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Navigating Microaggressions in the Clinical Environment: Follow-Up of a Case-Based Workshop 1 Year Later
No full textProblem: Microaggressions negatively impact the mental health and wellness of patients and health care workers. Despite efforts in medical education to address this issue, there is limited research on the effect of these strategies in clinical settings over time. We evaluated how a workshop on navigating microaggressions impacts medical students 1 year after the workshop.
Approach: A 60-minute workshop on microaggressions was implemented for medical students (n=85) across 3 clerkship sites. The workshop focused on identifying, responding to, and debriefing microaggressions as recipients or bystanders using a toolkit. Post-intervention surveys measured students’ satisfaction and perceived ability to navigate microaggressions. One year later, follow-up surveys from students (n=30) at intervention sites were compared with students (n=31) from non-intervention sites using quantitative and qualitative analyses.
Outcomes: Immediately after the workshop, students’ perceived abilities to recognize, respond to, and debrief microaggressions improved on a 5-point Likert scale (P\u3c.001). At the 1-year follow-up, there was no significant difference in confidence in or frequency of responding to microaggressions, the use of the toolkit, or debriefing microaggressions between the intervention and non-intervention groups.
Next Steps: A standardized workshop temporarily increased students’ confidence in responding to microaggressions, but the effect diminished after 1 year. This finding highlights the need for longitudinal, hands-on education embedded across all years of clinical training rather than one-off sessions
Weight loss induced bone loss: mechanism of action and clinical implications
No full textWeight loss, whether resulting from disease-related conditions or intentional interventions, has been increasingly recognized as a significant risk factor for compromised skeletal integrity. While moderate weight reduction may yield metabolic benefits, rapid or sustained weight loss is frequently associated with decreased bone mineral density, deterioration of bone microarchitecture, and heightened fracture risk. The mechanisms underlying weight loss-induced bone loss are complex and multifactorial. Emerging evidence highlights a range of contributing factors, including reduced mechanical loading, increased bone marrow adiposity, hormonal and endocrine alterations, nutritional deficiencies, and disruptions in energy metabolism. These mechanisms are intricately interconnected, ultimately impairing bone remodeling and homeostatic balance. In this review, we provide a comprehensive analysis of the current literature on the mechanistic pathways, clinical consequences, and therapeutic strategies related to weight loss-induced bone loss. We further differentiate the skeletal effects of disease-associated versus intervention-induced weight loss, with a focus on their distinct molecular underpinnings. Our goal is to offer novel insights into the optimization of bone health management in the context of weight loss, guided by a translational medicine perspective
Implementation facilitation improves readiness for emergency department-initiated buprenorphine to treat opioid use disorder
No full textINTRODUCTION: Treatment of opioid use disorder (OUD) with buprenorphine is safe and effective, but Emergency Department-initiated buprenorphine (ED BUP) uptake is suboptimal. As part of a randomized clinical trial (RCT), we evaluated Implementation Facilitation (IF)\u27s impact on EDs\u27 readiness to provide ED BUP. METHODS: From February 2020 to May 2024, we surveyed 31 ED Medical Directors (MDs) and site-Principal Investigators (PIs) across 33 Emergency Department-INitiated bupreNOrphine VAlidaTION (ED-INNOVATION) sites (29 of which proceeded to RCT enrollment) at three time points: pre-IF (baseline), early-IF (pre-enrollment), and late-IF (post-enrollment). We collected 10-point Likert scale ratings and performed linear regression modeling and correlation analysis to evaluate relationships between readiness, barriers, facilitators, and readiness changes over time. RESULTS: Across 31 responses for the three time points, mean readiness increased pre-IF to early-IF (6.29 vs. 8.23, p \u3c 0.0001) and pre-IF to late-IF (6.29 vs. 8.39, p \u3c 0.0001). We observed decreases in 13/15 barriers and increases in 13/19 facilitators. When examining relationships between changes in readiness, barriers, and facilitators, the strongest relationships were follow-up treatment availability (r = 0.64, p = 0.0001), prescribing practices knowledge (r = -0.64, p = 0.001); insurance coverage (r = -0.52, p = 0.002); nursing support (r = -0.48, p = 0.01); and knowledge about addiction and its treatment (r = 0.47, p = 0.007); weak relationships were length of stay impact (r = 0.02, p = 0.92), trained clinicians (r = 0.02, p = 0.91), and social complexity (r = -0.10, p = 0.60). CONCLUSIONS: IF was associated with improved readiness, decreases in barriers and an increase in facilitators of ED BUP. When faced with limited resources, these findings can help inform prioritization of addressable barriers and facilitators to improve readiness for ED BUP
Associations of Perfluoroalkyl and Polyfluoroalkyl Substances With Cardiovascular Disease Incidence in Adults With Prediabetes: Findings From the Diabetes Prevention Program
No full textBACKGROUND: Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are persistent, widespread environmental contaminants linked to cardiometabolic outcomes including obesity, hyperlipidemia, and diabetes. We examined whether baseline plasma PFAS concentrations are associated with incident cardiovascular disease (CVD) in adults with prediabetes, leveraging data from DPPOS (Diabetes Prevention Program Outcomes Study). METHODS: Among 1382 participants, we quantified baseline plasma concentrations of 6 PFAS. We used Cox proportional hazards models to estimate the risks of developing CVD outcomes during a median of 21 years of follow-up for each PFAS and used quantile g-computation to evaluate the joint effect of all 6 PFAS. Effect modification by age, sex, menopausal status, diet, and physical activity was explored. RESULTS: The incidence of major adverse cardiovascular events was 9.6%; 3.9% had CVD-related death. Each increase in interquartile range (1.1 ng/mL) in 2-(N-methyl-perfluorooctane sulfonamido) acetate was associated with a 16% higher risk of major adverse cardiovascular events (95% CI, 1-33%) and a 24% higher risk of CVD death (95% CI, 2-52%). Higher concentrations of perfluorohexane sulfonate, perfluorooctane sulfonate, 2-(N-ethyl-perfluorooctane sulfonamido) acetate, and perfluorooctanoate were associated with greater risk of CVD outcomes, including nonfatal myocardial infarction, hospitalized congestive heart failure, and cardiovascular death. However, PFAS mixture was not associated with CVD. Age, sex, treatment arm, physical activity, and diet did not modify the associations of individual PFAS. CONCLUSION: In adults with prediabetes, higher plasma concentrations of select PFAS, but not their mixture, were prospectively associated with increased CVD risk. These findings underscore PFAS as a potential environmental risk factor for CVD in high-risk populations. URL: https://clinicaltrials.gov/; Unique identifiers: NCT00004992 and NCT00038727
Integrating Behavioral Health Into Monitoring and Surveillance During Public Health Emergencies: Challenges and Opportunities
No full textOBJECTIVE: Limited guidance exists for public health agencies to use existing data sources to conduct monitoring and surveillance of behavioral health (BH) in the context of public health emergencies (PHEs). METHODS: We conducted a literature review and environmental scan to identify existing data sources, indicators, and analytic methods that could be used for BH surveillance in PHEs. We conducted exploratory analyses and interviews with public health agencies to examine the utility of a subset of these data sources for BH surveillance in the PHE context. RESULTS: Our comprehensive search revealed no existing dedicated surveillance systems to monitor BH in the context of PHEs. However, there are a few data sources designed for other purposes that public health agencies could use to conduct BH surveillance at the substate level. Some of these sources contain lagging indicators of BH impacts of PHEs. Most do not consistently collect the sociodemographic data needed to explore PHEs\u27 inequitable impacts on subpopulations, including at the intersection of race, gender, and age. CONCLUSIONS: Public health agencies have opportunities to strengthen BH surveillance in PHEs and build partnerships to act based on timely, geographically granular existing data
Providing Survivorship Care for a Young Adult With a History of Blood Cancer
No full textAdolescents and young adults (AYAs) with a history of cancer are at an increased risk for late effects from their cancer treatment and have higher rates of long-term morbidity and mortality compared to their age-matched peers. As a result, this vulnerable population needs attentive follow-up care, end-organ surveillance, and secondary cancer screening; however, a history of cancer can often become buried on a problem list or not addressed at all. This case report illustrates an AYA survivor of classic Hodgkin lymphoma who relocates to a new city and establishes care with a new primary care provider (PCP). The PCP\u27s awareness of a prior cancer diagnosis and the previous treatment regimen is a critical component in providing comprehensive care. In this case, the PCP\u27s first step is to reach out and collaborate with oncology providers to gather an accurate treatment summary and then consult evidence-based guidelines to develop a plan of care. Based on the patient\u27s previous treatment with chemotherapy adriamycin, bleomycin, vinblastine, and dacarbazine, the PCP orders recommended testing, reviews results, and provides subsequent counseling on health promotion and psychosocial wellness. This case illustrates strategies healthcare providers can use to provide coordinated, evidence-based care for AYA cancer survivors
Intermittent Auscultation vs Electronic Fetal Monitoring in Laboring Patients
Get PDFIn healthy laboring women, how does the use of Intermittent auscultation, compared to continuous monitoring, affect fetal and maternal outcomes?https://knowledgeconnection.mainehealth.org/nurseresidency/1033/thumbnail.jp
Platelet FcγRIIa as a Marker of Cardiovascular Risk After Myocardial Infarction
No full textBACKGROUND: A previous single-center study of patients with myocardial infarction (MI) showed that platelet FcγRIIa (pFCG) can distinguish patients at higher and lower risk of subsequent MI, stroke, and death. OBJECTIVES: The authors performed an 800-patient 25-center study to validate the prognostic implications of pFCG. METHODS: Patients with type 1 MI (ST-segment elevation and non-ST-segment elevation) were enrolled in a prospective noninterventional trial during their index hospitalization. Enrolled patients had at least 2 of the following characteristics: age ≥65 years, multivessel coronary artery disease, previous MI, chronic kidney disease, or diabetes mellitus. Flow cytometry was used to quantify pFCG at a core laboratory. A predefined threshold was used to identify high and low pFCG. Patients were queried every 6 months by telephone with a standardized questionnaire. Events were confirmed by review of medical records. RESULTS: Treatment with antithrombotic therapy (aspirin, P2Y inhibitors, and anticoagulants) was similar in patients with high and low pFCG. The primary composite endpoint (MI, stroke, death) occurred more frequently in patients with high pFCG (HR: 2.09; 95% CI: 1.34-3.26; P = 0.001). Among individual components of the composite, both death (HR: 2.57; 95% CI: 1.50-4.40; P = 0.001) and MI (HR: 3.24; 95% CI: 1.64-6.37; P = 0.001) were more frequent in patients with high pFCG. CONCLUSIONS: Quantifying pFCG identifies patients at higher and lower risk of subsequent cardiovascular events. This prognostic information will be useful in clinical decisions regarding the intensity and duration of antiplatelet therapy. (Assessment of Individual Risk of Cardiovascular Events by Platelet FcγRIIa; NCT05175261)
Strategies for implementing an electronic patient-reported outcomes-based symptom management program across six cancer centers
No full textBACKGROUND: Electronic patient-reported outcome (ePRO)-based symptom management improves cancer patients\u27 outcomes. However, implementation of ePROs is challenging, requiring technical resources for integration into clinical systems, substantial buy-in from clinicians and patients, novel workflows to support between-visit symptom management, and institutional investment. METHODS: The SIMPRO Research Consortium developed eSyM, an electronic health record-integrated, ePRO-based symptom management program for medical oncology and surgery patients and deployed it at six cancer centers between August 2019 and April 2022 in a type II hybrid effectiveness-implementation cluster randomized stepped-wedge study. Sites documented implementation strategies monthly using REDCap, itemized them using the Expert Recommendations for Implementation Change (ERIC) list and mapped their target barriers using the Consolidated Framework for Implementation Research (CFIR) to inform eSyM program enhancement, facilitate inter-consortium knowledge sharing and guide future deployment efforts. RESULTS: We documented 226 implementation strategies: 35 \u27foundational\u27 strategies were applied consortium-wide by the coordinating center and 191 other strategies were developed by individual sites. We consolidated these 191 site-developed strategies into 64 unique strategies (i.e., removed duplicates) and classified the remainder as either \u27universal\u27, consistently used by multiple sites (N = 29), or \u27adaptive\u27, used only by individual sites (N = 35). Universal strategies were perceived as having the highest impact; they addressed eSyM clinical preparation, training, engagement of patients/clinicians, and program evaluation. Across all documented SIMPRO strategies, 44 of the 73 ERIC strategies were addressed and all 5 CFIR barriers were addressed. CONCLUSION: Methodical collection of theory-based implementation strategies fostered the identification of universal, high-impact strategies that facilitated adoption of a novel care-delivery intervention by patients, clinicians, and institutions. Attention to the high-impact strategies identified in this project could support implementation of ePROs as a component of routine cancer care at other institutions. TRIAL REGISTRATION: ClinicalTrials.gov. NCT03850912. February 22, 2019. https://clinicaltrials.gov/ct2/show/NCT03850912?term=hassett&draw=2&rank=1
Association between community distress and return to work after burn injury
No full textINTRODUCTION: Community-level disadvantage is associated with reduced quality of life after burn injury. We evaluated the association between community-level disadvantage and return to work after burn injury. METHODS: A multicenter burn injury database was queried from 1998-2021. Participants 18-65 years old with documented employment status and ZIP codes were included. Exposures were community distress (Distressed Communities Index, DCI), patient demographics, and burn characteristics. The primary outcome was odds of employment 6 months after burn injury using stepwise logistic regression models, first with patient-level variables, then DCI. An interaction term was included to evaluate the modification of DCI and post-injury employment by race. RESULTS: 1960 participants were included, with a median age of 39.2 years (IQR 29.2, 49.3); 81 % were White, 75 % male, and 74 % were working at the time of injury. Participants unemployed 6 months post-injury were more often older, female, non-White, and unemployed at injury, with larger burn sizes and longer hospitalizations. 59 % of participants unemployed at 6 months were employed at the time of injury. Residence in the highest distress ZIP codes was associated with 2.21 (95 % CI 1.39-3.52) odds of 6 month unemployment. Older age, larger burn size, more operations, Black race, and pre-injury unemployment were associated with the greatest odds of unemployment. The interaction between race and DCI was not statistically significant. CONCLUSION: Patients from the highest distress communities have twice the odds of unemployment 6 months after injury. This association did not vary by race. Screening for DCI by ZIP code may be a useful tool to focus vocational rehabilitation resources