Assessing the Impact of a Hospice and Palliative Medicine Mentored Clinical Shadowing Experience for First-Year Medical and Dental Students: A Pilot Study.

Background: All physicians encounter patients with serious illness. Medical students recognize the value of hospice and palliative medicine (HPM) and desire more knowledge and skills in this area. However, both pre-clinical and clinical HPM content are underrepresented within medical school curricula. Objectives: To conduct a pilot study examining the impact of a novel required HPM clinical experience on pre-clinical medical and dental students' learning through mixed methods evaluation of student responses. Design: Students completed a two-part electronic survey following a half-day HPM mentored clinical shadowing experience (HPM-MCSE) which included an introductory session, a faculty-mentored shadowing experience and a debriefing session. Setting/subjects: 163 first-year students at Harvard Medical School in Boston, Massachusetts, USA in 2022. Measurements: The survey collected demographic information and student responses to both closed-ended (Likert-scale) and open-ended prompts. Data were analyzed quantitatively using descriptive statistics and qualitatively using constant comparative methodology. Results: 127 medical and dental students responded (78% response rate). Qualitative analysis yielded three overarching themes: acquisition of knowledge about operational dimensions of HPM, acquisition of knowledge about psychosocial dimensions of HPM, and personal impact including an awareness of discordance between expectations and lived experience of HPM practice. Of the 109 students who completed the entire survey, 67% indicated that this experience increased their interest in palliative care and 98% reported an increase in their understanding of how palliative care enhances patient care. Conclusions: Early clinical exposure to HPM for first year students stimulates multi-dimensional learning about HPM and evokes personal reflection about serious illness care.

Are Opioid Infusions Used Inappropriately at End of Life? Results From a Quality/Safety Project.

CONTEXT: Opioid continuous infusions are commonly used for end-of-life (EOL) symptoms in hospital settings. However, prescribing practices vary, and even the recent literature contains conflicting protocols and guidelines for best practice. OBJECTIVES: To determine the prevalence of potentially inappropriate opioid infusion use for EOL comfort care at an academic medical center, and determine if inappropriate use is associated with distress. METHODS: Through literature review and iterative interdisciplinary discussion, we defined three criteria for "potentially inappropriate" infusion use. We conducted a retrospective, observational study of inpatients who died over six months, abstracting demographics, opioid use patterns, survival time, palliative care (PC) involvement, and evidence of patient/caregiver/staff distress from the electronic medical record. RESULTS: We identified 193 decedents who received opioid infusions for EOL comfort care. Forty-four percent received opioid infusions that were classified as "potentially inappropriate." Insufficient use of as-needed intravenous opioid boluses and use of opioid infusions in opioid-naïve patients were the most common problems observed. Potentially inappropriate infusions were associated with more frequent patient (24% vs. 2%; P < 0.001) and staff distress (10% vs. 2%; P = 0.02) and were less common when PC provided medication recommendations (20% vs. 50%; P < 0.001). CONCLUSION: Potentially inappropriate opioid infusions are prevalent at our hospital, an academic medical center with an active PC team and existing contracts for in-hospital hospice care. Furthermore, potentially inappropriate opioid infusions are associated with increased patient and staff distress. We are developing an interdisciplinary intervention to address this safety issue.

Material Needs of Emergency Department Patients: A Systematic Review.

BACKGROUND: Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States. METHODS: We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles. RESULTS: Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs. CONCLUSIONS: Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.

Aerodigestive dysbiosis in children with chronic cough.

In pediatric patients with chronic cough, respiratory culture techniques commonly yield negative results. Studies using culture-independent methods have found a high relative abundance of oral microbes in the lower airways, suggesting that the topographical continuity, and dynamics of the intraluminal contents of the aerodigestive system likely influence the lower airway microbiota. We hypothesize that in subjects with chronic cough, clinical diagnosis will correlate with distinct microbial signatures detected using culture-independent methods. STUDY DESIGN AND METHODS: We enrolled 36 pediatric subjects with chronic cough in a cross-sectional study. Subjects were categorized into four clinical groups: asthma, bacterial bronchitis, neurologically impaired-orally fed, and neurologically impaired enterally fed. Samples from the aerodigestive tract were obtained through bronchoscopy and upper endoscopy. 16S rRNA gene sequencing compared the microbiota from bronchoalveolar lavage (BAL), tracheal, supraglottic, esophageal, gastric, and duodenal samples. RESULTS: We observed that the lower airway microbiota of asthma subjects had higher α diversity as compared with the other groups. ß diversity analysis of BAL samples revealed significant differences between the groups. Among the taxonomic differences found, most differentially enriched taxa were upper airway organisms such as Rothia, Gemellaceae (u.g. or uncharacterized genus), and Granulicatella in asthma, Prevotella in bacterial bronchitis, and Veillonella in neurologically impaired orally fed subjects. Greater dissimilarity between the upper airway and lower airway microbiota was associated with increased neutrophilic airway inflammation. CONCLUSIONS: Distinct dysbiotic signatures can be identified in the lower airway microbiota of pediatric subjects with chronic cough that relates to the degree and type of inflammation.

A Five-Year, In Situ Growth Study on Shallow-Water Populations of the Gorgonian Octocoral Calcigorgia spiculifera in the Gulf of Alaska.

Gorgonian octocorals are the most abundant corals in Alaska where they provide important structural habitat for managed species of demersal fish and invertebrates. Fifty-nine gorgonian species have been reported from Alaska waters but little is known about their life history characteristics to help us gauge their ability to recover from seafloor disturbance. Colonies of the holaxonian Calcigorgia spiculifera were tagged beginning in 1999 at three sites in Chatham Strait, Southeast Alaska, using scuba and their growth measured annually for up to 5 years. Colonies were video recorded, and computer image analysis tools provided calibration of video images for measuring the length of several branches. Growth data indicate that C. spiculifera grows much slower (6.0 mm yr-1) than other gorgonians in Alaska for which there are data and that intraspecific growth is highly variable. We fit a Bayesian linear mixed-effects model that showed that average colony growth was significantly reduced with warmer temperature and presence of necrosis. The model further indicated that growth may slow among larger (older) colonies. Based on these results and previous studies, we propose that gorgonian growth rates are taxonomically constrained at the Suborder level and that holaxonians grow the slowest followed by scleraxonians and calcaxonians (2-3 times as fast). Findings of this study indicate that it would take approximately 60 years for C. spiculifera to grow to its maximum size and depending on the location and size of the parental standing stock, at least one and possibly 10 additional years for recruitment to occur. Our results further indicate that colonies that are injured, perhaps chronically in areas of frequent disturbance, grow at slower rates and if the current trend of ocean warming continues then we can expect these corals to grow more slowly, and the habitats they form will require more time to recover from disturbance.