Geriatric Telehealth: A Standardized Patient Case for Medical Students.

Introduction: The COVID-19 pandemic has necessitated the rapid expansion of telemedicine. However, there has been minimal coverage of telemedicine in traditional undergraduate medicine curricula. Telemedicine presents specific challenges in the geriatric population, including unfamiliarity with technology, cognitive and sensory barriers, inclusion of family and/or caregivers, multimorbidity, and a high degree of medical complexity. Methods: We developed a workshop to allow rising third-year medical students to practice a telemedicine patient encounter while developing skills for assessing and communicating with geriatric patients. This 90-minute workshop consisted of an introductory didactic presentation and a standardized patient activity for small groups of two to five students. Students' level of comfort with telemedicine for assessment of geriatric patients was evaluated with a pre- and postsurvey. Results: Fifty-eight students participated in the workshop and completed the surveys (presurvey = 58, postsurvey = 40), with roughly half (52%) reporting prior experience with telemedicine. A 5-point Likert-type scale (1 = very uncomfortable, 5 = very comfortable) was used. Students reported statistically significant increases in comfort using telemedicine (presurvey = 3.1, postsurvey = 3.9, p < .001) and using telemedicine for patients ≥65 years (presurvey = 2.8, postsurvey = 3.9, p < .001) after completing the workshop. Discussion: Medical students' comfort levels using telemedicine and caring for patients ages 65 and older with a telehealth visit improved after participating in this workshop. To help prepare students for telehealth practice in their future careers, educators should provide them with opportunities to practice and develop this critical skill set.

Short-Term Complications Associated with Surgical Ligation of Patent Ductus Arteriosus in ELBW Infants: A 25-Year Cohort Study.

OBJECTIVE: This article aims to determine the incidence of short-term complications of surgical patent ductus arteriosus (PDA) ligations, the factors associated with those complications, and whether complications are associated with poor long-term outcomes. STUDY DESIGN: Retrospective cohort study of all extremely low birth weight (ELBW, < 1,000 g) infants who underwent surgical PDA ligation at a single-center neonatal intensive care unit from 1989 to 2015. Demographic, clinical, and laboratory data were reviewed. The primary outcome was development of a short-term (< 2 weeks from ligation) surgical complication. Secondary outcomes include bronchopulmonary dysplasia (BPD), length of stay, and mortality. RESULTS: A total of 180 ELBW infants were included; median gestational age and birth weight was 24 weeks and 683 g, respectively, and 44% of infants had at least one short-term complication. Need for vasopressors (33%) was the most common medical complication and vocal cord paralysis (9%) was the most common surgical complication. Younger corrected gestational age at time of repair was associated with increased risk for complications. Mortality, length of stay, and BPD rates were similar between infants with and without complications. CONCLUSION: Serious complications were seen in a minority of infants. Additional research is needed to determine if short-term complications are associated with long-term adverse outcomes.

Wearable Activity Tracker Use Among Australian Adolescents: Usability and Acceptability Study.

BACKGROUND: Wearable activity trackers have the potential to be integrated into physical activity interventions, yet little is known about how adolescents use these devices or perceive their acceptability. OBJECTIVE: The aim of this study was to examine the usability and acceptability of a wearable activity tracker among adolescents. A secondary aim was to determine adolescents' awareness and use of the different functions and features in the wearable activity tracker and accompanying app. METHODS: Sixty adolescents (aged 13-14 years) in year 8 from 3 secondary schools in Melbourne, Australia, were provided with a wrist-worn Fitbit Flex and accompanying app, and were asked to use it for 6 weeks. Demographic data (age, sex) were collected via a Web-based survey completed during week 1 of the study. At the conclusion of the 6-week period, all adolescents participated in focus groups that explored their perceptions of the usability and acceptability of the Fitbit Flex, accompanying app, and Web-based Fitbit profile. Qualitative data were analyzed using pen profiles, which were constructed from verbatim transcripts. RESULTS: Adolescents typically found the Fitbit Flex easy to use for activity tracking, though greater difficulties were reported for monitoring sleep. The Fitbit Flex was perceived to be useful for tracking daily activities, and adolescents used a range of features and functions available through the device and the app. Barriers to use included the comfort and design of the Fitbit Flex, a lack of specific feedback about activity levels, and the inability to wear the wearable activity tracker for water-based sports. CONCLUSIONS: Adolescents reported that the Fitbit Flex was easy to use and that it was a useful tool for tracking daily activities. A number of functions and features were used, including the device's visual display to track and self-monitor activity, goal-setting in the accompanying app, and undertaking challenges against friends. However, several barriers to use were identified, which may impact on sustained use over time. Overall, wearable activity trackers have the potential to be integrated into physical activity interventions targeted at adolescents, but both the functionality and wearability of the monitor should be considered.

Cranberries improve postprandial glucose excursions in type 2 diabetes.

Recent research supports a favorable role of cranberries on cardiometabolic health. Postprandial metabolism, especially hyperglycemia, has been shown to be an independent cardiovascular risk and few clinical studies have reported the role of berries in improving postprandial dysmetabolism. We investigated the postprandial effects of dried cranberries following a high-fat breakfast challenge in obese participants with type 2 diabetes (T2DM), in a randomized crossover trial. Blood draw and vascular measurements were conducted at fasting, 1, 2 and 4 hours (h), following the consumption of a fast-food style high-fat breakfast (70 g fat, 974 kcal) with or without cranberries (40 g). Analyses of our data (n = 25; BMI (kg m-2) (mean ± s.d.) = 39.5 ± 6.5; age (years) = 56 ± 6) revealed that postprandial increases in glucose were significantly lower in the cranberry vs. control at 2 & 4 h (p < 0.05). No significant differences were noted in insulin, insulin resistance evaluated by homeostasis model assessment, lipid profiles and blood pressure between the cranberry and control groups. Among the biomarkers of inflammation and oxidation, postprandial serum interleukin-18 and malondialdehyde were significantly lower at 4 h, and serum total nitrite was higher at 2 h in the cranberry vs. control group (all p < 0.05). No effects were noted on C-reactive protein or interlukin-6. Overall, dietary cranberries had notable effects in improving high-fat breakfast induced postprandial glucose and selected biomarkers of inflammation and oxidation in participants with T2DM. These findings provide evidence that adding whole cranberries to a high-fat meal may improve postprandial blood glucose management and warrant further investigation.

Special Circumstances and Populations.

Venous thromboembolism is a condition that includes both deep venous thrombosis and pulmonary embolism. Venous thromboembolism disease can result because of a combination of risk factors, including patient-related, treatment-related, and, more specifically, cancer-related factors. It is not disease-specific or a population-specific disorder, but it is more prevalent in certain specialty populations. This article will cover those specialty populations including cancer, pregnancy, and athletes.

Collaborating with obstetrical providers to promote infant safe sleep guidelines.

OBJECTIVES: To partner with obstetrical providers to increase promotion of the American Academy of Pediatrics guidelines for infant safe sleep. Specifically, this study evaluates the effectiveness of the Safe Sleep Toolkit during obstetrical visits. Secondary objectives include improving provider and maternal knowledge of safe sleep. METHODS: Obstetrical providers (n=11) and staff at an outpatient clinic were trained using the Safe Sleep Toolkit and encouraged to discuss infant safe sleep with pregnant women at their 28- or 36-week gestation appointment (n=111, 56 pre- and 55 post-intervention). Provider-reported time spent counseling women on safe sleep recommendations and safe sleep knowledge was measured before and after the intervention. Surveys were conducted with women assessing safe sleep knowledge, intention to follow guidelines, and whether safe sleep was discussed at the appointment. RESULTS: Significantly more post-intervention women reported their provider had discussed safe sleep (78% vs 32%) (P<.001). Similarly, provider-reported discussion with women increased significantly for all safe sleep guidelines (82%-90% vs 8%-12%) (all P<.001). Maternal knowledge, especially surrounding unsafe sleep practices, improved significantly post-intervention. CONCLUSION: Training obstetricians to use a toolkit to promote infant safe sleep guidelines increases the prenatal delivery of this information, and improves pregnant women's knowledge and intentions regarding safe infant sleep.

Validity of pain drawings for predicting psychological status outcome in patients with recurrent or chronic low back pain.

OBJECTIVES: To investigate the association between baseline pain drawings and future psychological status, and estimate the prognostic value of pain drawing assessment for predicting somatization, distress, and depression at one-year follow-up, in patients with recurrent or chronic low back pain (RCLBP). METHODS: This was a multi-center prospective cohort study of 138 patients with RCLBP. Participating patients completed at baseline and one-year follow-up: a blank pain drawing; the Modified Somatic Perceptions Questionnaire; modified Zung Depression Scale; and Distress and Risk Assessment Method. Pain drawings were analyzed quantitatively using the Pain Sites Score (PSS) and Simple Body Region (SBR) method. The association between baseline pain drawing assessment and one-year psychological status was estimated using correlation and Relative Risk (RR) statistics. RESULTS: We obtained complete data from 81 patients (59%). Psychological status and pain drawings did not differ significantly between completers and non-completers. Pain drawing area at baseline was associated with depression and somatization at one-year follow-up (Spearman's Rho 0.25, P = 0.022; 0.31 P = 0.006, respectively). Stronger associations resulted from analyses using the PSS, compared with the SBR. Patients with abnormal PSS pain drawings at baseline had significantly greater RR of depression (RR 6.1, 95% CI 1.1, 33.5), somatization (RR 4.1, 95% CI 1.7, 9.9) and distress (RR 6.8, 95% CI 1.9, 25.3) at one-year follow-up. DISCUSSION: These results provide the first evidence that abnormal baseline pain drawings predict greater risk of abnormal psychological states or poor psychological outcome at one-year follow-up, in patients with RCLBP.

7% Hypertonic saline in acute bronchiolitis: a randomized controlled trial.

BACKGROUND: Research suggests that hypertonic saline (HS) may improve mucous flow in infants with acute bronchiolitis. Data suggest a trend favoring reduced length of hospital stay and improved pulmonary scores with increasing concentration of nebulized solution to 3% and 5% saline as compared with 0.9% saline mixed with epinephrine. To our knowledge, 7% HS has not been previously investigated. METHODS: We conducted a prospective, double-blind, randomized controlled trial in 101 infants presenting with moderate to severe acute bronchiolitis. Subjects received either 7% saline or 0.9% saline, both with epinephrine. Our primary outcome was a change in bronchiolitis severity score (BSS), obtained before and after treatment, and at the time of disposition from the emergency department (ED). Secondary outcomes measured were hospitalization rate, proportion of admitted patients discharged at 23 hours, and ED and inpatient length of stay. RESULTS: At baseline, study groups were similar in demographic and clinical characteristics. The decrease in mean BSS was not statistically significant between groups (2.6 vs 2.4 for HS and control groups, respectively). The difference between the groups in proportion of admitted patients (42% in HS versus 49% in normal saline), ED or inpatient length of stay, and proportion of admitted patients discharged at 23 hours was not statistically significant. CONCLUSIONS: In moderate to severe acute bronchiolitis, inhalation of 7% HS with epinephrine does not appear to confer any clinically significant decrease in BSS when compared with 0.9% saline with epinephrine.

Regulation of adipose oestrogen output by mechanical stress.

Adipose stromal cells are the primary source of local oestrogens in adipose tissue, aberrant production of which promotes oestrogen receptor-positive breast cancer. Here we show that extracellular matrix compliance and cell contractility are two opposing determinants for oestrogen output of adipose stromal cells. Using synthetic extracellular matrix and elastomeric micropost arrays with tunable rigidity, we find that increasing matrix compliance induces transcription of aromatase, a rate-limiting enzyme in oestrogen biosynthesis. This mechanical cue is transduced sequentially by discoidin domain receptor 1, c-Jun N-terminal kinase 1, and phosphorylated JunB, which binds to and activates two breast cancer-associated aromatase promoters. In contrast, elevated cell contractility due to actin stress fibre formation dampens aromatase transcription. Mechanically stimulated stromal oestrogen production enhances oestrogen-dependent transcription in oestrogen receptor-positive tumour cells and promotes their growth. This novel mechanotransduction pathway underlies communications between extracellular matrix, stromal hormone output, and cancer cell growth within the same microenvironment.

Effect of a resident physician educational program on pediatric emergency department pharmacy interventions and medication errors.

PURPOSE: To determine the effects of a resident physician educational program in a pediatric emergency department (ED) on pharmacy interventions and medication errors, particularly dose adjustments, order clarifications, and adverse drug events (ADE). METHODS: The ED pharmacist recorded all interventions and medication errors on weekdays from 3 to 11 pm during a 9-month period, consisting of a preobservational (Quarter 1), observational (Quarter 2), and interventional (Quarter 3) phases. Program implementation occurred in Quarter 3, with an initial 3-hour lecture during the ED orientation, followed by daily patient case discussions. Weekly interventions and errors were analyzed using statistical process control u-chart analyses. Chi-square analyses of independence were also performed. Resident and ED staff feedback on the program was obtained through anonymous internet-based surveys. RESULTS: A total of 3507 interventions were recorded during the 9-month period. Chi-square approximation and interval estimation of odds ratio showed a statistically significant decrease between Quarters 1 and 3 in the number of dose adjustments (95% confidence interval [CI], 0.324-0.689) and order clarifications (95% CI, 0.137 to 0.382) after initiation of the program. The decline in ADE, while not as substantial (95% CI, 0.003 to 1.078), still achieved a level of significance (90% CI, 0.006 to 0.674). Survey results were positive toward the program. CONCLUSIONS: The implementation of a resident physician educational program in our pediatric ED significantly decreased the number of medication errors, increased resident physician awareness of the potential for errors, and increased ED pharmacist utilization.