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Jabbing at the Gap: Creation of a Sickle Cell Disease Registry to Address Ongoing Vaccination Disparities
No full textCME available for 1 year after presentation
CME Text Code: 97049
In order to claim CME credit, please complete an evaluation in CloudCME for each presentation.https://knowledgeconnection.mainehealth.org/pediatrics_gr/1089/thumbnail.jp
Toward Opioid-Free Total Hip Arthroplasty: A Retrospective Study of a Targeted Opioid Reduction Program in 229 Patients
No full textBACKGROUND: Prescription opioids leftover following arthroplasty surgery pose risks to patients and communitys. The purpose of this study was to capture opioid utilization patterns following primary total hip arthroplasty before and after a targeted intervention to decrease postoperative opioid prescription quantity. We hypothesized that reducing discharge pill count would not impact pain or functional outcomes. METHODS: Primary total hip arthroplasties performed by a high-volume, fellowship-trained arthroplasty surgeon between October 2022 and January 2024 were retrospectively evaluated for study inclusion; 229 patients met inclusion criteria. Beginning in April 2023, the surgeon gradually implemented a 38% reduction in postoperative opioid prescribing from 40 to 24 pills. Opioid consumption was evaluated by patient-reported pill count at the first postoperative visit. Patients were sorted into 2 groups: preintervention (n = 157) and postintervention (poI) (n = 72). Preintervention patients received between 300 and 420 oral morphine equivalents and poI patients received between 240 and 299.99 oral morphine equivalents. Demographics, pill counts, refills, 30-day emergency department visits, function (Hip Disability and Osteoarthritis Outcome Score Joint Replacement), pain (visual analog scale), and satisfaction scores were analyzed. RESULTS: Proportion of discharge prescription remaining at 2-week postoperative visit did not differ significantly between intervention groups (P = .33). There were no differences in opioid refill requests (P = .82), function (P = .75), or satisfaction with functional improvement (P = .61). Patients in the poI group reported lower pain at 6 weeks postoperatively (P \u3c .05). There were no differences in 30-day emergency department visits between groups (P = .57). CONCLUSIONS: Results support that arthroplasty surgeons can prescribe smaller quantities of opioids without compromising care. Such interventions can help reduce the number of prescription opioids available for misuse and diversion
A Mixed Methods Pilot Study of Neonatal Resuscitation Team Training for Rural Providers Using HoloBaby, a Mixed Reality Prototype Simulator
No full textINTRODUCTION: Newborns in rural hospitals face an increased risk of morbidity and mortality compared to those born in hospitals with a Neonatal Intensive Care Unit (NICU). Although causes are multifactorial, low delivery volume leads to infrequent neonatal resuscitation exposure. Simulation enables deliberate practice to maintain skills, but rural hospitals face barriers to accessing this training. The objectives of this study were to assess rural clinicians\u27 ability to assess and recognize changes of state in a mixed reality (MR) simulator, HoloBaby, developed for neonatal resuscitation training, and to compare their experience to mannequin-based simulation, and their real neonatal resuscitation experience, using a mixed methods study design. METHODS: Forty-five interprofessional clinicians from 3 rural hospitals participated in identical neonatal resuscitation simulations using first a programmable high-technology mannequin (HTM) and then HoloBaby. Surveys were conducted after each simulation experience and facilitated focus groups at the end of each study session to gauge clinicians\u27 experience with the simulation technologies and their ability to effectively assess and recognize changes in patients. Logistic mixed effects regression models assessed the association between survey question components and training method. Thematic analysis was used to identify codes and themes from the focus group transcripts. RESULTS: Participants reported that they were better able to effectively recognize shock in HoloBaby over the HTM. No other significant differences were noted between the technologies. Thematic analysis identified 3 main themes: novelty of MR technology, advantages and disadvantages of HoloBaby compared to the HTM, and value of simulation training (regardless of technology). CONCLUSION: The MR simulator, HoloBaby, offers the experience of simulation-based team training and matches the HTM in user ability to assess and recognize all changes in state measured, and exceeding HTM in users\u27 ability to recognize shock. In addition, MR could reduce financial and geographic barriers to accessing regular simulation training in rural settings
The logic of medical reasoning: toward an integrated inductive, deductive, and abductive approach to clinical practices.
No full textINTRODUCTION: This study explored the logical underpinnings of medical reasoning, focusing on the integration of abduction, deduction, and induction within clinical decision-making. It aimed to highlight the role of abduction in generating hypotheses, particularly in complex cases that defy standard protocols, and to examine the synergy between human expertise and AI-assisted tools in enhancing diagnostic accuracy.
METHODS: The research employed a qualitative approach, analyzing philosophical theories and integrating them with clinical case studies. The study examined the interplay of logical processes in medical diagnostics and the application of abduction in rare and novel cases. Additionally, the potential of AI-assisted tools to support clinical reasoning and reduce diagnostic noise was explored.
RESULTS: Abduction was identified as a critical yet often underappreciated element in medical reasoning essential for hypothesis generation. Deduction refines hypotheses against established medical knowledge, while induction validates decisions through empirical data. AI-assisted tools were found to enhance diagnostic accuracy by reducing noise, although they did not engage in the musement or genuine abductions that characterize human clinical reasoning.
DISCUSSION: The study concluded that a triadic approach to clinical reasoning, incorporating abduction, deduction, and induction, is essential for effective medical diagnostics. In particular, abduction plays a pivotal role in navigating the complexities of clinical decision-making. The integration of AI tools can reduce noise and improve diagnostic processes, but the essential human elements of insight and judgment remain irreplaceable in patient care
Clinical Consequences of Disproportionate Free Valproate Elevation in Critically Ill Adult Patients: A Multicenter Retrospective Cohort Study.
No full textBACKGROUND: Valproate has a narrow therapeutic index and unpredictable protein binding, and critically ill patients may experience unexpectedly elevated free concentrations. We sought to identify the clinical consequences and determinants of disproportionate free valproate concentration elevation in critically ill adults.
METHODS: This was a retrospective observational cohort study conducted at two academic medical centers from December 2015 to December 2023. Adult patients admitted to an intensive care unit who were receiving valproate and had concurrent total and free valproate concentrations measured were eligible for inclusion. We examined whether valproate concentrations were independently associated with adverse effects (AEs), including thrombocytopenia, hepatotoxicity, hyperammonemia, and pancreatic injury. Secondarily, determinants of disproportionate free valproate elevation, defined as a free valproate concentration that was greater than expected and out of proportion to the total concentration (e.g., free valproate above reference range but total valproate below reference range), were also identified.
RESULTS: A total of 311 patients (mean age 58 [SD ± 17] years, 36% female, 31% non-White, and 29% on valproate prior to admission) with 550 concurrent free valproate and total valproate pairs were included. The median total valproate concentration was 46 μg/mL (interquartile range [IQR] 34-63), and the median free valproate concentration was 17 μg/mL (IQR 11-23); the median free fraction was 35% (IQR 25-63%). Disproportionate free valproate elevation was observed in 462 (84%) samples. Each 2.5-μg/mL increase in free valproate concentration was associated with thrombocytopenia (adjusted odds ratio [aOR] 1.15, 95% confidence interval [CI] 1.05-1.26) and hepatotoxicity (aOR 1.11, 95% CI 1.05-1.18). Albumin concentration (aOR 0.17, 95% CI 0.08-0.36), blood urea nitrogen (aOR 1.36, 95% CI 1.09-1.70), and propofol exposure (aOR 3.06, 95% CI 1.38-6.79) were associated with disproportionate free valproate elevation.
CONCLUSIONS: Elevated free valproate concentrations were associated with hepatotoxicity and thrombocytopenia; free valproate concentrations should be directly measured in critically ill patients because it is underrepresented by total valproate. Most critically ill patients are at risk, especially those with hypoalbuminemia, uremia, and propofol exposure
October 8th, 2025: Syringe Tides- Rethinking the Role of Single-use Plastics in Healthcare
No full texthttps://knowledgeconnection.mainehealth.org/medicine_gr/1048/thumbnail.jp
Buprenorphine in the Intensive Care Unit: Commentary on the Unanswered Questions
No full textThe removal of the X-waiver in the Mainstreaming Addiction Treatment (MAT) Act of 2023 has substantial implications for buprenorphine prescribing as one of the options to treat opioid use disorder. The purpose of this commentary is to discuss the unanswered questions regarding buprenorphine in the intensive care unit (ICU) including how the passage of the MAT Act will affect ICU providers, which patients should receive buprenorphine, what is the most appropriate route of administration and dose of buprenorphine, what medications interact with buprenorphine, and how can transitions of care be optimized for these patients
Hospitalist Use of Point-of-Care Ultrasound During the COVID-19 Pandemic at a Single Academic Tertiary Care Center
Get PDFProblem: Point-of-care ultrasound (POCUS) use is limited by availability of standardized training and evaluation. Although the diagnostic accuracy of point-of-care ultrasound is superior to chest x-ray (CXR) for certain pulmonary indications, POCUS is underused.
Approach: A group of 19 hospitalists at MaineHealth Maine Medical Center participated in just-in-time training in pulmonary POCUS in mid-March 2020. The annual rate of CXRs ordered per shift was measured over a 3-year period to determine whether POCUS training resulted in a change in CXR ordering. CXR ordering rates were also evaluated among a group of 4 experienced POCUS users during the COVID-19 pandemic.
Outcomes: The POCUS training did not affect the rate of CXRs ordered by physicians who received training. A non-significant decrease in CXR ordering was seen among experienced POCUS users during the COVID-19 year only (CXRs ordered per shift 0.18 versus 0.10 for pre-COVID-19 and COVID-19 years, respectively, P = .0504). The decrease in CXR ordering by experienced POCUS users during the COVID-19 year suggests that early POCUS adopters with longitudinal training have greater use. Capacity strain (ie, personnel or lengthy disinfection procedures required for CXR) during the COVID-19 year may have also encouraged experienced POCUS users to choose POCUS over CXR for immediate bedside evaluation rather than a delayed work up. Experienced POCUS users may have been disincentivized as capacity strain in the post-pandemic era resolved.
Next steps: Short-term POCUS training alone is not sufficient to increase use. This study supports literature that longitudinal training is necessary to increase POCUS use, notably among novice users. Developing standards for longitudinal POCUS training and evaluation may facilitate POCUS integration into clinical practice