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Option C: Finding Stability and Peace in the Gray
No full textAs a clinician educator, I\u27ve long believed in the resilience of our profession. Yet recent challenges-ranging from systemic dysfunction to legislative interference-have shaken that belief. In this essay, I share my personal journey through burnout, disillusionment, and ultimately, a shift toward advocacy and self-agency. My hope is to contribute meaningfully to the ongoing dialogue about sustaining purpose and integrity in medicine
Mobile Telemedicine for Treating Chronic Hepatitis C Among Rural People Who Inject Drugs: A Randomized Clinical Trial
No full textImportance: Persons who inject drugs in the rural US have high rates of chronic hepatitis C virus (HCV) infection and poor access to HCV testing, direct-acting antiviral (DAA) treatment, and syringe services. Effective approaches to test and treat this population are needed to achieve national HCV elimination goals.
Objective: To test whether a mobile telemedicine-based HCV treatment intervention increases HCV treatment initiation and viral clearance and decreases sharing of injection equipment among rural persons who inject drugs.
Design, setting, and participants: This open-label, randomized, parallel-group clinical trial compared mobile telemedicine care (MTC) for HCV treatment with enhanced usual care (EUC), both integrated with van-based syringe services, from April 21, 2022, to September 13, 2024. Participants were persons aged 18 years or older with a history of drug injection and chronic HCV infection from 3 rural counties in New Hampshire and Vermont.
Intervention: MTC consisted of DAA treatment for HCV via telemedicine along with on-demand syringe services, all on a mobile van. EUC consisted of treatment referral by van staff, with care navigation to a local or regional clinician.
Main outcomes and measures: Primary outcomes were the proportion of participants who (1) initiated DAA treatment for HCV, (2) achieved viral clearance at the 12-week follow-up, and (3) reported no injection equipment sharing at any point after the expected treatment completion visit.
Results: Of 503 prescreened individuals, 169 were eligible and 150 were randomized to MTC (n = 75) or EUC (n = 75). Participants had a mean (SD) age of 38.1 (8.1) years, 103 (68.7%) were male, 105 (70.0%) experienced homelessness, and 97 (64.7%) reported drug injection in the past 30 days. MTC participants were more likely than EUC participants to initiate DAA treatment (43 [57.3%] vs 20 [26.7%]; relative risk [RR], 2.15 [95% CI, 1.41-3.28]) and to achieve viral clearance (28 [37.3%] vs 14 [18.7%]; RR, 2.00 [95% CI, 1.15-3.49]). No effect was detected on abstention from sharing of syringes or other injection equipment at follow-up (RR, 0.95; 95% CI, 0.68-1.32).
Conclusions and relevance: In this randomized clinical trial, telemedicine for chronic HCV treatment integrated with syringe services on a mobile van was associated with improved access to HCV treatment initiation and cure for people with a history of drug injection in rural communities where HCV treatment services are scarce, suggesting optimal strategies in rural areas should include convenient, low-threshold telemedicine treatment.
Trial registration: ClinicalTrials.gov Identifier: NCT05466331
Bi-allelic loss-of-function variants in JKAMP cause a neurodevelopmental syndrome associated with dysregulation of GPR37 trafficking
No full textThe endoplasmic reticulum (ER) serves as a key hub for protein homeostasis, maintaining a strict quality-control system that ensures only properly folded proteins reach their destinations, while misfolded proteins are degraded via ER-associated degradation (ERAD) or selective ER-phagy. JKAMP, which encodes an ER-resident transmembrane protein involved in ERAD, has not previously been associated with human disease. Here, we report bi-allelic loss-of-function variants in JKAMP in 14 affected individuals from 10 unrelated families presenting with a neurodevelopmental syndrome characterized by intellectual disability, developmental delay, seizures, hypotonia, microcephaly, and dysmorphic features. An in vivo zebrafish model lacking jkamp recapitulated key aspects of the human disorder, including developmental abnormalities and impaired myelin production, further corroborating its pathogenic role. Mechanistic studies identified GPR37, a brain-enriched orphan G protein-coupled receptor (GPCR) and known JKAMP interactor, as a critical downstream effector. GPR37 plays essential roles in dopaminergic signaling, inflammatory pain regulation, neuroprotection, and myelination. Loss of JKAMP resulted in defective folding and degradation of GPR37, leading to its accumulation within the ER and impaired trafficking to the plasma membrane, likely due to impaired ER quality control. These findings establish JKAMP as a previously unrecognized contributor to human neurodevelopment and uncover a pathogenic mechanism linking ER protein quality control to GPCR regulation and neurological disease.
Keywords: GPR37; JKAMP; bi-allelic loss-of-function variants; developmental delay; endoplasmic reticulum; intellectual disability; zebrafish model
Disparities in diagnosis and management of hypertension by incarceration status for patients receiving care in the emergency department
No full textBackground: Incarcerated individuals have increased rates of chronic diseases, including cardiovascular disease, but often receive no regular medical care. The primary objectives of this study were to examine the associations between incarceration and the presence of undiagnosed or uncontrolled hypertension in a patient population treated in the emergency department (ED) of a large, urban, safety-net hospital. We hypothesized that incarcerated patients would have higher odds of undiagnosed and uncontrolled hypertension compared to non-incarcerated patients.
Methods: This cross-sectional analysis identified all adult patients ≥25 years presenting to the Boston Medical Center ED. Multivariable generalized estimating equation logistic regression modeling was conducted to estimate odds ratios (ORs) and 95% confidence intervals (95%CI) to evaluate associations between incarceration status and undiagnosed/uncontrolled hypertension.
Results: Of 352,772 ED visits among 130,268 patients, 3216 visits (1%) were among incarcerated patients. Compared to non-incarcerated patients, incarcerated patients had 14% higher odds of hypertension (OR = 1.14, 95%CI = 1.03-1.27, p = 0.01) and 56% higher odds of undiagnosed hypertension (OR = 1.56, 95%CI = 1.41-1.73, p \u3c 0.0001). The prevalence of undiagnosed hypertension was higher for incarcerated patients (24.1% versus 15.4%) among all age groups, but the difference was greatest for the oldest patients aged 65 years or older (40.1% versus 17.0%). Among patients with a hypertension diagnosis and prescription medication for high blood pressure, incarcerated patients were at 64% higher odds of having uncontrolled high blood pressure (OR = 1.64, 95%CI = 1.21-2.21, p = 0.001). Despite these health disparities, incarcerated patients had equal odds of the ED visit resulting in a new prescription for hypertension medication.
Conclusion: Incarceration has profound impacts on the health of inmates. Interaction with emergency department clinicians provides an opportunity for chronic disease diagnosis and management in a population with limited healthcare access
Social and Patient Factors Associated With Disposition Change in Pediatric Mental Health Boarding: A Retrospective Case-Control Study
No full textThe current pediatric mental health crisis has resulted in an increase in boarding patients. We sought to understand the role of social factors in final disposition. A single-center retrospective case-control study was conducted. Patients \u3c 18 years old presenting for a mental health chief complaint and recommended for inpatient psychiatric treatment were included. Outcomes groups were (1) patients discharged to home or a lower level of care after re-evaluation and (2) patients transferred to an inpatient psychiatric facility. Univariate and multiple logistic regression analyses were conducted. Patient identification as LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and questioning and the + is intended to signify inclusivity of individuals who are not heterosexual or cisgender) was associated with a lower likelihood of discharge to home or a lower level of care (odds ratio [OR] = 0.39, 95% confidence interval [CI] = 0.18-0.77). We identified additional factors that were associated with final disposition. Further investigation is needed to clarify these associations and to determine the impact of disposition on long-term mental health outcomes.
Keywords: child psychiatry; disposition; mental health; pediatric boarding; social risk factors
Differences in influenza vaccine effectiveness by sex among adults hospitalized with acute respiratory illness-IVY network, January 24, 2022-September 1, 2024
No full textThis analysis assessed differences in influenza vaccine effectiveness (VE) and severe in-hospital outcomes between U.S. male and female adults hospitalized with laboratory-confirmed influenza in a multi-center network during 2022-2024. Compared with men, women hospitalized with influenza were less likely to smoke (21.5 % vs 25.3 %, P = 0.02), to have COPD (21.9 % vs 22.7 %, P \u3c 0.001), and to be admitted to an intensive care unit once hospitalized (17.3 % vs 20.7 %, P = 0.04). Influenza VE (95 % confidence interval [CI]) was significantly higher in women aged ≥50 years compared with men aged ≥50 years (48.5 % [39.2 %-56.4 %] vs 26.2 % [13.0 %-37.5 %]). VE was slightly lower in women aged 18-49 years compared with women ≥50 years (46.2 % [95 % CI: 24.2 %-61.8 % vs 61.3 % [41.0 %-74.6 %]) but significantly lower in men aged ≥50 years compared with men aged 18-49 years (61.3 % [41.0 %-74.6 %] vs 26.2 % [13.0 %-37.5 %]). Disaggregation of sex should be considered in future influenza VE studies.
Keywords: Hospitalization; Immune response; Influenza; Sex differences; Vaccine effectiveness
Effect of Age on Restrictive and Liberal Transfusion Outcomes in Patients with Anemia and Myocardial Infarction
No full textFor patients with anemia and myocardial infarction, the randomized, 3504-patient MINT trial found that a liberal transfusion threshold (10 g/dL) may be preferable to a restrictive threshold (8 g/dL) in terms of death or myocardial infarction. The relative effects of liberal versus restrictive transfusion in younger and older patients are unknown. The present prespecified MINT sub-study found no significant interaction between age and transfusion strategy for death or myocardial infarction, heart failure, revascularization procedures, cardiac death, pulmonary embolism or deep vein thrombosis, and bacteremia or pneumonia and death at 30 and 180 days. A liberal transfusion approach appears to be safe and may be the preferred transfusion strategy in anemic patients with myocardial infarction, regardless of age. MINT Trial, ClinicalTrials.gov Number NCT02981407, https://www.minttrial.org/.
Keywords: Anemia; myocardial infarction; transfusion
Coronary Artery Bypass Grafting After Acute Myocardial Infarction With Cardiogenic Shock: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database
No full textA Recommendation for FLS Certification for General Surgery Residents By the End of the PGY-2 Year
No full textThe Fundamentals of Laparoscopic Surgery (FLS) certification has been shown to establish achievement of basic levels of knowledge and skills competencies in laparoscopic surgery by surgical residents. Current evidence shows that this frequently occurs too late in training for residents to use these competencies to facilitate their advancement toward operative autonomy. The American Board of Surgery (ABS) General Surgery Board working with the Society of American Gastrointestinal and Endoscopic Surgeon (SAGES) FLS Committee have jointly formulated a recommendation that FLS certification should ideally be achieved by US surgical residents by the end of postgraduate year-2 in order to facilitate access to more advanced laparoscopic procedures and to achievement of practice readiness.
Keywords: laparoscopy; simulation; surgical competency; surgical education; surgical skills
Imaging and Clinical Outcomes with Sentinel Cerebral Embolic Protection During TAVR: A Meta-Analysis of Randomized Trials with Trial Sequential Analysis
No full textBackground: Stroke and subclinical cerebral ischemia remain important neurological complications of transcatheter aortic valve replacement (TAVR). The Sentinel cerebral embolic protection (CEP) device is designed to capture embolic debris during TAVR, but its impact on clinical and imaging outcomes remains incompletely characterized. Methods: PubMed, Embase, and Cochrane databases were systematically searched for randomized controlled trials (RCTs) comparing Sentinel CEP versus no protection when TAVR was performed. Outcomes of interest included all stroke, disabling stroke, infarct volume by diffusion-weighted MRI in protected and unprotected areas, all-cause mortality, acute kidney injury, and major vascular complications. Risk ratios (RRs) and median differences with 95% confidence intervals (CIs) were calculated using random-effects models and trial sequential analysis (TSA) assessed evidence robustness. Results: Four RCTs including 10,986 patients were analyzed. Sentinel CEP did not significantly reduce clinical stroke (RR 0.88, 95% CI 0.69-1.12) or disabling stroke (RR 0.68, 95% CI 0.41-1.14). Pooled DW-MRI data showed a significant reduction in new ischemic lesion volume within Sentinel CEP-protected territories (difference in medians -75.7 mm3; 95% CI -130.4 to -21.0). Subgroup analyses in elderly, female, and high-surgical-risk patients revealed no benefit with Sentinel CEP. Additionally, TSA indicated that current data are underpowered for definitive conclusions. Conclusions: The Sentinel CEP device during TAVR did not significantly reduce clinical stroke but was associated with lower MRI-detected ischemic lesion volumes compared with no protection. Further adequately powered RCTs integrating clinical and imaging endpoints are needed to define its role in neuroprotection during TAVR.
Keywords: CEP; TAVR; sentinel; stroke