smartphone screen, potentially providing an inexpensive and rapid method of STH visualization in communities where diagnostic laboratories with microscopes are inaccessible. In this study, a total of 45 community health workers who work within the health systems of Loreto, Peru, attended a 1-day training session with lectures and practicums on STH and SAM. Participants received a pre- and post-intervention questionnaire. Post-intervention, participants were significantly more confident using SAM and identifying parasite images, symptoms, transmission, and treatment (P ≤ 0.0045). Post-intervention, participants correctly labeled a median of five of seven SAM apparatus components and five of eight steps of Kato-Katz technique, were less likely to choose taking medicine to prevent parasite infection (P = 0.0075), and were more likely to select Kato-Katz technique as a type of diagnostic test (P < 0.0001). Most participants felt ready to use SAM in their communities and stated that it could help rural communities far from health centers or laboratories (24%); provide faster identification, results, diagnosis (19%); permit at-home or on-the-spot visualization (14%); and save money (14%). Results show that community health workers show a high level of willingness and competency to learn about both STH and SAM and may be a yet-unexplored practical method of augmenting STH visualization, bringing healthcare to communities in Loreto with poor access to diagnostic laboratories and clinics.
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Helmintiasis , Helmintos , Animales , Humanos , Helmintiasis/diagnóstico , Helmintiasis/epidemiología , Helmintiasis/parasitología , Suelo/parasitología , Perú/epidemiología , Microscopía , Sistemas de Atención de Punto , Agentes Comunitarios de Salud , Estudios de Factibilidad , Teléfono Inteligente , Heces/parasitología , PrevalenciaRESUMEN
BACKGROUND: Polycystic ovary syndrome (PCOS) causes anovulation and hyperandrogenism. Hormonal imbalance is known to contribute to systemic autoimmune diseases. OBJECTIVE: To examine the frequency of certain rheumatic diseases in PCOS. METHODS: This retrospective study utilized and analyzed electronic medical records from January 2004 through February 2020. A diagnosis of PCOS and specified rheumatic diseases was searched using ICD-9 and ICD-10 codes. A total of 754 adult patients with PCOS and 1,508 age- and body mass index-matched patients without PCOS were included. Frequencies of the rheumatic diseases were compared between PCOS and non-PCOS subjects or literature data. RESULTS: The prevalence of rheumatoid arthritis (RA) was found to be 2.25% (17/737) in the PCOS patients, numerically higher than 1.26% (19/1489) in the non-PCOS subjects. The difference was significant with a confidence level of 90% (1.04-3.15) but not at 95% with an odds ratio of 1.808 (95% CI = 0.934-3.4, p = 0.0747). When compared with the literature data from the US female population, the prevalence of RA in PCOS patients was significantly higher (2.25% vs. 1.40%, p < 0.0001). Among the autoimmune diseases examined, both systemic sclerosis (0.40% vs. 0.0%, p = 0.0369) and undifferentiated connective tissue disease (0.53% vs. 0.0%, p = 0.0123) were significantly more frequent in the PCOS patients than the non-PCOS. Additionally, PCOS patients had a significantly higher frequency of osteoarthritis than non-PCOS patients (5.44% vs. 2.92%, p = 0.0030) with an odds ratio of 1.913 (95% CI = 1.239-2.955). CONCLUSION: We have shown unprecedentedly that certain rheumatic diseases are more prevalent in PCOS. This study provides important insight into autoimmunity in association with PCOS. Key Points ⢠Polycystic ovary syndrome is postulated to cause systemic autoimmune disease due to its hormonal imbalance. ⢠We conducted the first epidemiologic assessment of the prevalence of systemic autoimmune diseases. ⢠Certain autoimmune and rheumatic diseases are more prevalent in polycystic ovary syndrome.
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Enfermedades Autoinmunes , Hiperandrogenismo , Síndrome del Ovario Poliquístico , Adulto , Enfermedades Autoinmunes/complicaciones , Enfermedades Autoinmunes/epidemiología , Femenino , Humanos , Síndrome del Ovario Poliquístico/complicaciones , Síndrome del Ovario Poliquístico/epidemiología , Prevalencia , Estudios RetrospectivosRESUMEN
OBJECTIVES: The purpose of this study is to evaluate clinical outcomes in patients with critical COVID-19 pneumonia requiring invasive mechanical ventilation who were treated with tocilizumab DESIGN: Single-center retrospective cohort study SETTING: Stony Brook University Hospital, a 600-bed academic tertiary medical center in Suffolk County, New York PARTICIPANTS: Consecutive patients with COVID-19 confirmed by nasopharyngeal polymerase chain reaction (PCR) who were admitted to Stony Brook University Hospital between March 10 and April 2 2020 and required mechanical ventilation in any intensive care unit during their hospitalization EXPOSURE: Treatment with tocilizumab while intubated MAIN OUTCOME: Overall mortality 30 days from the date of intubation RESULTS: Forty-five patients received tocilizumab compared to seventy controls. Baseline demographic characteristics, inflammatory markers, treatment with corticosteroids, and sequential organ failure assessment (SOFA) scores were similar between the two cohorts. Patients who received tocilizumab had significantly lower Charlson co-morbidity index (2.0 vs 3.0,P = 0.01) than controls. There was a trend towards younger mean age in the tocilizumab exposed group (56.2 vs 60.6; P = 0.09). In logistic regression analysis there was no reduction in mortality associated with receipt of tocilizumab (odds ratio (OR) 1.04; 95% CI, 0.27-3.75). There was no observed increased risk of secondary infection in patients given tocilizumab (28.9 vs 25.7; OR 1.17; 95% CI, 0.51-2.71). CONCLUSION: When controlling for age, severity of illness, and co-morbidities, tocilizumab was not associated with reduction in mortality in this retrospective cohort study of mechanically ventilated patients with COVID-19 pneumonia. Further studies are needed to determine the role of tocilizumab in the treatment of COVID-19.
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Anticuerpos Monoclonales Humanizados/uso terapéutico , Tratamiento Farmacológico de COVID-19 , Respiración Artificial , SARS-CoV-2 , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVES: Bedside ultrasound techniques have the unique ability to produce instantaneous, dynamic images, and have demonstrated widespread utility in both emergency and critical care settings. The aim of this article is to introduce a novel application of this imaging modality by utilizing an ultrasound based mathematical model to assess respiratory function. With validation, the proposed models have the potential to predict pulmonary function in patients who cannot adequately participate in standard spirometric techniques (inability to form tight seal with mouthpiece, etc.). METHODS: Ultrasound was used to measure diaphragm thickness (Tdi) in a small population of healthy, adult males at various points of the respiratory cycle. Each measurement corresponded to a generated negative inspiratory force (NIF), determined by a handheld meter. The data was analyzed using mixed models to produce two representative mathematical models. RESULTS: Two mathematical models represented the relationship between Tdi and NIFmax, or maximum inspiratory pressure (MIP), both of which were statistically significant with p-values <0.005: 1. log(NIF) = -1.32+4.02×log(Tdi); and 2. NIF = -8.19+(2.55 × Tdi)+(1.79×(Tdi2)). CONCLUSIONS: With validation, these models intend to provide a method of estimating MIP, by way of diaphragm ultrasound measurements, thereby allowing evaluation of respiratory function in patients who may be unable to reliably participate in standard spirometric tests.
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Diafragma/diagnóstico por imagen , Procesamiento de Imagen Asistido por Computador/métodos , Presiones Respiratorias Máximas/métodos , Modelos Biológicos , Adulto , Diafragma/fisiología , Femenino , Voluntarios Sanos , Humanos , Masculino , Persona de Mediana Edad , Ultrasonografía/métodosRESUMEN
BACKGROUND: Despite the Clinical Learning Environment Review's recommendations of their use, patient safety event reporting systems are underutilized by residents. OBJECTIVE: We aimed to identify perceived barriers to event reporting amongst internal medicine residents and implement a targeted quality improvement initiative to address the identified barriers and increase overall resident event report rates. METHODS: A total of 94 Internal Medicine (IM) residents participated in the educational intervention in 2018. We measured residents' perception of barriers to event reporting and employed the results of the questionnaire to create a skill-based educational workshop. We conducted the plan-do-study-act model to test a structured educational intervention and its effectiveness on pre-post IM residents' event report rates and compared it to report rates of Non-Internal Medicine (Non-IM) residents. Additionally, we assessed pre-post intervention knowledge, skills, and attitudes in event reporting. RESULTS: 94/94 (100%) of IM residents had a significantly higher median percent of patient safety event reporting when compared to pre-intervention (23.6% compared to 5.88%, p-value = 0.0030) and when compared to Non-IM residents (23.6% compared to 5.31%, p-value = 0.0002). Residents performed better on the post-test compared to the pre-test (90% compared to 30%, p-value = 0.0001) for knowledge. 100% of the critical action items were completed and 90% of participants reported their perception of the event reporting process improved. CONCLUSIONS: By elucidating common reasons why residents are not reporting patient safety events, a specific intervention can be created to target the identified impediments and improve resident event reporting. ABBREVIATIONS: IM: Internal Medicine IM; Non-IM: Non-Internal Medicine; IOM: Institute of Medicine I; ACGME CLER: Accreditation Council for Graduate Medical Education Clinical Learning Environment Review; GME: Graduate Medical Education; IRB: Institutional Review Board; PDSA: Plan, Do, Study, Act.
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Background: The management of inflammatory bowel disease (IBD) has become much more complex as our understanding of the disease pathology has improved and as new novel therapeutic options come into play. A factor that has not been studied in the management of this disease is the role that Direct-To-Consumer Advertisement (DTCA) plays in patients' decisions regarding their treatment options. Here we investigate the very role this mode of television advertisement has on influencing our patients. Methods: Following formal institutional review board approval, we devised a prospective, single institution, survey-based study in our university-based outpatient gastroenterology clinic. Surveys included major demographic features along with questions pertaining to patients' interactions with various advertisements. Surveys were collected over a 3-month period. Results: Overall, 103 surveys were collected. The data were not normally distributed. Fifty-three patients were female, and 40 patients were male. Eighty-one percent of patients with IBD were not affected in any way by advertisements with regard to influencing their decision to start new therapies. A subgroup analysis revealed that various parameters including age, sex, and marital status played a role in how DTCA influences patients with regard to their IBD treatments. Discussion: This study demonstrates that overall patients are not significantly influenced by DTCAs; however, some cohorts are influenced in more ways than others. This study highlights the importance of understanding the role DTCA plays in influencing our patients with IBD and sets the foundation for further inquiry into this very interesting relationship.
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BACKGROUND: Remotely guided ultrasound (US) examinations carried out by nonmedical personnel (novices) have been shown to produce clinically useful examinations, at least in small pilot studies. Comparison of the quality of such exams to those carried out by trained medical professionals is lacking in the literature. This study compared the objective quality and clinical utility of cardiac and pulmonary US examinations carried out by novices and trained physicians.METHODS: Cardiac and pulmonary US examinations were carried out by novices under remote guidance by an US expert and independently by US trained physicians. Exams were blindly evaluated by US experts for both a task-based objective score as well as a subjective assessment of clinical utility.RESULTS: Participating in the study were 16 novices and 9 physicians. Novices took longer to complete the US exams (median 641.5 s vs. 256 s). For the objective component, novices scored higher in exams evaluating for pneumothorax (100% vs. 87.5%). For the subjective component, novices more often obtained clinically useful exams in the assessment of cardiac regional wall motion abnormalities (56.3% vs. 11.1%). No other comparisons yielded statistically significant differences between the two groups. Both groups had generally higher scores for pulmonary examinations compared to cardiac. There was variability in the quality of exams carried out by novices depending on their expert guide.CONCLUSION: Remotely guided novices are able to carry out cardiac and pulmonary US examinations with similar, if not better, technical proficiency and clinical utility as US trained physicians, though they take longer to do so.Dufurrena Q, Ullah KI, Taub E, Leszczuk C, Ahmad S. Feasibility and clinical implications of remotely guided ultrasound examinations. Aerosp Med Hum Perform. 2020; 91(7):592-596.
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Competencia Clínica , Médicos , Ultrasonografía , Estudios de Factibilidad , Corazón/diagnóstico por imagen , Humanos , Pulmón/diagnóstico por imagen , Proyectos PilotoRESUMEN
BACKGROUND: Despite increasing use of telehealth, there are limited published curricula training primary care providers in utilizing telehealth to deliver complex interdisciplinary care. OBJECTIVE: To describe and evaluate a telehealth curriculum with a longitudinal objective structured clinical examination (OSCE) to improve internal medicine residents' confidence and skills in coordinating complex interdisciplinary primary care via televisits, electronic consultation, and teleconferencing. METHODS: In 2019, 56 first- and third-year residents participated in a 3-part, 5-week OSCE training them to use telehealth to manage complex primary care. Learners conducted a standardized patient (SP) televisit in session 1, coordinated care via inter-visit e-messaging, and led a simulated interdisciplinary teleconference in session 2. Surveys measured confidence before session 1 (pre), post-session 1 (post-1), and post-session 2 (post-2). SP televisit checklists and investigators' assessment of e-messages evaluated residents' telehealth skills. RESULTS: Response rates were pre 100%, post-1 95% (53 of 56), and post-2 100%. Post-intervention, more residents were "confident/very confident" in adjusting their camera (33%, 95% CI 20-45 vs 85%, 95% CI 75-95, P < .0001), e-messaging (pre 36%, 95% CI 24-49 vs post-2 80%, 95% CI 70-91, P < .0001), and coordinating interdisciplinary care (pre 35%, 95% CI 22-47 vs post-2 84%, 95% CI 74-94, P < .0001). More residents were "likely/very likely" to use telemedicine in the future (pre 56%, 95% CI 43-69, vs post-2 79%, 95% CI 68-89, P = .001). CONCLUSIONS: A longitudinal, interdisciplinary telehealth simulation is feasible and can improve residents' confidence in using telemedicine to provide complex patient care.
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Internado y Residencia , Telemedicina , Competencia Clínica , Curriculum , Humanos , Atención al Paciente , Simulación de Paciente , Atención Primaria de SaludRESUMEN
BACKGROUND: Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature. METHODS: We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed. RESULTS: A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC. CONCLUSION: To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles. LEVEL OF EVIDENCE: Diagnostic tests or criteria, Level III.
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Diafragma/diagnóstico por imagen , Fracturas de las Costillas/complicaciones , Ultrasonografía/métodos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Pruebas de Función Respiratoria , Centros TraumatológicosRESUMEN
BACKGROUND: Data regarding the benefits or harm associated with the continuation of Angiotensin Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Blockers (ARBs), especially the impact on inflammation, in hypertensive, hospitalized patients with COVID-19 in the United States is unclear. METHODS: This is a single-center cohort study of sequentially hospitalized patients with COVID-19 at Stony Brook University Medical Center from March 7, 2020 to April 1, 2020, inclusive of these dates. Data collection included history of known comorbidities, medications, vital signs and laboratory values (admission and during the hospitalization). Outcomes include inflammatory burden (composite scores for multiple markers of inflammation), acute kidney injury (AKI), admission to the intensive care unit (ICU), need for invasive mechanical ventilation, and mortality. RESULTS: Of the 300 patients in the study cohort, 80 patients (26.7%) had history of ACEI or ARB use prior to admission, with 61.3% (49/80) of these patients continuing the medications during hospitalization. Multivariable analysis revealed that the history of ACEI or ARB use prior to hospitalization was not associated with worse outcomes. In addition, the continuation of these agents during hospitalization was not associated with an increase in adverse outcomes and predicted fewer ICU admissions (OR=0.25, 0.08-0.81) with a decrease in the severity of inflammatory burden (peak CRP (6.9±3.1mg/dl, p=0.03) and peak inflammation score (2.3±1.1unit reduction, p=0.04)). CONCLUSION: Use of ACEI or ARBs prior to hospitalization was not associated with adverse outcomes in COVID-19 and the therapeutic benefits of continuing ACEI or ARB in hospitalized patients with COVID-19 was not offset by adverse outcomes.
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Antagonistas de Receptores de Angiotensina , Tratamiento Farmacológico de COVID-19 , Antagonistas de Receptores de Angiotensina/efectos adversos , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Estudios de Cohortes , Humanos , Sistema Renina-Angiotensina , Estudios Retrospectivos , SARS-CoV-2RESUMEN
BACKGROUND: Diabetes is associated with an increased risk of colorectal cancer (CRC). We conducted a retrospective analysis of adenoma detection rates (ADR) in initial screening colonoscopies to further investigate the role of diabetes in adenoma detection. METHODS: A chart review was performed on initial average risk screening colonoscopies (ages 45-75) during 2012-2015. Data collected included basic demographics, insurance, BMI, family history of CRC, smoking, diabetes, and aspirin use. Multivariable generalized linear mixed models for binary outcomes were used to examine the relationship between diabetes and variables associated with CRC risk and ADR. RESULTS: Of 2865 screening colonoscopies, 282 were performed on patients with type 2 diabetes (T2DM). Multivariable analysis suggested that T2DM (OR = 1.49, 95% CI:1.13-1.97, p = 0.0047) was associated with an increased ADR, as well as smoking, older age, higher BMI and male sex (all p < 0.05). For patients with T2DM, those not taking diabetes medications were more likely to have an adenoma than those taking medication (OR = 2.38, 95% CI:1.09-5.2, p = 0.03). CONCLUSION: T2DM has an effect on ADR after controlling for multiple confounding variables. Early interventions for prevention of T2DM and prescribing anti-diabetes medications may reduce development of colonic adenomas and may contribute to CRC prevention.
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Adenoma/complicaciones , Adenoma/epidemiología , Colonoscopía , Neoplasias Colorrectales/complicaciones , Neoplasias Colorrectales/epidemiología , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Adenoma/diagnóstico , Anciano , Colonoscopía/métodos , Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer , Femenino , Humanos , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Estadificación de Neoplasias , Oportunidad RelativaRESUMEN
BACKGROUND: The aim of this study was to evaluate whether pretest probability (PTP) assessment using the Diamond-Forrester Model (DFM) combined with coronary calcium scoring (CCS) can safely rule out obstructive coronary artery disease (CAD) and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients. METHODS: We retrospectively evaluated consecutive patients, age ≥18 years, with no known CAD, negative initial electrocardiogram, and troponin level. All patients had coronary computed tomographic angiography (CCTA) with CCS, and our final cohort consisted of 1988 patients. Obstructive CAD was defined as luminal narrowing of ≥50% in 1 or more vessels by CCTA. Patients were classified according to PTP as low (<10%), intermediate (10%-90%), or high (>90%). RESULTS: The DFM classified 293 (14.7%), 1445 (72.7%), and 250 (12.6%) of patients as low, intermediate, and high risk, respectively, with corresponding 30-day MACE rates of 0.0%, 2.35%, and 14.8%. For patients with intermediate PTP and CCS ≤10, the negative predictive value was 99.2% (95% confidence interval: 98.7-99.8) for 30-day MACE while it was 92.62% (95% confidence interval: 87.9-97.3) for patients with high PTP. Among patients with a high PTP and CCS of zero, the prevalence of 30-day MACE and obstructive CAD remained high (7.07% and 10.1%, respectively). CONCLUSIONS: In acute chest pain patients without evidence of ischemia on initial electrocardiogram and cardiac troponin, low PTP by DFM or the combination of intermediate PTP and CCS ≤10 had excellent negative predictive values to rule out 30-day MACE. CCS is not sufficient to exclude obstructive CAD and 30-day MACE in patients with high PTP.