Risks of Zolpidem among Patients with Chronic Obstructive Pulmonary Disease.

Rationale: Nonbenzodiazepine benzodiazepine receptor agonists (NBZRA, e.g., zolpidem) are frequently used to treat insomnia among patients with chronic obstructive pulmonary disease (COPD). However, multiple observational studies find that patients with COPD who are prescribed NBZRAs have greater risks for mortality and respiratory complications than patients without such prescriptions. Without an active comparator, these studies are susceptible to confounding by indication. Objectives: Compare the risk of death or inpatient COPD exacerbation among patients receiving zolpidem relative to patients receiving other hypnotics. Methods: Using nationwide Veterans Health Administration (VA) data, we identified patients with clinically diagnosed COPD and new receipt of zolpidem or another hypnotic available on VA formulary without prior authorization (melatonin, trazodone, doxepin). We excluded those receiving traditional benzodiazepines or multiple concurrent hypnotics. We propensity-matched patients receiving zolpidem to other hypnotics on 32 variables, including demographics, comorbidities, and markers of COPD severity. We compared risk of the primary composite outcome of death or inpatient COPD exacerbation over 1 year. In secondary analyses, we propensity-matched patients receiving zolpidem to those without hypnotic receipt. Results: Among 283,740 patients meeting inclusion criteria, 1,126 (0.4%) received zolpidem and 3,057 (1.1%) received other hypnotics. We propensity-matched patients receiving zolpidem 1:1 to peers receiving other hypnotics. We did not find a difference in the primary composite outcome of death or inpatient exacerbation (hazard ratio, 0.97; 95% confidence interval [CI], 0.77-1.23). In secondary analyses comparing patients receiving zolpidem to matched peers without hypnotic receipt, we observed greater risk of death or inpatient exacerbation with zolpidem (hazard ratio, 1.40; 95% CI, 1.09-1.81). Conclusions: Among patients with COPD, we did not observe greater risks after new receipt of zolpidem relative to other hypnotics. However, we did observe greater risks relative to those without hypnotic receipt. This latter finding may reflect: 1) residual, unmeasured confounding related to insomnia; or 2) true adverse effects of hypnotics across classes. Future work is needed to better understand the risks of hypnotics in COPD.

Health status of the red-billed tropicbird (Phaethon aethereus) determined by hematology, biochemistry, blood gases, and physical examination.

The red-billed tropicbird, Phaethon aethereus, is a species of seabird native to the Galápagos archipelago, and widely distributed across the neotropics. General health, blood chemistry, and haematology parameters have not been published for this species. Blood analyses were performed on samples drawn from 51 clinically healthy red-billed tropicbirds captured from their burrows at Islote Pitt on San Cristóbal Island in July, 2016 (21) and Daphne Major Island in June, 2017 (30). In the field, a point of care blood analyser (iSTAT) was used to obtain results for HCO3-, pH, pCO2, pO2, TCO2, iCa, Na, K, Cl, Hb, HCT, anion gap, creatinine, glucose and urea nitrogen. Additionally, a portable Lactate PlusTM analyser was used to measure blood lactate, and blood smears were also created in situ. The blood slides were used to estimate leukocyte counts and 100-cell differentials. Alongside these biochemistry and haematology parameters, average heart rate, respiratory rate, body temperature and scaled mass index (calculated from weight and a body measurement) were compared to determine the standard measurements for a healthy individual. The baseline data, and reference intervals reported in this paper are essential to detecting changes in the health of red-billed tropicbirds in the future.

Effects of Telemedicine on Pediatric Clinical Care During COVID-19.

Coronavirus disease 2019 (COVID-19) has provided unprecedented opportunity for the growth of telemedicine in pediatrics. Clinics rapidly expanded their telemedicine capabilities and converted in-person visits to virtual visits to offer patients continued care while limiting infection risks. Although the transition to video visits has several benefits-patient convenience, versatility of care, ease of follow up, and management of chronic conditions-these gains are only available to those who have the requisite technology access and literacy needed to conduct a video visit. The need for technology-dependent care stands to further widen preexisting disparities in access to care for those who cannot use or afford the necessary technology. Our article explores some of these benefits and challenges and reminds us that although telemedicine has proven to have high utility for many patients, there are improvements that must still be made to ensure equitable accessibility and durability of virtual visits. [Pediatr Ann. 2021;50(12):e503-e508.].

Using Human-Centered Design in Personalized Anticipatory Guidance: Enriching Anticipatory Guidance on Early Cognitive and Language Development.

In this study, we aimed to create a novel tool to assist providers at 2 Chicago-area Federally Qualified Health Centers in giving guidance on early cognitive and language development during well-child visits. We utilized a human-centered design (HCD) process to address specific barriers to providing this guidance and create a tool shaped by the needs of providers and parents. Phase I involved collaborative prototype design; phase II involved implementation, feedback gathering, and responsive iterations of the tool; and phase III involved a collective review of the HCD process. The final version of the tool was a concise, colorful, and parent-accessible "Brain Building Guide" intended for interactive provider and parent use. It featured personalized information about parental knowledge and suggested areas for guidance. It was both satisfactory to stakeholders and efficacious in improving parental knowledge immediately post-visit and 1 month out. It should be further evaluated in a randomized controlled trial.

HEALTH STATUS OF NAZCA BOOBIES (SULA GRANTI) ON DAPHNE MAJOR ISLAND IN THE GALÁPAGOS DETERMINED BY HEMATOLOGY, BIOCHEMISTRY, AND PHYSICAL EXAMINATION.

Island species are particularly vulnerable to environmental disturbances and introduced pathogens. Conducting health assessments of wild populations in the Galápagos improves the ability of wildlife managers and veterinarians to detect deteriorations in health status. Seabirds in particular are useful species to monitor due to their colonial breeding and wide migration range. Nazca boobies (Sula granti) in a breeding colony at Daphne Major (n = 30) were given physical examinations, and blood samples were collected for hematology and biochemistry using an iSTAT Portable Clinical Analyzer. Female boobies had longer wing length than males, as well as lower blood urea nitrogen, creatinine, and white blood cell counts. This could be attributed to sexual dimorphism or differences in foraging and mating strategies between the sexes. The time between capture and blood collection had a significant inverse relationship on plasma sodium, potassium, hemoglobin, anion gaps, and lymphocyte counts, suggesting that blood sampling in Nazca boobies should be done in less than 5 m to avoid the impacts of stress on hematological parameters. This is the first health assessment on the breeding colony of Nazca boobies at Daphne Major, and the results can inform future monitoring in this species as well as other sulids.

Clinician Perspectives on Telemedicine: Observational Cross-sectional Study.

BACKGROUND: Since the COVID-19 pandemic onset, telemedicine has increased exponentially across numerous outpatient departments and specialties. Qualitative studies examining clinician telemedicine perspectives during the pandemic identified challenges with physical examination, workflow concerns, burnout, and reduced personal connection with patients. However, these studies only included a relatively small number of physicians or were limited to a single specialty, and few assessed perspectives on integrating trainees into workflows, an important area to address to support the clinical learning environment. As telemedicine use continues, it is necessary to understand a range of clinician perspectives. OBJECTIVE: This study aims to survey pediatric and adult medicine clinicians at the University of Chicago Medical Center to understand their telemedicine benefits and barriers, workflow impacts, and training and support needs. METHODS: In July 2020, we conducted an observational cross-sectional study of University of Chicago Medical Center faculty and advanced practice providers in the Department of Medicine (DOM) and Department of Pediatrics (DOP). RESULTS: The overall response rate was 39% (200/517; DOM: 135/325, 42%; DOP: 65/192, 34%); most respondents were physicians (DOM: 100/135, 74%; DOP: 51/65, 79%). One-third took longer to prepare for (65/200, 33%) and conduct (62/200, 32%) video visits compared to in-person visits. Male clinicians reported conducting a higher percentage of telemedicine visits by video than their female counterparts (P=.02), with no differences in the number of half-days per week providing direct outpatient care or supervising trainees. Further, clinicians who conducted a higher percentage of their telemedicine by video were less likely to feel overwhelmed (P=.02), with no difference in reported burnout. Female clinicians were "more overwhelmed" with video visits compared to males (41/130, 32% vs 12/64, 19%; P=.05). Clinicians 50 years or older were "less overwhelmed" than those younger than 50 years (30/85, 35% vs 23/113, 20%; P=.02). Those who received more video visit training modalities (eg, a document and webinar on technical issues) were less likely to feel overwhelmed by the conversion to video visits (P=.007) or burnt out (P=.009). In addition, those reporting a higher ability to technically navigate a video visit were also less likely to feel overwhelmed by video visits (P=.02) or burnt out (P=.001). The top telemedicine barriers were patient-related: lack of technology access, lack of skill, and reluctance. Training needs to be focused on integrating learners into workflows. Open-ended responses highlighted a need for increased support staff. Overall, more than half "enjoyed conducting video visits" (119/200, 60%) and wanted to continue using video visits in the future (150/200, 75%). CONCLUSIONS: Despite positive telemedicine experiences, more support to facilitate video visits for patients and clinicians is needed. Further, clinicians need additional training on trainee education and integration into workflows. Further work is needed to better understand why gender and age differences exist. In conclusion, interventions to address clinician and patient barriers, and enhance clinician training are needed to support telemedicine's durability.

Teaching Telemedicine: The Next Frontier for Medical Educators.

The COVID-19 pandemic has pushed telemedicine to the forefront of health care delivery, and for many clinicians, virtual visits are the new normal. Although telemedicine has allowed clinicians to safely care for patients from a distance during the current pandemic, its rapid adoption has outpaced clinician training and development of best practices. Additionally, telemedicine has pulled trainees into a new virtual education environment that finds them oftentimes physically separated from their preceptors. Medical educators are challenged with figuring out how to integrate learners into virtual workflows while teaching and providing patient-centered virtual care. In this viewpoint, we review principles of patient-centered care in the in-person setting, explore the concept of patient-centered virtual care, and advocate for the development and implementation of patient-centered telemedicine competencies. We also recommend strategies for teaching patient-centered virtual care, integrating trainees into virtual workflows, and developing telemedicine curricula for graduate medical education trainees by using our TELEMEDS framework as a model.

Blood gases, biochemistry and haematology of Galápagos hawksbill turtles (Eretmochelys imbricata).

The hawksbill turtle, Eretmochelys imbricata, is a marine chelonian with a circum-global distribution, but the species is critically endangered and has nearly vanished from the eastern Pacific. Although reference blood parameter intervals have been published for many chelonian species and populations, including nesting Atlantic hawksbills, no such baseline biochemical and blood gas values have been reported for wild Pacific hawksbill turtles. Blood samples were drawn from eight hawksbill turtles captured in near shore foraging locations within the Galápagos archipelago over a period of four sequential years; three of these turtles were recaptured and sampled on multiple occasions. Of the eight sea turtles sampled, five were immature and of unknown sex, and the other three were females. A portable blood analyzer was used to obtain near immediate field results for a suite of blood gas and chemistry parameters. Values affected by temperature were corrected in two ways: (i) with standard formulas and (ii) with auto-corrections made by the portable analyzer. A bench top blood chemistry analyzer was used to measure a series of biochemistry parameters from plasma. Standard laboratory haematology techniques were employed for red and white blood cell counts and to determine haematocrit manually, which was compared to the haematocrit values generated by the portable analyzer. The values reported in this study provide reference data that may be useful in comparisons among populations and in detecting changes in health status among Galápagos sea turtles. The findings might also be helpful in future efforts to demonstrate associations between specific biochemical parameters and disease or environmental disasters.