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Nat Commun ; 11(1): 5493, 2020 10 30.
Artigo em Inglês | MEDLINE | ID: mdl-33127906

RESUMO

The relationship between SARS-CoV-2 viral load and risk of disease progression remains largely undefined in coronavirus disease 2019 (COVID-19). Here, we quantify SARS-CoV-2 viral load from participants with a diverse range of COVID-19 disease severity, including those requiring hospitalization, outpatients with mild disease, and individuals with resolved infection. We detected SARS-CoV-2 plasma RNA in 27% of hospitalized participants, and 13% of outpatients diagnosed with COVID-19. Amongst the participants hospitalized with COVID-19, we report that a higher prevalence of detectable SARS-CoV-2 plasma viral load is associated with worse respiratory disease severity, lower absolute lymphocyte counts, and increased markers of inflammation, including C-reactive protein and IL-6. SARS-CoV-2 viral loads, especially plasma viremia, are associated with increased risk of mortality. Our data show that SARS-CoV-2 viral loads may aid in the risk stratification of patients with COVID-19, and therefore its role in disease pathogenesis should be further explored.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/virologia , Pneumonia Viral/virologia , Adulto , Idoso , Anticorpos Antivirais/sangue , Betacoronavirus/genética , Betacoronavirus/crescimento & desenvolvimento , Biomarcadores/sangue , Proteína C-Reativa , Infecções por Coronavirus/sangue , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/patologia , Feminino , Hospitalização , Humanos , Inflamação/sangue , Inflamação/virologia , Interleucina-6/sangue , Estudos Longitudinais , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/mortalidade , Pneumonia Viral/patologia , RNA Viral/sangue , Índice de Gravidade de Doença , Carga Viral , Viremia/sangue , Viremia/virologia
15.
J Grad Med Educ ; 11(5): 535-542, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31636823

RESUMO

Background: Generalists who pursue research-intensive fellowships develop research skills and mentor-mentee relationships. Whether gender disparities in retention and promotion exist among this research-trained cohort is understudied. Objective: We measured whether disparities exist among graduates of research-intensive fellowships and how mentorship influences them. Methods: We surveyed generalists (internal medicine, pediatrics, family medicine, combined internal medicine-pediatrics) between July and August 2016 who graduated from research-intensive fellowships. Generalists ("mentees") were asked whether they remained or were promoted, and to name up to 10 influential mentors during or within 5 years of fellowship. Multivariable logistic regression estimated associations between mentee gender and retention and promotion. Next, we separately included 3 network characteristics: (1) mentee degrees (number of mentors reported per mentee); (2) mean mentor betweenness centrality (importance of each mentor within the network); and (3) largest community membership (mentee status in the largest interconnected mentor-mentee group within the network). All models adjusted for generalists' race, specialty, fellowship institution, and publications. Results: One hundred sixty-two graduates (51%) representing 19 institutions responded. In adjusted analyses, compared to men, women were as likely to remain in academic medicine (odds ratio [OR] 1.88; 95% confidence interval [CI] 0.72-4.89; P = .20), but less likely to be promoted within 5 years of fellowship (OR 0.26; 95% CI 0.09-0.80; P = .018). Inclusion of network measures did not alter these associations. Conclusions: Despite remaining in academic medicine as frequently as their male counterparts, fellowship-trained women were promoted less often. Features of mentors, measured using network analysis, may not explain these observed differences.


Assuntos
Mobilidade Ocupacional , Bolsas de Estudo/estatística & dados numéricos , Fatores Sexuais , Escolha da Profissão , Docentes de Medicina , Feminino , Humanos , Masculino , Mentores/estatística & dados numéricos , Inquéritos e Questionários
16.
JAMA Intern Med ; 2019 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-31633744
17.
J Am Coll Cardiol ; 73(25): 3243-3255, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31248544

RESUMO

BACKGROUND: Lower socioeconomic status (SES) associates with a higher risk of major adverse cardiac events (MACE) via mechanisms that are not well understood. OBJECTIVES: Because psychosocial stress is more prevalent among those with low SES, this study tested the hypothesis that stress-associated neurobiological pathways involving up-regulated inflammation in part mediate the link between lower SES and MACE. METHODS: A total of 509 individuals, median age 55 years (interquartile range: 45 to 66 years), underwent clinically indicated whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging and met pre-defined inclusion criteria, including absence of known cardiovascular disease or active cancer. Baseline hematopoietic tissue activity, arterial inflammation, and in a subset of 289, resting amygdalar metabolism (a measure of stress-associated neural activity) were quantified using validated 18F-fluorodeoxyglucose positron emission tomography/computed tomography methods. SES was captured by neighborhood SES factors (e.g., median household income and crime). MACE within 5 years of imaging was adjudicated. RESULTS: Over a median 4.0 years, 40 individuals experienced MACE. Baseline income inversely associated with amygdalar activity (standardized ß: -0.157 [95% confidence interval (CI): -0.266 to -0.041]; p = 0.007) and arterial inflammation (ß: -0.10 [95% CI: -0.18 to -0.14]; p = 0.022). Further, income associated with subsequent MACE (standardized hazard ratio: 0.67 [95% CI: 0.47 to 0.96]; p = 0.029) after multivariable adjustments. Mediation analysis demonstrated that the path of: ↓ neighborhood income to ↑ amygdalar activity to ↑ bone marrow activity to ↑ arterial inflammation to ↑ MACE was significant (ß: -0.01 [95% CI: -0.06 to -0.001]; p < 0.05). CONCLUSIONS: Lower SES: 1) associates with higher amygdalar activity; and 2) independently predicts MACE via a serial pathway that includes higher amygdalar activity, bone marrow activity, and arterial inflammation. These findings illuminate a stress-associated neurobiological mechanism by which SES disparities may potentiate adverse health outcomes.


Assuntos
Tonsila do Cerebelo/fisiopatologia , Arterite/etiologia , Cardiopatias/etiologia , Classe Social , Estresse Psicológico/complicações , Adulto , Idoso , Tonsila do Cerebelo/diagnóstico por imagem , Arterite/diagnóstico por imagem , Arterite/psicologia , Feminino , Fluordesoxiglucose F18 , Cardiopatias/psicologia , Hematopoese , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons , Estudos Retrospectivos , Estresse Psicológico/diagnóstico por imagem , Estresse Psicológico/fisiopatologia
18.
J Gen Intern Med ; 34(11): 2586-2591, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31197729

RESUMO

Discussing the uncertainty associated with a clinical decision is thought to be a critical element of shared decision-making. Yet, empirical evidence suggests that clinicians rarely communicate clinical uncertainty to patients, and indeed the culture within healthcare environments is often to equate uncertainty with ignorance or failure. Understanding the rationale for discussion of uncertainty along with the current evidence about approaches to communicating and managing uncertainty can advance shared decision-making as well as highlight gaps in evidence. With an increasing focus on personalized healthcare, and advances in genomics and new disease biomarkers, a more sophisticated understanding of how to communicate the limitations and errors that come from applying population-based, epidemiologic findings to predict individuals' futures is going to be essential. This article provides a narrative review of studies relating to the communication of uncertainty, highlighting current strategies together with challenges and barriers, and outlining a framework for future research.


Assuntos
Tomada de Decisão Compartilhada , Assistência Centrada no Paciente/métodos , Relações Médico-Paciente , Incerteza , Revelação , Humanos , Pesquisa/tendências
19.
Diagnosis (Berl) ; 6(3): 269-276, 2019 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-30753157

RESUMO

Background Communication and handoff failures are common causes of diagnostic errors in hospital. Human quest for certainty can increase the likelihood of premature closure in decision-making, the most common phenomenon in misdiagnosis. Little research exists on whether language choice in handoffs affects physicians' sense of uncertainty. Methods Medical students from a large US medical school were randomized to receive one of four language variations describing a presumed diagnosis in hypothetical handoffs from emergency department (ED) to inpatient ward. The control language arm used the word 'diagnosis'; experimental arms replaced this word with either 'hypothesis', 'probability of 60%', or 'working diagnosis' with a short differential. Outcome measures were students' anxiety due to uncertainty (range 5-30; higher scores indicating higher stress from uncertainty) and clinical uncertainty about the ED provider's presumed diagnosis. Results Mean anxiety due to uncertainty was significantly higher in subjects receiving the 'hypothesis' language arm compared to those receiving the control 'diagnosis' language [19.2 (4.6) vs. 15.5 (3.4); p<0.008]. Differences between subjects who received the probability language [17.2 (5.8) vs. 15.5 (3.4); p=0.26] and 'working diagnosis' language [16 (5) vs. 15.5 (3.4); p=0.69] were not statistically significant. There was no difference in items assessing clinical uncertainty after each scenario. Conclusions The word 'hypothesis' increased anxiety due to uncertainty compared to the word 'diagnosis', but did not change assessments of clinical uncertainty. Further research is needed to assess how use of language in clinical handoffs may influence perceptions and anxiety related to uncertainty and whether optimal language can be identified that leads to recognition of uncertainty without maladaptive stress or anxiety due to uncertainty.


Assuntos
Ansiedade/psicologia , Comunicação , Idioma , Transferência da Responsabilidade pelo Paciente/normas , Estudantes de Medicina/psicologia , Incerteza , Adulto , Tomada de Decisão Clínica , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino
20.
Healthc (Amst) ; 7(4)2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30744992

RESUMO

BACKGROUND: As physician groups consolidate and value-based payment replaces traditional fee-for-service systems, physician practices have greater need to accurately measure individual physician clinical productivity within team-based systems. We compared methodologies to measure individual physician outpatient clinical productivity after adjustment for shared practice resources. METHODS: For cardiologists at our hospital between January 2015 and June 2016, we assessed productivity by examining completed patient visits per clinical session per week. Using mixed-effects models, we sequentially accounted for shared practice resources and underlying baseline characteristics. We compared mixed-effects and Generalized Estimating Equations (GEE) models using K-fold cross validation, and compared mixed-effect, GEE, and Data Envelopment Analysis (DEA) models based on ranking of physicians by productivity. RESULTS: A mixed-effects model adjusting for shared practice resources reduced variation in productivity among providers by 63% compared to an unadjusted model. Mixed-effects productivity rankings correlated strongly with GEE rankings (Spearman 0.99), but outperformed GEE on K-fold cross validation (root mean squared error 2.66 vs 3.02; mean absolute error 1.89 vs 2.20, respectively). Mixed-effects model rankings had moderate correlation with DEA model rankings (Spearman 0.692), though this improved upon exclusion of outliers (Spearman 0.755). CONCLUSIONS: Mixed-effects modeling accounts for significant variation in productivity secondary to shared practice resources, outperforms GEE in predictive power, and is less vulnerable to outliers than DEA. IMPLICATIONS: With mixed-effects regression analysis using otherwise easily accessible administrative data, practices can evaluate physician clinical productivity more fairly and make more informed management decisions on physician compensation and resource allocation.

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