Comparison of hospitalist service staffing models at Baylor University Medical Center.

Background: Baylor University Medical Center benefits from being a quaternary care center with 900+ licensed beds and multiple different models to staff patients on the hospitalist service. These models include hospitalist only, resident teaching teams, and two different advanced practice practitioner teams. The primary goal of this study was to assess these different staffing models and to ascertain which model, if any, has better outcomes related to length of stay, total hospital charges, 30-day readmission rates, patient satisfaction, hospital-acquired infections, mortality, and early discharges. Methods: The study was an observational retrospective chart review of all discharges from the hospitalist service at Baylor University Medical Center from October 1, 2021, to February 28, 2022. Patients were included if the hospitalist team was the primary team of record at the time of discharge. A total of 7803 patients were included. Results: There was no difference in patient satisfaction, hospital-acquired infections, and mortality between the groups. The teaching teams had a shorter length of stay before the removal of outliers. Independent advanced practice practitioners reliably had more patients discharged before 11:30 am. Results support the concept of continuity of care, as well as lower patient-to-provider ratios. Conclusions: These results have actionable implications that support the use of different advanced practice practitioner teams for the safe care of hospitalized patients as well as the safe integration of residents into patient care.

Oncofertility patient navigation: The frontlines of fertility and reproductive health care in cancer.

Oncofertility is an emerging field that incorporates diverse disciplines working together to care for oncology patients from birth to adulthood who are facing surgery, radiation therapy, or chemotherapy that may impact their fertility potential and reproductive function. Providing this care to newly diagnosed oncology patients in an expedited manner can be challenging. There is currently a paucity of published data about how this care is provided, training and education of individuals providing this care, and patient-reported outcomes related specifically to oncofertility care. The role of the oncofertility patient navigator is to bridge the institutional and disciplinary boundaries so oncology patients of all ages can receive timely information regarding fertility risk and preservation options at diagnosis and throughout survivorship care. The purpose of this paper is to define the role of the oncofertility patient navigator within diverse models of care and health care systems, and provide a framework for ongoing efforts to improve reproductive care for those affected by cancer in their years of child-bearing potential.

Retention of Biomedical Knowledge in Medical Students Predicts USMLE Step 1 Scores.

This article was migrated. The article was marked as recommended. Introduction Medical students are tasked with learning a vast amount of medical knowledge prior to sitting for the USMLE Step 1 exam, a portion of which is either forgotten or becomes inaccessible to memory following each exam. In this study we examined whether accessibility and retention of 1 st-year biochemistry content predicts performance on high stakes exams such as USMLE Step1. Methods First-year medical students were retested on a subset of biochemistry final exam items 10.5 months after sitting for the original exam. Retention was measured as a percentage of the original final exam score. Availability of information was measured with cued recall (i.e., selecting from a list the multiple-choice distractors), while accessibility of information was captured through free recall (without the aid of multiple choice distractors). Results As expected, we found that free recall rates were much lower than cued recall rates, but that students who scored higher on Step 1 had a smaller gap between cued and free recall scores, demonstrating a greater ability to access information than lower-scoring students. Importantly, we also demonstrate that higher-scoring students retained a higher percentage of the original biochemistry material than lower-performing students after 10.5 months, and that the amount information retained in memory was associated with higher scores on Step 1, demonstrating the potential importance of teaching medical school content with the intention of making it stick, especially in students who are not as strong academically. Conclusion The methods employed in this study are straightforward and can be used to compare retention and accessibility of information across medical school courses, and may serve as a guide to curriculum and pedagogical improvements.

Does sleep protect memories against interference? A failure to replicate.

Across a broad spectrum of memory tasks, retention is superior following a night of sleep compared to a day of wake. However, this result alone does not clarify whether sleep merely slows the forgetting that would otherwise occur as a result of information processing during wakefulness, or whether sleep actually consolidates memories, protecting them from subsequent retroactive interference. Two influential studies suggested that sleep protects memories against the subsequent retroactive interference that occurs when participants learn new yet overlapping information (interference learning). In these studies, interference learning was much less detrimental to memory following a night of sleep compared to a day of wakefulness, an indication that sleep supports this important aspect of memory consolidation. In the current replication study, we repeated the protocol of and, additionally, we examined the impact of intrinsic motivation on performance in sleep and wake participants. We were unable to replicate the finding that sleep protects memories against retroactive interference, with the detrimental effects of interference learning being essentially the same in wake and sleep participants. We also found that while intrinsic motivation benefitted task acquisition it was not a modulator of sleep-wake differences in memory processing. Although we cannot accept the null hypothesis that sleep has no role to play in reducing the negative impact of interference, the findings draw into question prior evidence for sleep's role in protecting memories against interference. Moreover, the current study highlights the importance of replicating key findings in the study of sleep's impact on memory processing before drawing strong conclusions that set the direction of future research.

The Relationship Between Body Mass Index and Fluoroscopy Time During Intraarticular Hip Injection: A Multicenter Cohort Study.

BACKGROUND: Higher body mass index (BMI) is associated with difficulty in obtaining imaging studies. While there is a small body of literature regarding the relationship between fluoroscopy time and BMI during injections for pain management, this has not been studied for intraarticular (IA) hip injections. Further, in academic training centers, trainee involvement may affect this relationship. OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during IA hip injections, both with and without involvement of a trainee. STUDY DESIGN: Multicenter retrospective cohort study. SETTING: Three academic, outpatient musculoskeletal and pain medicine centers. METHODS: Patients who underwent fluoroscopically guided IA hip injections with encounter data regarding fluoroscopy time during the procedure and BMI were included. Mean and standard deviation fluoroscopy time were recorded. Comparisons were made between BMI categories of normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), and obese (greater than or equal to30.0 kg/m2). Statistical significance was set at P = 0.01 due to multiple comparisons. RESULTS: A total of 559 IA hip injections are represented in this cohort. Patients had a mean age of 58 (standard deviation [SD] 14) years and 63% were women. There was no significant difference in fluoroscopy time when comparing BMI categories (P = 0.02). However, when trainees were not involved in the injection, fluoroscopy times were significantly shorter with decreasing BMI category, with normal weight patients requiring the shortest fluoroscopy times (P = 0.01). LIMITATIONS: This study evaluated total fluoroscopy time, not radiation dose exposure per injection, which provides more direct and precise information with regard to provider and patient radiation exposure and overall safety. Future study of the impact of BMI on radiation dose during fluoroscopically guided IA hip injections is needed. CONCLUSIONS: Fluoroscopy times during IA hip injections increase with higher BMI categories in a statistically significant manner when performed by experienced clinicians but this relationship is not observed when injections are performed with a trainee in a teaching institution. This finding appears to be related to longer fluoroscopy time required to complete an IA hip injection in patients with lower BMI when a trainee is involved. KEY WORDS: Hip, injections, obesity, overweight, body mass index, fluoroscopy, radiation, pain.

Pain Reduction and Repeat Injections After Transforaminal Epidural Injection With Particulate Versus Nonparticulate Steroid for the Treatment of Chronic Painful Lumbosacral Radiculopathy.

BACKGROUND: The corticosteroid choice for a lumbar transforaminal epidural steroid injection (TFESI) remains controversial. Whether to utilize particulate or nonparticulate steroid preparations for these injections remains an unanswered question in the literature. OBJECTIVE: To determine if a particulate or nonparticulate steroid is more effective in the treatment of electromyography (EMG)-confirmed lumbosacral radiculopathy. DESIGN: Multicenter retrospective cohort study. SETTING: Two tertiary academic spine centers. PATIENTS: Consecutive patients, aged 18 years or older, with EMG-confirmed lumbosacral radiculopathy. INTERVENTIONS: TFESI with a particulate or nonparticulate steroid to treat radicular pain within 6 months of EMG. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients with ≥50% pain reduction on the numerical rating scale after TFESI. Secondary outcomes included mean numerical rating scale score reduction and number of repeat TFESIs. Short-term (<30 days) and intermediate (≥30 days) outcomes were compared between patients who received a TFESI with a particulate versus nonparticulate steroid. RESULTS: Seventy-eight patients, with an age ± standard deviation of 56 ± 16 years and a mean symptom duration of 49 ± 71 months, were included. Forty-one patients (52%) received dexamethasone, 23 (30%) received triamcinolone, and 14 (18%) received betamethasone. There was no statistically significant difference in the proportion of patients who reported ≥50% pain reduction between the particulate and nonparticulate groups at short-term follow-up (35%; 95% confidence interval [CI], 21-51 versus 28%; 95% CI, 13-43) or at intermediate follow-up (40%; 95% CI, 21-59 versus 39%; 95% CI, 19-59). There was no difference in the mean number of injections administered between groups at intermediate follow-up (P = .26). CONCLUSIONS: This study demonstrates no significant differences in pain reduction or the number of repeat injections with particulate compared with nonparticulate transforaminal epidural steroid injection in patients with EMG-confirmed painful lumbosacral radiculopathy. These findings suggest a new population for whom nonparticulate steroid appears to be an appropriate first-line therapy, although confirmation with a randomized study is needed. LEVEL OF EVIDENCE: III.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Sacroiliac Joint Injection? A Multicenter Cohort Study.

OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during intra-articular sacroiliac joint (SIJ) injections performed for a pain indication. DESIGN: Multicenter retrospective cohort study. SETTING: Three academic, outpatient pain treatment centers. SUBJECTS: Patients who underwent fluoroscopy guided SIJ injection with encounter data regarding fluoroscopy time during the procedure and body mass index (BMI). MAIN OUTCOME MEASURE: Median and 25-75% Interquartile Range (IQR) fluoroscopy time. RESULTS: 459 SIJ injections (350 patients) were included in this study. Patients had a median age of 57 (IQR 44, 70) years, and 72% were female. The median BMI in the normal weight, overweight, and obese groups were 23 (IQR 21, 24), 27 (IQR 26, 29), and 35 (IQR 32, 40), respectively. There was no significant difference in the median fluoroscopy time recorded between these BMI classes (p = 0.45). First-time SIJ injection (p = 0.53), bilateral injection (p = 0.30), trainee involvement (p = 0.47), and new trainee involvement (trainee participation during the first 2 months of the academic year) (p = 0.85) were not associated with increased fluoroscopy time for any of the three BMI categories. CONCLUSIONS: Fluoroscopy time during sacroiliac joint injection is not increased in patients who are overweight or obese, regardless of whether a first-time sacroiliac joint injection was performed, bilateral injections were performed, a trainee was involved, or a new trainee was involved.

Does Electrodiagnostic Confirmation of Radiculopathy Predict Pain Reduction after Transforaminal Epidural Steroid Injection? A Multicenter Study.

OBJECTIVE: Minimal definitive literature identifies patients with radicular pain who would benefit most from epidural steroid injection (ESI). This study investigated if electromyographic (EMG) confirmation of radiculopathy with active or chronic denervation predicts a positive treatment outcome following ESI. DESIGN: Longitudinal cohort study of adults who underwent EMG and subsequent transforaminal ESI within 6 months. The proportion of individuals who experienced >50% pain relief and mean change in daily morphine equivalents (DME) were calculated. RESULTS: 170 individuals with respective mean (Standard Deviation) age and duration of symptoms of 55 (15) years and 36 (56) months were included. Mean time to <30 day and >30 day follow-up post-injection were 18 (6) and 99 (130) days, respectively. At >30 day follow-up, a larger proportion of EMG-confirmed individuals (37.7%) reported >50% pain reduction compared to EMG-negative individuals (17.8%) (p=0.03). This was significant for lumbosacral (40% vs. 15%, p=0.01) but not cervical symptoms (p>0.05). Mean decrease in DME at long-term follow-up in EMG-confirmed compared to EMG-negative individuals trended toward significance (-4 vs. -1, p=0.11). There was no significant relationship between myotomal spontaneous activity and pain or opioid use. CONCLUSIONS: Needle EMG predicts long-term pain reduction from transforaminal ESI in patients with lumbosacral radiculopathy, regardless of the presence of active denervation.

Short-Term Functional, Emotional, and Pain Outcomes of Patients with Complex Regional Pain Syndrome Treated in a Comprehensive Interdisciplinary Pain Management Program.

BACKGROUND: Complex regional pain syndrome (CRPS) is difficult to effectively treat with unimodal approaches. OBJECTIVE: To investigate whether CRPS can be effectively treated in a comprehensive interdisciplinary pain management program. DESIGN: Observational cohort study of 49 patients aged 18-89 who fulfilled 'Budapest Criteria' for CRPS and completed an interdisciplinary pain management program. Preprogram to postprogram changes in physical functioning, perceived disability, emotional functioning, acceptance, coping, and pain were assessed. The measures used included: Pain Disability Index, Six minute walk test, 2-minute sit-to-stand, Numerical Rating Scale, Center for Epidemiologic Studies Depression Scale, Pain Anxiety Symptoms Scale, Chronic Pain Acceptance Questionnaire, Coping Strategies Questionnaire-Revised, RIC- Multidimensional Patient Global Impression of Change (RIC-MPGIC), and Medication Quantification Scale. For worker's compensation patients, the rate of successful release to work at the end of the program was calculated. RESULTS: Results indicated significant improvements in physical functioning and perceived disability (P's<0.001). Patients reported increased usage of an adaptive coping strategy, distraction (P = 0.010), and decreased usage of maladaptive and passive strategies (P's < 0.001). Patients showed greater chronic pain acceptance (P's ≤ 0.010) and reductions in emotional distress (P's < 0.001). Medication usage at 1-month follow-up was significantly reduced compared to program start (P < 0.001) and discharge (P = 0.004). Patients reported "much improvement" in overall functioning, physical functioning, mood, and their ability to cope with pain and flare-ups (RIC-MPGIC). Patient report of pain was not significantly reduced at discharge (P =0.078). Fourteen (88%) of 16 total worker's compensation patients were successfully released to work at the end of the program. CONCLUSIONS: This study demonstrates short-term improvements in physical and emotional functioning, pain coping, and medication usage. These findings are consistent with the rehabilitation philosophy of improving functioning and sense of well-being as of equal value and relevance to pain reduction.

Fecal microbiota transplantation in patients with cancer undergoing treatment.

Fecal microbiota transplantation (FMT) is a technique used to restore the normal body flora to the gut in cases of Clostridium difficile infection (CDI). It involves instillation of the stool of a healthy donor through a nasogastric tube or colonoscopy into the gastrointestinal tract of the patient. More research is needed to determine the parameters of FMT use in patients with cancer.

Glycosylation-related genes in NS0 cells are insensitive to moderately elevated ammonium concentrations.

NS0 and Chinese hamster ovary (CHO) cell lines are used to produce recombinant proteins for human therapeutics; however, ammonium accumulation can negatively impact cell growth, recombinant protein production, and protein glycosylation. To improve product quality and decrease costs, the relationship between ammonium and protein glycosylation needs to be elucidated. While ammonium has been shown to adversely affect glycosylation-related gene expression in CHO cells, NS0 studies have not been performed. Therefore, this study sought to determine if glycosylation in NS0 cells were ammonium-sensitive at the gene expression level. Using a DNA microarray that contained mouse glycosylation-related and housekeeping genes, these genes were analyzed in response to various culture conditions - elevated ammonium, elevated salt, and elevated ammonium with proline. Surprisingly, no significant differences in gene expression levels were observed between the control and these conditions. Further, the elevated ammonium cultures were analyzed using real-time quantitative reverse transcriptase PCR (qRT-PCR) for key glycosylation genes, and the qRT-PCR results corroborated the DNA microarray results, demonstrating that NS0 cells are ammonium-insensitive at the gene expression level. Since NS0 are known to have elevated nucleotide sugar pools under ammonium stress, and none of the genes directly responsible for these metabolic pools were changed, consequently cellular control at the translational or substrate-level must be responsible for the universally observed decreased glycosylation quality under elevated ammonium.

Glycosylation and post-translational modification gene expression analysis by DNA microarrays for cultured mammalian cells.

DNA microarray analysis of gene expression has become a valuable tool for bioprocessing research aimed at improving therapeutic protein yields. The highly parallel nature of DNA microarray technology allows researchers to assess hundreds of gene simultaneously, essentially enabling genome-wide snapshots. The quality and amount of therapeutic proteins produced by cultured mammalian cells rely heavily on the culture environment. In order to implement beneficial changes to the culture environment, a better understanding of the relationship between the product quality and culture environment must be developed. By analyzing gene expression levels under various environmental conditions, light can be shed on the underlying mechanisms. This paper describes a method for evaluating gene expression changes for cultured NS0 cells, a mouse-derived myeloma cell line, under culture environment conditions, such as ammonia buildup, known to affect product quality. These procedures can be easily adapted to other environmental conditions and any mammalian cell lines cultured in suspension, so long as a sufficient number of gene sequences are publicly available.

Improving heart failure symptom recognition: a diary analysis.

BACKGROUND: Heart failure (HF) is a costly and highly disabling syndrome affecting nearly 5 million individuals yearly. Lifestyle changes are crucial to the successful management of HF, and daily weight monitoring is an essential component of self-care. Daily weights provide an objective indicator of fluid volume status in patients with HF. However, the practice of performing daily weights is underappreciated and infrequently implemented by patients. This may contribute to an inability to recognize worsening HF and, ultimately, delay in seeking medical care. OBJECTIVE: The aim of this study was to evaluate weight monitoring diaries for adherence to daily weight monitoring, reasons for nonadherence, prevalence of weight gain of 3 lb or more in 1 day, and medical advice-seeking behavior after weight gain in a sample of patients with documented HF. METHODS: A cohort study design was used to analyze data from 20 HF patients who participated in a tailored, one-on-one educational intervention. The analysis is part of a parent pilot study designed to improve symptom recognition and response to symptoms of fluid overload. Diary data were collected for 3 months after the intervention. The diaries provided information regarding symptoms that participants experienced, daily weights, and a record of unplanned hospital visits or contacts with their physician. RESULTS: Of 20 participants in the study, 16 returned diaries for analysis. Two participants withdrew participation before the conclusion of the study and 2 participants who claimed to have completed their diary never returned the diary despite repeated reminders and telephone calls. Sixteen participant diaries were therefore available for analysis. The mean adherence score for these 16 participants was 79.4%. Seventy-five percent had weight gains of 3 lb or more in 1 day and only 1 person contacted his/her physician for weight gain. Vacation time was the most common reason for weighing nonadherence. CONCLUSION: This study revealed high adherence to daily weights in patients receiving an education session focused on fluid weight management. However, behavior related to daily weights did not lead to more appropriate use of physician or provider consultation. Diaries offer promise for symptom management and an opportunity for patients to engage in self-care; however, clinicians need to encourage patients to use the diary data to seek prompt medical care.