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Outcomes of Adding Computed Tomography Angiography for Pre-procedural Planning of Left Atrial Appendage Occlusion: a Systematic Review and Meta-analysis
No full textBackground: Multi-society expert consensus statements on catheter-based left atrial appendage occlusion (LAAO) suggest transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) for pre-procedural planning. However, evidence comparing the outcomes of adding CCTA to TEE on procedural success is limited.
Objective: Perform a systematic review and meta-analysis to determine the impact of adding CCTA to TEE for pre-procedural planning in patients undergoing LAAO.
Methods: We systematically searched Cochrane, Embase, and Medline for observational studies and randomized controlled trials (RCTs) comparing the addition of CCTA vs. TEE alone. The primary endpoint was procedural success. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled across studies using a random-effects model.
Results: Systematic review identified four studies for meta-analysis, three RCTs and one observational study, including a total of 824 patients, of whom 496 (60.2%) underwent additional CCTA. In the pooled analysis, procedural success was higher with added CCTA (RR 1.10; 95% CI 1.01-1.19; p = 0.022; I²=52%). A subgroup analysis of only RCTs confirmed these findings with a slightly higher magnitude of effect and lower heterogeneity (RR 1.15; 95% CI: 1.06-1.25; I2 = 0%).
Keywords: Atrial fibrillation; Cardiac CT; Left atrial appendage occlusion; Transesophageal echocardiography
Parent-identified opportunities for improving asthma care for children insured by Medicaid following implementation of statewide Medicaid Accountable Care Organizations in Massachusetts
No full textBackground: Childhood asthma is common and associated with extensive racial, ethnic and socioeconomic healthcare inequities and health disparities. Approximately 50% of children with asthma are insured by Medicaid in the U.S. and states have increasingly implemented Accountable Care Organization (ACO) models in their Medicaid programs, but little is known about the effects of ACOs on pediatric asthma quality of care, utilization, and disparities. Seventeen new ACOs were implemented in Massachusetts in 2018. Delivery System Reform Incentive Payments were provided to ACOs that could be used to improve outcomes for chronic diseases, such as asthma, through quality measures, enhanced care coordination, and community health worker staffing. This qualitative study explored caregiver experiences with pediatric asthma care for their Medicaid-insured child following ACO implementation in Massachusetts.
Methods: Semi-structured virtual interviews were conducted with caregivers of Medicaid-insured children with asthma in Massachusetts between July 1-December 31, 2023. Purposive sampling aimed to include a range of participant and practice characteristics. The overarching theoretical framework was an adaptation of the Framework of Asthma Disparities, and data were analyzed using rapid qualitative analytic methods.
Results: Of the 26 participants, 96% were female; 23% identified as Black and 39% as Hispanic. Key themes included: (1) Perceived lack of changes in asthma care related to Medicaid ACO implementation; (2) Insurance coverage influences on asthma care; (3) Perceptions of asthma management in primary care; (4) Perceptions of asthma specialist care; (5) Influence of health related social needs on pediatric asthma care and outcomes; and (6) Suggestions for improving pediatric asthma care in Medicaid ACOs. Continuity of care, communication, and asthma education were prominent subthemes.
Conclusions: Medicaid ACOs efforts to transform care delivery through increased resources and improved infrastructure for care coordination and other aspects of care may not have had a substantial influence on asthma care for children in early years of implementation, addressing a gap in knowledge about mixed-age ACOs\u27 effects on pediatric populations. Participants\u27 perceptions of the importance of care continuity, specialty access, and education may warrant further exploration in general and in the context of Medicaid ACO effects on asthma care for children at high risk for asthma disparities.
Keywords: ACO; asthma; health care reform; medicaid; pediatric; primary care; qualitative
Prehospital aspirin use is associated with improved clinical outcomes in pulmonary embolism: A retrospective case-control study
No full textBackground: Pulmonary embolism (PE) is a leading cause of cardiovascular mortality. Although anticoagulation is the cornerstone of treatment, aspirin\u27s potential to modulate thromboinflammation and improve outcomes in non-surgical PE patients remains underexplored.
Aim: To assess whether prehospital aspirin use is associated with improved outcomes in patients hospitalized with acute PE.
Methods: We conducted a retrospective case-control study of 323 adult patients admitted with computed tomography-confirmed acute PE from January 2020 to December 2023. Patients were stratified according to documented daily aspirin use for ≥ 7 days prior to hospital admission. Primary outcomes included right ventricular strain, intensive care admission, shock, mechanical ventilation, and in-hospital mortality. Univariate logistic regression was used. A P value \u3c 0.05 was considered significant.
Results: Total of 323 patients, 90 (27.9%) used aspirin prehospital. Aspirin users were older (74.2 ± 14.3 years vs 66.9 ± 16.7 years, P \u3c 0.001) and had more coronary artery disease. Aspirin use was associated with significantly lower rates of right ventricular strain on computed tomography [22.2% vs 34.8%, odds ratio (OR) = 0.536, 95% confidence interval (CI): 0.305-0.944, P = 0.029], Intensive care admission (16.7% vs 28.8%, OR = 0.496, 95%CI: 0.266-0.924, P = 0.025), shock (2.2% vs 9.9%, OR = 0.208, 95%CI: 0.048-0.899, P = 0.021), and in-hospital mortality (3.3% vs 11.6%, OR = 0.260, 95%CI: 0.080-0.889, P = 0.022).
Conclusion: Prehospital aspirin use is associated with reduced severity and mortality in acute PE. These findings support a potential protective role for aspirin and warrant validation in prospective, multicenter trials.
Keywords: Antiplatelet therapy; Aspirin; Intensive care unit; Mortality; Pulmonary embolism; Right ventricular strain; Shock
Global Emergency Medicine: A Scoping Review of the Literature From 2024
No full textObjective: The Global Emergency Medicine Literature Review (GEMLR) identifies impactful research in global emergency care. This 20th annual edition reviews GEM literature published in 2024 and highlights the growth of GEMLR over the years.
Methods: We conducted a scoping review of 2024 GEM articles through structured PubMed and gray literature searches. Reviewers and editors from 10 countries screened abstracts using predefined criteria for three domains: disaster and humanitarian response (DHR), emergency care in limited-resource settings (ECLRS), and emergency medicine development (EMD). Duplicates and articles lacking authorship equity or ethical oversight were excluded. Remaining publications were scored using tailored rubrics for original research (OR), review articles (RE), and gray literature (GRAY). The top 5% in each category were selected for critical appraisal. A retrospective summary of 20 years of GEMLR reviews was also completed.
Results: The search identified 46,714 PubMed and 12,575 gray literature articles. A total of 473 met inclusion criteria and were scored; 33 were selected as the top 5%, a decrease from 55 in 2023. Although the search string was unchanged, 2024 yielded ~10,000 fewer articles. Common themes included trauma, pediatrics, and clinical/triage protocols, with a new focus on mental health among clinicians and disaster victims. Over 20 years, 230 individuals have contributed 810 service-years to GEMLR. Nearly 75% of members were from the USA, while 32 (13.9%) were from LMICs and 27 (11.7%) from non-USA high-income countries. In total, 398,904 articles have been screened, 8476 scored, and 517 top articles narratively reviewed since 2005.
Conclusions: Over two decades, GEMLR has evolved into a large-scale, multinational, methodologically rigorous initiative, highlighting more than 500 high-impact GEM publications. In 2024, despite fewer articles screened, 33 top studies were identified across key domains. GEMLR emphasizes equitable LMIC representation, rigorous quality standards, and authorship equity, aiming to help shape the future of emergency care research
Serious Bacterial Infections and Hepatitis C Virus Among People Who Inject Drugs: A Syndemic or Intertwined Epidemics?
No full textLimited research has examined the possible synergistic interrelationships between serious bacterial infections (SBIs) of the heart (i.e., endocarditis), bone, spine, brain, or joints (e.g., osteomylelitis) and hepatitis C virus (HCV) infections. We examined whether syndemic interactions existed between SBI, HCV, and substance-use-related factors in rural communities, hypothesizing that injection-mediated risks elevated the likelihood for both SBIs and HCV infections, which could be exacerbated by synergistic biological-biological or biological and social interactions. We calculated the prevalence ratios (PRs) of past-year SBI associated with each risk factor in separate models. Effect modification among significant risk factors was assessed using multiplicative interaction. Among 1936 participants, 57% were male and 85% White, with a mean age of 36 years. Eighty-nine participants (5%) reported hospitalization for an SBI in the year prior to the survey. More than half tested HCV-antibody-positive (58%); 62 (5.6%) of the participants with a positive HCV antibody result reported past-year hospitalization with an SBI. Injection behaviors were correlated with other SBI risk factors, including multiple injections in the same injection event (MIPIE), injection equipment sharing, and fentanyl use. In adjusted models, MIPIE (PR: 1.79; 95% confidence interval [CI]: 1.03, 3.11) and fentanyl use (PR: 1.68; 95% CI: 1.04, 2.73) were significantly associated with past-year SBI. Our analyses pointed to co-occurring epidemics of SBI and HCV, related to the cumulative health effects of fentanyl use contributing to frequent injections and MIPIE. Both the SBI and HCV epidemics present public health challenges and merit tailored interventions.
Keywords: hepatitis C virus; people who inject drugs; rural; serious bacterial infections; syndemic
The relationship between hospital case mix, academic affiliation, program size, and American Board of Internal Medicine examination pass rates
No full textBackground: American Board of Internal Medicine (ABIM) certifying exam pass rates are crucial metrics for internal medicine residency programs, as lower pass rates influence accreditation. Additionally, higher scores correlate with lower hospitalist-specific mortality and readmission rates. Prior research identified associations between pass rates and factors such as US Medical Licensing Examination scores and in-training examination performance. However, little is known about how residency training factors such as hospital patient complexity, academic affiliation, region, and program size affect ABIM pass rates. This study aimed to identify determinants of ABIM pass rates to serve as a reference for residency applicants and residency program leaders.
Methods: Data from 550 US internal medicine residency programs were analyzed, incorporating publicly available ABIM pass rates (2022-2024), hospital case mix index (CMI) as a surrogate for patient acuity, academic affiliation, geographic region, and program size. Descriptive and inferential statistics were performed using JASP software.
Results: The average ABIM exam pass rate for first-time test takers was 86% (standard deviation 11.7). University-based programs had significantly higher pass rates than community-based and community-based university-affiliated programs (F(2542) = 52.70; P \u3c 0.001). Pass rates correlated positively with hospital CMI (r = 0.34, P \u3c 0.001) and program size (r = 0.272, P \u3c 0.001), but not geographic region (P = 0.21). A regression model showed CMI, program size, and academic affiliation as significant determinants, explaining 22.5% of pass rate variance.
Conclusion: Higher patient acuity, university-based affiliation, and larger residency programs significantly correlate with higher ABIM pass rates. These findings provide insights for residency applicants upon selecting training programs. Further research is needed to evaluate these factors in relation to clinical competence.
Keywords: Board pass rate; case mix index; clinical acuity; internal medicine residency training
Mit-O-My I Can\u27t Breath! Mitomycin C-Induced Pneumonitis Leading to Acute Respiratory Distress Syndrome, a Rare Case
No full textMitomycin C (MMC) pneumonitis leading to acute respiratory distress syndrome (ARDS) is a rare and life-threatening adverse reaction to MMC. Diagnosing MMC pneumonitis can be challenging as more frequent etiologies such as bacterial infections are often targeted first due to patients being immunocompromised from chemotherapy. We report a case of a middle-aged male who was administered MMC without concomitant vinca alkaloid, who developed ARDS secondary to MMC pneumonitis requiring intubation and intensive care. The patient recovered with steroid treatment after being on antibiotics for many days, and no infectious etiology was ever identified. This case emphasizes the importance of recognizing MMC as a potential cause for pneumonitis which can lead to ARDS and death
Could the shaking of infants in early childhood be a leading source of unexplained intellectual disability in India?
No full textBackground: Data from India and other low and middle-income countries reveal high rates of parent-reported shaking of infants. Very high rates of developmental disability have been reported in India. The convergence of these observations provides an opportunity to understand the nature and consequences of a potentially harmful child discipline practice.
Objective: To study whether caregiver shaking of an infant, even shaking insufficient to lead to an acute medical encounter, is associated with subsequent intellectual disability (ID).
Methods: We conducted a matched case-control study at an academic medical center in Lucknow, India. We compared 75 children with ID of unknown etiology to 75 control children aged 24-72 months, matched by age, gender, maternal age, and maternal education. All children received a neurological evaluation and were IQ and lead tested. We questioned parents about early discipline practices, including shaking. If parents reported shaking, we asked them to demonstrate using a shaken baby simulator. We examined the association between ID and shaking using conditional logistic regression.
Results: Children\u27s median age was 43.4 (IQR: 25.1) months; 64% were boys. 24% of all study children were reported shaken before 24 months: 38.% of the case children and 9% of the controls. The adjusted odds of reported shaking of children with ID, before age 24 months, is 8.3 (95% CI: 2.4, 28.2) times higher than controls.
Conclusion: Shaking children \u3c 2 years of age in northern India is common; a strong association exists between early shaking and unexplained intellectual disability. Possibly contributing to intellectual disability, the role of infant shaking needs to be explored further.
Keywords: Abusive head trauma; Intellectual disability; Low and middle-income countries; Matched case-control studies; Shaking
