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Association between Income, Neighborhood Vulnerability, and 5-Year Survival after COPD Hospitalization in Medicare Beneficiaries
No full textThe core competencies in hospital medicine: Procedures 2025 update
No full textThis article presents an updated framework from the Society of Hospital Medicine for individual learning objectives related to key procedures in hospital medicine. Building upon the 2017 framework, these objectives have been revised to reflect evolving clinical evidence, advancements, and shifts in hospital medicine practice patterns. The methodology included a comprehensive literature review, expert consensus panels, and feedback from practicing hospitalists across diverse clinical settings. The updated learning objectives address procedural competencies for the most common interventions in hospital medicine, including arthrocentesis, emergency procedures, interpretation of chest radiographs and electrocardiograms, lumbar puncture, paracentesis, thoracentesis, and vascular access. These revised learning objectives provide a framework to guide curricular development, continuing medical education, and hospital medicine practitioners in developing and maintaining procedural competence essential for high-quality inpatient care
A Home Hemodialysis Objective Structured Clinical Examination (OSCE) for Formative Assessment of Nephrology Fellows
No full textBackground: The Accreditation Council for Graduate Medical Education requires graduating nephrology fellows demonstrate competence in home hemodialysis (HHD). Because low patient numbers may lead to training gaps, clinical experience may be enhanced using simulation. We designed and preliminarily validated a formative objective structured clinical examination (OSCE) assessing clinical care of an uncomplicated patient initiating HHD, using a unified model of construct validity.
Methods: The OSCE was developed by a nephrology fellow and five faculty (three practicing HHD). The nine-member test committee (five in HHD practice; one HHD care partner) assessed test item difficulty/relevance and determined passing scores. The final test consisted of 27 items (31 possible points); seven were evidence-based/standard-of-care questions (9.5 possible points). Passing score was 20 out of 31 points (65%). Median relevance for all items was important or essential . Content validity index was 0.84. On preliminary validation by 11 board-certified volunteers (four practicing HHD), overall mean±SD score was 27.5±2 (100% passing); kappa=0.83 [95% confidence interval (CI) 0.67-0.99]. Validator evidence-based question score was 9.0 ± 0.6 .
Results: Thirty-eight fellows (nine programs, 21 first-year; 17 second-year) were tested. Seventy one percent passed (Cronbach\u27s alpha=0.70). Fellows\u27 mean±SD scores were lower than validators: 21.5±4.0 vs. 27.5±2, p\u3c 0.001, as were their scores on evidence-based questions: 7.4±1.4 vs. 9.0±0.6, p\u3c 0.001. Eighty-eight percent of evidence-based/standard-of-care questions were answered correctly by validators vs. 62% by fellows; p \u3c 0.001. Forty-two percent of fellows were able to name four potential benefits and two risks associated with HHD; 79% recognized that the primary risk of buttonhole cannulation was infection. Seventy-four percent correctly identified minimum single pool Kt/V for thrice-weekly hemodialysis, and 29% knew the minimum standard weekly Kt/V target. Eighty-eight percent of fellows surveyed (22 out of 25) agreed/strongly agreed that the OSCE was useful in self-assessing proficiency.
Conclusions: The OSCE may be used as a formative assessment of fellow proficiency in prescribing HHD
High-Precision Micro-Total Analysis of Sodium Ions in Breast Milk
No full textMeasuring sodium ion concentration in breast milk can provide crucial health information for both mother and infant, including early signs of low-grade infection and reduced milk supply. Traditional sensing methods are slow, bulky, expensive, and require skilled operators. Here, we develop a coverslip-sized, high-precision lab-on-a-chip device that processes and detects sodium ions in human breast milk. The device uses micro-electrodialysis to extract sodium ions into a simple acceptor solution with 92 ± 3% efficiency and employs a graphene ion-selective sensor for high-performance quantification. We demonstrate a straightforward calibration strategy, enabling the device to measure breast-milk sodium ion levels in 141 seconds, with accuracy comparable to inductively coupled plasma mass spectrometry. Our approach offers a promising pathway to efficient, point-of-care diagnosis of conditions associated with metal-ion levels in complex liquid-biopsy samples.
Keywords: Lab on a chip; breast milk; graphene; ion-selective field-effect transistor; micro electrodialysis; microTAS; sodium ions
Prevalence and correlates of multiple injections per injection episode among people who inject drugs in rural U.S. communities
No full textBackground: Multiple injections per injection episode (MIPIE) is increasingly common among people who inject drugs (PWID). While MIPIE may lower overdose risk, it could elevate infectious disease risk. This study examined the prevalence of MIPIE among rural PWID in the United States and its associations with injection behaviors associated with disease transmission (e.g., syringe mediated drug sharing, receptive supply sharing) and health outcomes (e.g., hepatitis C virus (HCV) status, naloxone possession, and overdose).
Methods: The Rural Opioid Initiative includes eight research cohorts of rural people who use drugs from across the U.S., recruited from 01/2018 to 03/2020. MIPIE was dichotomized as any vs. none using the question: How many times in the past 30 days did you inject more than one time in one sitting? We employed a fixed effects meta-analytic approach to examine cross-sectional associations through adjusted regression analyses.
Results: Among 2441 PWID, most reported MIPIE (71% [n=1729]). In adjusted analyses, MIPIE was associated with a higher prevalence of past 30-day receptive syringe sharing (Prevalence Ratio (PR)=2.02; 95% confidence interval (CI)=1.74-2.34), syringe-mediated drug sharing (PR=1.92; 95%CI=1.69-2.18), receptive supply sharing (PR=1.99; 95%CI=1.75-2.26), distributive supply sharing (PR=2.30; 95%CI=1.99-2.65), HCV (PR=1.26; 95%CI=1.11-1.44), naloxone possession (PR=1.32; 95%CI=1.17-1.50), overdose ever (PR=1.42; 95%CI=1.25-1.57), and overdose in the prior 90 days (PR=2.09; 95%CI=1.52-2.87).
Conclusions: MIPIE is a common practice among rural PWID and is associated with injection behaviors associated with disease transmission, HCV, and overdose. Intervention studies should develop harm reduction strategies that address both overdose prevention and infectious disease mitigation related to MIPIE.
Keywords: Drug injection; Health disparities; Hepatitis C; Opioid-related disorders; Overdose prevention; Risk factors; Rural health; Substance-related disorders; Syringe exchange programs
Mediational analysis of severe retinal injury causation in children with acute closed head injury
No full textBackground: While generally regarded as discriminating findings, elevating the probability of abusive head trauma, the association of severe retinal injuries with inertial biomechanics, shaking, and abuse has been challenged.
Objective: Evaluate five causational models of severe retinal injury utilizing multivariable mediational analysis.
Participants: Children, under age three-years, admitted to 18 pediatric intensive care units with acute, symptomatic, closed head injury who had not been injured in a car-crash and who had received an ophthalmologist\u27s retinal examination.
Methods: Multivariable logistic regression, and multiple mediational analysis were applied to five causational models of severe retinal injury. Primary causes evaluated were inertial injury biomechanics, severe parenchymal brain injury, and provision of cardio-respiratory resuscitation. Results were reported as direct and mediated log-odds (ꞵ), with standard errors and p-values.
Results: The most explanatory model, having the greatest total effect (ꞵ = 3.768, p ≤ 0.001) and direct effect (ꞵ = 2.431, p ≤ 0.001), identified isolated inertial injuries as the primary cause of severe retinal injury. Additional indirect effects were mediated by radiographically evident diffuse parenchymal brain injury (ꞵ = 0.834, p ≤ 0.001) and the presence of extra-axial blood on imaging (ꞵ = 0.589, p ≤ 0.001).
Conclusions: Causational modeling of cross-sectional data in this population best supports inertial head injury biomechanics, above a threshold to cause diffuse parenchymal brain injury and extra-axial hemorrhage, as the most likely cause of severe retinal injury. Support for other causal pathways is statistically significant, but less robust.
Keywords: Abusive head trauma; Etiology; Mediational analysis; Retinal hemorrhage
Early Intervention Referral Rates of Infants With Neonatal Opioid Withdrawal Syndrome Are Not Significantly Affected by Race, Payor, Maternal Medication for Opioid Use Disorder, or NICU Hospitalization
No full textIn this study, we examined the factors influencing enrollment in early intervention (EI) programs for neonates diagnosed with nonopioid-associated neonatal abstinence syndrome (NAS) and neonatal opioid withdrawal syndrome (NOWS). The primary goal was to examine characteristics linked to completing an individualized family service plan (IFSP), marking EI enrollment. Patient records were reviewed using data from neonates discharged with NOWS/NAS at a Massachusetts hospital in 2017 to identify demographic and medical factors related to NOWS/NAS cases. Out of 125 cases, 111 were analyzed, with patient outcomes analyzed in subgroups of those with NOWS and non-opioid-associated NAS. Findings indicated that neonates with NICU hospitalization, race, payor, and maternal medication for opioid use disorder (MOUD) did not have significantly different rates of IFSP completion. Additionally, no significant difference was observed in IFSP completion rates between neonates with NAS or NOWS. This study reports baseline data from a quality improvement initiative not designed to detect statistically significant differences. However, it highlights potential areas for further investigation to improve EI access for NOWS- and NAS-affected neonates, although more extensive studies are needed to further elucidate these differences.
Keywords: early intervention; neonatal abstinence syndrome; neonatal intensive care unit; neonatal opioid withdrawal syndrome; pediatric hospital medicine
Organ Failure, Endotoxin Activity, and Mortality in Septic Shock
No full textImportance: The relationship between endotoxin activity, organ failure, and mortality is not well understood.
Objective: To test whether the combination of endotoxin activity and organ failure identifies patients at higher risk of death from sepsis and determine the relationship to previously described sepsis phenotypes.
Design, setting, and participants: Prospective observational study in four ICUs enrolling critically ill patients with septic shock.
Main outcomes and measures: Endotoxin activity assay (EAA) results, Sequential Organ Failure Assessment (SOFA), and multiple organ dysfunction (MODS) and 28-day mortality.
Results: We enrolled 90 patients aged 25-95 years and set an EAA cutoff of greater than or equal to 0.6 together with SOFA greater than 11 or MODS greater than 9 to define endotoxic septic shock (ESS). At baseline mean EAA was 0.64 (sd = 0.19), whereas mean SOFA and MODS were 10.3 (sd 3.2) and 5.8 (sd 3.1), respectively. EAA greater than or equal to 0.6 and SOFA greater than 11 were present in 20 patients (23.3%) and these patients had 60% mortality. EAA greater than or equal to 0.6 and SOFA less than or equal to 11 occurred in 31 (36.0%) with mortality 12.9%. Of the 35 remaining patients with EAA less than 0.6, 29 (33.7%) had SOFA less than or equal to 11 and 5 of them (17.2%) died. Only six patients (7.0%) had EAA less than 0.6 and SOFA greater than 11 and none died (p \u3c 0.001). All patients with MODS greater than 9 also had EAA greater than or equal to 0.6 (12 patients) with 75% mortality. EAA greater than or equal to 0.6 with MODS less than or equal to 9 occurred in 39 patients with 17.9% mortality (p \u3c 0.001). ESS (EAA ≥ 0.6 together with SOFA \u3e 11 or MODS \u3e 9) occurred in 21 patients and they had significantly higher mortality (57.1% vs. 15.9%, p \u3c 0.001) compared with non-ESS, with a relative risk for death of 3.58 (95% CI, 1.86-6.91). Among ESS patients, 7 (33.3%) had δ phenotype, whereas only 4 (5.8%) had δ among non-ESS (p = 0.001).
Conclusions and relevance: ESS compromises patients with the highest mortality rate from sepsis. Such patients are most appropriate for trials testing anti-endotoxin therapy for improving survival.
Keywords: endotoxin; multiple organ failure; polymyxin B; sepsis; septic shock
Direct Oral Anticoagulants versus Warfarin for Left Ventricular Thrombus: A Meta-Analysis of Randomized-Controlled Trials
No full textCharacteristics and Outcomes of Palliative Continuous Intravenous Inotrope Support Among Medicare Beneficiaries With Heart Failure
No full textBackground: Continuous intravenous inotropic support (CIIS) can improve symptoms and functional status for patients with stage D heart failure (HF), but characteristics and outcomes of large cohorts treated with CIIS as a palliative therapy have not been described.
Methods and results: We identified Medicare fee-for-service (FFS) beneficiaries with diagnostic codes for HF in 2016 to 2017. After excluding beneficiaries who received advanced HF surgical therapies 2014 to 2018 and prior CIIS, we included remaining beneficiaries who initiated CIIS from 2016 to 2017. Primary outcomes were rates of admission, death, palliative care, and hospice utilization within 1 year of CIIS initiation. We identified 1 463 942 Medicare beneficiaries with HF in 2016 to 2017, of whom 3706 (0.3%) beneficiaries initiated palliative CIIS (58.9% male, 82.1% White, 67.1% from urban areas, average age 78 [SD=6.8] years). Average Charlson Comorbidity Index Score was 5.8 (SD=3.1). Only 6.5% of CIIS users had a diagnostic code suggesting receipt of palliative care services. Within 1 year of CIIS initiation, 72.2% of beneficiaries had at least 1 all-cause admission, 55.7% had ≥2 admissions, and 38% had died. Almost 18% of CIIS users had a claim for hospice services; of CIIS users who died, 43.3% had a hospice claim.
Conclusions: Among Medicare FFS beneficiaries with HF, palliative CIIS is rare and primarily utilized among older beneficiaries with high global comorbidity. Despite the palliative indication, beneficiaries have high rates of admission and low use of palliative care services. Palliative care and associated services should be better integrated into the care of patients with palliative CIIS.
Keywords: dobutamine; heart failure; inotropes; milrinone; palliative care; stage D heart failure