Prescriber Behavior in Clostridioides difficile Testing: A 3-Hospital Diagnostic Stewardship Intervention.

Computerized clinical decision support (CCDS) significantly reduced Clostridioides difficile testing at 3 hospitals; from 12.6 to 9.5, from 10.1 to 6.4, and from 14.0 to 9.6 average weekly tests per 1000 inpatient days. There were no related adverse events. Senior providers were more likely than interns or residents to follow CCDS.

Contactless Electrical and Structural Characterization of Semiconductor Nanowires with Axially Modulated Doping Profiles.

Efficient characterization of semiconductor nanowires having complex dopant profiles or heterostructures is critical to fully understand these materials and the devices built from them. Existing electrical characterization techniques are slow and laborious, particularly for multisegment nanowires, and impede the statistical understanding of highly variable samples. Here, it is shown that electro-orientation spectroscopy (EOS)-a high-throughput, noncontact method for statistically characterizing the electrical properties of entire nanowire ensembles-can determine the conductivity and dimensions of two distinct segments in individual Si nanowires with axially encoded dopant profiles. This analysis combines experimental measurements and computational simulations to determine the electrical conductivity of the nominally undoped segment of two-segment Si nanowires, as well as the ratio of the segment lengths. The efficacy of this approach is demonstrated by comparing results generated by EOS with conventional four-point-probe measurements. This work provides new insights into the control and variability of semiconductor nanowires for electronic applications and is a critical first step toward the high-throughput interrogation of complete nanowire-based devices.

Two Novel Urban Health Primary Care Residency Tracks That Focus On Community-Level Structural Vulnerabilities.

BACKGROUND: Although residency programs are well situated for developing a physician workforce with knowledge, skills, and attitudes that incorporate the strengths and reflect the priorities of community organizations, few curricula explicitly do so. AIM: To develop urban health primary care tracks for internal medicine and combined internal medicine-pediatrics residents. SETTING: Academic hospital, community health center, and community-based organizations. PARTICIPANTS: Internal medicine and combined internal medicine-pediatrics residents. PROGRAM DESCRIPTION: The program integrates community-based experiences with a focus on stakeholder engagement into its curriculum. A significant portion of the training (28 weeks out of 3 years for internal medicine and 34 weeks out of 4 years for medicine-pediatrics) occurs outside the hospital and continuity clinic to support residents' understanding of structural vulnerabilities. PROGRAM EVALUATION: Sixteen internal medicine and 14 medicine-pediatrics residents have graduated from our programs. Fifty-six percent of internal medicine graduates and 79% of medicine-pediatrics graduates are seeking primary care careers, and eight overall (27%) have been placed in community organizations. Seven (23%) hold leadership positions. DISCUSSION: We implemented two novel residency tracks that successfully placed graduates in community-based primary care settings. Integrating primary care training with experiences in community organizations can create primary care leaders and may foster collective efficacy among medical centers and community organizations.

Mitochondria Protection after Acute Ischemia Prevents Prolonged Upregulation of IL-1ß and IL-18 and Arrests CKD.

The innate immune system has been implicated in both AKI and CKD. Damaged mitochondria release danger molecules, such as reactive oxygen species, DNA, and cardiolipin, which can cause NLRP3 inflammasome activation and upregulation of IL-18 and IL-1ß It is not known if mitochondrial damage persists long after ischemia to sustain chronic inflammasome activation. We conducted a 9-month study in Sprague-Dawley rats after 45 minutes of bilateral renal ischemia. We detected glomerular and peritubular capillary rarefaction, macrophage infiltration, and fibrosis at 1 month. Transmission electron microscopy revealed mitochondrial degeneration, mitophagy, and deformed foot processes in podocytes. These changes progressed over the study period, with a persistent increase in renal cortical expression of IL-18, IL-1ß, and TGF-ß, despite a gradual decline in TNF-α expression and macrophage infiltration. Treatment with a mitoprotective agent (SS-31; elamipretide) for 6 weeks, starting 1 month after ischemia, preserved mitochondrial integrity, ameliorated expression levels of all inflammatory markers, restored glomerular capillaries and podocyte structure, and arrested glomerulosclerosis and interstitial fibrosis. Further, helium ion microscopy vividly demonstrated the restoration of podocyte structure by SS-31. The protection by SS-31 was sustained for ≥6 months after treatment ended, with normalization of IL-18 and IL-1ß expression. These results support a role for mitochondrial damage in inflammasome activation and CKD and suggest mitochondrial protection as a novel therapeutic approach that can arrest the progression of CKD. Notably, SS-31 is effective when given long after AKI and provides persistent protection after termination of drug treatment.

There's a Lot More to Being a Physician: Insights From an Intensive Clinical Shadowing Experience in Internal Medicine.

Phenomenon: Although most premedical students shadow physicians prior to starting medical school, there is no set of guidelines or expectations to facilitate effective experiences for students and physicians, nor is there data on the value of shadowing medical trainees as a way to learn about the training environment. We sought to understand premedical student perspectives on an intensive resident shadowing experience. APPROACH: This was a qualitative study using anonymous data from focus groups conducted with premedical student participants in a month-long time motion analysis of internal medicine interns at two large academic medical centers. The authors convened, professionally transcribed verbatim, and analyzed data using step-by-step thematic analysis from 3 focus groups in 2012. Focus group questions included goals of participants, shadowing experiences, patient safety experiences, and thoughts on physician training. FINDINGS: Twenty of the 22 students who were involved in the time motion study participated in the focus groups (91%). Three major themes were generated from the transcripts: qualities of a good physician, the inefficiencies of the healthcare system and the hospital, and the realities of graduate medical education. Insights: The intensive shadowing experience exposed premedical students to the hospital environment and many of the challenges they will face as future residents. Observing patient care firsthand, students considered the qualities of good intern physicians and appreciated the teamwork and collaboration essential to patient care in an academic medical center. Students witnessed some of the fundamental challenges of graduate medical training, including time pressures, documentation requirements, and the medical hierarchy. They also observed the difficulties of providing quality care in the current healthcare system, including hospital inefficiencies, interprofessional tensions, and financial barriers to care. Intensive shadowing of residents can begin the process of socialization to the culture of medicine by giving premedical students a realistic perspective of both positive and negative aspects of medical training and inpatient care.

Change in Medical Student Attitudes Toward Patients with Substance Use Disorders After Course Exposure.

OBJECTIVE: Negative physician attitudes toward patients with substance use disorders (SUD) pose a significant barrier to treatment. This study tests the overall and intra-individual change in attitudes of second year medical students after exposure to a 15 hour SUD course. METHODS: Two cohorts of second year medical students (2014 and 2015) responded to an anonymous 13-item previously published survey exploring personal views regarding patients with SUD using a four-point Likert scale. Students were surveyed one day before and up to one month after course completion. Survey items were grouped into the following categories: treatment optimism/confidence in intervention, moralism, and stereotyping. The Wilcoxon nonparametric signed-rank test (α=0.05) was used to compare the pre- and post- survey responses. RESULTS: In 2014 and 2015 respectively, 118 and 120 students participated in the SUD course with pre- and post-response rates of 89.0% and 75.4% in 2014 and 95.8% and 97.5% in 2015. Of the 13 survey questions, paired responses to eight questions showed a statistically significant positive change in attitudes with a medium (d = 0.5) to large effect size (d = 0.8). Items focused on treatment optimism and confidence in treatment intervention reflected a positive attitude change, as did items associated with stereotyping and moralism. CONCLUSIONS: These results support the hypothesis that exposure to a course on SUD was associated with positive change in medical students' attitudes toward patients with SUD.

Faces of all clinically engaged staff: a quality improvement project that enhances the hospitalised patient experience.

BACKGROUND: Patients often cannot recognise the names and faces of providers involved in their hospital care. OBJECTIVE: The aim of this study was to determine whether photographs of a patient's providers (physicians and ancillary support staff) using the FACES (Faces of All Clinically Engaged Staff) instrument would increase recognition of the healthcare team, improve the perception of teamwork, and enhance patient satisfaction. METHODS: Cluster randomised controlled trial with patients admitted to four adult internal medicine services of an urban, tertiary care hospital. Patients randomly admitted to two services received the FACES instrument, while the remainder served as control. Study measurements included the proportion of patients able to recognise their care providers by photograph, name and role, as well as patient rating of communication among healthcare team members and their satisfaction with the hospital experience as assessed by a survey. RESULTS: A total of 197 of the 322 (61.2%) patients screened for participation proved eligible for the study. Key exclusion criteria included cognitive or visual impairment and non-fluency with English. Patients receiving the FACES instrument recognised more provider names, faces and roles than controls (all P<.001). The intervention group more strongly agreed with statements that healthcare providers communicated frequently and effectively with each other (68% vs 52%, P=.02), and worked well together (69% vs 53%, P=.02). When rating their satisfaction with the hospital experience, 50% of patients in the intervention group assigned the highest possible rating, compared with 36% of control (P=.06). LIMITATIONS: Nursing staff, although integral to healthcare teams, were not included in the FACES instrument due to privacy concerns. CONCLUSIONS: The FACES instrument improved patients' recognition of providers' names and roles, as well as patients' perception of inter-provider teamwork. There was a non-significant trend towards improved satisfaction.

Internal medicine resident knowledge, attitudes, and barriers to naloxone prescription in hospital and clinic settings.

BACKGROUND: The United States is facing an epidemic of opioid use and misuse leading to historically high rates of overdose. Community-based overdose education and naloxone distribution has effectively trained lay bystanders to recognize signs of overdose and administer naloxone for reversal. There has been a movement to encourage physicians to prescribe naloxone to all patients at risk of overdose; however, the rate of physician prescribing remains low. This study aims to describe resident knowledge of overdose risk assessment, naloxone prescribing practices, attitudes related to naloxone, and barriers to overdose prevention and naloxone prescription. METHODS: The HOPE (Hospital-based Overdose Prevention and Education) Initiative is an educational campaign to teach internal medicine residents to assess overdose risk, provide risk reduction counseling, and prescribe naloxone. As part of a needs assessment, internal medicine residents at an academic medical center in Baltimore, Maryland, were surveyed in 2015. Data were collected anonymously using Qualtrics. RESULTS: Ninety-seven residents participated. Residents were overwhelmingly aware of naloxone (80%) and endorsed a willingness to prescribe (90%). Yet despite a high proportion of residents reporting patients in their panels at increased overdose risk (79%), few had prescribed naloxone (15%). Residents were willing to discuss overdose prevention strategies, although only a minority reported doing so (47%). The most common barriers to naloxone prescribing were related to knowledge gaps in how to prescribe and how to assess risk of overdose and identify candidates for naloxone (52% reporting low confidence in ability to identify patients who are at risk). CONCLUSIONS: Medicine residents are aware of naloxone and willing to prescribe it to at-risk patients. Due to decreased applied knowledge and limited self-efficacy, few residents have prescribed naloxone in the past. In order to improve rates of physician prescribing, initiatives must help physicians better assess risk of overdose and improve prescribing self-efficacy.

Primary Care Providers' Comfort Levels in Caring for Patients with Sickle Cell Disease.

OBJECTIVE: The purpose of this study was to determine the comfort levels of primary care providers in caring for individuals with sickle cell disease (SCD) and determine factors that improved or lessened provider comfort. METHODS: We surveyed providers at the annual Johns Hopkins Community Physicians retreat. The survey consisted of 19 questions and measured comfort levels in four domains: providing ambulatory care to individuals with SCD, managing SCD comorbidities, managing SCD-specific issues, and managing chronic pain. We conducted bivariate analyses to identify any demographic or practice characteristics associated with comfort levels. Multivariable analyses were conducted to identify independent correlates of physician comfort. RESULTS: The majority of respondents lacked confidence with each of the four aspects of caring for individuals with SCD. Having treated patients with SCD and using knowledge from residency were both independently associated with increased confidence when providing ambulatory care and managing SCD-specific issues in multivariable analyses. CONCLUSIONS: The delivery of high-quality care to adults with SCD in primary care may be limited because of a lack of provider comfort in providing that care. Because provider reliance on knowledge gained from residency significantly affected the management of patients with SCD, it is essential that continuing medical education on SCD is readily available to ensure that providers are using current information and knowledge. In addition, as comfort increases with the number of patients with SCD in a provider's panel, it may be beneficial to identify a subset of primary care providers interested in SCD and refer patients to those providers.

Development of a disease-based hospital-level diagnostic intensity index.

OBJECTIVES: Low-value care is associated with increased healthcare costs and direct harm to patients. We sought to develop and validate a simple diagnostic intensity index (DII) to quantify hospital-level diagnostic intensity, defined by the prevalence of advanced imaging among patients with selected clinical diagnoses that may not require imaging, and to describe hospital characteristics associated with high diagnostic intensity. METHODS: We utilized State Inpatient Database data for inpatient hospitalizations with one or more pre-defined discharge diagnoses at acute care hospitals. We measured receipt of advanced imaging for an associated diagnosis. Candidate metrics were defined by the proportion of inpatients at a hospital with a given diagnosis who underwent associated imaging. Candidate metrics exhibiting temporal stability and internal consistency were included in the final DII. Hospitals were stratified according to the DII, and the relationship between hospital characteristics and DII score was described. Multilevel regression was used to externally validate the index using pre-specified Medicare county-level cost measures, a Dartmouth Atlas measure, and a previously developed hospital-level utilization index. RESULTS: This novel DII, comprised of eight metrics, correlated in a dose-dependent fashion with four of these five measures. The strongest relationship was with imaging costs (odds ratio of 3.41 of being in a higher DII tertile when comparing tertiles three and one of imaging costs (95 % CI 2.02-5.75)). CONCLUSIONS: A small set of medical conditions and related imaging can be used to draw meaningful inferences more broadly on hospital diagnostic intensity. This could be used to better understand hospital characteristics associated with low-value care.

In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?

BACKGROUND: The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data. OBJECTIVE: In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital. DESIGN: Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012. PARTICIPANTS: Twenty-nine interns at the two residency programs. MAIN MEASURES: The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels. KEY RESULTS: Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns' time. There was no significant difference in time spent in these activities between the two sites. CONCLUSIONS: Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.

Residency schedule, burnout and patient care among first-year residents.

BACKGROUND: The 2011 US Accreditation Council for Graduate Medical Education (ACGME) mandates reaffirm the need to design residency schedules to augment patient safety and minimise resident fatigue. OBJECTIVES: To evaluate which elements of the residency schedule were associated with resident burnout and fatigue and whether resident burnout and fatigue were associated with lower perceived quality of patient care. METHODS: A cross-sectional survey of first-year medicine residents at three hospitals in May-June 2011 assessed residency schedule characteristics, including hours worked, adherence to 2003 work-hour regulations, burnout and fatigue, trainee-reported quality of care and medical errors. RESULTS: Response rate was 55/76 (72%). Forty-two of the 55 respondents (76%) met criteria for burnout and 28/55 (51%) for fatigue. After adjustment for age, gender and residency programme, an overnight call was associated with higher burnout and fatigue scores. Adherence to the 80 h working week, number of days off and leaving on time were not associated with burnout or fatigue. Residents with high burnout scores were more likely to report making errors due to excessive workload and fewer reported that the quality of care provided was satisfactory. CONCLUSIONS: Burnout and fatigue were prevalent among residents in this study and associated with undesirable personal and perceived patient-care outcomes. Being on a rotation with at least 24 h of overnight call was associated with higher burnout and fatigue scores, but adherence to the 2003 ACGME work-hour requirements, including the 80 h working week, leaving on time at the end of shifts and number of days off in the previous month, was not. Residency schedule redesign should include efforts to reduce characteristics that are associated with burnout and fatigue.

Measuring the impact of enhanced kinship navigator services for informal kinship caregivers using an experimental design.

While relative care may offer significant benefits to kin children as compared to non-relative foster care, informal kinship caregivers often experience various hardships and needs without the resources of the child welfare system to aid them. They may benefit from services provided by an expanded kinship navigator program. This study, using an experimental design, adds to knowledge about the characteristics and needs of kinship caregivers and the impact of enhanced navigator services. The relative effect of this more intensive intervention was mixed. Caregivers had many of their expressed needs met. Yet, the enhanced services group did not demonstrate: an increase in perceived social support; reduction in caregiver stress; or improvement in child behavior compared to the families receiving brief, traditional navigator services. Little difference was found in post intervention involvement in the child welfare system. Further enhancements to the model are suggested.

A collaborative approach to teaching medical students how to screen, intervene, and treat substance use disorders.

Few medical schools require a stand-alone course to develop knowledge and skills relevant to substance use disorders (SUDs). The authors successfully initiated a new course for second-year medical students that used screening, brief intervention, and referral to treatment (SBIRT) as the course foundation. The 15-hour course (39 faculty teaching hours) arose from collaboration between faculty in Departments of Medicine and Psychiatry and included 5 hours of direct patient interaction during clinical demonstrations and in small-group skills development. Pre- and post-exam results suggest that the course had a significant impact on knowledge about SUDs. The authors' experience demonstrates that collaboration between 2 clinical departments can produce a successful second-year medical student course based in SBIRT principles.

An intra-cytoplasmic route for SARS-CoV-2 transmission unveiled by Helium-ion microscopy.

SARS-CoV-2 virions enter the host cells by docking their spike glycoproteins to the membrane-bound Angiotensin Converting Enzyme 2. After intracellular assembly, the newly formed virions are released from the infected cells to propagate the infection, using the extra-cytoplasmic ACE2 docking mechanism. However, the molecular events underpinning SARS-CoV-2 transmission between host cells are not fully understood. Here, we report the findings of a scanning Helium-ion microscopy study performed on Vero E6 cells infected with mNeonGreen-expressing SARS-CoV-2. Our data reveal, with unprecedented resolution, the presence of: (1) long tunneling nanotubes that connect two or more host cells over submillimeter distances; (2) large scale multiple cell fusion events (syncytia); and (3) abundant extracellular vesicles of various sizes. Taken together, these ultrastructural features describe a novel intra-cytoplasmic connection among SARS-CoV-2 infected cells that may act as an alternative route of viral transmission, disengaged from the well-known extra-cytoplasmic ACE2 docking mechanism. Such route may explain the elusiveness of SARS-CoV-2 to survive from the immune surveillance of the infected host.

Intrinsic (Trap-Free) Transistors Based on Epitaxial Single-Crystal Perovskites.

The first experimental realization of the intrinsic (not dominated by defects) charge conduction regime in lead-halide perovskite field-effect transistors (FETs) is reported. The advance is enabled by: i) a new vapor-phase epitaxy technique that results in large-area single-crystalline cesium lead bromide (CsPbBr3 ) films with excellent structural and surface properties, including atomically flat surface morphology, essentially free from defects and traps at the level relevant to device operation; ii) an extensive materials analysis of these films using a variety of thin-film and surface probes certifying the chemical and structural quality of the material; and iii) the fabrication of nearly ideal (trap-free) FETs with characteristics superior to any reported to date. These devices allow the investigation of the intrinsic FET and (gated) Hall-effect carrier mobilities as functions of temperature. The intrinsic mobility is found to increase on cooling from ≈30 cm2 V-1 s-1 at room temperature to ≈250 cm2 V-1 s-1 at 50 K, revealing a band transport limited by phonon scattering. Establishing the intrinsic (phonon-limited) mobility provides a solid test for theoretical descriptions of carrier transport in perovskites, reveals basic limits to the technology, and points to a path for future high-performance perovskite electronic devices.

A Resident-Led Intervention to Increase Initiation of Buprenorphine Maintenance for Hospitalized Patients With Opioid Use Disorder.

BACKGROUND: Hospitalized patients with opioid use disorder (OUD) are rarely started on buprenorphine or methadone maintenance despite evidence that these medications reduce all-cause mortality, overdoses, and hospital readmissions. OBJECTIVE: To assess whether clinician education and a team of residents and hospitalist attendings waivered to prescribe buprenorphine increased the rate of starting patients with OUD on buprenorphine maintenance. DESIGN, SETTING, AND PARTICIPANTS: Quality improvement study conducted at a large, urban, academic hospital in Maryland involving hospitalized patients with OUD on internal medicine resident services. INTERVENTION: We developed a protocol for initiating buprenorphine maintenance, presented an educational conference, and started the resident-led Buprenorphine Bridge Team of residents and attendings waivered to prescribe buprenorphine to bridge patients from discharge to follow-up. MEASUREMENTS: The percent of eligible inpatients with OUD initiated on buprenorphine maintenance, 24 weeks before and after the intervention; engagement in treatment after discharge; and resident knowledge and comfort with buprenorphine. RESULTS: The rate of starting buprenorphine maintenance increased from 10% (30 of 305 eligible patients) to 24% (64 of 270 eligible patients) after the intervention, with interrupted time series analysis showing a significant increase in rate (14.4%; 95% CI, 3.6%-25.3%; P = .02). Engagement in treatment after discharge was unchanged (40%-46% engaged 30 days after discharge). Of 156 internal medicine residents, 89 (57%) completed the baseline survey and 66 (42%) completed the follow-up survey. Responses demonstrated improved resident knowledge and comfort with buprenorphine. CONCLUSION: Internal medicine resident teams were more likely to start patients on buprenorphine maintenance after clinician education and implementation of a Buprenorphine Bridge Team.