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1. Frequency, nature, effects, and correlates of conflicts of interest in published clinical cancer research

Author: Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan ; Fax: (734) 763-7370 ; Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5010, University of Michigan Medical School, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan ; Department of Internal Medicine, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, Jagsi, Reshma, Sheets, Nathan, Jankovic, Aleksandra, Motomura, Amy R., Amarnath, Sudha, Ubel, Peter A., Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan ; Fax: (734) 763-7370 ; Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5010, University of Michigan Medical School, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor, Michigan ; Department of Internal Medicine, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, Jagsi, Reshma, Sheets, Nathan, Jankovic, Aleksandra, Motomura, Amy R., Amarnath, Sudha, and Ubel, Peter A.
Abstract: BACKGROUND: Relationships between clinical researchers and industry are becoming increasingly complex. The frequency and impact of conflicts of interest in the full range of high-impact, published clinical cancer research is unknown. METHODS: The authors reviewed cancer research published in 8 journals in 2006 to determine frequency of self-reported conflicts of interest, source of study funding, and other characteristics. They assessed associations between the likelihood of conflicts of interest and other characteristics by using chi-squared testing. They also compared the likelihood of positive outcome in randomized trials with and without conflicts of interest by chi-squared testing. RESULTS: The authors identified 1534 original oncology studies; 29% had conflicts of interest (including industrial funding) and 17% declared industrial funding. Conflicts of interest varied by discipline ( P < .001), continental origin ( P < .001), and sex ( P < .001) of the corresponding author and were most likely in articles with corresponding authors from departments of medical oncology (45%), those from North America (33%), and those with male first and senior authors (37%). Frequency of conflicts also varied considerably depending upon disease site studied. Studies with industrial funding were more likely to focus on treatment (62% vs 36%; P < .001), and randomized trials that assessed survival were more likely to report positive survival outcomes when a conflict of interest was present ( P = .04). CONCLUSIONS: Conflicts of interest characterize a substantial minority of clinical cancer research published in high-impact journals. Therefore, attempts to disentangle the cancer research effort from industry merit further attention, and journals should embrace both rigorous standards of disclosure and heightened scrutiny when conflicts exist. Cancer 2009. ?? 2009 American Cancer Society.
Published: 2009

2. Surgeon perspectives about local therapy for breast carcinoma

Author: Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan ; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan ; Fax: (734) 936-8944 ; Department of Health Management and Policy, University of Michigan, 300 N. Ingalls, Suite 7E12, P. O. Box 0429, Ann Arbor, MI 48109-0429, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, Department of Family Medicine, Wayne State University, Detroit, Michigan ; Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, Katz, Steven J., Lantz, Paula M., Janz, Nancy K., Fagerlin, Angela, Schwartz, Kendra, Liu, Lihua, Deapen, Dennis, Salem, Barbara, Lakhani, Indu, Morrow, Monica, Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan ; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan ; Fax: (734) 936-8944 ; Department of Health Management and Policy, University of Michigan, 300 N. Ingalls, Suite 7E12, P. O. Box 0429, Ann Arbor, MI 48109-0429, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, Department of Family Medicine, Wayne State University, Detroit, Michigan ; Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, Katz, Steven J., Lantz, Paula M., Janz, Nancy K., Fagerlin, Angela, Schwartz, Kendra, Liu, Lihua, Deapen, Dennis, Salem, Barbara, Lakhani, Indu, and Morrow, Monica
Abstract: BACKGROUND Geographic variations in the use of mastectomy and the use of radiation therapy (RT) after breast-conserving surgery (BCS) have motivated concerns that surgeons are not uniformly adhering to treatment standards. METHODS The authors surveyed attending surgeons of a population-based sample of patients with breast carcinoma diagnosed in Detroit and Los Angeles from December 2001 to January 2003 ( n = 365; response rate, 80.0%). Clinical scenarios were used to evaluate opinions about local therapy. RESULTS On average, surgeons reported that they devoted 31.3% of their total practice to breast carcinoma. Approximately one-half of surgeons practiced in a community hospital setting, whereas 18.8% practiced in a cancer center. Compared to low volume surgeons, high volume surgeons were more likely to favor BCS with RT for invasive breast carcinoma (60.8%, 74.0%, and 87.2% for low, moderate, and high volume surgeons, respectively, P < 0.001). Surgeons who favored BCS were more likely to perceive greater quality of life (QOL) benefits for BCS than mastectomy (85.9%) compared with surgeons who favored mastectomy (28.6%) and those who did not favor 1 procedure over the other (60.0%, P < 0.001). In a ductal carcinoma in situ scenario, 35.0% of surgeons favored BCS without RT and 61.0% favored BCS with RT. Opinions regarding the role of RT after BCS varied by geographic site, surgeon volume, and patient age. CONCLUSIONS Variation in surgeon opinion concerning local therapy reflected clinical uncertainty about the benefits of alternative treatments. High volume surgeons more frequently endorsed current clinical guidelines that favor BCS compared with mastectomy. This may partly be explained by the greater belief that BCS confers a better patient QOL than mastectomy. Cancer 2005. ?? 2005 American Cancer Society.
Published: 2006

3. Hospitalist time usage and cyclicality: Opportunities to improve efficiency

Author: Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Telephone: 734-647-2892; Fax: 734-615-8401 ; MD, MBA, Assistant Professor, Internal Medicine, Assistant Professor, Pediatrics and Communicable Diseases, University of Michigan Medical School, Division of General Medicine, Department of Internal Medicine, 3119 Taubman Center, Box 5376, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5376, Ross School of Business, University of Michigan, Ann Arbor, Michigan, Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, Kim, Christopher S., Lovejoy, William, Paulsen, Michael, Chang, Robert, Flanders, Scott A., Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Telephone: 734-647-2892; Fax: 734-615-8401 ; MD, MBA, Assistant Professor, Internal Medicine, Assistant Professor, Pediatrics and Communicable Diseases, University of Michigan Medical School, Division of General Medicine, Department of Internal Medicine, 3119 Taubman Center, Box 5376, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5376, Ross School of Business, University of Michigan, Ann Arbor, Michigan, Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, Kim, Christopher S., Lovejoy, William, Paulsen, Michael, Chang, Robert, and Flanders, Scott A.
Abstract: BACKGROUND: Academic medical centers (AMCs) have a constrained resident work force. Many AMCs have increased the use of nonresident service hospitalists to manage continued growth in clinical volume. To optimize their time in the hospital, it is important to understand hospitalists' work flow. DESIGN: We performed a time-motion study of hospitalists carrying the admission pager throughout the 3 types of shifts we have at our hospital (day shift, swing shift, and night shift). SETTING: Tertiary academic medical center in the Midwest. RESULTS: Hospitalists spend about 15% of their time on direct patient care, and two-thirds of their time on indirect patient care. Of the indirect activities, communication and documentation dominate. Travel demands make up over 7% of a hospitalists' time. There are spikes in indirect patient care, followed closely by spikes in direct patient care, at shift changes. CONCLUSIONS: At our AMC, indirect patient care activities accounted for the majority of the admitting hospitalists' time spent in the hospital, with documentation and communication dominating this time. Travel takes a significant fraction of hospitalists' time. There is also a cyclical nature to activities performed throughout the day, which can cause patient delays and impose variability on support services. There is a need for both service-specific and systemic improvements for AMCs to efficiently manage further growth in their inpatient volume. Journal of Hospital Medicine 2010;5:329???334. ?? 2010 Society of Hospital Medicine.
Published: 2010

4. Understanding the variation in treatment intensity among patients with early stage bladder cancer

Author: Robert Wood Johnson Foundation Clinical Scholar Program, University of Michigan, Ann Arbor, Michigan ; Department of Urology, Division of Health Services Research, University of Michigan, Ann Arbor, Michigan, Department of Urology, Division of Health Services Research, University of Michigan, Ann Arbor, Michigan, Veterans Affairs Ann Arbor Healthcare System, Center for Practice Management and Outcomes Research, Ann Arbor, Michigan ; Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, Department of Urology, Division of Health Services Research, University of Michigan, Ann Arbor, Michigan ; Michigan Surgical Collaborative for Outcomes Research and Evaluation, Ann Arbor, Michigan ; Fax: (734) 232-2400 ; Department of Urology, The University of Michigan, Room 1032B, Michigan House, 2301 Commonwealth Boulevard, Ann Arbor, MI 48105-2967, Hollingsworth, John M., Zhang, Yun, Krein, Sarah L., Ye, Zaojun, Hollenbeck, Brent K., Robert Wood Johnson Foundation Clinical Scholar Program, University of Michigan, Ann Arbor, Michigan ; Department of Urology, Division of Health Services Research, University of Michigan, Ann Arbor, Michigan, Department of Urology, Division of Health Services Research, University of Michigan, Ann Arbor, Michigan, Veterans Affairs Ann Arbor Healthcare System, Center for Practice Management and Outcomes Research, Ann Arbor, Michigan ; Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, Department of Urology, Division of Health Services Research, University of Michigan, Ann Arbor, Michigan ; Michigan Surgical Collaborative for Outcomes Research and Evaluation, Ann Arbor, Michigan ; Fax: (734) 232-2400 ; Department of Urology, The University of Michigan, Room 1032B, Michigan House, 2301 Commonwealth Boulevard, Ann Arbor, MI 48105-2967, Hollingsworth, John M., Zhang, Yun, Krein, Sarah L., Ye, Zaojun, and Hollenbeck, Brent K.
Abstract: BACKGROUND: Given the uncertainty surrounding the optimal management for early stage bladder cancer, physicians vary in how they approach the disease. The authors of this report linked cancer registry data with medical claims to identify the sources of variation and opportunities for improving the value of cancer care. METHODS: By using data from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2005), patients with early stage bladder cancer were abstracted (n = 18,276). The primary outcome was the intensity of initial treatment that patients received, as measured by all Medicare payments for bladder cancer incurred in the 2 years after diagnosis. Multilevel models were fitted to partition the variation in treatment intensity attributable to patient versus provider factors, and the potential savings to Medicare from reducing the physician contribution were estimated. RESULTS: Provider factors accounted for 9.2% of the variation in treatment intensity. Increasing provider treatment intensity did not correlate with improved cancer-specific survival ( P = .07), but it was associated with the subsequent receipt of major interventions, including radical cystectomy ( P < .001). If provider-level variation was reduced and clinical practice was aligned with that of physicians who performed in the 25th percentile of treatment intensity, then total payments made for the average patient could be lowered by 18.6%, saving Medicare $18.7 million annually. CONCLUSIONS: The current results indicated that a substantial amount of the variation in initial treatment intensity for early stage bladder cancer is driven by the physician. Furthermore, a more intensive practice style was not associated with improved cancer-specific survival or the avoidance of major interventions. Therefore, interventions aimed at reducing between-provider differences may improve the value of cancer care. Cancer 2010. ?? 2010 American Cancer Society.
Published: 2010

5. Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia 1

Author: Division of General Medicine, University of Michigan, Ann Arbor, Michigan, USA, Department of Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California, USA, Center for Health Policy, Stanford University, Stanford, California, USA, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts, USA, Division of Research, Kaiser Permanente Medical Care Program (Northern California Region), Oakland, California, USA, Department of Gastroenterology, Kaiser Permanente Medical Center, Walnut Creek, California, USA, Division of Gastroenterology, San Francisco General Hospital, San Francisco, California, USA, Northern California Institute for Research and Education, San Francisco, California, USA, Groeneveld, Peter W., Lieu, Tracy A., Fendrick, A. Mark, Hurley, Leo B., Ackerson, Lynn M., Levin, Theodore R., Allison, James E., Division of General Medicine, University of Michigan, Ann Arbor, Michigan, USA, Department of Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California, USA, Center for Health Policy, Stanford University, Stanford, California, USA, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts, USA, Division of Research, Kaiser Permanente Medical Care Program (Northern California Region), Oakland, California, USA, Department of Gastroenterology, Kaiser Permanente Medical Center, Walnut Creek, California, USA, Division of Gastroenterology, San Francisco General Hospital, San Francisco, California, USA, Northern California Institute for Research and Education, San Francisco, California, USA, Groeneveld, Peter W., Lieu, Tracy A., Fendrick, A. Mark, Hurley, Leo B., Ackerson, Lynn M., Levin, Theodore R., and Allison, James E.
Abstract: Previous economic studies of Helicobacter pylori eradication in dyspepsia and peptic ulcer disease have not measured quality of life using utilities (preference probabilities), which are needed to compare the cost-effectiveness of such treatment to other health care interventions. The goals of this study were to measure quality of life in patients with dyspepsia or peptic ulcer and apply these measurements to published models of disease management to determine cost-effectiveness in dollars per quality-adjusted life year (QALY) gained. Methods : Utilities for dyspepsia and peptic ulcer disease were measured in adult patients (n = 73) on chronic acid suppression for peptic ulcer or ulcer-like dyspepsia. Median utility values were applied to the results of published cost-effectiveness analyses and a previously validated dyspepsia model. Cost-utility ratios for early H. pylori eradication in uninvestigated dyspepsia and peptic ulcer disease were then computed. Results : The total disutility, or lost quality of life, for an ulcer was 0.11 QALY, of which 0.09 QALY was attributed to dyspeptic symptoms. After these results were incorporated into published studies, cost-utility ratios for ulcer treatment varied from $3,100 to $12,500 per QALY gained, whereas estimates for uninvestigated dyspepsia management ranged from $26,800 to $59,400 per QALY. Sensitivity analyses indicated a range of $1,300 to $27,300 per QALY for management of duodenal ulcer and $15,000 to $129,700 per QALY for dyspepsia. Conclusions: Strategies that emphasize early H. pylori eradication were cost-effective for patients with peptic ulcer and possibly cost-effective for patients with uninvestigated dyspepsia, relative to other medical interventions. Dyspeptic symptoms cause significant disutility that should be incorporated in future cost-effectiveness analyses of treatment strategies.
Published: 2010

6. Under-representation of women in high-impact published clinical cancer research

Author: Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan ; Fax: (734) 763-7370 ; Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5010, Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, University of Michigan Medical School, Ann Arbor, Michigan, Center for Behavioral and Decision Sciences in Medicine, Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, Michigan, Jagsi, Reshma, Motomura, Amy R., Amarnath, Sudha, Jankovic, Aleksandra, Sheets, Nathan, Ubel, Peter A., Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan ; Fax: (734) 763-7370 ; Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5010, Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, University of Michigan Medical School, Ann Arbor, Michigan, Center for Behavioral and Decision Sciences in Medicine, Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, Michigan, Jagsi, Reshma, Motomura, Amy R., Amarnath, Sudha, Jankovic, Aleksandra, Sheets, Nathan, and Ubel, Peter A.
Abstract: BACKGROUND. Adequate representation of women in research has been deemed essential. METHODS. Cancer research published in 8 journals in 2006 was reviewed. The percentage of women among study participants was compared with the proportion expected from population-based estimates of sex-specific cancer incidence, using binomial tests. Differences were assessed in sex distribution of participants by funding source, author sex, and focus of research with the Student t test, and in a linear regression model controlling for cancer type. RESULTS. A total of 1534 cancer research articles were identified, of which 661 (representing 1,096,098 participants) were prospective clinical studies and were analyzed further. For all 7 non-sex???specific cancer types assessed, the majority of studies analyzed included a lower proportion of women than the proportion of women among patients having cancer of that type in the general population. Among studies focusing on cancer treatment, women constituted a significantly lower overall proportion of the participants in the analyzed studies than expected for 6 of 7 non-sex???specific cancer types ( P < .001). Among non-sex???specific studies, the mean percentage of participants who were women was 38.8%. Non-sex???specific studies reporting government funding had a higher percentage of female participants (mean 41.3% vs 36.9%; P = .005). In a regression model controlling for cancer type, lack of government funding ( P = .03) and focus on cancer treatment ( P = .03) were found to be independent significant predictors of a lower percentage of female participants. CONCLUSIONS. Women were under-represented as participants in recently published, high-impact studies of non-sex???specific cancers. Studies that received government funding included a higher proportion of female subjects. Cancer 2009. ?? 2009 American Cancer Society.
Published: 2009

7. Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer

Author: Section of Plastic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan ; Veterans Administration Center for Practice Management and Outcomes Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan ; Fax: (734) 763-5354 ; Plastic and Reconstructive Surgery, University of Michigan, 2130 Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0340, Veterans Administration Center for Practice Management and Outcomes Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan ; Division of General Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, Robert Wood Johnson Clinical Scholars Program and the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, Alderman, Amy K., Hawley, Sarah T., Waljee, Jennifer, Mujahid, Mahasin, Morrow, Monica, Katz, Steven J., Section of Plastic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan ; Veterans Administration Center for Practice Management and Outcomes Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan ; Fax: (734) 763-5354 ; Plastic and Reconstructive Surgery, University of Michigan, 2130 Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0340, Veterans Administration Center for Practice Management and Outcomes Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan ; Division of General Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, Robert Wood Johnson Clinical Scholars Program and the Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, Alderman, Amy K., Hawley, Sarah T., Waljee, Jennifer, Mujahid, Mahasin, Morrow, Monica, and Katz, Steven J.
Abstract: BACKGROUND. Reconstruction is rarely incorporated into the decision-making process for surgical breast cancer treatment. We examined the importance of knowing about reconstruction to patients' surgical decision-making for breast cancer. METHODS. We surveyed women aged ???79 years with breast cancer (N = 1844) who were reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) cancer registries (response rate, 77.4%). The dependent variables were 1) patients' report of having a discussion about breast reconstruction with their general surgeon (yes/no), 2) whether or not this discussion had an impact on their willingness to be treated with a mastectomy (yes/no), and 3) whether the patient received a mastectomy (yes/no). The independent variables included age, race, education, tumor size, tumor behavior, and presence of comorbidities. Chi-square, Student t test, and logistic regression were used for analyses. RESULTS. Only 33% of patients had a general surgeon discuss breast reconstruction with them during the surgical decision-making process for their cancer. Surgeons were significantly more likely to have this discussion with younger, more educated patients with larger tumors. Knowing about reconstructive options significantly increased patients' willingness to consider a mastectomy (OR, 2.06; P <.01). In addition, this discussion influenced surgical treatment. Patients who discussed reconstruction with their general surgeon were 4 times more likely to receive a mastectomy compared with those who did not (OR, 4.48; P < .01). CONCLUSIONS. Most general surgeons do not discuss reconstruction with their breast cancer patients before surgical treatment. When it occurs, this discussion significantly impacts women's treatment choice, making many more likely to choose mastectomy. This highlights the importance of multidisciplinary care models to facilitate an informed surgical treatment decision-making process. Cancer 2008. ?? 2007 American Ca
Published: 2008

8. Lean health care: What can hospitals learn from a world-class automaker?

Author: Division of General Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan ; University of Michigan, Division of General Medicine, Department of Internal Medicine, 3119 Taubman Center, Box 0376, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0376, Division of General Internal Medicine, University of Michigan, Ann Arbor, Michigan, Department of Internal Medicine, Medical School Administration, University of Michigan, Ann Arbor, Michigan, Kim, Christopher S., Spahlinger, David A., Kin, Jeanne M., Billi, John E., Division of General Internal Medicine, University of Michigan, Ann Arbor, Michigan ; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan ; University of Michigan, Division of General Medicine, Department of Internal Medicine, 3119 Taubman Center, Box 0376, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0376, Division of General Internal Medicine, University of Michigan, Ann Arbor, Michigan, Department of Internal Medicine, Medical School Administration, University of Michigan, Ann Arbor, Michigan, Kim, Christopher S., Spahlinger, David A., Kin, Jeanne M., and Billi, John E.
Abstract: BACKGROUND With health care costs continuing to rise, a variety of process improvement methodologies have been proposed to address the reported inefficiencies in health care delivery. Lean production is one such method. The management philosophy and tools of lean production come from the manufacturing industry, where they were pioneered by Toyota Motor Corporation, which is viewed as the leader in utilizing these performance improvement methods. Lean has already enjoyed tremendous success in improving quality and efficiency in both the manufacturing and the service sector industries. RESULTS Health care systems have just begun to utilize lean methods, with reports of improvements just beginning to appear in the literature. We describe some of the basic philosophy and principles of lean production methods and how these concepts can be applied in the health care environment. We describe some of the early success stories and ongoing endeavors of lean production in various health care organizations. We believe the hospital is an ideal setting for use of the lean production method, which could significantly affect how health care is delivered to patients. CONCLUSIONS We conclude by discussing some of the potential challenges in introducing and implementing lean production methods in the health care environment. Lean production is a novel approach to delivering high-quality and efficient care to patients, and we believe that the health care sector can anticipate the same high level of success that the manufacturing and service industries have achieved using this approach. Hospitalists are primed to take action in delivering care of greater quality with more efficiency by applying these new principles in the hospital setting. Journal of Hospital Medicine 2006;1:191–199. © 2006 Society of Hospital Medicine.
Published: 2007

9. Economic immunity in the ICU: continued support or pull the plug?

Author: Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA, US, Ann Arbor, Fendrick, A.M., Saint, Sanjay, Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA, US, Ann Arbor, Fendrick, A.M., and Saint, Sanjay
Published: 2006

10. Changing patterns of hospital use for patients with musculoskeletal diseases in Michigan, 1980 to 1987

Author: Department of Internal Medicine, School of Medicine, Health Services Management and Policy, and Biostatistics, School of Pubic Health, University of Michigan ; Division of General Medicine, Department of Internal Medicine, University of Michigan Medical Center, 3116 Taubman, Ann Arbor, MI 48109-0376, Department of Internal Medicine, School of Medicine, Health Services Management and Policy, and Biostatistics, School of Pubic Health, University of Michigan, McMahon, Laurence F., Petroni, Gina R., Tedeschi, Philip J., McLaughlin, Catherine G., Department of Internal Medicine, School of Medicine, Health Services Management and Policy, and Biostatistics, School of Pubic Health, University of Michigan ; Division of General Medicine, Department of Internal Medicine, University of Michigan Medical Center, 3116 Taubman, Ann Arbor, MI 48109-0376, Department of Internal Medicine, School of Medicine, Health Services Management and Policy, and Biostatistics, School of Pubic Health, University of Michigan, McMahon, Laurence F., Petroni, Gina R., Tedeschi, Philip J., and McLaughlin, Catherine G.
Abstract: Over the past 10 years there have been dramatic changes in health care financing in the United States, such as Medicare's Prospective Payment System for hospitalized Medicare beneficiaries, and in health services delivery, such as the growth in health maintenance organizations and other forms of managed care. These changes have occurred largely in response to payors' concerns about the rising cost of health care. A study of such changes in financing and delivery, and how specific groups of patients are affected is necessary so that the effects of these changes on patients' health can be determined. We examined the hospitalization rates for patients with musculoskeletal diseases in Michigan from 1980 through 1987. During this period, the overall ageadjusted hospitalization rates decreased 7.0% per year (p = 0.001). The decrease occurred less for surgical discharges (6.0% per year) than for medical discharges (8.6% per year) (p <0.001). While these overall trends are of interest, they obscure disease-specific trends that vary significantly from both the overall, and the medical and surgical trends. For example, while surgical discharges, in general declined, procedures related to major joint and limb reattachment (DRG # 209) increased at a rate of 6.3% per year. And while medical discharges in general decreased over this period, discharges for osteomyelitis increased 5.4% per year. The patterns of diseasespecific trends offers insight into the possible causes for these changes. Finally, it is important to understand the epidemiology of hospital use to evaluate the effects of new medical care delivery and payment systems on the care of subsets of patients.
Published: 2006

11. Promoting Respect and Ongoing Safety Through Patient-centeredness, Engagement, Communication and Technology (PROSPECT)

Author: Gordon and Betty Moore Foundation and David W. Bates, MD, MSc, Chief, Division of General Medicine
Published: 2022

12. Miami Healthy Heart Initiative a Behavioral Study on Cardiovascular Risk Factors (MHHI)

Author: National Heart, Lung, and Blood Institute (NHLBI) and Olveen Carrasquillo, Chief, Division of General Medicine
Published: 2018

13. A National Study of Intravenous Medication Errors

Author: Johns Hopkins University, Winchester Medical Center, Central DuPage Hospital, Vanderbilt University, Massachusetts General Hospital, University of California, San Diego, Valleywise Health, Danbury Hospital, Association for the Advancement of Medical Instrumentation, CareFusion foundation, Candler Hospital, and David W. Bates, MD, MSc, Chief, Division of General Medicine
Published: 2016

14. Coordination of Breast Cancer Care Between Radiation Oncologists and Surgeons: A Survey Study

Author: Katz, Steven [Department of Internal Medicine, Division of General Medicine and Department of Health Management and Policy, School of Public Health, University of Michigan Health System, Ann Arbor, MI (United States)]
Published: 2012
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15. Differential value of risk factors and clinical signs for diagnosing pulmonary embolism according to age

Author: Arnaud Perrier, Drahomir Aujesky, Guy Meyer, Marc Philip Righini, P.-M. Roy, Henri Bounameaux, G. Le Gal, Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), Université de Brest (UBO)-Institut Brestois Santé Agro Matière (IBSAM), Université de Brest (UBO)-Université de Brest (UBO), Service d'angiologie et d'hémostase (MR), Hôpital Universitaire de Genève, Service des Urgences (PMR), CHRU - ANGERS, Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Division of General Medicine (DGM), Lausanne university hospital, Department of Internal Medicine (AP), and Geneva University Hospital (HUG)
Subjects: Male, MESH: Pulmonary Embolism, Pleural effusion, 030204 cardiovascular system & hematology, Chest pain, Cohort Studies, Electrocardiography, 0302 clinical medicine, Risk Factors, MESH: Risk Factors, Prospective Studies, 030212 general & internal medicine, MESH: Cohort Studies, Cardiopulmonary disease, Venous Thrombosis, MESH: Aged, MESH: Middle Aged, Age Factors, MESH: Follow-Up Studies, Hematology, Middle Aged, MESH: Predictive Value of Tests, 3. Good health, Pulmonary embolism, Venous thrombosis, MESH: Thromboembolism, Female, Radiography, Thoracic, medicine.symptom, medicine.medical_specialty, Tachypnea, Diagnosis, Differential, 03 medical and health sciences, Predictive Value of Tests, MESH: Diagnosis, Differential, Thromboembolism, Internal medicine, medicine, Humans, Intensive care medicine, Aged, MESH: Age Factors, MESH: Humans, business.industry, Emergency department, MESH: Radiography, Thoracic, medicine.disease, MESH: Prospective Studies, MESH: Male, MESH: Electrocardiography, MESH: Venous Thrombosis, Etiology, Pulmonary Embolism, business, MESH: Female, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, Follow-Up Studies
Abstract: International audience; INTRODUCTION: The diagnostic value of clinical presentation of pulmonary embolism (PE) is uncertain in the elderly, who often have concomitant cardiopulmonary diseases that may mimic PE. The aim of our study was to assess the differential value of risk factors, symptoms and clinical signs of venous thromboembolism, results of electrocardiogram and chest X-ray for the diagnosis of PE in suspected patients according to age. METHODS: We analyzed data from two outcome studies which enrolled 1721 consecutive patients presenting in the emergency department with clinically suspected PE defined as acute onset of new or worsening shortness of breath or chest pain without any other obvious etiology. All patients underwent a sequential diagnostic work-up and a 3-month follow-up. RESULTS: The proportion of confirmed PE was 24.2% (416 of 1721). Strength of the association with PE did not differ according to age group for history of venous thromboembolism (VTE), recent surgery, tachypnea at admission or right ventricular strain on electrocardiogram. Active malignancy, hemoptysis, tachycardia, hemidiaphragmatic elevation and pleural effusion at chest X-ray were no more associated with PE in the patients aged of 75 years or more. Finally, symptoms and signs of deep venous thrombosis, and an alternative diagnosis less probable than PE were associated with PE in all age groups, but the strength of this association decreased significantly with advancing age. CONCLUSION: Some risk factors, symptoms and signs of VTE are less strongly or even not at all associated with PE in the elderly. Physicians should take this into account when attending elderly patients suspected of PE and when assessing their clinical probability of PE.
Published: 2005
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16. Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions

Author: Lynn Ramirez-Avila, Valériane Leroy, Kenneth A. Freedberg, Andrea L. Ciaranello, Rochelle P. Walensky, Ji-Eun Park, Department of Infectious Disease [Boston], Massachusetts General Hospital [Boston], Division of General Medicine, Division of Infectious Diseases, Boston Children's Hospital, Center for AIDS Research [Cambridge], Harvard University [Cambridge], Division of Infectious Disease, Brigham and Women's Hospital [Boston], Epidémiologie et Biostatistique [Bordeaux], Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Université Bordeaux Segalen - Bordeaux 2, Funding for this work was provided by the National Institute of Allergy and Infectious Disease (K01 AI078754 (ALC), R01 AI058736 (KAF, RPW, JP), the National Institute of Child Health and Human Development (T32HD 055148-02 (LR)), the Elizabeth Glaser Pediatric AIDS Foundation (ALC, JP, KF, RPW), and the French National Institute of Health and Medical Research (VL)., and BMC, Ed.
Subjects: medicine.medical_specialty, Pediatrics, Cost effectiveness, Cost-Benefit Analysis, Population, MEDLINE, Human immunodeficiency virus (HIV), lcsh:Medicine, Developing country, HIV Infections, Context (language use), Review, medicine.disease_cause, 03 medical and health sciences, 0302 clinical medicine, [SDV.BBM.GTP]Life Sciences [q-bio]/Biochemistry, Molecular Biology/Genomics [q-bio.GN], Humans, Medicine, 030212 general & internal medicine, Intensive care medicine, education, Developing Countries, Medicine(all), 0303 health sciences, education.field_of_study, Cost–benefit analysis, Clinical Laboratory Techniques, 030306 microbiology, business.industry, lcsh:R, Infant, General Medicine, 3. Good health, Early Diagnosis, Treatment Outcome, [SDV.BBM.GTP] Life Sciences [q-bio]/Biochemistry, Molecular Biology/Genomics [q-bio.GN], business, Limited resources
Abstract: International audience; ABSTRACT: Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a "cascade" of events must successfully occur. A frequently-cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost-effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings.
Published: 2011
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17. Scaling up the 2010 World Health Organization HIV Treatment Guidelines in resource-limited settings: a model-based analysis

Author: Rochelle P Walensky, Robin Wood, Andrea L Ciaranello, A David Paltiel, Sarah B Lorenzana, Xavier Anglaret, Adam W Stoler, Kenneth A Freedberg, CEPAC-International Investigators, Department of Infectious Disease [Boston], Massachusetts General Hospital [Boston], Division of General Medicine, Center for AIDS Research [Cambridge], Harvard University [Cambridge], Division of Infectious Disease, Brigham and Women's Hospital [Boston], Desmond Tutu HIV Centre, University of Cape Town-Institute of Infectious Disease and Molecular Medicine, Department of Epidemiology, Yale School of Medicine [New Haven, Connecticut] (YSM), Epidémiologie et Biostatistique [Bordeaux], Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Université Bordeaux Segalen - Bordeaux 2, Department of Health Policy and Management, Harvard School of Public Health, This work was supported by the National Institute of Allergy and Infectious Diseases (R01 AI058736, K24 AI062476, P30 AI060354, K01 AI078754), National Institute on Drug Abuse (R01 DA015612), and the Doris Duke Charitable Foundation (Clinical Scientist Development Award)., the CEPAC-International Investigators, Mouillet, Evelyne, and Faculty of Health Sciences
Subjects: Male, Pediatrics, Life expectancy, Cost-Benefit Analysis, lcsh:Medicine, HIV Infections, 030204 cardiovascular system & hematology, MESH: World Health Organization, 0302 clinical medicine, [SDV.MHEP.MI]Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Medicine, Opportunistic infections, 030212 general & internal medicine, Hiv treatment, MESH: Anti-HIV Agents, MESH: Models, Theoretical, Stavudine, MESH: Guidelines as Topic, General Medicine, Cost-effectiveness analysis, MESH: HIV Infections, Public Health and Epidemiology/Global Health, Infectious Diseases/HIV Infection and AIDS, Antiretroviral therapy, 3. Good health, AIDS, MESH: Young Adult, Cohort, [SDV.MHEP.MI] Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Female, medicine.drug, Research Article, Adult, medicine.medical_specialty, Anti-HIV Agents, Guidelines as Topic, Public Health and Epidemiology/Health Policy, World Health Organization, World health, 03 medical and health sciences, Young Adult, Acquired immunodeficiency syndrome (AIDS), Treatment guidelines, Humans, MESH: Acquired Immunodeficiency Syndrome, Acquired Immunodeficiency Syndrome, MESH: Humans, business.industry, lcsh:R, HIV, MESH: Adult, Guideline, Models, Theoretical, medicine.disease, Virology, MESH: Male, [SDV.SPEE] Life Sciences [q-bio]/Santé publique et épidémiologie, [SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie, business, MESH: Female, MESH: Cost-Benefit Analysis
Abstract: Rochelle Walensky and colleagues use a model-based analysis to examine which of the 2010 WHO antiretroviral therapy guidelines should be implemented first in resource-limited settings by ranking them according to survival, cost-effectiveness, and equity., Background The new 2010 World Health Organization (WHO) HIV treatment guidelines recommend earlier antiretroviral therapy (ART) initiation (CD4, Editors' Summary Background Since 1981, acquired immunodeficiency syndrome (AIDS) has killed more than 25 million people, and about 33 million people (30 million of them in low- and middle-income countries) are now infected with the human immunodeficiency virus (HIV), which causes AIDS. HIV destroys immune system cells (including CD4 cells, a type of lymphocyte), leaving infected individuals susceptible to other infections (so-called opportunistic infections). Early in the AIDS epidemic, most people with HIV died within 10 years of infection. Then, in 1996, highly active antiretroviral therapy (ART)—a combination of several powerful antiretroviral drugs—was developed. Now, in resource-rich countries, clinicians care for people with HIV by prescribing ART regimens tailored to each individual's needs. They also regularly measure the amount of virus in their patients' blood, test for antiretroviral-resistant viruses, and monitor the health of their patients' immune systems through regular CD4 cell counts. As a result, the life expectancy of patients with HIV in developed countries has dramatically improved. Why Was This Study Done? Initially, resource-limited countries could not afford to provide ART for their populations, and the life expectancy of HIV-positive people remained low. Now, through the concerted efforts of governments, the World Health Organization (WHO), and other international agencies, more than a third of the people in low- and middle-income countries who need ART are receiving it. However, many without access are still in need of ART, and ART programs in developing countries follow a public-health approach rather than an individualized approach. That is, drug regimens, clinical decision-making, and disease monitoring are all standardized and follow recommendations in the 2006 WHO ART guidelines. This year (2010), these guidelines were revised. The guidelines now recommend the following: earlier ART initiation—when the CD4 count falls below 350/µl of blood, instead of below 200/µl as in the 2006 guidelines; the provision of sequential ART regimens instead of a single regimen; and the replacement of the antiretroviral drug stavudine with tenofovir, a less toxic but more expensive drug, in first-line ART regimens. However, many resource-limited countries are still struggling to implement the 2006 guidelines, so which of these new recommendations should be prioritized? Here, the researchers use a mathematical model to address this question. What Did the Researchers Do and Find? The Cost Effectiveness of AIDS Complications (CEPAC)–International model simulates the natural history and treatment of HIV disease. The researchers entered South African clinical and cost data for HIV treatment into this model and then used it to project survival and costs in a hypothetical group of South African HIV-positive patients under alternative guideline prioritization scenarios. The reference strategy for the simulations (denoted as “stavudine/WHO/one-line”) assumed that patients (with a mean CD4 count of 375/µl) began a single stavudine-based ART regimen when they developed WHO stage III/IV HIV disease (i.e., when patients develop multiple opportunistic infections such as tuberculosis and pneumonia). When the new guideline recommendations were considered separately, ART initiation at CD4
Published: 2010
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18. Lost but Not Forgotten - The Economics of Improving Patient Retention in AIDS Treatment Programs

Author: Elena Losina, Hapsatou Touré, Lauren M Uhler, Xavier Anglaret, A David Paltiel, Eric Balestre, Rochelle P Walensky, Eugène Messou, Milton C Weinstein, François Dabis, Kenneth A Freedberg, ART-LINC Collaboration of International Epidemiological Databases to Evaluate AIDS (IeDEA), CEPAC International investigators, Division of General Medicine, Massachusetts General Hospital [Boston], Department of Orthopedic Surgery, Brigham and Women's Hospital [Boston], Department of Biostatistics, Boston University [Boston] (BU), Epidémiologie et Biostatistique [Bordeaux], Université Bordeaux Segalen - Bordeaux 2-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre de Prise en charge, de Recherche et de Formation (CePReF), ACONDA, Yale University [New Haven], Department of Infectious Disease [Boston], Center for AIDS Research [Cambridge], Harvard University [Cambridge], Division of Infectious Disease, Department of Medicine, Harvard Medical School [Boston] (HMS), Department of Health Policy and Management, Harvard School of Public Health, Department of Genetics [Boston], Supported by the US National Institute of Allergy and Infectious Diseases (R01 AI058736, K24 AI062476, P30 AI 060354 Harvard University Center for AIDS Research, and 5U01AI069919 ART-LINC of IeDEA), the French Agence Nationale de Recherches sur le SIDA et les hépatites (ANRS 12 138 ART-LINC LTFU), the Office of AIDS Research (National Institutes of Health), the National Cancer Institute, the Eunice Kennedy Shriver National Institute of Child Health & Human Development, and the Doris Duke Charitable Foundation, Clinical Scientist Development Award (to RPW)., the ART-LINC Collaboration of International Epidemiological Databases to Evaluate AIDS, the CEPAC International investigators, Mouillet, Evelyne, and Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Université Bordeaux Segalen - Bordeaux 2
Subjects: Gerontology, Cost effectiveness, Cost-Benefit Analysis, lcsh:Medicine, Public Health and Epidemiology/Infectious Diseases, HIV Infections, MESH: Antiretroviral Therapy, Highly Active, 0302 clinical medicine, [SDV.MHEP.MI]Life Sciences [q-bio]/Human health and pathology/Infectious diseases, Antiretroviral Therapy, Highly Active, Global health, 030212 general & internal medicine, Hiv treatment, MESH: Anti-HIV Agents, Sida, MESH: Developing Countries, health care economics and organizations, MESH: Treatment Outcome, biology, 1. No poverty, General Medicine, MESH: Follow-Up Studies, MESH: HIV Infections, Public Health and Epidemiology/Global Health, Infectious Diseases/HIV Infection and AIDS, Human development (humanity), 3. Good health, [SDV.MHEP.MI] Life Sciences [q-bio]/Human health and pathology/Infectious diseases, MESH: Life Expectancy, Research Article, medicine.medical_specialty, MESH: Cote d'Ivoire, 030231 tropical medicine, MESH: Health Care Costs, Cote d ivoire, Child health, 03 medical and health sciences, Acquired immunodeficiency syndrome (AIDS), medicine, Humans, MESH: Humans, business.industry, lcsh:R, medicine.disease, biology.organism_classification, Cote d'Ivoire, Socioeconomic Factors, [SDV.SPEE] Life Sciences [q-bio]/Santé publique et épidémiologie, Family medicine, [SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie, business, MESH: Cost-Benefit Analysis, Follow-Up Studies
Abstract: Based on data from West Africa, Elena Losina and colleagues predict that interventions to reduce dropout rates from HIV treatment programs (such as eliminating copayments) will be cost-effective., Background Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa. Methods and Findings We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infection-related drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of, Editors' Summary Background Acquired immunodeficiency syndrome (AIDS) has killed more than 25 million people since the first reported case in 1981. Currently, about 33 million people are infected with the human immunodeficiency virus (HIV), which causes AIDS. Two-thirds of people infected with HIV live in sub-Saharan Africa. HIV infects and destroys immune system cells, thereby weakening the immune system and rendering infected individuals susceptible to infection. There is no cure for HIV/AIDS. Combination antiretroviral therapy (ART), a mixture of antiretroviral drugs that suppress the replication of the virus in the body, is used to treat and prevent HIV infection. ART is expensive but major international efforts by governments, international organizations, and funding bodies have increased ART availability. According to World Health Organization (WHO) estimates, at least 9.7 million people in low- and middle-income countries need ART and as of 2007, 3 million of those people had reliable access to the drugs. Why Was This Study Done? Although ART is an effective treatment for HIV, a large number of individuals who initiate ART do not receive long-term follow-up care. These patients are generally sicker and have a worse long-term outcome than those who receive follow-up care. Loss to follow up (LTFU) is a significant problem that can undermine the benefits of expanding ART availability. Strategies to improve follow up concentrate on bringing lost patients back into the health care system, but such patients often die before they can be contacted. Prevention of LTFU might be a better strategy to improve HIV care after ART initiation, but there is little information available on which specific interventions might best accomplish this goal. What Did the Researchers Do and Find? Given the lack of reported data on the actual costs and effectiveness of LTFU prevention, the researchers used a model to estimate the clinical impact and cost-effectiveness of several possible strategies to prevent LTFU in HIV-infected persons receiving ART in Côte d'Ivoire, West Africa. The researchers used the previously developed Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model and combined it with data from a program of ART delivery in Abidjan, Côte d'Ivoire. They then projected the clinical benefits and the cost required to attain a given level of benefit (cost-effectiveness ratio) of different LTFU-prevention strategies from the perspective of the payer (the organization that pays all the medical costs to provide care). Several interventions were considered, including reducing costs to patients (eliminating patient co-payments and paying for transportation) and increasing services to patients at their visits (improving staff training in HIV care, and providing meals at clinic times). LTFU was predicted to cause a 54.3%–58.3% reduction in the estimated life expectancy beyond age 37; patients continuing HIV care were predicted to live a further 144.7 months whie those lost to follow up by 1 year after ART initiation were predicted to live only for a further 73.9–80.7 months. LTFU-prevention strategies in the Côte d'Ivoire were deemed to be cost-effective if they cost less than $2,823 (which is 3× gross domestic product per capita) per year of life saved. The efficacy and cost of the different LTFU-prevention strategies varied in the analyses; stopping ART co-payment alone would be cost-effective at a cost of $22/person/year if it reduced LTFU rates by 12%, while including all the LTFU-prevention strategies described would be cost-effective at $77/person/year if they reduced LTFU-rates by 41%. What Do These Findings Mean? The findings suggest that moderately effective strategies for preventing LTFU in resource-limited settings would improve survival, provide good value for money, and should be used to improve HIV treatment programs. Although modeling is valuable to explore the costs and effectiveness of LTFU-prevention strategies it cannot replace the need for more reported data to shed light on problems leading to LTFU and the prevention strategies required to combat it. Also, Côte d'Ivoire might not be representative of all West African countries or resource-limited settings. A similar analysis using data from other ART programs in different countries would be useful to provide better understanding of the impact of LTFU in HIV treatment programs. Finally, the research highlights the cost of second-line ART (a new antiretroviral drug combination for patients in whom first-line treatment fails) as a crucial issue. It is estimated that 5% of all people receiving ART in low- and middle-income countries receive second-line ART and these numbers are expected to increase. Second-line ART had major effects on cost-effectiveness, and a reduction in the cost of this treatment is critical in order to guarantee continued access to HIV treatment. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000173. This study is further discussed in a PLoS Medicine Perspective by Gregory Bisson and Jeffrey Stringer WHO provides information on disease prevention, treatment, and HIV/AIDS programs and projects The UN Millennium Development Goals project site contains information on worldwide efforts to halt the spread of HIV/AIDS aidsmap, a nonprofit, nongovernmental organization, provides information on HIV and supporting those living with HIV
Published: 2009
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19. Better mental health and fewer depressive symptoms are associated with greater psychological resilience after hip fracture.

Author: McClennen T, Sharma H, Kiel DP, Fortinsky RH, Guild CP, Orwig D, Magaziner J, Binder EF, and Berry SD
Abstract: Background: High psychological resilience is associated with improved functional outcomes for older adults recovering from hip fracture. The objective of this study was to identify factors associated with increased psychological resilience in older women after hip fracture., Methods: 129 women aged ≥65 years with recent surgically-repaired hip fracture were enrolled in a trial of exercise and testosterone therapy. The Brief Resilience Scale (BRS) measured baseline resilience, and was categorized as low (BRS<4) or high (BRS≥4). Sociodemographic (e.g., education), medical, and neuropsychological factors (e.g., cognition by Short Blessed Test, mental health by a Global Mental Health Score (PROMIS-GMH), and depressive symptoms by Geriatric Depression Score (GDS)) were considered as independent variables. Individual factors were evaluated for their association with resilience using bivariate regression, and those having a significance level of p≤0.10 were entered into age-adjusted multivariate logistic regression models., Results: 57 women (44%) reported high resilience. Neither education nor cognition was significantly associated with resilience. Lower GDS and better PROMIS-GMH scores were associated with high resilience in adjusted models. For every one-point worsening in GDS, the adjusted odds ratio (AOR) for high vs. low resilience was 0.76 (95% CI 0.61,0.93). In a model with GDS, PROMIS-GMH, and age, positive mental health remained significantly associated with higher resilience (AOR 1.34, 95% CI 1.14,1.58)., Conclusions: In older women after hip fracture, fewer depressive symptoms and better mental health were associated with higher psychological resilience. Addressing overall mental health when recovering from hip fracture could contribute to increasing psychological resilience thereby maximizing recovery potential., (© The Author(s) 2025. Published by Oxford University Press on behalf of the Gerontological Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)
Published: 2025
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20. Cost-Effectiveness of a Polypill for Cardiovascular Disease Prevention in an Underserved Population.

Author: Kohli-Lynch CN, Moran AE, Kazi DS, Bibbins-Domingo K, Jordan N, French D, Zhang Y, Wang TJ, and Bellows BK
Abstract: Importance: The Southern Community Cohort Study (SCCS) Polypill Trial showed that a cardiovascular polypill (a single pill containing a statin and 3 half-standard dose antihypertensive medications) effectively controls cardiovascular disease (CVD) risk factors in a majority Black race and low-income population. The cost-effectiveness of polypill treatment in this population has not been previously studied., Objective: To determine the cost-effectiveness of the cardiovascular polypill., Design, Setting, and Participants: A discrete-event simulation version of the well-established CVD policy model simulated clinical and economic outcomes of the SCCS Polypill Trial from a health care sector perspective. A time horizon of 10 years was adopted. Polypill treatment was priced at $463 per year in the base-case analysis. Model input data were derived from the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, pooled longitudinal cohort studies, the SCCS Polypill Trial, and published literature. Two cohorts were analyzed: an SCCS Polypill Trial-representative cohort of 100 000 individuals and all trial-eligible non-Hispanic Black US adults. Study parameters and model inputs were varied extensively in 1-way and probabilistic sensitivity analysis., Exposures: Polypill treatment or usual care., Main Outcome and Measures: Primary outcomes were direct health care costs (US dollar 2023) and quality-adjusted life-years (QALYs), both discounted 3% annually, and the incremental cost per QALY gained., Results: In the trial-representative cohort of 100 000 individuals (mean [SD] age, 56.9 [5.9] years; 61 807 female [61.8%]), polypill treatment was projected to yield a mean of 1190 (95% uncertainty interval, 287-2159) additional QALYs compared with usual care, at a cost of approximately $10 152 000. Hence, polypill treatment was estimated to cost $8560 per QALY gained compared with usual care and was high value (<$50 000 per QALY gained) in 99% of simulations. Polypill treatment was estimated to be high value when priced at $559 or less per year and cost saving when priced at $443 or less per year. In almost all sensitivity analyses, polypill treatment remained high value. In a secondary analysis of 3 602 427 trial-eligible non-Hispanic Black US adults (mean [SD] age, 55.4 [7.6] years; 2 006 597 female [55.7%]), polypill treatment was high value, with an estimated cost of $13 400 per QALY gained., Conclusions and Relevance: Results of this economic evaluation suggest that polypill treatment could be a high value intervention for a low-income, majority Black population with limited access to health care services. It could additionally reduce health disparities.
Published: 2025
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21. Nurse Experiences in an Electronic Health Record Transition: A Mixed Methods Analysis.

Author: Brunner J, Amano A, Davila J, Krein S, Sullivan SC, Church V, Sayre G, and Rinne ST
Abstract: Transitions from one EHR to another can be enormously disruptive to care. Nurses are the largest group of EHR users, but nurse experiences with EHR transitions have not been well documented. We sought to understand nurse experiences with an EHR transition at the US Department of Veterans Affairs. We used a mixed methods design, combining a cumulative 26 longitudinal interviews with 317 survey free-text responses and quantitative measures from a repeated cross-sectional survey, all from nurses at one of the first facilities to transition from the Department of Veterans Affairs' homegrown EHR to a commercial system. We conducted inductive/deductive content analysis of qualitative data and paired qualitative findings with descriptive statistics of survey questions. Analyses yielded insights about three key aspects of the transition: (1) EHR functionality: diverse perceived causes of challenges using the new EHR; (2) transition process: barriers and facilitators of nurses' EHR training and technical support; and (3) outcomes: nurse-perceived impacts on safety, quality, nurse satisfaction, and efficiency. Alongside improvements to EHR functionality, findings underscore the need for organizationally informed training and careful alignment between the new EHR and the organization's nursing practices-all of which have been undertaken by Department of Veterans Affairs nurses informed by this and other studies., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)
Published: 2025
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22. Medicaid Unwinding Experiences in Dual-Eligible Older Adults.

Author: Tipirneni R, Furst W, Ruggiero DA, Singer DC, Solway E, Beathard E, Patel SR, Stefanescu AR, Kullgren JT, Ayanian JZ, and Roberts ET
Subjects: Humans, United States, Aged, Female, Male, Cross-Sectional Studies, Medicare economics, Eligibility Determination, Aged, 80 and over, Medicaid statistics & numerical data, Health Services Accessibility economics, Health Services Accessibility statistics & numerical data
Abstract: Importance: Dual-eligible older adults rely on Medicaid to pay for Medicare premiums and cost sharing in addition to supplemental services including dental and long-term care. However, the unique experiences of dual-eligible older adults with Medicaid unwinding remain unknown., Objective: To assess the awareness and experiences of dual-eligible older adults with Medicaid redetermination., Design, Setting, and Participants: A cross-sectional national survey of community-dwelling US adults aged 65 years or older with incomes less than or equal to 100% of the federal poverty level, via internet and telephone, was conducted from January 23 through February 19, 2024. Participants were recruited from NORC probability-based and 2 additional national nonprobability panels., Main Outcomes and Measures: Weighted percentage values for respondent awareness of Medicaid redeterminations, experiences navigating reenrollment, and cost-related barriers to accessing care., Results: Of 843 respondents, most were female (62.9%), aged 65 to 74 years (62.3%), and had completed up to high school education (72.3%). Overall, 16.1% (95% CI, 12.4%-19.9%) had heard a lot and 34.6% (95% CI, 28.9%-40.4%) a little about states returning to Medicaid renewals; 49.0% (95% CI, 43.0%-55.0%) heard nothing at all. A total of 45.1% completed a Medicaid renewal, 37.0% did not complete a renewal, and 17.7% did not know about renewal requirements. A total of 87.7% maintained Medicaid, 5.9% lost Medicaid but got it back, and 5.5% lost Medicaid and did not get it back. In the last 6 months, 7.7% reported delaying or forgoing care due to cost. Delayed or forgone care was more common among those who lost Medicaid and did not get it back (18.4%) and those who lost Medicaid but got it back (30.6%) compared with those who maintained Medicaid (5.5%). Cost-related barriers were more common for dental (25.1%) and home health services (18.5%), which are frequently covered by Medicaid., Conclusions and Relevance: The findings highlight a need to address informational gaps and navigational barriers related to Medicaid unwinding among older adults with dual eligibility for Medicare and Medicaid. Addressing these gaps may help to avoid Medicaid losses that contribute to difficulties accessing care.
Published: 2025
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23. National Telehealth Contingency Staffing Program and Primary Care Quality in the VHA.

Author: Liu T, Wheat CL, Rojas J, O'Shea AMJ, Nelson KM, and Reddy A
Subjects: Humans, United States, Male, Female, Retrospective Studies, Middle Aged, Aged, Quality of Health Care statistics & numerical data, Quality Improvement, Veterans statistics & numerical data, Hypertension therapy, Diabetes Mellitus therapy, Primary Health Care statistics & numerical data, Primary Health Care standards, United States Department of Veterans Affairs, Telemedicine statistics & numerical data
Abstract: Importance: The Veterans Health Administration (VHA) launched the Clinical Resource Hub (CRH), a national telehealth contingency staffing program, to address primary care staffing shortages and improve veteran access to primary care. How this large-scale telehealth intervention affects quality of care is unknown., Objective: To assess the quality of care for chronic disease management among US veterans receiving high vs low levels of CRH-delivered primary care services and whether racial and ethnic minority veterans experience outcomes similar to those of White veterans when receiving CRH-delivered care., Design, Setting, and Participants: This retrospective quality improvement study was conducted using VHA administrative data. Veterans receiving primary care services from CRH clinicians between October 1, 2022, to September 30, 2023, were included., Exposures: Low, medium, and high tertiles of CRH intensity, defined as the proportion of a veteran's CRH primary care visits to their total primary care visits within the study period., Main Outcomes and Measures: The main outcomes were chronic disease quality measures for 2 common conditions in ambulatory care: diabetes and hypertension. Logistic regression models were used to estimate the association between individual-level receipt of care from a CRH clinician and the study outcomes., Results: This study included 71 508 veterans (mean [SD] age, 66 [15] years; 91.4% were male). Veterans who received a higher proportion of care from CRH clinicians were more likely to have improved blood pressure control compared with those who received a lower proportion of care. Higher vs lower CRH intensity was associated with improved blood pressure control among veterans with diabetes (79.5% [95% CI, 78.5%-80.4%] vs 76.6% [95% CI, 75.7%-77.5%]) and veterans with hypertension (76.8% [95% CI, 76.0%-77.5%] vs 73.9% [95% CI, 73.2%-74.7%]). Among racial and ethnic minority veterans, no association between CRH intensity and clinical quality was observed., Conclusions and Relevance: In this large retrospective cohort study among veterans receiving primary care services through a national telehealth contingency staffing program, veterans with a higher proportion of care from CRH clinicians had improvement in blood pressure outcomes. These findings suggest that the CRH program may be helpful in addressing veteran primary care needs without introducing or worsening disparities in ambulatory quality measures among racial and ethnic minority veterans. As health systems face staffing shortages in primary care, these findings can inform strategies for equitable implementation of large-scale telehealth initiatives to fill these gaps and maintain timely access to primary care.
Published: 2025
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24. Association between psoas muscle mass index and bone mineral density in patients undergoing hemodialysis.

Author: Ito K, Ookawara S, Sanayama H, Kakuda H, Kanai C, Iguchi K, Shindo M, Tanno K, Ishibashi S, Kakei M, Tabei K, and Morishita Y
Subjects: Humans, Male, Female, Aged, Middle Aged, Osteoporosis etiology, Sarcopenia etiology, Femur Neck diagnostic imaging, Bone Density, Psoas Muscles diagnostic imaging, Renal Dialysis adverse effects, Absorptiometry, Photon
Abstract: Patients undergoing dialysis are at risk of osteoporosis and sarcopenia because of mineral and bone disorders or malnutrition. Additionally, maintaining muscle mass is important to prevent osteoporosis. The psoas muscle mass index (PMI) was recently used to evaluate muscle mass. However, few studies have evaluated the association between the PMI and bone mineral density (BMD); therefore, we examined the association between PMI and BMD in the femoral neck (FN) of 80 patients (45 males, age, 71 (60-76) years; dialysis duration, 74 (36-140) months) undergoing hemodialysis. FN-BMD was measured using dual-energy X-ray absorptiometry, and PMI was evaluated using psoas muscle areas on computed tomography. FN-BMD and PMI were significantly higher in males than in females. In a correlation analysis, sex, BMI, serum creatinine levels, HbA1c levels, and PMI were positively correlated with FN-BMD, whereas age, history of bone fracture, difficulty in walking and bone-specific alkaline phosphatase level were negatively correlated. In the multivariate regression analysis using clinical factors significantly correlated to FN-BMD, including PMI, both sex (standardized coefficient: 0.249, p = 0.028) and PMI (standardized coefficient: 0.249, p = 0.038) were extracted. Multivariable linear regression analysis using PMI and traditional osteoporosis factors revealed that PMI was significantly and independently associated with FN-BMD (standardized coefficient: 0.308, p = 0.010). In conclusion, PMI was positively associated with FN-BMD. Attention should be paid to the possibility of decreased BMD with decreased muscle mass., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethics declaration: Studies involving human participants were reviewed and approved by the Institutional Review Board of Minami-Uonuma City Hospital (R3-3). Due to the retrospective nature of the study, the Institutional Review Board of Minami-Uonuma City Hospital waived the need to obtain informed consent., (© 2024. The Author(s).)
Published: 2025
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25. Industry Payments to Physicians During Medical Specialty Society Conferences.

Author: Wilson LM, Donahoe JT, Herzig SJ, and Anderson TS
Abstract: Competing Interests: Declarations:. Conflict of Interest:: Dr. Anderson reports receiving grants from the American Heart Association, American College of Cardiology, and Boston Older Adults Independence Center Pepper Center as wells as personal fees from the American Medical Association and American Medical Student Association outside the submitted work. Dr. Donahoe reports previously receiving consulting fees from Greylock McKinnon Associates related to pharmaceutical litigation. Dr. Herzig reports receiving grants from the Agency for Healthcare Research and Quality outside of the submitted work. Ms. Wilson reports receiving personal fees from the American Medical Student Association outside the submitted work. Role of the Funder/Sponsor:: The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Published: 2025
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26. Midline vs Peripherally Inserted Central Catheter for Outpatient Parenteral Antimicrobial Therapy.

Author: Paje D, Walzl E, Heath M, McLaughlin E, Horowitz JK, Tatarcuk C, Swaminathan L, Kaatz S, Malani AN, Vaughn VM, Bernstein SJ, Flanders SA, and Chopra V
Abstract: Importance: Little is known about the safety of midline catheters vs peripherally inserted central catheters (PICCs) for outpatient parenteral antimicrobial therapy (OPAT)., Objective: To compare outcomes from midline catheters vs PICCs for OPAT., Design, Setting, and Participants: This retrospective cohort study included patients who received antimicrobial therapy through a midline catheter or PICC between January 2017 and November 2023 across 69 Michigan hospitals. Because peripherally compatible OPAT was the indication of interest, vancomycin therapy was excluded. Data were analyzed from April to June 2024., Exposures: Insertion of a midline catheter or PICC for OPAT following hospitalization., Main Outcomes and Measures: The primary outcome was major device complications (ie, catheter-related bloodstream infection or catheter-related venous thromboembolism). Secondary outcomes included minor device complications (eg, catheter dislodgement, occlusion, tip migration, infiltration, superficial thrombophlebitis, or exit site concerns) and device failure, defined as catheter removal following device complication. Cox proportional hazards regression models were fit to device type and outcomes, adjusting for patient and device confounders and device dwell., Results: Of 2824 included patients, 1487 (53.5%) were male, and the median (IQR) age was 66.8 (55.9-77.1) years. Of 2824 devices placed for OPAT, 1999 (70.8%) were midline catheters and 825 (29.2%) were PICCs. The median (IQR) dwell time was 12 (8-17) days for midline catheters and 19 (12-27) days for PICCs (P < .001). A major device complication occurred in 44 patients (1.6%) overall, including 16 (0.8%) with midline catheters and 28 (3.4%) with PICCs (P < .001). OPAT delivered via midline catheters was associated with a lower risk of major complications vs PICCs (adjusted hazard ratio [aHR], 0.46; 95% CI, 0.23-0.91). Risks of minor complications and device failure were similar across device types (minor complications: 206 of 1999 [10.3%] vs 114 of 825 [13.8%]; aHR, 1.07; 95% CI, 0.83-1.38; device failure: 191 of 1999 [9.6%] vs 100 of 825 [12.1%]; aHR, 1.26; 95% CI, 0.96-1.65). For device dwell of 14 or fewer days, midline catheters were associated with a lower risk of major complications (12 of 1324 [0.9%] vs 16 of 304 [5.3%]; aHR, 0.29; 95% CI, 0.12-0.68) and similar risk of failure (151 of 1324 [11.4%] vs 52 of 304 [17.1%]; aHR, 0.79; 95% CI, 0.56-1.12) vs PICCs. For dwell longer than 14 days, no significant difference in rates of major complications (4 of 675 [0.6%] vs 12 of 521 [2.3%]; aHR, 0.42; 95% CI, 0.13-1.40) or device failure (40 of 675 [5.9%] vs 48 of 521 [9.2%]; aHR, 1.02; 95% CI, 0.64-1.61) were observed., Conclusions and Relevance: In this study, midline catheters appeared to be safe alternatives to PICCs for OPAT, particularly if infusions were planned for 14 or fewer days.
Published: 2025
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27. Point-counterpoint: Should hospitalists perform their own bedside procedures?

Author: Cool JA, Galen BT, and Dancel R
Published: 2025
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28. Treatment Preference Archetypes in Eosinophilic Esophagitis and Their Implications for Therapy.

Author: Chang JW, Brophy K, Ryan KA, Rubenstein JH, Dellon ES, Wallner LP, Kim HM, and De Vries AR
Subjects: Humans, Male, Female, Adult, Middle Aged, Decision Making, Eosinophilic Esophagitis therapy, Eosinophilic Esophagitis psychology, Eosinophilic Esophagitis drug therapy, Patient Preference
Abstract: Introduction: Little is known about how patients make decisions about and prioritize therapies and disease management in eosinophilic esophagitis (EoE). We aimed to systematically identify and characterize patient perspectives and attitudes that influence decision making for EoE management., Methods: To understand the diverse attitudes and values of patients with EoE, we designed a study using the Q-method. We iteratively developed 31 statements related to EoE disease management. Participants sorted statements by ranking from +4 (most agree) to -4 (most disagree). By-person factor analysis, using 2-factor and 3-factor rotation, revealed distinct preference archetypes., Results: Thirty-four adults with EoE (mean age 40.9 years, 51.4% male, 82.9% White) were recruited from gastroenterology and allergy clinics from a single center. We identified 2 treatment-centered archetypes: Medication preference, driven by symptoms and the desire to minimize risk of complications and Natural treatment preference , focusing on identifying trigger foods and diet adherence. Three-factor analysis revealed an additional archetype: Treatment ambivalent, a view of EoE as a mild and episodic (not chronic) disease with low priority to treat. Comparison by factor revealed 54% of those in the natural preference archetype were recategorized as treatment ambivalent , suggesting that they see natural treatment as a less complicated or milder strategy and may be at risk of nonadherence and reduced treatment uptake., Discussion: We identified 3 distinct treatment preference archetypes among individuals with EoE, underscoring the need for personalized treatment strategies, especially for those favoring natural approaches but masking ambivalence, and may be at risk of nonadherence or loss to follow-up., (Copyright © 2024 by The American College of Gastroenterology.)
Published: 2025
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29. Primary myelofibrosis as the etiology of pulmonary alveolar proteinosis: a rare clinical scenario.

Author: Lyu TW, Yung K, Chien YC, Tsai XC, and Hou HA
Published: 2025
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30. A Mixed Methods Analysis of Standardized Documentation of Serious Illness Conversations Within an Electronic Health Record Module During Hospitalization.

Author: Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, and Dalal AK
Subjects: Humans, Female, Male, Middle Aged, Aged, Adult, Aged, 80 and over, Documentation standards, Critical Illness, Grounded Theory, Physician-Patient Relations, Communication, Electronic Health Records, Hospitalization
Abstract: Background: Analysis of documented Serious Illness Conversations (SICs) in the inpatient setting can help clinicians align management to address patient and caregiver needs., Methods: We conducted a mixed methods analysis of the first instance of standardized documentation of a SIC within a structured module among hospitalized general medicine patients from 2018 to 2019. Percentage of documentations that included a description of patient or family understanding of the patient's medical condition and use of radio buttons to answer the "prognostic information shared," "hopes," and "worries" modules are reported. Using grounded theory approach, physicians analyzed free text entries to: "What is important to the patient/family?" and "Recommendations or next steps planned.", Results: Out of 5142 patients, 59 patients had a documented SIC. Patient or family understanding of the medical condition(s) was reported in 56 (95%). For "prognostic information shared," the most frequently selected radio buttons were: 49 (83%) incurable disease and 28 (48%) prognosis of weeks to months while those for "hopes" were: 52 (88%) be comfortable and 27 (46%) be at home and for "worries" were: 49 (83%) other physical suffering and 36 (61%) pain. Themes generated from entries to "What's important to patient/family?" included being with loved ones; comfort; mentally and physically present; and reliable care while those for "Recommendations" were coordinating support services; symptom management; and support and communication., Conclusions: SIC content indicated concern about pain and reliable care suggesting the complex, intensive nature of caring for seriously ill patients and the need to consider SICs earlier in the life course of patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Published: 2025
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31. Metapneumovirus-Induced Myocarditis Complicated by Klebsiella pneumoniae Co-Infection: A Case Report.

Author: Wang SH, Lee MH, Lee YJ, and Liu YC
Subjects: Humans, Male, Aged, Fatal Outcome, Myocarditis, Coinfection, Klebsiella Infections diagnosis, Klebsiella Infections complications, Klebsiella pneumoniae isolation & purification, Metapneumovirus isolation & purification, Paramyxoviridae Infections complications, Paramyxoviridae Infections diagnosis
Abstract: BACKGROUND Human metapneumovirus (hMPV), classified in the Pneumoviridae family, is primarily known for causing lower respiratory tract infections in children, the elderly, and immunocompromised individuals. However, rare instances have shown that hMPV can also affect other systems, such as the cardiovascular system, leading to conditions like myocarditis. CASE REPORT We describe a 68-year-old man with a medical history of diabetes, hypertension, and liver cirrhosis who presented to the Emergency Department (ED) exhibiting symptoms of fever, cough, and dyspnea. His condition deteriorated rapidly, progressing to septic shock and requiring increased oxygen support, which led to his transfer to the medical intensive care unit (MICU). Diagnostic evaluations, including cardiac echocardiography and coronary angiography (CAG), confirmed the presence of myocarditis while excluding acute myocardial infarction. Despite aggressive interventions, including extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) therapy, the patient's condition worsened, and he died 3 days after admission. Polymerase chain reaction (PCR) testing of a throat swab confirmed hMPV infection, with Klebsiella pneumoniae simultaneously identified via sputum culture. The bacterial susceptibility report indicated that the bacteria were sensitive to piperacillin/tazobactam, which had been administered since the patient arrived at our ED, which suggests that the bacterial infection alone cannot fully explain the patient's condition. CONCLUSIONS Compared to previously reported cases of hMPV-related myocarditis, this case is the first to demonstrate notably adverse outcomes associated with the concurrent presence of bacterial infection. The rapid progression and poor outcome despite aggressive treatment emphasize the need for early diagnosis and management of such co-infections.
Published: 2024
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32. Oral Frailty and Its Relationship with Physical Frailty in Older Adults: A Longitudinal Study Using the Oral Frailty Five-Item Checklist.

Author: Kusunoki H, Hasegawa Y, Nagasawa Y, Shojima K, Yamazaki H, Mori T, Tsuji S, Wada Y, Tamaki K, Nagai K, Matsuzawa R, Kishimoto H, Shimizu H, and Shinmura K
Subjects: Humans, Aged, Female, Male, Longitudinal Studies, Aged, 80 and over, Japan epidemiology, Cross-Sectional Studies, Hand Strength, Oral Health, Tooth Loss epidemiology, Xerostomia epidemiology, Mastication physiology, Deglutition Disorders epidemiology, Walking Speed, Muscle, Skeletal physiopathology, Frailty epidemiology, Frail Elderly statistics & numerical data, Geriatric Assessment methods, Checklist
Abstract: Background/objectives: Oral frailty, first identified in Japan in 2014, refers to a state between healthy oral function and severe decline, marked by minor issues, such as tooth loss and chewing difficulties. The oral frailty five-item checklist (OF-5) enables non-dental professionals to evaluate oral frailty using five key indicators: remaining teeth count, chewing difficulties, swallowing difficulties, dry mouth, and articulatory oral skills. Limited studies exist., Methods: This study examined the relationship between oral and physical frailties in older adults and assessed the prognosis of physical frailty using the OF-5. Participants aged ≥65 years were recruited from the frail elderly in the Sasayama-Tamba area, Hyogo, Japan, and their physical function was assessed in terms of grip strength, walking speed, and skeletal muscle mass. Blood markers, such as cystatin C, an indicator of renal function, were also analyzed., Results: A cross-sectional analysis indicated that oral frailty was correlated with reduced muscle mass, walking speed, and physical function. Women had lower hemoglobin and albumin levels and a greater prevalence of frailty than men. Longitudinal analysis revealed that initial OF-5 scores predicted increased physical frailty after 2-3 years, especially in those with higher baseline scores. The OF-5 was a significant factor for frailty progression in both sexes., Conclusions: These results suggest that early detection of oral frailty via the OF-5 may be useful in preventing the progression of overall frailty in older adults.
Published: 2024
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33. Reducing Unnecessary Admissions in the Emergency Department.

Author: Kneifati-Hayek JZ and Incze MA
Published: 2024
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34. Clinical Inertia in the Diagnosis and Management of Hypertension Following Ambulatory Blood Pressure Monitoring.

Author: Flatow JS, Byfield R, Singer J, Chang MJ, Schwartz JE, Shimbo D, and Kronish IM
Abstract: Background: Clinical inertia is common when blood pressure (BP) is high in the office. Little is known about the extent of clinical inertia after ambulatory BP monitoring (ABPM)., Methods: This was an electronic health record-based retrospective cohort study of patients with high office BP (≥140/90 mmHg) referred for ABPM at a medical center in New York City between 2016 and 2020. Diagnostic inertia was defined as clinicians not newly diagnosing or treating hypertension in patients with high ABPM (i.e., mean awake BP ≥135/85 mmHg). Therapeutic inertia was defined as clinicians not intensifying treatment for patients with established hypertension after high ABPM. Multilevel modeling was used to assess patient and clinician characteristics associated with inertia., Results: Among 329 patients without prior hypertension, 144 (44%) had high awake BP, and of these, diagnostic inertia occurred in 45 of 144 (31%). Among 239 patients taking antihypertensive medication, 141 (59%) had high awake BP, and of these, therapeutic inertia occurred in 73 of 141 (52%). In multilevel models, male gender (OR 2.81, 95%CI 1.11 - 7.08), lower awake SBP (OR 0.73 per 5 mmHg increase, 95%CI 0.53 - 1.00), and specialist vs primary care clinician type (OR 4.57, 95%CI 1.78 - 11.75) were associated with increased diagnostic inertia. Increasing age (OR 1.16 per 5-year increase, 95%CI 1.00 - 1.28) and lower awake SBP (OR 0.82 per 5 mmHg increase, 95%CI 0.66 - 0.95) were associated with increased therapeutic inertia., Conclusions: Diagnostic and therapeutic inertia were common after ABPM, particularly when awake SBP was near the threshold., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)
Published: 2024
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35. Comparison of Management and Outcomes of Hip Fractures Among Low- and High-Income Patients in Six High-Income Countries.

Author: Huang N, Hatfield LA, Al-Azazi S, Bakx P, Banerjee A, Burrack N, Chen YC, Fu C, Godoy Junior C, Heine R, Ko DT, Lix LM, Novack V, Pasea L, Qiu F, Ravi B, Stukel TA, Groot CU, Cram P, and Landon BE
Abstract: Background: There is a perception that income-based disparities are present in most countries but may differ in magnitude. However, there are few international comparisons that describe income-based disparities across countries and none that focus on hip fractures., Objective: To compare treatment patterns and outcomes of high- and low-income older adults hospitalized with hip fracture across six high-income countries., Design: Retrospective serial cross-sectional cohort study., Participants: Adults aged ≥ 66 years hospitalized with hip fracture from 2013 to 2019 in Canada, England, Israel, the Netherlands, Taiwan, and the USA using population-representative patient-level administrative data., Main Measures: Older adults in the top and bottom income quintiles within countries were compared on 30-day and 1-year mortality, treatment approaches, hospital length of stay (LOS), 30-day readmission rates, time to surgery, and discharge disposition., Key Results: Annual age- and sex-standardized incidence rates of hip fracture were higher for low- than for high-income populations in all countries except in the USA. In all countries, adjusted 1-year mortality was lower for high-income than low-income patients, with the largest difference in Israel (- 10.0 percentage points [95% confidence interval [CI], - 15.2 to - 4.8 percentage points]). Across countries, utilization of total hip arthroplasty was 0.1 (95% CI, 0.0-0.2 percentage points) to 6.9 percentage points (95% CI, 4.6-9.2 percentage points) higher among high- vs. low-income populations. With few exceptions, LOS, adjusted 30-day readmission rate, and time to surgery were shorter and lower for high-income patients., Conclusions: Income-based disparities in treatments and outcomes for older adults hospitalized for hip fractures differed in magnitude, but were present in all six high-income countries. Defying our expectations, the USA did not have consistently larger disparities than other countries suggesting that the impacts of poverty exist in vastly different healthcare systems and transcend geopolitical borders., Competing Interests: Declarations:. Conflict of Interest:: The authors declare that they do not have a conflict of interest., (© 2024. The Author(s).)
Published: 2024
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36. Preventable diagnostic errors of lower gastrointestinal perforation: a secondary analysis of a large-scale multicenter retrospective study.

Author: Harada T, Watari T, Watanuki S, Kushiro S, Miyagami T, Syusa S, Suzuki S, Hiyoshi T, Hasegawa S, Nabeshima S, Aihara H, Yamashita S, Tago M, Yoshimura F, Kunitomo K, Tsuji T, Hirose M, Tsuchida T, and Shimizu T
Abstract: Background: Lower gastrointestinal perforation (LGP) is an acute abdominal condition associated with a high mortality rate. Timely and accurate diagnosis is crucial. Nevertheless, a diagnostic delay has been estimated to occur in approximately one-third of the cases, and the factors contributing to this delay are yet to be clearly understood. This study aimed to evaluate the diagnostic process for appropriate clinical reasoning and availability of image interpretation in cases of delayed diagnosis of LGP., Methods: A secondary data analysis of a large multicenter retrospective study was conducted. This descriptive study analyzed data from a multicenter, observational study conducted across nine hospitals in Japan from January 2015 to December 2019. Out of 439 LGP cases, we included 138 cases of delayed diagnosis, excluding patients with traumatic or iatrogenic perforations, or those secondary to mesenteric ischemia, appendicitis, or diverticulitis. Clinical history and computed tomography (CT) imaging information were collected for 138 cases. Additionally, information on the clinical course of 50 cases, which were incorrectly diagnosed as gastroenteritis, constipation, or small bowel obstruction, was also collected., Results: In 42 (30.4%) cases of delayed diagnosis of LGP, CT imaging was performed before diagnosis, indicating a missed opportunity for timely diagnosis. Moreover, 33 of the 50 patients initially diagnosed with gastroenteritis, constipation, or small bowel obstruction at the time of initial examination had atypical findings that were not consistent with the initial diagnosis. Of the 138 cases with delayed diagnosis in our study, 67 cases (48.6%) showed problems with either the interpretation of CT scans or with the process of clinical reasoning., Conclusion: Our retrospective study results indicate that approximately half of the cases with delayed diagnosis of LGP were due to problems in interpreting CT images or in clinical reasoning. This finding suggests that clinical reasoning and image interpretation by radiologists are important in improving the diagnostic process for LGP., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the ethical review board of Showa University Koto Toyosu Hospital (No. 20T7044) and conducted in accordance with the Declaration of Helsinki. Written informed consent was waived owing to the retrospective study design by the ethical review board of Showa University Koto Toyosu Hospital. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)
Published: 2024
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37. Self-Reported Time-at-Bedside and Its Association with In-Training Examination Scores of Residents in Japan.

Author: Katayama K, Takada T, Nishizaki Y, Nagasaki K, Shimizu T, Yamamoto Y, Watari T, Tokuda Y, Chopra V, and Ohira Y
Abstract: Background: Time-at-bedside plays a central role in clinical medicine. However, the amount of time Japanese clinical residents spend at patients' bedsides remains unexplored., Objective: To quantify time-at-bedside and examine its association with in-training examination scores during clinical residency in Japan., Design: Nationwide multicenter cross-sectional study., Participants: First- and second-year postgraduate residents who took the General Medicine In-Training Examination at the end of the 2022 academic year., Interventions: Time-at-bedside was defined as the average time per day the residents spend providing care at patients' bedsides during their residency. Time-at-bedside was classified into six categories: C1 (10-20 min per day), C2 (30-50 min per day), C3 (60-80 min per day), C4 (90-110 min per day), C5 (120-140 min per day), and C6 (150 min or more per day). Data on time-at-bedside were collected through an electronic survey conducted immediately after the General Medicine In-Training Examination., Main Measures: The primary outcome was the General Medicine In-Training Examination score. A multi-level analysis examined the association between self-reported time-at-bedside and the General Medicine In-Training Examination score., Key Results: A total of 5344 residents were included in this study. Of these, 2760 were first-year residents, and 2584 were second-year residents. Of the 5334 residents, 66.9% reported spending less than 60 min at a patient's bedside. Compared to the C1, C2 (adjusted score difference [aSD] = 1.1, 95% confidence interval [95% CI] 0.48 to 1.79), C3 (aSD = 1.5, 95% CI 0.75 to 2.20), and C5 (aSD = 2.0, 95 CI 0.62 to 3.38) were positively associated with the General Medicine In-Training Examination score. However, C4 (aSD = 1.1, 95% CI - 0.15 to 2.26) and C6 (aSD = 0, 95% CI - 1.79 to 1.87) were not associated with the General Medicine In-Training Examination score., Conclusion: Self-reported time-at-bedside positively correlates with in-training examination scores among Japanese resident physicians., Competing Interests: Declarations:. Disclosures:: Dr. Nishizaki received an honorarium from JAMEP as a GM-ITE project manager. Dr. Tokuda is the director of JAMEP and received an honorarium as a speaker for the JAMEP lecture. Dr. Shimizu and Dr. Yamamoto received an honorarium from JAMEP as test authors for the GM-ITE. Ethical Approval:: The study and its protocol were approved by the Ethics Review Board of the Japan Organization of Advancing Medical Education Program (JAMEP) (22–9). Patient Consent Statement:: All the participants provided informed consent to participate in this study before the survey. The research consent document stated that the questionnaire results would be anonymized. Conflict of Interest: The authors declare that they do not have a conflict of interest for this article., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)
Published: 2024
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38. Grayken Lessons: a patient who developed opioid use disorder after traumatic brain injury.

Author: Reed G, Lugo H, Adams RS, and Walley AY
Subjects: Humans, Male, Adult, Cognitive Dysfunction rehabilitation, Cognitive Dysfunction etiology, Brain Injuries, Traumatic rehabilitation, Brain Injuries, Traumatic complications, Opioid-Related Disorders rehabilitation
Abstract: Background: Traumatic brain injury (TBI) is common in people with substance use disorders (SUDs). TBI often results in cognitive deficits which can affect the clinical course of SUD., Case Presentation: Here we present the case of a 34-year-old Spanish-speaking man with severe opioid use disorder and two prior TBIs affecting his cognitive abilities. He was linked to outpatient addiction specialty care at a community health center. After identification of his TBI history, his care team, which included a language-concordant physician and peer recovery coach, worked to develop a treatment plan that accounted for his unique cognitive deficits and behavioral challenges. He was also connected with community resources including a rehabilitation program designed for people with TBI. These individualized aspects of treatment helped to better engage and retain the patient in quality care for his SUD., Conclusions: By identifying TBI history in people with SUDs, the treatment plan can be tailored to accommodate TBI-related deficits. An effective care plan should incorporate not only medical providers, but also resources such as peer recovery supports and TBI-focused rehabilitation programs when and where they are available, with an emphasis on improving functional capacity., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Patient provided witnessed and signed consent form for publication of this case report. Institutional (Boston Medical Center) consent form used for this purpose. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)
Published: 2024
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39. Lack of an association between spleen volume and risk of pneumococcal infection in cancer patients: a nested case-control study.

Author: Kurihara I, Yamazaki H, Kato S, Oyama-Manabe N, and Sugawara H
Subjects: Humans, Male, Female, Case-Control Studies, Middle Aged, Aged, Retrospective Studies, Risk Factors, Japan epidemiology, Adult, Streptococcus pneumoniae isolation & purification, Organ Size, Pneumonia, Pneumococcal complications, Pneumonia, Pneumococcal epidemiology, Tomography, X-Ray Computed, Spleen pathology, Spleen diagnostic imaging, Neoplasms complications, Pneumococcal Infections epidemiology
Abstract: Background: The spleen is a key organ in preventing pneumococcal infection, especially in patients with immunocompromised condition such as those with cancer. Previous studies have shown that a small spleen volume in pneumococcal pneumonia patients is associated with severe disease course. However, it is unknown whether a small spleen increases risk of pneumococcal infection. We investigated the association between spleen volume and risk of pneumococcal infection., Methods: This study was a retrospective cohort study using a nested case-control design and involved adult patients with malignancy who underwent chest and/or abdominal CT scans from January 1, 2008, to September 30, 2020, at a tertiary care center in Japan. Exclusion criteria comprised patients diagnosed with hepatic cirrhosis, leukemia, lymphoma, and/or post-splenectomy. From the cohort group that met all selection criteria (n = 22475), we identified all incident cases of pneumococcal infection (pneumococcal pneumonia and/or invasive pneumococcal diseases) and matched them with four controls by age, sex, and follow-up duration. Odds ratios (ORs) for the association between spleen volume and pneumococcal infection were estimated using conditional logistic regression models adjusted for body surface area, performance status, Charlson comorbidity index, and metastatic cancer., Results: The median spleen volume was 85.8 (interquartile range, 65.8-120.8) cm 3 . Over a median follow-up of 4.95 (interquartile range, 1.54-9.25) years, 60 patients were diagnosed with pneumococcal infection (20 with invasive pneumococcal disease and 40 with pneumonia without invasive pneumococcal disease) and matched with 240 controls. Spleen volume reduction (per 10 cm 3 ) did not increase risk of pneumococcal infection in a crude analysis [OR 1.04 (95% CI 0.98-1.11)]. The outcome remained unchanged in the multivariable analysis (OR 1.01 [95% CI 0.95-1.08])., Conclusions: Small spleen volume did not increase risk of pneumococcal infection in cancer patients., Competing Interests: Declarations. Ethical approval and participation consent: The current study was approved by the ethics committee of the Jichi Medical University Saitama Medical Center (Approval Number: Clinical S20-176). In accordance with Japanese ethical guidelines for medical and health research involving human subjects, the need for written informed consent was waived by the ethics committee of the Jichi Medical University Saitama Medical Center due to retrospective nature of the study. The study was conducted using a non-participation method based on our hospital’s website. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)
Published: 2024
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40. Clinical Characteristics and Current Management of U.S. Adults at Elevated Risk for Heart Failure Using the PREVENT Equations: A Cross-Sectional Analysis.

Author: Sussman JB, Wilson LM, Burke JF, Ziaeian B, and Anderson TS
Abstract: Competing Interests: Disclosures: Disclosure forms are available with the article online.
Published: 2024
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41. Blood Pressure Trajectories During Young Adulthood and Cardiovascular Events in Later Life.

Author: Xia M, An J, Fischer H, Allen NB, Xanthakis V, and Zhang Y
Subjects: Humans, Adult, Female, Male, Young Adult, Adolescent, Risk Assessment, Hypertension epidemiology, Hypertension physiopathology, United States epidemiology, Age Factors, Middle Aged, Risk Factors, Time Factors, Prognosis, Heart Disease Risk Factors, Blood Pressure, Cardiovascular Diseases epidemiology, Cardiovascular Diseases physiopathology
Abstract: Background: Studying the association between blood pressure (BP) trajectories during young adulthood and subsequent cardiovascular disease (CVD) risk can provide insights into how long-term BP patterns in early-life influence the development of CVD later in life., Methods: We pooled data from 2 US cohorts (Coronary Artery Risk Development in Young Adults, Framingham Heart Study). We used latent growth curve models to identify distinct BP trajectory groups between ages 18 and 39 years. We then used Cox proportional hazards models to assess the associations between BP trajectories and CVD events (composite of coronary heart disease [CHD], stroke, and heart failure [HF]) after age 40 years., Results: We included 6,579 participants and identified 4 distinct systolic BP (SBP) trajectory groups during young adulthood. During a median follow-up of 18.2 years after age 40 years, 213 CHD, 139 stroke, 120 HF, and 400 composite CVD events occurred. Individuals in an elevated-increasing vs. low-stable SBP trajectory during young adulthood were associated with a higher risk of CVD after adjusting for traditional CVD risk factors, with hazard ratios (95% confidence interval) of 3.25 (1.63, 6.46) for CHD, 3.92 (1.63, 9.43) for stroke, 8.30 (2.97, 23.17) for HF, and 3.91 (2.38, 6.41) for composite CVD outcomes. Adding BP trajectory to BP at baseline improved model discrimination for all outcomes (changes in Harrell's C-index 0.0084-0.0192)., Conclusions: An elevated-increasing BP trajectory during young adulthood is associated with a higher risk of CVD later in life, highlighting the importance of maintaining a low-stable BP trajectory throughout the young adulthood period for prevention of CVD in later life., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)
Published: 2024
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42. Dysanapsis Genetic Risk Predicts Lung Function Across the Lifespan.

Author: Debban CL, Ambalavanan A, Ghosh A, Li Z, Buschur KL, Ma Y, George E, Pistenmaa C, Bertoni AG, Oelsner EC, Michos ED, Moraes TJ, Jacobs DR Jr, Christenson S, Bhatt SP, Kaner RJ, Simons E, Turvey SE, Vameghestahbanati M, Engert JC, Kirby M, Bourbeau J, Tan WC, Gabriel SB, Gupta N, Woodruff PG, Subbarao P, Ortega VE, Bleecker ER, Meyers DA, Rich SS, Hoffman EA, Barr RG, Cho MH, Bossé Y, Duan Q, Manichaikul A, and Smith BM
Subjects: Humans, Female, Male, Middle Aged, Adult, Aged, Genetic Predisposition to Disease, Child, Respiratory Function Tests, Risk Factors, Genome-Wide Association Study, Lung diagnostic imaging, Lung physiopathology, Pulmonary Disease, Chronic Obstructive genetics, Pulmonary Disease, Chronic Obstructive physiopathology, Tomography, X-Ray Computed
Abstract: Rationale: Dysanapsis refers to a mismatch between airway tree caliber and lung size arising early in life. Dysanapsis assessed by computed tomography (CT) is evident by early adulthood and associated with chronic obstructive pulmonary disease (COPD) risk later in life. Objectives: By examining the genetic factors associated with CT-assessed dysanapsis, we aimed to elucidate its molecular underpinnings and physiological significance across the lifespan. Methods: We performed a genome-wide association study of CT-assessed dysanapsis in 11,951 adults, including individuals from two population-based and two COPD-enriched studies. We applied colocalization analysis to integrate genome-wide association study and gene expression data from whole blood and lung. Genetic variants associated with dysanapsis were combined into a genetic risk score that was applied to examine association with lung function in children from a population-based birth cohort ( n = 1,278) and adults from the UKBiobank ( n = 369,157). Measurements and Main Results: CT-assessed dysanapsis was associated with genetic variants from 21 independent signals in 19 gene regions, implicating HHIP (hedgehog interacting protein), DSP , and NPNT as potential molecular targets based on colocalization of their expression. A higher dysanapsis genetic risk score was associated with obstructive spirometry among 5-year-old children and among adults in the fifth, sixth, and seventh decades of life. Conclusions: CT-assessed dysanapsis is associated with variation in genes previously implicated in lung development, and dysanapsis genetic risk is associated with obstructive lung function from early life through older adulthood. Dysanapsis may represent an endophenotype link between the genetic variations associated with lung function and COPD.
Published: 2024
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43. Non-invasive assessment of portal hypertension in patients with primary biliary cholangitis is affected by severity of cholestasis.

Author: Calvaruso V, Celsa C, Cristoferi L, Scaravaglio M, Smith R, Kaur S, Di Maria G, Capodicasa L, Pennisi G, Gerussi A, Nofit E, Malinverno F, Lampertico P, Cazzagon N, Marzioni M, Vespasiani-Gentilucci U, Colapietro F, Andreone P, De Nalda AL, Rigamonti C, Viganò M, Giannini EG, Russello M, Vanni E, Cerini F, Orlandini A, Brunetto M, Niro GA, Vettori G, Castellaneta A, Cardinale V, Alvaro D, Mega A, Palitti VP, Cossiga V, Morisco F, Bellanti F, Baiocchi L, Fabris L, Persico M, Degasperi E, Labanca S, Bonaiuto E, Pezzato F, Federico A, Petta S, Di Marco V, Mells GF, Culver E, Invernizzi P, Cammà C, and Carbone M
Abstract: Background&aims: Non-invasive tests (NITs) for ruling-out clinical significant portal hypertension (CSPH) and high-risk varices (HRV) in patients with primary biliary cholangitis(PBC) and compensated advanced chronic liver disease (cACLD) are lacking. We evaluated NITs in these patients and the influence of cholestasis on their performance., Methods: Consecutive patients from the "Italian PBC registry" and two UK large-volume PBC referral centres with upper endoscopy within 6 months from biochemical evaluation and transient elastography were included. RESIST, Baveno-VI (BVI) and Expanded Baveno-VI (EBVI) criteria for ruling-out HRV were assessed according to alkaline phosphatase levels (ALP)(1.5 ULN). Decision curve analysis (DCA) was performed. Prevalence of any-sized esophageal varices among patients fitting Baveno VII (BVII) criteria was also calculated., Results: The final cohort consisted of 293 patients with cACLD. RESIST criteria were associated with the lowest rate of missed HRV (2.5% vs 9.8% for BVI and 8.9% for EBVI). In patients with ALP levels>1.5 times ULN, BVI and EBVI missed a higher rate of HRV (15.5% and 14.5%, respectively) than RESIST (3.1%). DCA demonstrated the highest net benefit of RESIST criteria for ruling out HRV, regardless ALP levels. Among 75 patients classified as low risk of CSPH according to BVII, 14 (18.7%) showed esophageal varices., Conclusions: Biochemical-based RESIST criteria demonstrate the highest net benefit compared to elastography-based criteria for ruling out HRV. The severity of cholestasis affects NITs performance to rule out HRV and CSPH in patients with PBC and cACLD., (Copyright © 2024. Published by Elsevier Inc.)
Published: 2024
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44. Pretransplant MRD detection of fusion transcripts is strongly prognostic in KMT2A-rearranged acute myeloid leukemia.

Author: Loo S, Potter N, Ivey A, O'Nions J, Moon R, Jovanovic J, Fong CY, Anstee NS, Tiong IS, Othman J, Chua CC, Renshaw H, Baker R, Fleming S, Russell NH, Ritchie D, Bajel A, Hou HA, Dillon R, and Wei AH
Subjects: Humans, Prognosis, Male, Middle Aged, Female, Adult, Gene Rearrangement, Aged, Hematopoietic Stem Cell Transplantation, Oncogene Proteins, Fusion genetics, Young Adult, Adolescent, Myeloid-Lymphoid Leukemia Protein genetics, Neoplasm, Residual diagnosis, Neoplasm, Residual genetics, Histone-Lysine N-Methyltransferase genetics, Leukemia, Myeloid, Acute genetics, Leukemia, Myeloid, Acute mortality, Leukemia, Myeloid, Acute diagnosis
Abstract: Abstract: Pretransplant detection of KMT2Ar measurable residual disease ≥0.001% by quantitative polymerase chain reaction was associated with significantly inferior posttransplant survival (2-year relapse-free survival 17% vs 59%; P = .001) and increased 2-year cumulative incidence of relapse (75% vs 25%, P = .0004)., (© 2024 American Society of Hematology. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)
Published: 2024
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45. Inflammatory Indices and Their Associations With Postoperative Delirium.

Author: Mintz GE, Marcantonio ER, Walston JD, Dillon ST, Jung Y, Trivedi S, Gu X, Fong TG, Cavallari M, Touroutoglou A, Dickerson BC, Jones RN, Shafi MM, Pascual-Leone A, Travison TG, Inouye SK, Libermann TA, Ngo LH, and Vasunilashorn SM
Subjects: Humans, Female, Male, Aged, Chitinase-3-Like Protein 1 blood, Aged, 80 and over, Delirium epidemiology, Delirium blood, Delirium diagnosis, Delirium etiology, Biomarkers blood, Postoperative Complications blood, C-Reactive Protein analysis, C-Reactive Protein metabolism, Inflammation blood, Interleukin-6 blood
Abstract: Background: Although the pathogenesis of delirium is poorly understood, increasing evidence supports a role for inflammation. Previously, individual inflammatory biomarkers have been associated with delirium. Aggregating biomarkers into an index may provide more information than individual biomarkers in predicting certain health outcomes (eg, mortality); however, inflammatory indices have not yet been examined in delirium., Methods: Four inflammatory markers, C-reactive protein, interleukin-6, soluble tumor necrosis factor alpha receptor-1, and chitinase-3 like protein-1, were measured preoperatively and on postoperative day 2 in 548 adults aged 70+ undergoing major noncardiac surgery (mean age 76.7 [standard deviation 5.2], 58% female, 24% delirium). From these markers, 4 inflammatory indices were considered: (i) quartile summary score, (ii) weighted summary score, (iii) principal component score, and (iv) a well-established inflammatory (least absolute shrinkage and selection operator-derived) index associated with mortality. Delirium was assessed using the Confusion Assessment Method, supplemented by chart review. Generalized linear models with a log-link term were used to determine the association between each inflammatory index and delirium incidence., Results: Among the inflammatory indices, the weighted summary score demonstrated the strongest association with delirium: participants in the weighted summary score quartile (Q)4 had a higher risk of delirium versus participants in Q1, after clinical variable adjustment (relative risk, 95% confidence interval for preoperatively: 3.07, 1.80-5.22; and postoperative day 2: 2.65, 1.63-4.30). The weighted summary score was more strongly associated with delirium than the strongest associated individual inflammatory marker (preoperatively chitinase-3 like protein-1 [relative risk 2.45, 95% confidence interval 1.53-3.92]; postoperative day 2 interleukin-6 [relative risk 2.39, 95% confidence interval 1.50-3.82])., Conclusions: A multi-protein inflammatory index using a weighted summary score provides a slight advantage over individual inflammatory markers in their association with delirium., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Gerontological Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)
Published: 2024
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46. Things We Do for No Reason™: Avoiding naltrexone for alcohol use disorder in liver disease.

Author: Kee DP, Buyske JJ, and Calcaterra SL
Abstract: Hospitalizations related to alcohol use disorder (AUD) are common. Yet, few patients receive pharmacotherapy consistent with guideline recommendations. Previous concerns over the potential hepatotoxicity of naltrexone have been disproven and recent studies have shown its safety and efficacy in patients with cirrhosis. Naltrexone is an effective therapy to reduce heavy alcohol consumption, however, lack of knowledge among prescribers inhibits greater uptake. Hospitalization is an opportune time for change-naltrexone can promote the reduction or cessation of unhealthy alcohol consumption, as well as subsequent readmissions or progression of alcohol-related liver disease. Hospitalists should stop avoiding naltrexone in the treatment of AUD., (© 2024 Society of Hospital Medicine.)
Published: 2024
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47. Letter to the Editor Response: The General Internal Medicine Physician's Role in Addressing the Maternal Health Crisis in the USA.

Author: Cameron NA, Weil A, and Dolan BM
Abstract: Competing Interests: Declarations. Conflict of Interest: The authors have no conflicts of interest. Drs. Weil and Dolan serve as the SGIM Liaisons to the WPSI; the opinions noted here are their own and do not represent WPSI.
Published: 2024
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48. USMLE Performance, Subsequent Standardized Testing, and ABIM Certification Exam Preparation for Internal Medicine Residency Programs: A Narrative Review.

Author: Smith DT, Matelski AT, Hall MAK, Phadke VK, Vettese T, Law K, and Hemrajani R
Abstract: Standardized examinations measure progress throughout medical education. Successful completion of the American Board of Internal Medicine Certification Examination (ABIM-CE) benchmarks completion of internal medicine (IM) residency training. Recent declines in initial ABIM-CE pass rates may prompt residency programs to examine strategies to improve learner performance. We synthesized published literature on associations between the United States Medical Licensing Examination (USMLE), in-training examination (ITE), and board preparation to support residents for ABIM-CE. We searched MEDLINE for test performance and preparation strategies for IM board certification during training. Relevant articles published until March 15, 2024, were screened using pre-defined criteria for narrative review, then codified into three domains (USMLE, ITE, curriculum/program strategies). Findings were grouped by theme into considerations for training programs seeking guidance on learning augmentation plans to improve resident performance on ABIM-CE. Themes drawn from articles focused on USMLE include validity in predicting CE performance, noting (1) failing USMLE Step 1 is associated with failing ABIM-CE, (2) any USMLE score < 220 increases failure probability, and (3) a mean USMLE ≥ 250 approximates ~ 100% pass rates on board examination. Inferences from ITE-focused articles support use as a predictive tool; specifically, a score < 35th percentile signals a resident at risk for failing the ABIM-CE while > 70th percentile is predictive of passing. Lastly, inferences from curriculum- and program-focused articles suggest standard contents (conferences) do not correlate with CE passage, while targeted clinical reasoning and remediation plans do. IM residency programs should consider adopting learning augmentation strategies targeted to at-risk residents to support CE passage., Competing Interests: Declarations:. Conflict of Interest:: The authors declare that they do not have a conflict of interest., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)
Published: 2024
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49. Childcare as a social determinant of access to healthcare: a scoping review.

Author: McArthur M, Tian P, Kho KA, Bhavan KP, Balasubramanian BA, and Ganguly AP
Subjects: Humans, Child, Child, Preschool, COVID-19, Health Services Accessibility, Social Determinants of Health, Child Care
Abstract: Introduction: As health systems strive to screen for and address social determinants of health (SDOH), the role of access to childcare and barriers to healthcare posed by childcare needs remains underexplored. A gap exists in synthesizing existing evidence on the role of access to childcare as a SDOH., Methods: This scoping review aimed to examine and analyze existing literature on the role of childcare needs as a social determinant of access to healthcare. We conducted a structured literature search across PubMed, Scopus, health policy fora, and professional healthcare societies to inclusively aggregate studies across interdisciplinary sources published between January 2000 and June 2023. Two independent reviewers reviewed results to determine inclusions and exclusions. Studies were coded into salient themes utilizing an iterative inductive approach., Results: Among 535 search results, 526 met criteria for eligibility screening. Among 526 eligible studies, 91 studies met inclusion criteria for analysis. Five key themes were identified through data analysis: (1) barriers posed by childcare needs to healthcare appointments, (2) the opportunity for alternative care delivery models to overcome childcare barriers, (3) the effect of childcare needs on participation in medical research, (4) the impact of the COVID-19 pandemic on childcare needs, and (5) the disproportionate burden of childcare experienced by vulnerable populations., Discussion: Childcare needs remain underexplored in existing research. Current evidence demonstrates the relevance of childcare needs as a barrier to healthcare access, however dedicated studies are lacking. Future research is needed to understand mechanisms of childcare barriers in access to healthcare and explore potential interventions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 McArthur, Tian, Kho, Bhavan, Balasubramanian and Ganguly.)
Published: 2024
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50. Associations of Internal Medicine Residency Ratings and Certification Examination Scores With Patient Outcomes-Reply.

Author: Gray BM and Landon BE
Published: 2024
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