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Palliative Care Initiated in the Emergency Department: A Cluster Randomized Clinical Trial
No full textImportance: The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness.
Objective: To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness.
Design, setting, and participants: Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded.
Intervention: A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff.
Main outcome and measures: The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months.
Results: There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]).
Conclusions and relevance: This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness.
Trial registration: ClinicalTrials.gov Identifier: NCT03424109
Global variation in the assessment of psychological trauma in pregnancy
No full textA history of psychologically traumatic experiences can impact health outcomes for pregnant people and their infants. The perception and prevalence of traumatic experiences during pregnancy may differ by geographical region. To better understand trends in how and what kinds of psychological trauma are assessed globally, we conducted a secondary analysis on a larger systematic review examining psychological trauma measurement in pregnancy. Through a systematic literature review conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, completed between July 2021 and September 2023 using Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, PsycInfo and Cochrane, we identified 576 research studies assessing psychological trauma during pregnancy that were conducted across nine geopolitical regions. Most of these studies took place in North America, followed by sub-Saharan Africa, Europe, Asia, the Middle East or Northern Africa, Oceania, South America, and Central America. The fewest number of studies was conducted across multiple regions. We found that most studies measuring psychological trauma in pregnancy across the nine geopolitical regions assessed interpersonal trauma, and the fewest number of studies assessed healthcare trauma. Moreover, for each type of psychological trauma assessed, the greatest number of studies was conducted in North America. We also found that Central America, Oceania, sub-Saharan Africa, Asia, Middle East or Northern Africa, Europe, and studies conducted across multiple regions had one-third or more studies that only used in-house assessments, rather than previously validated assessments of psychological trauma. The results of this review emphasize the need for regionally specific and culturally appropriate measures of psychological trauma for pregnant people, which prioritize the types of psychological trauma that are most common in a given region. Newly developed measures can be used for screening and treatment of patients using trauma-informed obstetric care.
Keywords: global trauma; perinatal trauma; post-traumatic stress disorder; pregnancy; psychological trauma
Leveraging individual development plans to support women physicians navigating academic medicine
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Cross-Pollinating Expertise : Collaborative Educational Sessions for Emergency and Internal Medicine Residents
No full textBackground: Medical Education between residencies remains siloed. Once residents have chosen their career track, they often lack opportunities to learn with residents in other disciplines. However, residents care for patients in a continuous fashion as they navigate the healthcare system. We created an annual educational session for Internal Medicine and Emergency Medicine residents to learn together about common medical problems they encounter.
Aim: Readers will: 1. describe the benefits of participating in interdisciplinary resident education, 2. increase confidence in how to improve interdisciplinary communication, and 3. improve ability to plan and implement interdisciplinary education among residencies.
Setting: An independent academic medical center in western Massachusetts.
Participants: Internal Medicine (54), Medicine/Pediatrics (32), and Emergency Medicine (48) residents.
Program description: Leadership from both residencies identified high yield topics that would provide optimal opportunities to collaborate about patient care and hand offs.
Program evaluation: Resident evaluations highlighted positive feedback, indicating improved understanding and desire for continued collaboration. Thematic analysis revealed enhanced collegiality and a preference for small-group, case-based learning.
Discussion: Instituting yearly combined education amongst residencies can enhance collegiality and allow opportunities to enhance patient care during transitions from primary care, emergency care and hospitalization. Implementing shared education enhances resident interaction and potentially improves patient care transitions
Impact of adding the immune checkpoint inhibitor atezolizumab to first-line chemotherapy on progression-free survival in poor-prognosis ovarian cancer: A retrospective analysis from the IMagyn050 trial
No full textPurpose: Adding the anti-PD-L1 antibody atezolizumab to frontline chemotherapy-bevacizumab regimen did not improve progression-free survival (PFS) in ovarian cancer (OC) patients in IMagyn050 trial. This post-hoc analysis assessed the efficacy of atezolizumab in a subgroup of patients with particularly poor prognosis, as defined by the GCIG meta-analysis-characterized by a poor chemosensitivity and a suboptimal surgical resection.
Methodology: This analysis included 1199 evaluable participants with ≥3 available CA-125 concentrations, as required for KELIM score. The prognostic factors were identified through univariable and multivariable analyses. If both the KELIM score (unfavorable \u3c 1.0, vs favorable ≥1.0) and surgical outcome (suboptimal, vs optimal resection) demonstrated independent prognostic value, they were to be combined into prognostic subgroups. The PFS benefit of atezolizumab versus placebo was then evaluated within each of these defined subgroups.
Results: Both the KELIM score and surgical outcome were independent prognostic factors. Combining these two parameters generated three distinct prognostic subgroups. In the poor prognosis subgroup (n = 269), defined by both an unfavorable KELIM score (\u3c 1.0) and suboptimal cytoreduction, the addition of atezolizumab was associated with a significantly longer median PFS compared to placebo (14.3 vs 11.3 months; HR 0.75, 95 % CI 0.59-0.95). This benefit was observed in both neoadjuvant and adjuvant settings. No significant PFS benefit was observed in the other prognostic subgroups.
Conclusion: The poor prognostic OC patient subgroup, may have an extension of PFS from treatment intensification with atezolizumab added to frontline chemotherapy-bevacizumab regimen. This hypothesis-generating outcome warrants further understanding on the added role of ICI in the frontline setting.
Keywords: Atezolizumab [supplementary concept]; CA-125 antigen; Immune checkpoint inhibitors; Ovarian neoplasms; Prognosis
Case Report: Inflammatory CADASIL phenotype associated with a rare cysteine-sparing NOTCH3 variant
No full textWe present a 50-year-old female who has a longstanding history of migraine with aura. She experienced one episode of partial visual field loss associated with a small acute/subacute lesion involving the cortex and subcortical white matter (showing contrast enhancement), alongside extensive white matter hyperintensities. Given these findings, CADASIL was suspected. Genetic testing identified a rare heterozygous NOTCH3 variant (c.6102dup, p.Gly2035Argfs*60), currently classified as a variant of uncertain significance. Concurrent cerebrospinal fluid analysis revealed elevated myelin basic protein, an elevated IgG index, and 4 oligoclonal bands, indicating an inflammatory process. Her visual evoked potentials showed no evidence of optic nerve or tract impairment. Approximately 9 months later, the occipital lesion evolved into encephalomalacia and gliosis without enhancement, while the extensive white matter hyperintensities remained stable. A repeat lumbar puncture 1 year later showed persistently elevated myelin basic protein and IgG index, now with 7 oligoclonal bands (some shared with serum). Currently, her neurological examination is normal. She is managed on dual antiplatelet therapy, and her migraines are effectively controlled with calcium-channel blocker prophylaxis. Notably, her mother, diagnosed with multiple sclerosis for several decades despite imaging findings suggestive of CADASIL, shares the same NOTCH3 variant. One of her two children tested negative for the variant and had normal imaging, while the other minor child has a significant history of migraines with aura. Our patient\u27s clinical presentation and comprehensive findings raise the possibility of an inflammatory phenotype potentially associated with the rare NOTCH3 c.6102dup variant, though causation remains unclear. Coexistence with another demyelinating central nervous system disease is possible, and further research is needed to clarify this relationship. If inflammatory variants of CADASIL exist, alternative treatments targeting inflammation may need consideration.
Keywords: CADASIL; NOTCH3; case report; cysteine-sparing; inflammation; variant of uncertain significance
Forum of ESRD Networks: 50 years of Collaboration, Innovation, and Education to Promote Equitable and Optimal Kidney-Patient Centered Care
No full textStress and Strain: Ergonomic Practices and Associated Injuries Among Pediatric Surgeons
No full textIntroduction: Ergonomic injuries pose significant risks to surgeons, affecting health, productivity, care access, and retirement age. Despite unique challenges in pediatric surgery, including varied patient sizes and operations, little is known about pediatric surgeons\u27 ergonomics. This study aimed to assess ergonomic practices and associated injuries among pediatric surgeons.
Methods: A cross-sectional survey was distributed to the American Pediatric Surgical Association regular members and fellows. Data collected included demographics, physical health, surgical practices, operating habits, discomfort, injuries, interventions, and outcomes. Associations with injury were analyzed using Fisher\u27s exact test, Pearson\u27s Chi-squared test, and Wilcoxon rank-sum tests.
Results: One hundred seventeen (11%) surgeons responded, 53% were male with a median of 15 y in practice (interquartile range: 6-25). Regarding operating habits, 76% did not take regular breaks, 48% double-gloved, and 51% used loupes regularly. Notably, 90% experienced discomfort or pain, and 30% sustained injuries from operating, primarily affecting the neck and cervical spine (53%). White-identifying pediatric surgeons (80%) reported significantly more ergonomic injuries than other races (P \u3c 0.01). Only 18% of respondents received ergonomic training. Ergonomics training and operating with a resident or co-surgeon were associated with less injury (P \u3c 0.05). Among those experiencing discomfort or injury, 13% underwent a procedure, 63% experienced sleep disturbance, 74% reported contribution to burnout, and 88% used pain medications.
Conclusions: Ergonomic-related discomfort and injuries occurred in nearly 90% of pediatric surgeons who responded. Few had ergonomic training and most reported an impact on well-being. Modifiable ergonomic factors for pediatric surgeons, along with targeted interventions to reduce injuries, can improve surgeon well-being.
Keywords: Discomfort; Ergonomics; Injury; Occupational hazard; Pediatric surgery; Surgical education; Well-being
Multimorbidity Profiles and Severe In-Hospital Outcomes in Adults with Respiratory Syncytial Virus
No full textBackground: Adults hospitalized with acute respiratory infections, including respiratory syncytial virus (RSV), often have multiple underlying conditions. Few data are available on the combined effect of conditions on risk of severe outcomes from RSV disease.
Methods: We enrolled adults hospitalized with RSV at 26 hospitals in 20 US states admitted January 2022-July 2024. Seventeen underlying conditions were selected after excluding those with rare prevalence (≤1%) or high pairwise correlation (≥0.7). We applied Bayesian profile regression to identify profiles of conditions associated with increased risk of RSV severe outcomes, stratifying among adults aged 18-59 and ≥60 years.
Results: We analyzed data from 1111 adults hospitalized with RSV (median age [IQR] = 66 [53-75]). Among 397 adults aged 18-59 years, two profiles were identified: (1) minimal prevalence with fewer underlying conditions and a posterior median ICU admission risk of 21% (95% credible interval = [16‒25]); (2) cardiorenal/diabetes with frequent heart failure, chronic kidney disease, diabetes, and increased ICU admission risk (37% [27‒48]). Among 714 adults aged ≥60 years, four profiles were identified: (1) minimal prevalence (ICU admission risk = 22% [18‒26]), (2) cardiorenal/diabetes (27% [21‒34]), (3) hematologic malignancy and transplant receipt (12% [6‒21]), and (4) chronic pulmonary disease with home oxygen dependence (44% [25‒66]).
Conclusion: Distinct underlying condition profiles with varying risks of critical illness were observed among inpatients with RSV. These findings could support recognition of high-risk patients to inform RSV prevention strategies and suggest the role of multimorbidity in severe RSV disease risk warrants further attention.
Keywords: ICU admission; respiratory syncytial virus; risk factors; statistical clustering; underlying conditions