Training Physicians in the Digital Health Era: How to Leverage the Residency Elective.

Digital health is an expanding field and is fundamentally changing the ways health care can be delivered to patients. Despite the changing landscape of health care delivery, medical trainees are not routinely exposed to digital health during training. In this viewpoint, we argue that thoughtfully implemented immersive elective internships with digital health organizations, including start-ups, during residency are valuable for residents, residency programs, and digital health companies. This viewpoint represents the opinions of the authors based on their experience as resident physicians working as interns within a start-up health navigation and telehealth company. First, residents were able to apply their expertise beyond the traditional clinical environment, use creativity to solve health care problems, and learn from different disciplines not typically encountered by most physicians in traditional clinical practice. Second, residency programs were able to strengthen their program's educational offerings and better meet the needs of a heterogenous group of residents who are increasingly seeking nontraditional ways to learn more about care delivery transformation. Third, digital health companies were able to expand their clinical team and receive new insights from physicians in training. We believe that immersive elective internships for physicians in training provide opportunities for experiential learning in a fast-paced environment within a field that is rapidly evolving. By creating similar experiences for other resident physicians, residency programs and digital health companies have a key opportunity to influence future physician-leaders and health care innovators.

Outcomes of thrombectomy procedures performed in hemodialysis grafts with early failure.

PURPOSE: Percutaneous declotting is usually not offered for hemodialysis access grafts clotting < 30 days after placement because of concerns regarding safety of percutaneous transluminal angioplasty in fresh anastomoses, potential need for surgical correction of the underlying cause, and poor outcomes. The authors sought to determine acute and long-term outcomes of declotting of grafts with early failure. MATERIALS AND METHODS: Of 860 percutaneous mechanical thrombectomies performed between July 2001 and June 2007, 23 were performed in grafts < 30 days after initial placement. In addition, 16 percutaneous thrombectomies performed in grafts 31-60 days after placement were identified. Data collected included medical history, graft characteristics, immediate technical and clinical success, complications, and subsequent graft patency and survival. Kaplan-Meier analysis compared outcomes in grafts < 30 days (U30) versus those 31-60 days (U60) old. RESULTS: There was no difference between the U30 and U60 groups in primary patency (13 vs 19 days, respectively, P = 0.17) or in postintervention access patency (38 vs 189 days, respectively, P = 0.63). A strong trend toward shorter secondary patency in U30 grafts was observed (17 vs 73 days, P = 0.06). Underlying lesions not amenable to percutaneous treatment were found in 62% of U30 grafts and 33% of U60 grafts (P = 0.18). Neither group achieved the K/DOQI Guidelines' recommended 85% technical success or 40% 90-day primary patency; in the U30 group it was 0% and in the U60 group 17%. CONCLUSIONS: Percutaneous declotting of grafts yields poor outcomes, well below the K/DOQI threshold not only within 30 days but also within 60 days of placement.

Inpatient addiction consultation and post-discharge 30-day acute care utilization.

BACKGROUND: Addiction Consult Services care for hospitalized patients with substance use disorders (SUD), who frequently utilize costly medical services. This study evaluates whether an addiction consult is associated with 30-day acute care utilization. METHODS: This was a retrospective cohort study of 3905 inpatients with SUD. Acute care utilization was defined as any emergency department visit or re-hospitalization within 30 days of discharge. Inverse probability of treatment weighted generalized estimating equations logistic regression models were used to evaluate the relationship between receipt of an addiction consult and 30-day acute care utilization. Exploratory subgroup analyses were performed to describe whether this association differed by type of SUD and discharge on medication for addiction treatment. RESULTS: The 30-day acute care utilization rate was 39.5 % among patients with a consult and 36.0 % among those without. Addiction consults were not significantly associated with care utilization (Adjusted Odds Ratio 1.02; 0.82, 1.28). No significant differences were detected in subgroup analyses; however, the decreased odds among patients with OUD given medication was clinically notable (AOR 0.69; 0.47, 1.02). DISCUSSION: Repeat acute care utilization is common among hospitalized patients with SUD, particularly those seen by the addiction consult services. While this study did not detect a significant association between addiction consults and 30-day acute care utilization, this relationship merits further evaluation using prospective studies, controlling for key confounders and with a focus on the impact of medications for opioid use disorder.

Which patients receive an addiction consult? A preliminary analysis of the INREACH (INpatient REadmission post-Addiction Consult Help) study.

INTRODUCTION: Despite the high prevalence and significant health risks of substance use disorders (SUDs), a minority of individuals with SUDs receive treatment of any kind. The aims of this study are to describe inpatients with an SUD who receive an addiction consult at a large urban safety net hospital and explore characteristics associated with receiving an addiction consult. METHODS: This is a retrospective cohort study of all adult patients with a discharge diagnosis of an SUD from July 2015 to July 2016. A generalized estimating equation (GEE) logistic regression model was used to explore patient factors associated with receipt of an addiction consult, such as demographics, social, medical, and SUD characteristics. RESULTS: A total of 3905 patients with SUD diagnoses with 5979 hospitalization encounters were included in this study. There were 694 addiction consults (11.6%, 95% CI: 10.71% to 12.5%) across all of the encounters and 576 unique patients that received consults. Patients with opioid use disorder had higher odds of receiving a consult (Adjusted Odds Ratio: 6.39, 95% CI 5.14-7.94), as did patients with acute complications from their substance use (AOR: 1.64, 95% CI 1.34-2.02), patients with human immunodeficiency virus (HIV) (AOR: 2.06, 95% CI 1.59-2.67), and homeless patients (AOR: 1.31, 95% CI 1.08-1.59). Patients with a psychiatry consult had higher odds of receiving an addiction consult (AOR: 1.75, 95% CI 1.37-2.23), and so did patients receiving benzodiazepines and/or phenobarbital (AOR: 1.88, 95% CI 1.55-2.28). Older patients (AOR: 0.82, 95% CI 0.76-0.88 per 10 year increase) had lower odds of receiving a consult, as did patients with an overdose diagnosis (AOR: 0.71, 95% CI 0.53-0.96). CONCLUSION: A minority of inpatients with SUD received an addiction consult, however, inpatients with opioid use disorder, acute complications (medical, mental health) and homelessness had higher odds of receiving an addiction consult. Patients surviving overdose, a severe acute complication of substance use, had lower odds of receiving a consult and, thus, warrant development of care pathways to provide overdose prevention and addiction treatment engagement.

Brain weight differences associated with induced focal microgyria.

BACKGROUND: Disrupting neural migration with bilateral focal freezing necrosis on postnatal day 1 (P1) results in the formation of 4-layered microgyria. This developmental injury triggers a pervasive neural reorganization, which is evident at the electrophysiological, behavioral, and anatomical levels. In this experiment, we investigated changes in brain weight as an index of global disruption of neural systems caused by focal damage to the developing cortical plate. RESULTS: We found a dramatic reduction in overall brain weight in microgyric subjects. This reduction in brain weight among animals with microgyria is reflected in decreased total brain volume, with a disproportionate decrease in neocortical volume. This effect is so robust that it is seen across varied environments, at variable ages, and across the sexes. CONCLUSIONS: This finding supports previous work suggesting that substantial reorganization of the brain is triggered by the induction of bilateral freezing damage. These results have critical implications for the profound re-organizational effects of relatively small focal injuries early in development to distributed systems throughout the brain, and particularly in the cerebral cortex.

Learning and memory associated with aggression in Drosophila melanogaster.

Male Drosophila melanogaster (Canton-S strain) exhibit aggression in competition for resources, to defend territory, and for access to mates. In the study reported here, we asked: (i) how long flies fight; (ii) whether flies adopt distinct winning and losing strategies as hierarchical relationships are established; (iii) whether flies exhibit experience-dependent changes in fighting strategies in later fights; and (iv) whether flies fight differently in second fights against familiar or unfamiliar opponents. The results showed that flies fought for up to 5 h. As hierarchical relationships were established, behavioral strategies changed: winners progressively lunged more and retreated less, whereas losers progressively lunged less and retreated more. Encounters between flies were frequent during the first 10 min of pairing and then dropped significantly. To ask whether flies remembered previous fights, they were re-paired with familiar or unfamiliar opponents after 30 min of separation. In familiar pairings, there were fewer encounters during the first 10 min of fighting than in unfamiliar pairings, and former losers fought differently against familiar winners than unfamiliar winners. Former losers lost or no decision was reached in all second fights in pairings with familiar or unfamiliar winners or with naive flies. Winner/winner, loser/loser, and naive/naive pairings revealed that losers used low-intensity strategies in later fights and were unlikely to form new hierarchical relationships, compared with winners or socially naive flies. These results strongly support the idea that learning and memory accompany the changes in social status that result from fruit fly fights.