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INTRODUCTION: Despite national policy changes, perspective changes on pregnancy and parenting in training are often lacking. We evaluated current viewpoints regarding pregnancy, parenthood, leave needs, and perceptions of support across trainees at our institution. METHODS: A cross-sectional survey was sent to all residents and fellows at a tertiary care academic center with >700 trainees. Demographic information, opinions on maternity and paternity leave, and opinions on institutional support and career goals were collected. The survey was sent via the Graduate Medical Education Office listserv -- 66 Accreditation Council for Graduate Medical Education (ACGME) programs and 40 non-ACGME programs. RESULTS: Seven hundred and forty-seven house officers received the survey with a response rate of 21.9% (n = 164). Of respondents, 81% were residents and 99 respondents were female (representing 31% of female trainees at our institution). Thirty-seven point two percent of respondents reported being parents. Twenty-five point three percent of respondents had been pregnant while a trainee with no statistical difference by specialty type (P = 0.0817). Statistically significant difference was noted in having children based on sex with men becoming parents at twice the rate of women (56% vs 26%, P < 0.001). No difference was noted between specialties on perceived support while pregnant and peripartum. Thirty percent of parent respondents reported thinking about leaving medical training after having children given family stressors. Statistical difference in thoughts of leaving medicine overall between females (46%) and males (17.6%; P = 0.0238). CONCLUSIONS: Men and women need support as they navigate becoming parents at a naturally stressful transition period. Females consider leaving medicine at twice the rate of males after becoming parents. Our institution and other ACGME programs need greater transparency and consistent leave practices that reflect changing times.
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Internato e Residência , Masculino , Criança , Humanos , Feminino , Gravidez , Estudos Transversais , Desenvolvimento Psicológico , Licença Parental , Educação de Pós-Graduação em Medicina , Inquéritos e QuestionáriosRESUMO
The occurrence of chemotherapy-resistant tumors makes ovarian cancer (OC) the most lethal gynecological malignancy. While many factors may contribute to chemoresistance, the mechanisms responsible for regulating tumor vulnerability are under investigation. Our analysis of gene expression data revealed that Sab, a mitochondrial outer membrane (MOM) scaffold protein, was down-regulated in OC patients. Sab-mediated signaling induces cell death, suggesting that this apoptotic pathway is diminished in OC. We examined Sab expression in a panel of OC cell lines and found that the magnitude of Sab expression correlated to chemo-responsiveness; wherein, OC cells with low Sab levels were chemoresistant. The Sab levels were reflected by a corresponding amount of stress-induced c-Jun N-terminal kinase (JNK) on the MOM. BH3 profiling and examination of Bcl-2 and BH3-only protein concentrations revealed that cells with high Sab concentrations were primed for apoptosis, as determined by the decrease in pro-survival Bcl-2 proteins and an increase in pro-apoptotic BH3-only proteins on mitochondria. Furthermore, overexpression of Sab in chemoresistant cells enhanced apoptotic priming and restored cellular vulnerability to a combination treatment of cisplatin and paclitaxel. Contrariwise, inhibiting Sab-mediated signaling or silencing Sab expression in a chemosensitive cell line resulted in decreased apoptotic priming and increased resistance. The effects of silencing on Sab on the resistance to chemotherapeutic agents were emulated by the silencing or inhibition of JNK, which could be attributed to changes in Bcl-2 protein concentrations induced by sub-chronic JNK inhibition. We propose that Sab may be a prognostic biomarker to discern personalized treatments for OC patients.
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Proteínas Adaptadoras de Transdução de Sinal/genética , Antineoplásicos/farmacologia , Apoptose/efeitos dos fármacos , Regulação Neoplásica da Expressão Gênica/efeitos dos fármacos , Neoplasias Ovarianas/genética , Proteínas Adaptadoras de Transdução de Sinal/metabolismo , Apoptose/genética , Biomarcadores Tumorais/genética , Biomarcadores Tumorais/metabolismo , Linhagem Celular Tumoral , Feminino , Humanos , Proteínas Quinases JNK Ativadas por Mitógeno/genética , Proteínas Quinases JNK Ativadas por Mitógeno/metabolismo , Proteínas Mitocondriais/genética , Proteínas Mitocondriais/metabolismo , Neoplasias Ovarianas/metabolismo , Neoplasias Ovarianas/patologia , Transdução de Sinais/efeitos dos fármacos , Transdução de Sinais/genéticaRESUMO
CASE: A 12-year-old girl presented with significant right elbow pain following a fall during soccer which caused an osseous triceps avulsion injury and nondisplaced type II Salter-Harris radial neck fracture. The patient was treated with successful open repair utilizing suture anchor fixation, resulting in full return of function and return to previous activities. CONCLUSION: Timely and accurate diagnosis and treatment of displaced triceps sleeve avulsion injuries is critical and can result in excellent patient outcomes and return to previous functional level. This unique case contributes to the diagnosis and management of this rare condition in pediatric populations.
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Lesões no Cotovelo , Humanos , Feminino , Criança , Fraturas do Rádio/cirurgia , Fraturas do Rádio/diagnóstico por imagem , Fratura Avulsão/cirurgia , Fratura Avulsão/diagnóstico por imagem , Âncoras de SuturaRESUMO
OBJECTIVES: This resident-driven quality improvement project aimed to better understand the known problem of a misaligned clinical decision support (CDS) strategy and improve CDS utilization. METHODS: An internal survey was sent to all internal medicine (IM) residents to identify the most bothersome CDS alerts. Survey results were supported by electronic health record (EHR) data of CDS firing rates and response rates which were collected for each of the three most bothersome CDS tools. Changes to firing criteria were created to increase utilization and to better align with the five rights of CDS. Findings and proposed changes were presented to our institution's CDS Governance Committee. Changes were approved and implemented. Postintervention firing rates were then collected for 1 week. RESULTS: Twenty nine residents participated in the CDS survey and identified sepsis alerts, lipid profile reminders, and telemetry renewals to be the most bothersome alerts. EHR data showed action rates for these CDS as low as 1%. We implemented changes to focus emergency department (ED)-based sepsis alerts to the right provider, better address the right information for lipid profile reminders, and select the right time in workflow for telemetry renewals to be most effective. With these changes we successfully eliminated ED-based sepsis CDS reminders for IM providers, saw a 97% reduction in firing rates for the lipid profile CDS, and noted a 55% reduction in firing rates for telemetry CDS. CONCLUSION: This project highlighted that alert improvements spearheaded by resident teams can be completed successfully using robust CDS governance strategies and can effectively optimize interruptive alerts.
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Sistemas de Apoio a Decisões Clínicas , Internato e Residência , Humanos , Registros Eletrônicos de Saúde , Inquéritos e QuestionáriosRESUMO
Evaluating patients with a traumatic spinal cord injury can be complicated by other injuries. In this case, a 24-year-old woman injured by a needlefish presented with combined motor and sensory defects, cranial nerve deficits, and a blunt vascular injury. This case highlights the importance of neurologic and vascular localizations and an understanding of spinal cord injuries involving various ascending and descending tracts. Appreciation of these anatomical considerations through this case illustrates the diagnostic approach to neurologic evaluation. While we present a traumatic etiology for multiple neurologic syndromes, this case gives readers an opportunity to develop a comprehensive differential diagnosis and tailor investigations for other relevant etiologies. Readers walking through this stepwise process will ultimately arrive at several distinct but related diagnoses.
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Beloniformes , Lesões do Pescoço , Traumatismos da Medula Espinal , Ferimentos Penetrantes , Feminino , Animais , Humanos , Adulto Jovem , Adulto , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/diagnóstico por imagem , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico por imagem , Lesões do Pescoço/complicações , Lesões do Pescoço/diagnóstico por imagem , Raciocínio ClínicoRESUMO
Previous studies on pain experiences in retired contract sport athletes have been cross-sectional, leaving gaps in our understanding of the evolution of pain interference (PI) and factors that influence trajectories decades after sport discontinuation. This study investigated the longitudinal course of PI in former male National Football League (NFL) players over a 19-year period following sport discontinuation and examined factors influencing overall levels and trajectories of PI. Former NFL players completed health surveys in 2001, 2010, and 2019, with PI ratings measured using the 36-Item Short Form Health Survey (2001 and 2010) and the Patient-Reported Outcomes Measurement Information System (2019). Unconditional latent growth curve models analyzed overall PI severity and trajectories. Conditional latent growth curve models explored the influence of musculoskeletal injuries, osteoarthritis (OA), and depression diagnosis on PI. Over 19 years (N = 338; mean age = 48.96 ± 9.35), PI significantly increased (slope = .179, P < .001; mean Patient-Reported Outcomes Measurement Information System PI t-scores 2001 = 54.19, 2010 = 54.64, 2019 = 57.38). Cumulative musculoskeletal injuries (B = .092, P < .001) and baseline depression diagnosis (B = 4.463, P < .001) were associated with overall PI levels but not change over time. OA was significantly associated with overall PI levels (B = 6.536, P < .001) and trajectory (B = -.253, P < .001); those endorsing OA in 2001 had lower PI increases over 19 years. The body region of injury and level of play during injuries mirrored overall injury effects. PI mildly increased over 19 years, with multiple factors independently influencing overall PI levels. Enhancing former contact sport athletes' daily functionality may be achieved through holistic biopsychosocial interventions addressing musculoskeletal injuries, OA, and depression. Future research should identify factors influencing elevated trajectories of long-term PI post-sport discontinuation. PERSPECTIVE: This study assessed PI in former NFL athletes over 2 decades, revealing notable interindividual variability in trajectories over time. Musculoskeletal injuries, depression, and OA correlated with overall PI. Prevention and intervention in these 3 areas present the potential to improve disruptions in daily living due to pain in former athletes.
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This case report describes an early-adolescent boy with an osteochondritis dissecans (OCD) lesion of the left femoral head secondary to significant acetabular dysplasia and coxa valga of the proximal femur. Patient underwent left proximal femur varus osteotomy. Follow-up imaging demonstrates healing and resolution of the OCD lesion. Future plan for left hip is periacetabular osteotomy, following triradiate cartilage closure, to correct acetabular dysplasia. The aim of this case report is to support clinicians in the assessment and treatment of this rare condition.
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Luxação do Quadril , Osteocondrite Dissecante , Masculino , Adolescente , Humanos , Criança , Cabeça do Fêmur/diagnóstico por imagem , Cabeça do Fêmur/cirurgia , Osteocondrite Dissecante/diagnóstico por imagem , Osteocondrite Dissecante/cirurgia , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Luxação do Quadril/cirurgia , Osteotomia/métodos , Acetábulo/cirurgiaRESUMO
BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, there was a concern for the 2020 general election becoming a superspreader event due to in-person voting. OBJECTIVES: Our project addressed this concern by disseminating nonpartisan websites detailing safe voter options in the state of North Carolina to prevent community spread of the virus as much as possible. METHODS: In this study, patient portals were used to disseminate a Research Electronic Data Capture survey containing embedded links to voter resources including nonpartisan websites discussing voting options. The survey also asked for demographic data and sentiments regarding the resources provided. Quick response (QR) codes with the survey link were also placed in the clinics during the study period. RESULTS: The survey was sent to 14,842 patients who had at least one patient encounter in the past 12 months at one of three General Internal Medicine clinics at Atrium Health Wake Forest Baptist. Survey participation through both the patient portals and QR codes was assessed. Patient sentiments toward the voter resources in regard to (1) interest and (2) perceived helpfulness were collected in the survey. In total, 738 (4.99%) patients filled out the survey. Eighty-seven percent of survey respondents reported that the voter resources were helpful. Significantly more black patients than white (29.3 vs. 18.2, p < 0.05) voiced interest in voter resources. There was no statistical significance across gender or reported comorbidities. CONCLUSION: Multicultural, underserved, and underinsured patients perceived the most benefit. During public health crises, patient portal messages can be used to bridge information gaps and promote better health outcomes in a timely and effective manner.
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COVID-19 , Portais do Paciente , Humanos , COVID-19/epidemiologia , Pandemias , Relações Comunidade-Instituição , PolíticaRESUMO
Introduction: Studies show that physicians and medical trainees who identify as underrepresented in medicine or as women experience higher rates of microaggressions during patient encounters. We designed, implemented, and evaluated an active bystander training workshop focused on mitigating microaggressions using standardized patient (SP) methodology. Methods: Internal medicine faculty members and chief residents led the workshop. Participants included 31 PGY 1 categorical and preliminary internal medicine residents. They participated in three case simulations with SPs involving microaggressions from patients toward a member of the health care team. Prior to the case simulations, a brief presentation outlined examples of microaggressions and reviewed the behavioral response framework WAKE (work with who you are, ask questions/make direct statements, involve key people, and employ distraction techniques). After each encounter, residents debriefed with an internal medicine faculty member and discussed questions related to each scenario. Results: All 31 residents participated in the workshop and, before and after the activity, completed a survey that asked them to rank their agreement with statements via a Likert scale. Participants reported statistically significant improvement in recognizing microaggressions (12% reported increase, p = .002), the ability to respond to patients who exhibit microaggressions (23% reported increase, p < .001), andâ¯the ability to debrief with team membersâ¯(20% reported increase, p < .001). Discussion: SP simulations can be an effective teaching modality for microaggression response strategies during patient encounters. Additional studies are needed to further characterize the workshop's effect on other medical workforce trainees and retention of skills over time.
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Internato e Residência , Microagressão , Humanos , Feminino , Educação de Pós-Graduação em Medicina/métodos , Medicina Interna/educação , Docentes de MedicinaRESUMO
The availability of next-generation sequencing (NGS) technologies and their continually declining costs have resulted in the accumulation of large genomic data sets. NGS results have traditionally been delivered in PDF format, and in some cases, structured data, e.g., XML or JSON formats, are also made available, but there is a lack of uniformity around the profiling of external vendor testing platforms. Atrium Health Wake Forest Baptist and TriNetX have harmonized and mapped genomic data to FHIR Genomic standards and imported it into the TriNetX database through a data pipeline. This process is translatable to other sequencing platforms and to other institutions. The addition of genotypic data to the TriNetX database to the reservoir of phenotypic data will promote enhanced industry trial recruitment, (ii) comprehensive intra-institutional genomic benchmarking/quality improvement, and eventually (iii) sweeping inter-institutional genomic research and treatment paradigm shifts.
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Interruptive clinical decision support systems, both within and outside of electronic health records, are a resource that should be used sparingly and monitored closely. Excessive use of interruptive alerting can quickly lead to alert fatigue and decreased effectiveness and ignoring of alerts. In this review, we discuss the evidence for effective alert stewardship as well as practices and methods we have found useful to assess interruptive alert burden, reduce excessive firings, optimize alert effectiveness, and establish quality governance at our institutions. We also discuss the importance of a holistic view of the alerting ecosystem beyond the electronic health record.
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Sistemas de Apoio a Decisões Clínicas , Sistemas de Registro de Ordens Médicas , Ecossistema , Registros Eletrônicos de SaúdeRESUMO
BACKGROUND: Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden. OBJECTIVE: (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics. MATERIALS AND METHODS: We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric. RESULTS: Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden. CONCLUSION: Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used.