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Recent Research Articles from JPS Health Network

Associations Between Race, Perceived Psychological Stress, and the Gut Microbiota in a Sample of Generally Healthy Black and White Women: A Pilot Study on the Role of Race and Perceived Psychological Stress.

Tue, 09/10/2019 - 07:27
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Associations Between Race, Perceived Psychological Stress, and the Gut Microbiota in a Sample of Generally Healthy Black and White Women: A Pilot Study on the Role of Race and Perceived Psychological Stress.

Psychosom Med. 2018 09;80(7):640-648

Authors: Carson TL, Wang F, Cui X, Jackson BE, Van Der Pol WJ, Lefkowitz EJ, Morrow C, Baskin ML

Abstract
OBJECTIVE: Racial health disparities persist among black and white women for colorectal cancer. Understanding racial differences in the gut microbiota and related covariates (e.g., stress) may yield new insight into unexplained colorectal cancer disparities.
METHODS: Healthy non-Hispanic black or white women (age ≥19 years) provided survey data, anthropometrics, and stool samples. Fecal DNA was collected and isolated from a wipe. Polymerase chain reaction was used to amplify the V4 region of the 16SrRNA gene and 250 bases were sequenced using the MiSeq platform. Microbiome data were analyzed using QIIME. Operational taxonomic unit data were log transformed and normalized. Analyses were conducted using linear models in R Package "limma."
RESULTS: Fecal samples were analyzed for 80 women (M (SD) age = 39.9 (14.0) years, 47 black, 33 white). Blacks had greater average body mass index (33.3 versus 27.5 kg/m, p < .01) and waist circumference (98.3 versus 86.6 cm, p = .003) than whites. Whites reported more stressful life events (p = .026) and greater distress (p = .052) than blacks. Final models accounted for these differences. There were no significant differences in dietary variables. Unadjusted comparisons revealed no racial differences in alpha diversity. Racial differences were observed in beta diversity and abundance of top 10 operational taxonomic units. Blacks had higher abundances than whites of Faecalibacterium (p = .034) and Bacteroides (p = .038). Stress was associated with abundances of Bifidobacterium. The association between race and Bacteroides (logFC = 1.72, 0 = 0.020) persisted in fully adjusted models.
CONCLUSIONS: Racial differences in the gut microbiota were observed including higher Bacteroides among blacks. Efforts to cultivate an "ideal" gut microbiota may help reduce colorectal cancer risk.

PMID: 29901485 [PubMed - indexed for MEDLINE]

Participation and retention can be high in randomized controlled trials targeting underserved populations: a systematic review and meta-analysis.

Tue, 09/10/2019 - 07:27
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Participation and retention can be high in randomized controlled trials targeting underserved populations: a systematic review and meta-analysis.

J Clin Epidemiol. 2018 06;98:154-157

Authors: Ojha RP, Jackson BE, Lu Y, Burton M, Blair SE, MacDonald BR, Chu TC, Teigen KJ, Acosta M

PMID: 29183689 [PubMed - indexed for MEDLINE]

Fixed-dose gabapentin augmentation in the treatment of alcohol withdrawal syndrome: a retrospective, open-label study.

Sat, 09/07/2019 - 05:03

Fixed-dose gabapentin augmentation in the treatment of alcohol withdrawal syndrome: a retrospective, open-label study.

Am J Drug Alcohol Abuse. 2019 Sep 06;:1-9

Authors: Andaluz A, DeMoss D, Claassen C, Blair S, Hsu J, Bakre S, Khan M, Atem F, Rush AJ

Abstract
Background: Lorazepam use in the treatment of alcohol withdrawal syndrome (AWS) is not without risk. Objective: This study compares AWS outcomes using a standard, symptom-triggered lorazepam dosing protocol (control group) and symptom-triggered lorazepam dosing augmented with a gabapentin loading dose and taper (GABA group). Methods: Consecutive, non-randomized adults (n = 982; 64.0% male) undergoing treatment for AWS were included in this retrospective, open-label study. Symptom-triggered lorazepam dosing was informed by scores on the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar). Gabapentin augmentation utilized an initial loading dose (900 mg) and a three-day taper. Outcomes included average symptom severity per treatment hour and average lorazepam dose per treatment hour. Average time in the protocol by group, stratified by highest CIWA-Ar score, was examined as a secondary outcome. A priori group differences were controlled statistically. Results: GABA patients were older and exhibited somewhat more severe withdrawal symptoms than controls. After controlling for confounders, gabapentin augmentation did not significantly lower average lorazepam dosing per treatment hour or withdrawal symptom severity per treatment hour. Compared to controls, overall withdrawal symptoms diminished somewhat more rapidly for GABA patients experiencing low or moderate-level withdrawal symptoms; however, severe withdrawal symptoms remitted more slowly in the GABA group. Results should be interpreted in light of the uncontrolled nature of group assignment and other confounders. Conclusions: Compared to symptom-triggered lorazepam dosing alone, gabapentin augmentation did not produce better outcomes during treatment of acute AWS. These results do not support the use of scheduled gabapentin as an augmentation to benzodiazepines during inpatient treatment of AWS.

PMID: 31490712 [PubMed - as supplied by publisher]

Addition of Advanced Practice Registered Nurses to the Trauma Team: An Integrative Systematic Review of Literature.

Thu, 09/05/2019 - 09:01
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Addition of Advanced Practice Registered Nurses to the Trauma Team: An Integrative Systematic Review of Literature.

J Trauma Nurs. 2019 May/Jun;26(3):141-146

Authors: Crawford CC

Abstract
The total cost of inpatient care from a traumatic mechanism of injury in the United States between 2001 and 2011 was $240.7 billion. Medical resident work hour reductions mandated in 2011 left a shortage of available in-hospital providers to care for trauma patients. This created gaps in continuity of care, which can lead to costly increased lengths of stay (LOS) and increased medical errors. Adding advanced practice nurses (APNs) specializing in acute or trauma care to the trauma team may help fill this shortage in trauma care providers. The purpose of this integrative systematic review of the literature was to determine whether adding APNs to the admitting trauma team would decrease LOS. A systematic review of primary research in CINAHL and PubMed databases was performed using the following terms: nurse practitioner, advanced practice nurse, trauma team, and length of stay. Included studies examined the effects of adding APNs to trauma teams, were written in English, and were published in 2007-2017. Six studies were included in the final sample, and all were completed at Level I trauma centers in the United States except one from Canada. Combined sample size was 25,083 admitted trauma patients. All 6 studies reported a decrease in LOS ranging from 0.8 to 2.54 days when APNs were added to the trauma team. More research is needed to identify the best utilization of an APN on a trauma team. It is recommended that all trauma centers add APNs to the trauma team to not only decrease admitted trauma patients' LOS but also provide continuity of care, decreasing costs, and minimizing errors.

PMID: 31483771 [PubMed - in process]

Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury.

Thu, 09/05/2019 - 09:01
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Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury.

J Am Coll Surg. 2018 05;226(5):769-776.e1

Authors: Teixeira PGR, Brown CVR, Emigh B, Long M, Foreman M, Eastridge B, Gale S, Truitt MS, Dissanaike S, Duane T, Holcomb J, Eastman A, Regner J, Texas Tourniquet Study Group

Abstract
BACKGROUND: Tourniquet use has been proven to reduce mortality on the battlefield. Although empirically transitioned to the civilian environment, data substantiating survival benefit attributable to civilian tourniquet use is lacking. We hypothesized that civilian prehospital tourniquet use is associated with reduced mortality in patients with peripheral vascular injuries.
STUDY DESIGN: We conducted a multicenter retrospective review of all patients sustaining peripheral vascular injuries admitted to 11 Level I trauma centers (January 2011 through December 2016). The study population was divided into 2 groups based on prehospital tourniquet use. Baseline characteristics were compared and factors associated with mortality identified. Logistic regression, adjusting for demographic, physiologic and injury-related parameters, was used to evaluate the association between prehospital tourniquet use and mortality. Delayed amputation was the secondary end point.
RESULTS: During 6 years, 1,026 patients with peripheral vascular injuries were admitted. Prehospital tourniquets were used in 181 (17.6%) patients. Tourniquet time averaged 77.3 ± 63.3 minutes (interquartile range 39.0 to 92.3 minutes). Traumatic amputations occurred in 98 patients (35.7% had a tourniquet). Mortality was 5.2% in the non-tourniquet group compared with 3.9% in the tourniquet group (odds ratio 1.36; 95% CI 0.60 to 1.65; p = 0.452). After multivariable analysis, the use of tourniquets was found to be independently associated with survival (adjusted odds ratio 5.86; 95% CI 1.41 to 24.47; adjusted p = 0.015). Delayed amputation rates were not significantly different between the 2 groups (1.1% vs 1.1%; adjusted odds ratio 1.82; 95% CI 0.36 to 9.99; adjusted p = 0.473).
CONCLUSIONS: Although still underused, civilian prehospital tourniquet application was independently associated with a 6-fold mortality reduction in patients with peripheral vascular injuries. More aggressive prehospital application of extremity tourniquets in civilian trauma patients with extremity hemorrhage and traumatic amputation is warranted.

PMID: 29605726 [PubMed - indexed for MEDLINE]

Women in Podiatry and Medicine.

Sat, 08/31/2019 - 07:57
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Women in Podiatry and Medicine.

Clin Podiatr Med Surg. 2019 Oct;36(4):707-716

Authors: Brower BA, Jennings MM, Butterworth ML, Crawford ME

Abstract
The role of female physicians has advanced among western medicine. Women now constitute a majority within medical schools, and the number of women in podiatric medicine and surgery has increased over the last 5 decades. Conversely, female physicians continue to face barriers to closing the gender gap. They have lower academic standings and fewer publications, receive less awards/grants, are underrepresented in leadership positions, have a lower incidence pursuing surgical specialties, and receive lower compensation. Women experience an increased rate of burnout, gender discrimination, and sexual harassment. Increasing awareness of the gender gap is vital to the enhancement of the medical community.

PMID: 31466577 [PubMed - in process]

Cognitive Behavior Therapy for Postpartum Depression.

Fri, 08/16/2019 - 07:54
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Cognitive Behavior Therapy for Postpartum Depression.

Am Fam Physician. 2019 Aug 15;100(4):244-245

Authors: Buck K, Zekri S, Nguyen L, Ogar UJ

PMID: 31414780 [PubMed - in process]

Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use.

Wed, 08/14/2019 - 05:12
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Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use.

Curr Pharm Teach Learn. 2018 07;10(7):955-963

Authors: Nduaguba SO, Ford KH, Bamgbade BA, Ubanyionwu O

Abstract
BACKGROUND AND PURPOSE: This study assessed pharmacy students' self-rated ability to provide cessation counseling for e-cigarette use and traditional cigarette smoking.
EDUCATIONAL ACTIVITY AND SETTING: A cross-sectional study was conducted in spring 2014 at The University of Texas at Austin. Participants included first through fourth year (P1-P4) doctor of pharmacy (PharmD) students. Perceived confidence and knowledge to counsel on cigarette smoking cessation and e-cigarette cessation were self-rated and based on the Ask-Advise-Assess-Assist-and Arrange (5 A's) follow-up model as well as general counseling skills for recreational nicotine product use cessation. Comparisons were made between students' confidence to counsel patients on traditional cigarette smoking cessation and e-cigarette cessation and by class level.
FINDINGS: Compared to cigarette smoking cessation counseling, students were less confident in their ability to counsel on e-cigarette cessation using the 5 A's model and general counseling skills. Students perceived themselves to be less knowledgeable about the harmful effects of e-cigarettes, pharmacists' role in counseling on e-cigarette cessation, and how patients can benefit from e-cigarette cessation counseling. A higher proportion of students reported having no training on e-cigarette cessation compared to cigarette smoking cessation (59% vs 9%).
SUMMARY: Targeted training on how to counsel patients on e-cigarette cessation should be included in pharmacy curricula. Such training is expected to increase the confidence of pharmacists-in-training to address the needs of patients who use e-cigarettes.

PMID: 30236434 [PubMed - indexed for MEDLINE]

Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial.

Thu, 08/08/2019 - 09:00
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Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial.

Cancer Epidemiol Biomarkers Prev. 2019 Aug 06;:

Authors: Lieberman A, Gneezy A, Berry E, Miller S, Koch M, Ahn C, Balasubramanian BA, Argenbright KE, Gupta S

Abstract
BACKGROUND: Financial incentives may improve health behaviors. We tested the impact of offering financial incentives for mailed fecal immunochemical test (FIT) completion annually for three years.
METHODS: Patients, aged 50-64 years, not up-to-date with screening were randomized to receive either a mailed FIT outreach (n=6,565), outreach plus $5 (n=1,000), or $10 (n=1,000) incentive for completion. Patients who completed the test were re-invited using the same incentive the following year, for 3 years. In Year 4, patients who returned the kit in all preceding three years were re-invited without incentives. Primary outcome was FIT completion among patients offered any incentive versus outreach alone each year. Secondary outcomes were FIT completion for groups offered $5 vs. outreach alone, $10 vs. outreach alone, and $5 vs. $10.
RESULTS: Year 1 FIT completion was 36.9% with incentives vs. 36.2% outreach alone (P=0.59) and was not statistically different for $10 (34.6%; P=0.31) or $5 (39.2%; P=0.070) vs. outreach alone. Year 2 completion was 61.6% with incentives vs. 60.8% outreach alone (P=0.75) and not statistically different for $10 or $5 vs. outreach alone. Year 3 completion was 79.4% with incentives vs. 74.8% outreach alone (P=0.080), and was higher for $10 (82.4%) vs. outreach alone (P=.033), but not for $5 vs. outreach alone. Completion was similar across conditions in Year 4 (no incentives).
CONCLUSIONS: Offering small incentives did not increase FIT completion relative to standard outreach.
IMPACT: This was the first longitudinal study testing the impact of repeated financial incentives, and their withdrawal, on FIT completion.

PMID: 31387970 [PubMed - as supplied by publisher]

Novel Investigation of the Deep Band of the Lateral Plantar Aponeurosis and Its Relationship With the Lateral Plantar Nerve.

Thu, 08/08/2019 - 09:00
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Novel Investigation of the Deep Band of the Lateral Plantar Aponeurosis and Its Relationship With the Lateral Plantar Nerve.

Foot Ankle Int. 2019 Aug 06;:1071100719864352

Authors: Beck CM, Dickerson AR, Kadado KJ, Cohen ZA, Blair SE, Motley TA, Holcomb JC, Fisher CL

Abstract
BACKGROUND: We describe a thick fascial band arising from the medial aspect of the lateral plantar aponeurosis diving deep into the forefoot crossing over a branch of the lateral plantar nerve. Because a review of current literature resulted in limited and outdated sources, we sought to first determine the frequency of this fascial band and the location where it crosses the lateral plantar nerve and, second, discuss the clinical applications these anatomical findings could have.
METHODS: 50 pairs of cadaveric feet (n = 100) were dissected to investigate for presence of the fascial band and its interaction with the lateral plantar nerve. Images were taken of each foot with the fascial band. ImageJ was used to take 2 measurements assessing the relationship of the tuberosity of the base of the fifth metatarsal to where the nerve crossed deep to the fascial band.
RESULTS: Overall, 38% of the feet possessed the fascial band. It was found unilaterally in 10 pairs and bilaterally in 14 pairs. On average, the point at which the lateral plantar nerve passed deep to the fascial band was 2.0 cm medial and 1.7 cm anterior to the tuberosity of the base of the fifth metatarsal.
CONCLUSION: When present, the deep band of the lateral plantar aponeurosis (PA) was consistently found to be crossing the lateral plantar nerve. The discovery of the location where this most commonly occurs has not been previously reported and adds an interesting dimension that elevates an anatomical study to one that has clinical potential.
CLINICAL RELEVANCE: The established target zone gives a precise location for where the relationship between the deep band of the lateral PA and the lateral plantar nerve exists when evaluating the foot. The target zone provides a potential springboard for future investigations concerning said relationship clinically.

PMID: 31387386 [PubMed - as supplied by publisher]

Emergency Medicine Resident Efficiency and Emergency Department Crowding.

Wed, 07/31/2019 - 06:37
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Emergency Medicine Resident Efficiency and Emergency Department Crowding.

AEM Educ Train. 2019 Jul;3(3):209-217

Authors: Kirby R, Robinson RD, Dib S, Mclarty D, Shaikh S, Cheeti R, Ho AF, Schrader CD, Zenarosa NR, Wang H

Abstract
Objectives: Provider efficiency has been reported in the literature but there is a lack of efficiency analysis among emergency medicine (EM) residents. We aim to compare efficiency of EM residents of different training levels and determine if EM resident efficiency is affected by emergency department (ED) crowding.
Methods: We conducted a single-center retrospective observation study from July 1, 2014, to June 30, 2017. The number of new patients per resident per hour and provider-to-disposition (PTD) time of each patient were used as resident efficiency markers. A crowding score was assigned to each patient upon the patient's arrival to the ED. We compared efficiency among EM residents of different training levels under different ED crowding statuses. Dynamic efficiency changes were compared monthly through the entire academic year (July to next June).
Results: The study enrolled a total of 150,920 patients. A mean of 1.9 patients/hour was seen by PGY-1 EM residents in comparison to 2.6 patients/hour by PGY-2 and -3 EM residents. Median PTD was 2.8 hours in PGY-1 EM residents versus 2.6 hours in PGY-2 and -3 EM residents. There were no significant differences in acuity across all patients seen by EM residents. When crowded conditions existed, residency efficiency increased, but such changes were minimized when the ED became overcrowded. A linear increase of resident efficiency was observed only in PGY-1 EM residents throughout the entire academic year.
Conclusion: Resident efficiency improved significantly only during their first year of EM training. This efficiency can be affected by ED crowding.

PMID: 31360813 [PubMed]

Management of Orbital Fractures.

Sun, 07/28/2019 - 06:07
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Management of Orbital Fractures.

Atlas Oral Maxillofac Surg Clin North Am. 2019 Sep;27(2):157-165

Authors: Kholaki O, Hammer DA, Schlieve T

PMID: 31345491 [PubMed - in process]

Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association (OTA) Members and Evidence-Based Treatment Recommendations.

Wed, 07/24/2019 - 11:31
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Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association (OTA) Members and Evidence-Based Treatment Recommendations.

J Orthop Trauma. 2019 Jun 26;:

Authors: Coles CP, Tornetta P, Obremskey WT, Spitler CA, Ahn J, Mirick G, Krause P, Nana A, Rodriguez-Buitrago A, Orthopaedic Trauma Association’s Evidence-Based Quality Value and Safety Committee

Abstract
OBJECTIVES: The goal of this study was to describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system.
DESIGN: Web-based survey PARTICIPANTS:: Orthopaedic Trauma Association (OTA) members METHODS:: A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures.
RESULTS: One hundred and sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. The majority of responses are in keeping with best evidence available.
CONCLUSIONS: Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey.
LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

PMID: 31335507 [PubMed - as supplied by publisher]

Successful implementation of an appendectomy process improvement protocol.

Sat, 07/20/2019 - 07:28
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Successful implementation of an appendectomy process improvement protocol.

Trauma Surg Acute Care Open. 2019;4(1):e000303

Authors: Bradley M, Kindvall A, Logan J, Bailey J, Elster E, Rodriguez C

Abstract
Background: A key component of a process improvement program is the institution of hospital-specific protocols to address certain disparities and streamline patient care. In that regard, we evaluated the implementation of an outpatient laparoscopic appendectomy (OLA) protocol at a tertiary military hospital. We hypothesized that OLA would reduce length of stay (LOS) without increasing complications.
Methods: In August 2016, our institution implemented an OLA protocol-defined as discharge within 24 hours of surgery. Exclusion criteria included age <18 years old, grade 4 or 5 appendicitis, immunosuppression, current pregnancy, and no supervision during the first 24 hours postdischarge. To determine OLA's effect on LOS, analysis of variance was used to perform a comparison between the years 2014 and 2017. Successful outpatient appendectomies were recorded preprotocol and postprotocol, as well as readmission complications.
Results: In 2017, the first full year of protocol implementation, 44 of 59 (75%) patients met the inclusion criteria, and all but 2 (42 of 44, 95%) stayed for less than 24 hours. Of the two outliers, one developed acute on chronic kidney disease and one had a slow return of bowel function following grade 3 appendicitis. Complications were low across all years (one per year). In 2017, the readmission was for percutaneous drainage of an abscess. Overall, protocol implementation produced a significant decrease in LOS.
Discussion: OLA protocol decreased LOS at a military hospital and should be expanded to other department of defense (DoD) facilities. Further research is needed to identify cost benefit to the military health system.
Level of evidence: III.

PMID: 31321311 [PubMed]

Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study.

Sat, 07/06/2019 - 07:14
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Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study.

BMC Health Serv Res. 2019 Jul 04;19(1):451

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, Ho AF, D'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
BACKGROUND: It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients.
METHODS: This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions.
RESULT: A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001).
CONCLUSIONS: Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

PMID: 31272442 [PubMed - in process]

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Thu, 07/04/2019 - 05:23

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

Fam Med. 2019 Jul 02;:

Authors: Penwell-Waines L, Runyan C, Kolobova I, Grace A, Brennan J, Buck K, Ross V, Schneiderhan J

Abstract
BACKGROUND AND OBJECTIVES: The Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force released a comprehensive Well-Being Action Plan as a guide to help programs create a culture of wellness. The plan, however, does not offer a recommendation as to which elements may be most important, least resource intensive, or most feasible. This study sought to identify the most essential components of the AFMRD's Well-Being Action Plan, as rated by expert panelists using a modified Delphi technique.
METHODS: Sixty-eight selected experts were asked to participate; after three rounds of surveys, the final sample included 27 participants (7% residents, 38% MD faculty, 54% behavioral science faculty).
RESULTS: Fourteen elements were rated as essential by at least 80% of the participants. These components included interventions at both the system and individual level. Of those elements ranked in the top five by a majority of the panel, all but one do not mention specific curricular content, but rather discusses the nature of a wellness curriculum.
CONCLUSIONS: The expert consensus was that an essential curriculum should begin early, be longitudinal, identify a champion, and provide support for self-disclosure of struggles.

PMID: 31269221 [PubMed - as supplied by publisher]

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Thu, 07/04/2019 - 05:23

Family Physician Burnout and Resilience: A Cross-Sectional Analysis.

Fam Med. 2019 Jul 02;:

Authors: Buck K, Williamson M, Ogbeide S, Norberg B

Abstract
BACKGROUND AND OBJECTIVES: Current physician burnout levels are at historically high levels, especially in family medicine, with many factors playing a role. The goal of this study was to understand demographic, psychological, environmental, behavioral, and workplace characteristics that impact physician wellness and burnout, focusing on family medicine physicians and residents.
METHODS: Survey respondents were 295 family medicine residents and faculty members across 11 residency programs within the Residency Research Network of Texas (RRNeT). Subjects completed multiple measures to assess resilience, burnout, psychological flexibility, and workplace stress. Respondents also reported personal wellness practices and demographic information. The primary outcome variables were burnout (depersonalization, emotional exhaustion, and personal achievement) and resilience.
RESULTS: The predictor variables contributed significant variance (depersonalization=27.1%, emotional exhaustion=39%, accomplishment=37.7%, resilience=37%) and resulted in large effect sizes (depersonalization f²=.371, emotional exhaustion f²=.639, accomplishment f²=.605, resilience f²=.587) among the three burnout models and the resilience model for the sample. Similar variance and effect sizes were present for independent resident and program faculty samples, with resilience being the only outcome variable with significant differences in variance between the samples.
CONCLUSIONS: This study demonstrates the roles of both individual and organization change needed to impact provider wellness, with special attention to resilience across faculty and residents. The results of this study may inform workplace policies (ie, organizational practice change) and wellness programming and curricula (ie, individual level) for family medicine residents and program faculty.

PMID: 31269220 [PubMed - as supplied by publisher]

Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

Sun, 06/30/2019 - 06:49
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Identifying diverse concepts of discharge failure patients at emergency department in the USA: a large-scale retrospective observational study.

BMJ Open. 2019 Jun 27;9(6):e028051

Authors: Schrader CD, Robinson RD, Blair S, Shaikh S, d'Etienne JP, Kirby JJ, Cheeti R, Zenarosa NR, Wang H

Abstract
OBJECTIVES: Identifying patients who are at high risk for discharge failure allows for implementation of interventions to improve their care. However, discharge failure is currently defined in literature with great variability, making targeted interventions more difficult. We aim to derive a screening tool based on the existing diverse discharge failure models.
DESIGN, SETTING AND PARTICIPANTS: This is a single-centre retrospective cohort study in the USA. Data from all patients discharged from the emergency department were collected from 1 January 2015 through 31 December 2017 and followed up within 30 days.
METHODS: Scoring systems were derived using modified Framingham methods. Sensitivity, specificity and area under the receiver operational characteristic (AUC) were calculated and compared using both the broad and restricted discharge failure models.
RESULTS: A total of 227 627 patients were included. The Screening for Healthcare fOllow-Up Tool (SHOUT) scoring system was derived based on the broad and restricted discharge failure models and applied back to the entire study cohort. A sensitivity of 80% and a specificity of 71% were found in SHOUT scores to identify patients with broad discharge failure with AUC of 0.83 (95% CI 0.83 to 0.84). When applied to a 3-day restricted discharge failure model, a sensitivity of 86% and a specificity of 60% were found to identify patients with AUC of 0.79 (95% CI 0.78 to 0.80).
CONCLUSION: The SHOUT scoring system was derived and used to screen and identify patients that would ultimately become discharge failures, especially when using broad definitions of discharge failure. The SHOUT tool was internally validated and can be used to identify patients across a wide spectrum of discharge failure definitions.

PMID: 31248927 [PubMed - in process]

Association Between Empathy and Burnout Among Emergency Medicine Physicians.

Thu, 06/27/2019 - 06:09
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Association Between Empathy and Burnout Among Emergency Medicine Physicians.

J Clin Med Res. 2019 Jul;11(7):532-538

Authors: Wolfshohl JA, Bradley K, Bell C, Bell S, Hodges C, Knowles H, Chaudhari BR, Kirby R, Kline JA, Wang H

Abstract
Background: The association between physician self-reported empathy and burnout has been studied in the past with diverse findings. We aimed to determine the association between empathy and burnout among United States emergency medicine (EM) physicians using a novel combination of tools for validation.
Methods: This was a prospective single-center observational study. Data were collected from EM physicians. From December 1, 2018 to January 31, 2019, we used the Jefferson scale of empathy (JSE) to assess physician empathy and the Copenhagen burnout inventory (CBI) to assess burnout. We divided EM physicians into different groups (residents in each year of training, junior/senior attendings). Empathy, burnout scores and their association were analyzed and compared among these groups.
Results: A total of 33 attending physicians and 35 EM residents participated in this study. Median self-reported empathy scores were 113 (interquartile range (IQR): 105 - 117) in post-graduate year (PGY)-1, 112 (90 - 115) in PGY-2, 106 (93 - 118) in PGY-3 EM residents, 112 (105 - 116) in junior and 114 (101 - 125) in senior attending physicians. Overall burnout scores were 43 (33 - 50) in PGY-1, 51 (29 - 56) in PGY-2, 43 (42 - 53) in PGY-3 EM residents, 33 (24 - 47) in junior attending and 25 (22 - 53) in senior attending physicians separately. The Spearman correlation (ρ) was -0.11 and β-weight was -0.23 between empathy and patient-related burnout scores.
Conclusion: Self-reported empathy declines over the course of EM residency training and improves after graduation. Overall high burnout occurs among EM residents and improves after graduation. Our analysis showed a weak negative correlation between self-reported empathy and patient-related burnout among EM physicians.

PMID: 31236173 [PubMed]

Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Tue, 06/25/2019 - 07:56
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Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

Am J Emerg Med. 2019 Jun 10;:

Authors: Dahlquist RT, Young JM, Reyner K, Farzad A, Moleno RB, Gandham G, Ho AF, Wang H

Abstract
BACKGROUND: The use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED.
METHODS: We conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016-April 2017) and after (Oct. 2017-April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May-Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared.
RESULTS: Pre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p < 0.001) with similar 90-day post-discharge stroke occurrence (2 in pre-implementation versus 1 in post-implementation groups, p > 0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p = 0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310 min (201, 420) in pre- and 275 min (222, 342) in post-implementation cohorts (p > 0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort.
CONCLUSIONS: The initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.

PMID: 31230922 [PubMed - as supplied by publisher]

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