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Introduction: Telehealth, especially the use of real-time video and phone visits in ambulatory care, is increasingly important in the wake of the COVID-19 pandemic. The current state of internal medicine (IM) interns' telehealth training at the start of residency is unknown. Objective: To characterize the attitudes, training, and preparedness of IM interns regarding the use of telehealth video and phone visits in ambulatory care. Materials and Methods: We conducted a cross-sectional survey of IM interns at four IM residency programs in the United States in 2020. Results: One hundred fifty-six surveys were analyzed (response rate 82%). Seventy-five percent of interns rated training in the use of real-time video and phone visits for ambulatory care as important or very important. The vast majority received no training (74%) or clinical experience (90% no prior video visits, 81% no prior phone visits) during medical school. More interns believed that primary care may be effectively delivered via video visits compared with phone visits (77% vs. 35%). Most interns (69%) missed clinical time during medical school due to the COVID-19 pandemic; 41% felt that the pandemic negatively affected their ambulatory care preparation. Overall, the majority of interns (58%) felt prepared for primary care; only 12% felt prepared to deliver primary care using either video or phone visits. Conclusions: Although IM interns had favorable attitudes toward video and phone visits, few had training or clinical experience; most felt unprepared. Residency programs may need to close training gaps for current interns in conducting telehealth video and phone visits. [ABSTRACT FROM AUTHOR]

This study estimates the frequency and duration of boarding for pediatric mental health conditions at US acute care hospitals and describes hospital resources available to support youths during boarding. [ABSTRACT FROM AUTHOR]

Background and Aims: Chronic hepatitis B (CHB) is a major cause of cirrhosis and end-stage liver disease. Not all patients with CHB require antiviral treatment but long-term monitoring is critical to identify patients who would benefit from antiviral therapy. CHB patients followed in various clinical settings may differ in disease characteristics and rates of treatment eligibility in long-term follow-up.Methods: We conducted a retrospective cohort study of 359 consecutive treatment-naive, treatment-ineligible CHB patients (228 from community GI clinics; 73 from university hepatology clinic; 58 from primary care clinic). Primary end points were the proportion of patients meeting eligibility criteria in follow-up, and the eligibility comparison among patients in various clinical settings. Univariate and multivariate Cox's proportional hazard models were used to calculate hazard ratios to identify predictors of treatment eligibility in follow-up.Results: While the majority of patients remained treatment ineligible by guideline recommendations, a sizeable proportion (23 %, 95 % CI 18-27 %) of patients subsequently met treatment eligibility in study follow-up. Reasons for meeting US Panel treatment eligibility on multivariate analysis included baseline ALT ≥ ULN (HR 1.91, p = 0.03) and baseline HBV DNA ≥ 2000 IU/mL (HR 2.6, p = 0.001). Practice setting was not a predictor.Conclusions: A significant number of patients with CHB (23 %) who were not initially treatment eligible later met treatment criteria in longer-term follow-up. Significant independent predictors of treatment eligibility included a baseline ALT ≥ ULN and elevated HBV DNA (≥2000 IU/mL for US Panel eligibility and ≥20,000 IU/mL for AASLD eligibility). This study underscores the importance of long-term follow-up for patients with CHB. [ABSTRACT FROM AUTHOR]

Describes the tracking of the evolutionary of the severe acute respiratory sydrome using high-throuput, high-density resequencing arrays in the U.S. Disruption of the tendency for cohesive evolution; Identification of several recurrent sequence variants capable of distinguishing genotypes linked to strains; Provision of important clues to the geographic origins of infection.

The article comments on the paper "Contemporary trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: Implications for healthcare planning" by N. J. Patel and colleagues. Topics discussed include the emergence of atrial fibrillation (AF) as an epidemic, comorbidities of AF and increasing hospitalization rate for AF. Also highlighted is the need for public health interventions which focus on the prevention and management of risk factors.

The article presents a study on the clinical and molecular evidence for in-flight transmission of Influenza A (H1N1/2009). The study included five cases of travelers from U.S. to Asia via Europe (Flight A), who were diagnosed with Influenza A. The study found that transmission of influenza A was possibly the result of human interaction in a crowded cabin.

Abstract: Methamphetamine is one of the most addictive and neurotoxic drugs of abuse. It produces large elevations in extracellular dopamine in the striatum through vesicular release and inhibition of the dopamine transporter. In the U.S. abuse prevalence varies by ethnicity with very low abuse among African Americans relative to Caucasians, differentiating it from cocaine where abuse rates are similar for the two groups. Here we report the first comparison of methamphetamine and cocaine pharmacokinetics in brain between Caucasians and African Americans along with the measurement of dopamine transporter availability in striatum. Methamphetamine''s uptake in brain was fast (peak uptake at 9 min) with accumulation in cortical and subcortical brain regions and in white matter. Its clearance from brain was slow (except for white matter which did not clear over the 90 min) and there was no difference in pharmacokinetics between Caucasians and African Americans. In contrast cocaine''s brain uptake and clearance were both fast, distribution was predominantly in striatum and uptake was higher in African Americans. Among individuals, those with the highest striatal (but not cerebellar) methamphetamine accumulation also had the highest dopamine transporter availability suggesting a relationship between METH exposure and DAT availability. Methamphetamine''s fast brain uptake is consistent with its highly reinforcing effects, its slow clearance with its long-lasting behavioral effects and its widespread distribution with its neurotoxic effects that affect not only striatal but also cortical and white matter regions. The absence of significant differences between Caucasians and African Americans suggests that variables other than methamphetamine pharmacokinetics and bioavailability account for the lower abuse prevalence in African Americans. [Copyright &y& Elsevier]

Background: There are disparities in statin therapy for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The role of structural racism in this disparity has not been examined., Methods: This is a cross-sectional study of participants with ASCVD in the Medical Expenditure Panel Survey from 2014-2017. Mediation analysis is utilized to estimate the direct effect of race and indirect effect of financial resources, access to care, and quality of care on statin usage., Results: The proportion of participants using statins by race/ethnicity were 58.5% for non-Hispanic Whites, 45% for Hispanics, 48.6% for Blacks, 61.6% for Asians, and 46.8% for Others. Statin usage was lower for Hispanics (OR = 0.79, 95% confidence interval [0.65-0.96]) and Blacks (OR = 0.80 [0.66-0.95]) compared to Whites. Hispanic, Black, and Other participants with the same financial resources, access to care, and quality of care as White participants did not have significantly different statin usage compared to White participants (Hispanic: OR = 0.98 [0.79-1.13]; Black (OR = 0.88 [0.76-1.06], Other: OR 0.76, 95% CI [0.56-1.15]). Hispanic, Black, and Other participants had significantly lower statin usage than subjects of the same race but with financial resources, access to care, and quality of care observed in White subjects (Hispanic: OR = 0.83 [0.83-0.92]; Black: OR = 0.91[0.88-0.94]; Other: OR = 0.92 [0.87-0.98])., Discussion: The indirect effect of race and ethnicity on statin therapy are significant but the direct effect of race and ethnicity on statin therapy are insignificant among Blacks and Hispanics compared to non-Hispanic Whites. This suggests that racial disparities in statin therapy are mediated through inequitably distributed resources, suggestive of the impact of structural racism., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Wong et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In patients with persistent atrial fibrillation (PerAF), antiarrhythmic drugs (AADs) are considered a first-line rhythm-control strategy, whereas catheter ablation is a reasonable alternative., Objectives: This study sought to examine the prevalence, patient characteristics, and clinical outcomes of patients with PerAF who underwent catheter ablation as a first or second-line strategy., Methods: This multicenter observational study included consecutive patients with PerAF who underwent first-time ablation between January 2020 and September 2021 in 9 medical centers in the United States. Patients were divided into those who underwent ablation as first-line therapy and those who had ablation as second-line therapy. Patient characteristics and clinical outcomes were compared between the groups., Results: A total of 2,083 patients underwent first-time ablation for PerAF. Of these, 1,086 (52%) underwent ablation as a first-line rhythm-control treatment. Compared with patients treated with AADs as first-line therapy, these patients were predominantly male (72.6% vs 68.1%; P = 0.03), with a lower frequency of hypertension (64.0% vs 73.4%; P < 0.001) and heart failure (19.1% vs 30.5%; P < 0.001). During a mean follow-up of 325.9 ± 81.6 days, arrhythmia-free survival was similar between the groups (HR: 1.13; 95% CI: 0.92-1.41); however, patients in the second-line ablation strategy were more likely to continue receiving AAD therapy (41.5% vs 15.9%; P < 0.001)., Conclusions: A first-line ablation strategy for PerAF is prevalent in the United States, particularly in men with fewer comorbidities. More data are needed to identify patients with PerAF who derive benefit from an early intervention strategy., Competing Interests: Funding Support and Author Disclosures Dr Barkagan has received consulting fees from Biosense Webster and Cardiodet. Dr Gerstenfeld has received research grants and speaking honoraria from Abbott Medical; has served on the advisory board of Biosense Webster; and has served on the data safety monitoring board of Abbott Medical. Dr Narayan has served as a consultant for Abbott, LifeSignals, and TDK. Dr Tzou has served as a consultant for Abbott, Biosense Webster, Boston Scientific, and Medtronic. Dr Siddiqui has received consulting fees from Abbott, Biosense Webster, Boston Scientific, Medtronic, and Stereotaxis. Dr Natale has served as a consultant for Abbott, Baylis, Biosense Webster, Biotronik, Boston Scientific, and Medtronic. Dr Anter has received research grants and speaking honoraria from Biosense Webster and Boston Scientific; and has previously held stock in Affera Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Emergency department (ED) patients may be billed for critical care time (current procedural terminology codes 99291 and 99292) if they receive at least 30 min of critical care services. We sought to determine the median cash (self-pay) prices for critical care time performed in the ED in the United States and assess for associations between hospital characteristics and prices., Methods: We performed a cross-sectional analysis of hospital cash prices for critical care time performed in the ED using the first 25 alphabetical states. For each hospital, we recorded hospital characteristics including state, control (nonprofit, governmental, or for-profit), size, teaching status, and system. We then searched for each hospital's cash prices for 99291 and 99292 using Turquoise and hospital websites. We determined the median price for 99291 nationally, regionally, and for large hospital systems. We performed multivariable quantile regression to assess for associations between hospital characteristics and prices for 99291., Results: Of the 2629 eligible hospitals, 2245 (85.4%) and 1893 (72.0%) reported cash prices for 99291 and 99292, respectively. For 99291, the cash price ranged from $45 to $84,775 with a median of $1816 (IQR: $1039-3237). For 99292, the median price was $567 (IQR: $298-1008). On multivariable analysis, hospitals had higher cash prices for 99291 if they were located in the West, for-profit, or part of a large system. In particular, hospitals owned by Tenet Healthcare charged the most for 99291 (median $28,244)., Conclusion: The cash prices for critical care time vary substantially based on hospital characteristics. In particular, for-profit hospitals and those in the West tend to charge the most. Given that patients who require critical care are unlikely to be able to choose the hospital to which they present, standardization of critical care time fees should be considered., Competing Interests: Declaration of Competing interest Dr. Zitek previously worked for a hospital owned by HCA Healthcare. Otherwise, the authors declare no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Most people with lower-limb loss (PLL) have musculoskeletal conditions and range-of-motion and muscle performance impairments. Such impairments limit potential for functional movement but can be reduced with manual therapy. Manual therapy, however, is rarely used for PLL. This case demonstrated how integrating manual therapy, exercise, and functional training led to lasting benefits for one low functioning PLL., Case Description: A 54-year-old woman more than 1 year after transtibial amputation due to peripheral artery disease presented with multiple comorbidities and yellow flags. Her function remained limited to the Medicare K-1 household walking level with slow gait speed <0.25 m/s. Treatment included four weekly sessions each beginning with manual therapy, followed by exercise and functional training., Outcomes: After 1 month, performance-based strength, balance, walking speed, and physical activity increased. She advanced to the K-2 limited community walking level and maintained her functional level without further treatment after 3 months., Discussion: Improvements maintained without treatment expanded upon research that lacked follow-up and excluded K-1 level walkers. Marked improvement after only four sessions was noteworthy since exercise protocols require ≥4 sessions., Conclusion: Manual therapy followed by exercise and functional training may optimize movement potential and contribute to improving strength, balance, gait, and physical activity among PLL.

Introduction: It is unclear whether entecavir (ETV) and tenofovir disoproxil fumarate (TDF) differ in their effectiveness for preventing hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB)., Methods: This retrospective cohort study analyzed an international consortium that encompassed 19 centers from 6 countries or regions composed of previously untreated CHB patients then treated with either ETV or TDF monotherapy. Those who developed HCC before antiviral treatment or within 1 year of therapy were excluded. The association between antiviral regimen and HCC risk was evaluated using competing-risk survival regression. We also applied propensity score matching (PSM) to 1:1 balance the 2 treatment cohorts. A total of 5,537 patients were eligible (n = 4,837 received ETV and n = 700 received TDF) and observed for HCC occurrence until December 23, 2018. Before PSM, the TDF cohort was significantly younger and had generally less advanced diseases., Results: In the unadjusted analysis, TDF was associated with a lower risk of HCC (subdistribution hazard ratio [SHR], 0.45; 95% confidence interval [CI], 0.26-0.79; P = 0.005). The multivariable analysis, however, found that the association between TDF and HCC no longer existed (SHR, 0.81; 95% CI, 0.42-1.56; P = 0.52) after adjustment for age, sex, country, albumin, platelet, α-fetoprotein, cirrhosis, and diabetes mellitus. Furthermore, the PSM analysis (n = 1,040) found no between-cohort differences in HCC incidences (P = 0.51) and no association between regimens (TDF or ETV) and HCC risk in the multivariable-adjusted analysis (adjusted SHR, 0.89; 95% CI, 0.41-1.92; P = 0.77)., Discussion: TDF and ETV did not significantly differ in the prevention of HCC in patients with CHB.

The spectrum of illnesses caused by group A streptococcus (GAS) includes invasive infections, noninvasive infections, and noninfectious complications. Increasingly virulent infections associated with high morbidity and mortality have been observed since the late 1980s and continue to be prevalent in North America and worldwide. Penicillin remains the therapy of choice, with the addition of clindamycin recommended in high risk cases. Early recognition of GAS as the cause of these serious clinical syndromes is critical for timely administration of appropriate therapy. In this review, the pathophysiology, clinical manifestations, and treatment of invasive GAS infections are discussed., (Copyright © 2013 Elsevier Inc. All rights reserved.)