Addition of constitutional symptoms to the SLEDAI-2K improves overall disease activity assessment: A pilot study.

OBJECTIVE: Constitutional symptoms (fatigue, lymphadenopathy, and weight loss) are not included in the SLE disease activity index-2000 (SLEDAI-2K). In this pilot study, we assessed the concurrent and construct validity of a revised SLEDAI-2K (SLED-R) that included these symptoms with the original SLEDAI-2K (SLED-O), using the physician global assessment of disease activity (PGA) as the reference. METHODS: Our revised SLED-R substituted the SLED-O's fever descriptor with a constitutional descriptor that included fever, fatigue, lymphadenopathy, and/or weight loss. SLED-O, SLED-R, PGA and patient global assessment (PtGA) scores were collected prospectively. Bland-Altman correlations for repeated measures were calculated and Meng's z-test was used to compare correlations between dependent and overlapping correlation coefficients. Associations between constitutional symptoms and disease activity measures were analyzed using Mann-Whitney U, Kruskal-Wallis, Chi-square tests and repeated measures correlations. RESULTS: 1123 SLED-O, SLED-R, PGA, and 1066 PtGA were collected in 239 subjects. The new descriptor was scored in 45 subjects (18.8%) and 92 instances (8.1%), while the original descriptor, fever, was scored in only 4 subjects (1.7%) and 5 instances (0.4%). Mean SLED-O, PGA and PtGA scores were higher when the constitutional descriptor was scored versus not (p < .001). The correlation between SLED-R and PGA was marginally higher than between SLED-O and PGA (p < .001). Fatigue contributed most to this increase (p = .001) and associated with both higher PGA and PtGA scores (p < .001). Mean SLED-O and PGA scores were higher when ≥1 constitutional symptom(s) were scored versus not (p < .002). Correlations between PGA and PtGA when the new descriptor was scored versus not were similar (p = .860). The frequency of concordance between PGA and PtGA was lower when the new descriptor was scored (55%) versus not (72.5%), with PGA > PtGA when the new descriptor was scored (p < .001). CONCLUSION: The addition of constitutional symptoms to SLEDAI-2K, particularly fatigue, resulted in a marginal increase in its correlation with PGA, and new constitutional symptoms associated with higher SLED-O and PGA scores. As fatigue is subjective and difficult to attribute to SLE, its validity and inter-rater reliability in scoring remains uncertain. The clinical utility of SLED-R remains unclear, and further studies of its validity and reliability are needed.

New York State cases of anaphylaxis in elderly patients from 2000 to 2010.

BACKGROUND: Limited information is available on the effect of anaphylaxis, a severe, potentially life-threatening allergic reaction, in the elderly population. OBJECTIVE: To elucidate the frequency of anaphylaxis and the demographic characteristics of elderly patients admitted to New York hospitals from 2000 to 2010. METHODS: A retrospective analysis of hospitalized patients aged 65 years and older in New York from 2000 to 2010 was conducted using the Statewide Planning and Research Cooperative System, a statewide administrative database. Cases were identified using anaphylaxis International Classification of Diseases, Ninth Revision (ICD-9) codes or an ICD-9-based diagnostic algorithm incorporating the National Institutes of Allergy and Infectious Disease diagnostic criteria. The χ2 test was used to measure the association between demographic characteristics and group membership. Regression was used to model group and age as a function of hospital rates. RESULTS: A total of 3673 hospitalizations were analyzed. Anaphylaxis ICD-9 codes identified 1790 cases (48.7%), the algorithms identified 1701 cases (46.3.%), and 182 cases (5.0%) were identified by both. Hospitalization rates increased significantly during this period (P < .001). Women comprised 61.5% and people of white race comprised 69.8% of the sample. Distribution by age differed by ascertainment method (ICD-9 vs algorithm) among the early-old group (65-74 years of age; 53.8% vs 41.8%) and among the late-old group (≥85 years of age; 11.2% vs 19.3%). CONCLUSION: Hospitalization rates and anaphylaxis cases increased during the study period among the hospitalized elderly population of New York. Relying on anaphylaxis ICD-9 codes alone missed approximately half of possible cases. The identification and possibly the effect of anaphylaxis among the elderly population may differ, depending on age, race, payer, New York County, and disposition.

Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study.

BACKGROUND: Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes. METHODS: A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides. RESULTS: Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse. CONCLUSIONS: These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes. TRIAL REGISTRATION: NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.

Knowledge, Attitudes, and Interactions with Chaplains and Nursing Staff Outcomes: A Survey Study.

We conducted a cross-sectional survey of nursing staff (n = 51) in an academic hospital finding a significant inverse relationship between the frequency of chaplaincy interaction and perceived stress (r = - 0.27, p = 0.05). We also found a significant positive relationship between rated importance of having a chaplain at the hospital and secondary trauma (r = 0.30, p = 0.03). There was a significant positive relationship between religiosity and rated importance for having a chaplain (r = 0.30, p = 0.03) and rated helpfulness of chaplains (r = 0.32, p = 0.02). Similarly, there was a significant positive relationship between spirituality and average length of conversations with a chaplain, rated importance for having a chaplain, and helpfulness of chaplains (r = 0.32, p = 0.03; r = 0.44, p = 0.001; and r = 0.52, p = 0.0001, respectively). Interaction with chaplains is associated with decreased employee perceived stress for nursing staff who provide care for severely ill patients.

Tumor budding in colorectal carcinoma: An institutional interobserver reliability and prognostic study of colorectal adenocarcinoma cases.

BACKGROUND: Colorectal carcinomas are one of the most commonly diagnosed malignancies. There are many prognostic factors relating to clinical course and disease progression, including tumor stage, metastasis, and tumor budding. In 2016, the International Tumor Budding Consensus Conference (ITBCC) created a system to uniformly assess tumor budding. This system includes a 3-tier system for the grading of tumor budding. In the past, there lacked uniform consensus, however the general grading practice was based on a 2-tiered system. Given that tumor budding is considered to have prognostic value, the accuracy and reproducibility of its assessment is vital. Our study aims to look at interobserver agreement in the scoring of tumor budding. DESIGN: A total of 233 cases of colorectal carcinoma diagnosed in our health system were retrospectively analyzed and routine H&E stained slides of these cases were collected. A representative slide for tumor budding was selected per case. Four investigators with different levels of experience and expertise evaluated the selected slide of each case for tumor budding. Scoring was based on the ITBCC protocol. Clinico-pathological data was collected for each case and analyzed with tumor budding scores. Tumor budding scores per individual investigator and consensus tumor budding score were compared to patient and tumor characteristics including patient survival, tumor grade, tumor stage, and lymph node status. RESULTS: Inter-observer agreement was calculated using Gwet's Agreement Coefficient (AC1) and associated 95% confidence intervals was used to compare the ratings made by 4 pathologists. Overall, there was variation among pathologists in tumor budding score (Gwet's agreement coefficient = 0.25 and 0.326 for 3-tier and 2-tier grading system, respectively). Results show higher reliability with the 2-tier system compared to the 3-tier system. Tumor stage was significantly associated with budding score for all individual investigators and the consensus value (p value < 0.001). CONCLUSION: There is low inter-observer agreement in the assessment of tumor budding in colorectal carcinoma. This suggests that it is difficult to uniformly grade tumor budding and that our classification system needs improvement. We found that the older 2-tier system (Hase et al.) results in slightly higher inter-observer agreement than the recently proposed 3-tier grading system (ITBCC, 2016), though both systems lead to suboptimal agreement. Worth noting is that observers with subspecialty GI training and more work experience had higher inter-observer agreement. Our results showed that subspecialty training tends to increase agreement more than overall work experience. In addition, our exploratory results showed that there is an association of tumor budding score to tumor stage. While increasing refinement in classification, the 3-tiered system resulted in decreased agreement in tumor budding assessment. Clearly, there is more work to be done in the identification and quantification of tumor buds.

Using Pleth Variability as a Triage Tool for Children With Obstructive Airway Disease in a Pediatric Emergency Department.

OBJECTIVES: Patients with obstructive airway disease have varying degrees of pulsus paradoxus that correlate with illness severity. Pulsus paradoxus can be measured using plethysmography. We investigated whether plethysmograph (pleth) variability on admission to the pediatric emergency department (ED) could predict patient disposition. We hypothesized that patients with a larger pleth variability would have a higher likelihood of being admitted to a general pediatrics unit or the intensive care unit (ICU). METHODS: We conducted a prospective single-center study of children aged 1 to 18 years who presented to a pediatric ED with a diagnosis of asthma or reactive airway disease. The pleth variability index (PVI) was calculated from their initial plethysmography tracing. Disposition from the ED was recorded as discharge, admission to the floor, or admission to the ICU. RESULTS: A total of 117 patients were included in our study. Forty-eight patients were discharged home, 61 were admitted to the floor, and 8 were admitted to the ICU. The median PVI for each of these groups was 0.27 (interquartile range [IQR], 0.19-0.39) for discharges, 0.29 (IQR, 0.20-0.44) for patients admitted to the floor, and 0.56 (IQR, 0.35-0.70) for patients admitted to the ICU. A Kruskal-Wallis test demonstrated a significant difference in the PVI between each of the groups (P = 0.0087). CONCLUSIONS: Our results suggest that PVI may be a useful tool in the triage of children who present to the ED with obstructive airway disease. Further studies should aim to assess the validity of PVI in predicting the response to bronchodilator therapy during the course of a patient's hospitalization.

The Impact and Statistical Analysis of a Multifaceted Anticoagulation Strategy in Children Supported on ECMO: Performance and Pitfalls.

BACKGROUND: We sought to determine whether the introduction of a new anticoagulation protocol improved the frequency with which target anticoagulation parameters were met in children supported with extracorporeal membrane oxygenation (ECMO). Additionally, we sought to correlate the results of various tests of anticoagulation with the heparin infusion dose (HID) for patients on ECMO and to evaluate the utility of these anticoagulation monitoring tests for the titration of the HID. METHODS: A retrospective chart review of 18 patients who received ECMO at an academic tertiary care children's hospital. Nine patients who were managed using a new anticoagulation protocol were matched by age and diagnosis with 9 patients managed with the old protocol. We collected data relating to patient demographics, type of extracorporeal support, disease process, and incidence of bleeding or thrombosis. Anticoagulation parameters collected include the activated clotting time (ACT), activated partial thromboplastin time (aPTT), prothrombin time/international normalized ratio, anti-factor Xa level, and antithrombin 3 level along with the HID at each time point. Patient groups were compared using a Generalized Linear Mixed Model, a mixed model analysis of variance, and correlational studies. MAIN RESULTS: The percentage of in-range ACT values was not different between the 2 protocols, whereas the percentage of in-range aPTT values was higher in the new anticoagulation protocol (ACT: 37.7% vs 39.5%; aPTT: 25.1% vs 39.8%). After accounting for repeated and variable measures within patients, the probability of obtaining an in-range ACT and aPTT did not differ significantly between the 2 protocols (ACT: P = .3488; aPTT: P = .16). The mean HID did not differ between the 2 groups (35.0 unit/kg/h vs 37.6 unit/kg/h, P = .56). Correlation coefficients demonstrated a significant inverse correlation between the ACT and the HID in both the groups (old: r = -.22, P < .0001; new: r = -.26, P < .0001). We observed a significant positive correlation between the aPTT and the HID in the historical group (r = .25, P < .0001), but no correlation between the aPTT and the HID in the current group (r = -.02, P = .71). The anti-factor Xa level showed a significantly positive correlation with the HID in the current group (r = .62, P < .0001). CONCLUSIONS: A multipronged monitoring regimen slightly increased the amount of time that anticoagulation parameters were within range. Correlations between the HID and the aPTT differed based on anticoagulation protocol, with a positive correlation in the older protocol and no correlation in the new protocol. This may highlight a problem in study design and analysis that requires further examination. Further trials are needed to assess the most useful markers with which anticoagulation protocols for ECMO can be created, adjusted, and evaluated.

Do residents need end-of-life care training?

OBJECTIVE: As medical education evolves, emphasis on chronic care management within the medical curriculum becomes essential. Because of the consistent lack of appropriate end-of-life care training, far too many patients die without the benefits of hospice care. This study explores the association between physician knowledge, training status, and level of comfort with hospice care referral of terminally ill patients. METHOD: In 2011, anonymous surveys were distributed to physicians in postgraduate years 1, 2, and 3; fellows; hospital attending physicians; specialists; and other healthcare professionals in five hospitals of a large health system in New York. Demographic comparisons were performed using χ2 and Fisher's exact tests. Spearman correlations were calculated to determine if professional status and experience were associated with comfort and knowledge discussing end-of-life topics with terminal patients. RESULTS: The sample consisted of 280 participants (46.7% response rate). Almost a quarter (22%) did not know key hospice referral criteria. Although 88% of respondents felt that knowledge of hospice care is an important competence, 53.2% still relinquished advance directives discussion to emergency room (ER) physicians. Fear of patient/family anger was the most frequently reported hospice referral barrier, although 96% of physicians rarely experienced reprisals. Physician comfort level discussing end-of-life issues and hospice referral was significantly associated with the number of years practicing medicine and professional status. SIGNIFICANCE OF RESULTS: Physicians continue to relinquish end-of-life care to ER staff and palliative care consultants. Exploring unfounded and preconceived fears associated with hospice referral needs to be integrated into the curriculum, to prepare future generations of physicians. Medical education should focus on delivering the right amount of end-of-life care training, at the right time, within the medical school and residency curriculum.

Ensuring fidelity: key elements to consider in disseminating a diabetes telemanagement program for underserved Hispanic/Latinos living with type 2 diabetes.

Background: The Hispanic/Latino population has greater risk (estimated >50%) of developing type 2 diabetes (T2D) and developing it at a younger age. The American Diabetes Association estimates costs of diagnosed diabetes in 2017 was $327 billion; with medical costs 2.3x higher than patients without diabetes. The purpose of this manuscript is to describe the methodology utilized in a randomized controlled trial aimed at evaluating the efficacy of a diabetes telemanagement (DTM) program for Hispanic/Latino patients with T2D. The intent is to provide information for future investigators to ensure that this study can be accurately replicated. Methods: This study was a randomized controlled trial with 240 participants. Eligible patients (Hispanic/Latino, aged 18+, living with T2D) were randomized to Comprehensive Outpatient Management (COM) or DTM. DTM was comprised of usual care, including routine clinic visits every three months, as well as: Biometrics (a tablet, blood glucose meter, blood pressure monitor, and scale); Weekly Video Visits (facilitated in the patient's preferred language); and Educational Videos (including culturally congruent diabetes self-management education and quizzes). COM consisted of usual care including routine clinic visits every three months. For this study, COM patients received a glucometer, glucose test strips, and lancets. Establishing a therapeutic nurse-patient relationship was a fundamental component of our study for both groups. First contact (post-enrollment) centered on ensuring that patients and caregivers understood the program, building trust and rapport, creating a non-judgmental environment, determining language preference, and establishing scheduling availability (including evenings and weekends). DTM were provided with a tablet which allowed for self-paced education through videos and weekly video visits. The research team and Community Advisory Board identified appropriate educational video content, which was incorporated in diabetes educational topics. Video visits allowed us to assess patient involvement, motivation, and nonverbal communication. Communicating in Spanish, and awareness of diverse Hispanic/Latino backgrounds was critical, as using relevant and commonly-used terms can increase adherence and improve outcomes. Shared decision-making was encouraged to make realistic health care choices. Conclusion: Key elements discussed above provide a framework for future dissemination of an evidence-based DTM intervention to meet the needs of underserved Hispanic/Latino people living with T2D.

Beliefs and attitudes towards participating in genetic research - a population based cross-sectional study.

BACKGROUND: Biobanks have the potential to offer a venue for chronic disease biomarker discovery, which would allow for disease early detection and for identification of carriers of a certain predictor biomarker. To assess the general attitudes towards genetic research and participation in biobanks in the Long Island/Queens area of New York, and what factors would predict a positive view of such research, participants from the NSLIJ hospital system were surveyed. METHODS: Participants were recruited at six hospital centers in the NSLIJ system during the summers of 2009 and again in 2011 (n = 1,041). Those who opted to participate were given a questionnaire containing 22 questions assessing demographics, lifestyle and attitudes towards genetic research. These questions addressed individual participant's beliefs about the importance of genetic research, willingness to participate in genetic research themselves, and their views on informed consent issues. RESULTS: Respondents took a generally positive view of genetic research in general, as well as their own participation in such research. Those with reservations were most likely to cite concerns over the privacy of their medical and genetic information. Those who were married tended to view genetic research as important, while those in the younger age group viewed it as less important. Prior blood donation of respondents was found to be a predictor of their approval for genetic research. Demographic factors were not found to be predictive of personal willingness to participate in genetic research, or of approval for the opt-out approach to consent. CONCLUSIONS: While respondents were generally inclined to approve of genetic research, and those who disapproved did not do so based on an underlying moral objection to such research, there is a disconnect between the belief in the importance of genetic research and the willingness of individuals to participate themselves. This indicates a continued concern for the ways in which genetic materials are safeguarded once they are collected. Also indicated was a general lack of understanding about the various consent processes that go along with genetic research, which should be addressed further to ensure the successful continuation of biobanks.

Longitudinal predictors of uremic pruritus.

OBJECTIVE: Pruritus is a common problem among hemodialyzed patients. Its causes are poorly understood, and, as a result, itching is often attributed to elevated serum phosphorus and other disorders of bone and minerals. The primary purpose of this study was to analyze the relationship between pruritus and common tests of bone and mineral disease. METHODS: This study was a post hoc analysis of data from a randomized controlled trial of 3 months of ergocalciferol versus placebo treatment in 50 hemodialysis patients with uremic pruritus. A pruritus survey was administered at baseline and then every 2 weeks for 12 weeks. Concurrent serum phosphorus, intact parathyroid hormone (PTH), serum calcium, and calcium-phosphate product were measured. RESULTS: Pruritus score was not found to be associated or correlated with serum phosphate, intact PTH, serum calcium, or calcium-phosphate product at each time interval or over time. Likewise, when analyzed by original study group (placebo or ergocalciferol), no association or correlation between the mineral and bone indicators and itching were found. CONCLUSION: Neither serum phosphate nor other tests of bone and mineral status were found to be significant predictors of pruritus at any point in time or over time.

Differential spatiotemporal gait effects with frequency and dopaminergic modulation in STN-DBS.

Objective: The spatiotemporal gait changes in advanced Parkinson's disease (PD) remain a treatment challenge and have variable responses to L-dopa and subthalamic deep brain stimulation (STN-DBS). The purpose of this study was to determine whether low-frequency STN-DBS (LFS; 60 Hz) elicits a differential response to high-frequency STN-DBS (HFS; 180 Hz) in spatiotemporal gait kinematics. Methods: Advanced PD subjects with chronic STN-DBS were evaluated in both the OFF and ON medication states with LFS and HFS stimulation. Randomization of electrode contact pairs and frequency conditions was conducted. Instrumented Stand and Walk assessments were carried out for every stimulation/medication condition. LM-ANOVA was employed for analysis. Results: Twenty-two PD subjects participated in the study, with a mean age (SD) of 63.9 years. Significant interactions between frequency (both LFS and HFS) and electrode contact pairs (particularly ventrally located contacts) were observed for both spatial (foot elevation, toe-off angle, stride length) and temporal (foot speed, stance, single limb support (SLS) and foot swing) gait parameters. A synergistic effect was also demonstrated with L-dopa and both HFS and LFS for right SLS, left stance, left foot swing, right toe-off angle, and left arm range of motion. HFS produced significant improvement in trunk and lumbar range of motion compared to LFS. Conclusion: The study provides evidence of synergism of L-dopa and STN-DBS on lower limb spatial and temporal measures in advanced PD. HFS and LFS STN-DBS produced equivalent effects among all other tested lower limb gait features. HFS produced significant trunk and lumbar kinematic improvements.

Patient Notification About Breast Arterial Calcification on Mammography: Empowering Women With Information About Cardiovascular Risk.

OBJECTIVE: To assess the impact of informing women about the presence of breast arterial calcification (BAC) on mammography by determining whether those notified about the presence of BAC would seek cardiovascular evaluation. METHODS: This IRB-approved prospective study included 494 patients who underwent screening mammography between June 8, 2021, and April 22, 2022. Mammograms were reviewed by a radiologist, and patients were notified via e-mail about the presence or absence of BAC. Patients with BAC were advised to discuss the results with their physicians and were surveyed 3 months later. Frequencies and proportions were calculated for study participation, presence of BAC, survey participation, health actions, and perceptions. Confidence intervals were calculated for proportions of health actions and perceptions. RESULTS: Of 494 study participants, 68/494 (13.8%; 95% CI: 10.9%-17.1%) had BAC detected on mammography and 42/68 (61.8%; 95% CI: 61.1%-62.1%) with BAC completed the follow-up survey at 3 months. Of these 42 survey respondents, 24/42 (57.1%; 95% CI: 41.1%-72.3%) reported discussing results with their primary care physician (PCP) or a cardiologist. In addition, 34/42 (81.0%; 95% CI: 65.9%-91.4%) reported finding it helpful to receive information about BAC and 32/42 (76.2%; 95% CI: 60.6%-88.0%) believed all women should be informed about BAC after mammography. CONCLUSION: After notification about the presence of BAC on screening mammography, the majority (57.1%) of survey respondents reported discussing the results with a PCP or cardiologist. These results suggest that providing mammography patients with information about BAC may promote preventive cardiovascular health.

COVID-19 stressors for Hispanic/Latino patients living with type 2 diabetes: a qualitative study.

Background and aim: During the early stages of the COVID-19 pandemic, nationwide lockdowns caused disruption in the diets, physical activities, and lifestyles of patients with type 2 diabetes. Previous reports on the possible association between race/ethnicity, COVID-19, and mortality have shown that Hispanic/Latino patients with type 2 diabetes who are socioeconomically disadvantaged are disproportionately affected by this novel virus. The aim of this study was to explore stressors associated with changes in diabetes self-management behaviors. Our goal was to highlight the health disparities in these vulnerable racial/ethnic minority communities and underscore the need for effective interventions. Methods and participants: Participants were enrolled in part of a larger randomized controlled trial to compare diabetes telehealth management (DTM) with comprehensive outpatient management (COM) in terms of critical patient-centered outcomes among Hispanic/Latino patients with type 2 diabetes. We conducted a thematic analysis using patient notes collected from two research nurses between March 2020 and March 2021. Two authors read through the transcripts independently to identify overarching themes. Once the themes had been identified, both authors convened to compare themes and ensure that similar themes were identified within the transcripts. Any discrepancies were discussed by the larger study team until a consensus was reached. Results: Six themes emerged, each of which can be categorized as either a source or an outcome of stress. Sources of stress associated with the COVID-19 pandemic were (1) fear of contracting COVID-19, (2) disruptions from lockdowns, and (3) financial stressors (e.g., loss of income). Outcomes of COVID-19 stressors were (1) reduced diabetes management (e.g., reduced diabetes monitoring and physical activity), (2) suboptimal mental health outcomes (e.g., anxiety and depression), and (3) outcomes of financial stressors. Conclusion: The findings indicated that underserved Hispanic/Latino patients with type 2 diabetes encountered a number of stressors that led to the deterioration of diabetes self-management behaviors during the pandemic.

Lumbar Radicular Pain Response to First Injection with Non-particulate Steroid.

Introduction Recent studies on the use of transforaminal epidural steroid injection (TFESI) to treat lumbar radicular pain have highlighted controversies pertaining to the choice of corticosteroid agent utilized in lumbosacral TFESI, in terms of both safety and efficacy. The primary objective was to characterize the radicular pain response after a first transforaminal injection with dexamethasone. The secondary objective was to document the response of those who failed to respond to a dexamethasone injection when particulate steroid was utilized for a second injection. Methods It was a retrospective study of 94 consecutive patients undergoing transforaminal injection for lumbosacral radicular pain. At two-week follow-up, patients rated their pain response on a clinically oriented five-point survey. First injection non-responders were given a second injection with particulate steroid and again completed the survey. Results Approximately one-third (N = 31/94) of patients received no meaningful relief from a single injection with dexamethasone. No patients achieved lasting and complete pain relief after a single injection. Of initial non-particulate steroid non-responders, approximately two-thirds (N = 19/28) demonstrated a notable or complete response to a second injection with particulate steroid. Conclusions We are now able to better inform patients with regard to their anticipated pain response to an initial dexamethasone injection. Only one-third of patients realized more significant and lasting relief after a single injection. Of those who did not demonstrate a more meaningful response, a second injection with particulate steroid resulted in more pronounced pain relief in two-thirds of patients.

Toward the Quadruple Aim: Impact of a Humanistic Mentoring Program to Reduce Burnout and Foster Resilience.

OBJECTIVE: To assess the effect of a faculty development program (Mentoring and Professionalism in Training [MAP-IT]) that fosters humanism in medicine on elements of burnout and the development of resilience. PARTICIPANTS AND METHODS: The cohort of participants was drawn from a cross-section of disciplines and represented a diverse group of health professionals, including physicians, nurses, physician assistants, pharmacists, psychologists, social workers, and chaplains. The 106 participants were divided into 12 groups, each of which was facilitated by two or three leaders. Each group completed the MAP-IT curriculum from October 1, 2017, through July 31, 2018. All participants and leaders completed the Connor-Davidson Resilience Scale and the Maslach Burnout Inventory (assessing emotional exhaustion, depersonalization, and personal accomplishment) before and after completion of the program. RESULTS: The participants' scores for emotional exhaustion and depersonalization remained unchanged following the completion of the MAP-IT curriculum. However, their scores for personal accomplishment and resilience increased significantly and approximated those of the leaders. CONCLUSION: The MAP-IT program has shown effectiveness both in fostering resilience and a sense of personal accomplishment. The time is ripe for institutional programming to create and foster the personal tools needed to prevent burnout and its sequelae.

PROMIS-29 survey confirms major impact of fatigue on health-related quality of life in common variable immunodeficiency.

Health-related quality of life (HRQOL) is an emerging topic of interest in patients with immunodeficiency. Information about HRQOL in common variable immunodeficiency (CVID) is limited. The primary objective was to compare primary immunodeficiency disease (PIDD) patients with and without common variable immunodeficiency (CVID) on HRQOL domains using Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey data from the United States Immunodeficiency Network (USIDNET) registry. The primary endpoint variables were scores on 7 HRQOL domains. The USIDNET registry was used to select patients with baseline PROMIS-29 data collected between 2015 and 2018. Descriptive statistics, Fisher's exact test, and Student's two-sample t test were used to compare patients with CVID versus patients with non-CVID on demographic and clinical characteristics. The single-sample t test was used to compare sample means to the normed population mean of 50. A general linear model approach to multiple regression with backward selection was used to remove factors that did not contribute significant information to the multivariable models, while controlling for multiple testing. Potential explanatory variables included group (CVID/non-CVID), sex, age, and BMI. Among 184 PIDD patients, 146 (79%) were diagnosed with CVID. Patients had a mean (SD) age of 53 (13.8), were predominantly female (83%), and were Caucasian (98%). PROMIS-29 results revealed a significant effect of group (CVID/non-CVID) on the anxiety, fatigue, and social participation domains, with fatigue being the most statistically significant. Fatigue, anxiety, and social participation may be key factors influencing HRQOL among patients with CVID. Future prospective longitudinal studies using PROMIS-29 will be needed to confirm these findings and to determine the mechanisms through which these factors develop in CVID, and how they can be improved.

Prelude to Death or Practice Failure? Trombley-Brennan Terminal Tissue Injury Update.

In 2012, we published a study in this journal exploring the emergence of unique skin changes in end-of-life patients admitted to a palliative care unit. The purpose of the study was to describe the skin changes and identify the relationship between these changes and time of death. In the above study of 80 patients, the skin changes were found to be unique and different from Kennedy terminal ulcers and deep tissue injuries. Median time from identification of skin changes and death was 36 hours. The phenomenon was named as Trombley-Brennan terminal tissue injury. The current article presents findings that include the study of additional 86 patients. The results further validate the phenomenon and its relationship with time of death.

A Novel Curriculum to Prepare Internal Medicine Residents for Fellowship Interviews.

BACKGROUND: Applications to the Fellowship Match through the National Resident Matching Program (NRMP) Specialties Matching Service (SMS) are at an all-time high. Data regarding the preparedness of medical residents who go through the interview process is limited. OBJECTIVE: To assess whether the implementation of an interview curriculum could improve medical resident preparedness for and performance during fellowship interviews. METHODS: All third-year internal medicine residents (N = 18) at the Zucker School of Medicine at Hofstra/Northwell (Northwell) applying to subspecialty fellowship participated in an interview curriculum that comprised a didactic session and an Objective Structured Teaching Exercise (OSTE). Participants were surveyed on preparedness before and after the curriculum and medical residents and faculty were surveyed on medical resident performance after their OSTE and after their Northwell fellowship interview. RESULTS: Out of the total possible number of participants, 16 (89%) were included in our analysis. Pre and post-test statistical differences in survey responses were evaluated using the Wilcoxon signed rank test. Medical resident preparedness and resident perceived performance increased in all measured categories, including overall preparedness (P = .001) and overall interview skills (P = .008). No significant change in faculty-rated resident performance was observed. CONCLUSION: The development and institution of a formal interview curriculum improved medical resident preparedness and perceived performance. However, this significant improvement seen between medical resident pre and post surveys did not translate to improvement between faculty pre and post surveys. Future studies should look at fellowship match rates to objectively assess the impact of the curriculum.

Compassionate Coverage: A Patient Access Linen System.

BACKGROUND: Patient attire is paramount to patient's dignity and overall experience. In this pilot study and in concert with a designer and clinician, we developed, patented, tested, and evaluated patient and provider preference and experience with a novel patient gowning system. Our objective was to survey obstetrics and gynecology hospital inpatients' and providers' experience with a novel hospital attire system; the patient access linen system (PALS). METHODS: Patients were provided a PALS item at the beginning of a provider's shift or at the start of an outpatient visit. Following their use of the PALS item, the patients and providers completed a separate multiple-choice and free-response question survey. Surveys were completed by patients each time a PALS item was returned to the provider for processing. RESULTS: Patients and providers had a significantly positive experience with the PALS. The majority of patients had positive responses to each question about comfort and function of the PALS system, showed consistent preference for the PALS in comparison to a traditional hospital gown and demonstrated that comfort of hospital clothing is a priority for patients. The majority of providers found PALS easy to use when compared to the traditional gown with regard to clinical examinations. CONCLUSION: Patients in our pilot prioritized hospital attire as a key element in their overall hospital experience, and both patients and providers preferred the PALS system over the traditional hospital gown. Further study is needed on patient attire and evaluation of the potential clinical impact of the PALS.