Southern Medical Journal最新文献

Objectives: We aimed to study the impact of gout as a correlative risk factor in the incidence of acute myocardial infarction (AMI) among patients without known MI risk factors. Our study population was obtained from the National Inpatient Sample (NIS) 2011-2018 using the International Classification of Diseases, Ninth and Tenth Revisions.

Methods: This study included patients without cardiovascular disease (CVD), and various outcomes were compared among patients with and without gout. Cohorts were weighted using an algorithm provided by the NIS, which allows for national estimates. Our primary endpoint was the odds of developing an MI, and secondary endpoints were adverse hospital events and length of stay. In total, 117,261,842 patients without CVD risk factors were included in this study, 187,619 (0.16%) of whom had a diagnosis of gout.

Results: Patients without CVD risk factors who had gout were older and more likely to be male compared with patients without gout. Among patients without CVD risk factors, the odds of having an AMI were significantly higher in those with gout compared with those without, even after adjusting for chronic nonsteroidal anti-inflammatory drug and oral steroid use. Moreover, patients without CVD risk factors and with gout were more likely to develop acute renal failure, acute thromboembolic event, shock, acute gastrointestinal bleed, and arrhythmia compared with those without gout. Furthermore, patients without CVD risk factors who were admitted with gout had higher mortality compared with those without gout.

Conclusions: In our study, we found that patients without risk factors for AMI who had gout were more likely to develop AMI compared with those without gout. Furthermore, the same patients were more likely to develop other adverse outcomes. Even with proper management, these individuals should be monitored closely for coronary events.

Objectives: Upper extremity deep vein thrombosis (UEDVT) is associated with pulmonary embolism and other complications, but there are no recommendations for UEDVT prophylaxis. The purpose of this study was to establish incidence and risk factors for UEDVT and to determine efficacy of pharmacologic prophylaxis for UEDVT prevention.

Methods: For this retrospective cohort study, we identified medical patients aged 18 years and older admitted to 13 Cleveland Clinic hospitals from January 2011 to December 2019. Patients with venous thromboembolism (VTE) on admission, length of stay <1 day, and who received therapeutic anticoagulation were excluded. The potential risk factors included demographics, comorbidities, and medical procedures. Comorbidities were identified via International Classification of Diseases codes, (ICD9 and ICD10), procedures from flowsheets, and prophylaxis from medications administered in the electronic medical record. DVT events were identified by a combination of International Classification of Diseases codes and confirmed by chart review. We performed multivariable logistic regression to identify independent risk factors and the association between VTE prophylaxis and UEDVT. The model's C statistic was obtained using 1000 bootstrap runs.

Results: Of 194,809 patients, 496 (0.25% of cohort, 36.8% of all VTE) developed UEDVT by 14 days. In the logistic regression model (bias-corrected C statistic 0.87), 11 risk factors predicted UEDVT, the strongest being peripherally inserted central catheter (odds ratio [OR] 4.62, 95% confidence interval [CI] 3.81-5.60) and central venous catheter (OR 3.57, 95% CI 2.91-4.37). The predicted risk among individuals ranged from 0.02% to 23.4%. Prophylaxis was negatively associated with the development of UEDVT (OR 0.72, 95% CI 0.60-0.87).

Conclusions: UEDVT is rare but some patients are high risk. Therefore, UEDVT risk factors should be added to VTE risk assessment models, and patients at high risk for UEDVT should receive chemoprophylaxis.

Objectives: Hypertension (HTN) affects nearly half of US adults. Our multi-institutional survey revealed that Internal Medicine residents lack proficiency in advanced HTN topics. We developed a curriculum to address knowledge gaps in these topics and aimed to assess the effects of the curriculum on residents' confidence, desire for future training, and knowledge in advanced HTN topics.

Methods: HTN experts taught four advanced topics in HTN: conducting a workup for secondary HTN, managing HTN in chronic kidney disease, managing HTN in patients who are or may become pregnant, and managing hypertensive urgency (severe asymptomatic HTN) in the outpatient setting. The setting of the curriculum was an ambulatory educational half-day, during which residents rotated through small-group sessions dedicated to each HTN topic. We developed pre-, immediate post-, and 8 weeks postcurriculum surveys assessing residents' confidence and desire for future training in the four topics (4-point Likert scales), and multiple-choice quizzes to assess changes in knowledge. We used repeated-measures analysis of variance to compare means between time points for surveys and quizzes.

Results: A total of 112 Internal Medicine residents participated in the curriculum. The mean confidence scores for all four topics increased from 1.79 to 2.61 precurriculum to 2.90 to 3.45 immediately postcurriculum (all P < 0.001) and remained higher (2.53-3.18) than precurriculum at 8 weeks postcurriculum (all P < 0.02). The mean desire for future training scores decreased from 2.74 to 2.96 precurriculum to 2.06 to 2.36 immediately postcurriculum (all P < 0.001 except for managing HTN in patients who are or may become pregnant, which was P = 0.17) and remained lower (2.08-2.36) than precurriculum at 8 weeks postcurriculum (all P ≤ 0.003). The mean knowledge score increased from 48% precurriculum to 62% immediate postcurriculum (P < 0.001) and remained higher (55%) than precurriculum at 8 weeks postcurriculum (P = 0.015).

Conclusions: A curriculum on advanced HTN topics produced durable gains in confidence and knowledge and partially satisfied the desire for future learning among Internal Medicine residents.

In the context of early-phase clinical trials, research subjects often confuse the differences between clinical research and personal treatment. This phenomenon, known as therapeutic misconception, potentially undermines the validity of informed consent. Several interventions have been proposed to help mitigate therapeutic misconception, although few have considered the role of religious belief. This is a notable omission, given that an association between therapeutic misconception and religious belief has been shown to exist. This perspective calls for more research into the nature of the association between therapeutic misconception and religious belief and suggests a framework that may help clinicians and researchers distinguish between the two, thereby bolstering the informed consent process.

Objectives: Adults with intellectual disabilities will frequently experience sedentary behavior and excessive weight, which may cause or exacerbate a multitude of medical and behavioral problems. This study examined a program to encourage increased activity and weight loss in an outpatient service for adults with intellectual disabilities.

Methods: Behavioral methods were used to treat obesity in 33 male and 21 female adults with intellectual disabilities for a mean of 9 months. They were retrospectively analyzed to determine the effects of treatment on muscle and adiposity using body composition analysis.

Results: The 54 participants of the original 122 (44.3%) who did not drop out were divided into three groups: weight loss ≥3 kg/3% (n = 20, 37%), weight loss <3 kg/3% (n = 17, 31.5%), and no weight loss or weight gain (n = 17, 31.5%). Only men and women who lost ≥3 kg/3%, demonstrated significant gain of relative muscle mass. Those who gained weight lost muscle mass.

Conclusions: If motivation remains high and follow-up is reasonably long, then a multicomponent obesity treatment program can lead to significant weight loss with preservation of muscle in adults with intellectual disabilities.

Objectives: Current evidence describing physical activity (PA) and sedentary time (ST) in people with and without heart failure (HF) is limited. This study examines PA participation and ST in a nationally representative sample of US adults with and without self-reported HF.

Methods: The study sample (N = 21,633) included US adult (40 years old and older) participants from the 2007-2018 National Health and Nutrition Examination Survey. PA participation, ST, and HF status were assessed via a questionnaire.

Results: Compared with participants without HF (68%), 84% of participants with HF reported not meeting PA recommendations (P < 0.05). Compared with participants without HF (63%), 75% of participants with HF reported >4.5 hours/day of ST (P < 0.05). Unadjusted analysis suggests that participants with HF had 60% (P < 0.05) lower odds of reporting meeting PA recommendations when compared with those without HF. In a fully adjusted model, these odds were attenuated (odds ratio 0.74, P < 0.05). Similarly, unadjusted analysis illustrated those individuals with HF had 42% (P < 0.05) lower odds of reporting ≤4.5 hours/day of ST. In a fully adjusted model, these odds also were attenuated (odds ratio 0.66, P < 0.05).

Conclusions: Our findings suggest that US adults with HF report significantly less PA and greater amounts of ST than those without HF.

Objectives: Early abortion increasingly is provided in the primary care setting, allowing improved access, continuity of care, and contraception, if desired. We aimed in this retrospective chart review to describe postabortion contraception provision in a family medicine office.

Methods: Participants were those patients who obtained an induced abortion during an 11-year period at a family medicine office. We documented contraception provision within 30 days of abortion and used simple proportions, Fisher exact tests, and χ² tests to describe differences in contraceptive provision by type of abortion and continuity status.

Results: Most of the patients who underwent abortions (254/353, 72%) had documentation of a contraceptive method within 30 days of abortion, which was similar for patients who had either a medication (124/166, 75%) or an aspiration abortion (130/187, 70%, P = 0.71). The most common contraceptives were contraceptive pills (104/353, 29%) or intrauterine devices (68/353, 19%). Patients who chose a tier 1 method were more likely to have a procedure abortion (50/87, 57%), whereas patients who chose a tier 2 method were likely to have a medication abortion (83/160, 52%). Fewer than half (45%, 158/353, P = 0.0002) were continuity patients and established patients in the primary care office. Most tier 1 contraceptive users were continuity patients (49/87, 60%), whereas most patients without a contraceptive method were noncontinuity patients (72/99, 73%).

Conclusions: The primary care setting is uniquely equipped for providing early abortion and postabortion contraception. Although the providers offered all contraceptive options to eligible patients, continuity patients were more likely to receive more effective contraception in their primary care office.

Objectives: Medical student-run patient navigation (PN) programs enhance healthcare access in underserved communities. This study examines the relationship between patient demographics and PN outcomes in a student-led PN program.

Methods: Patients with moderate or high-risk health concerns were paired with medical students at health fairs. Statistical analysis evaluates program success and demographic influences.

Results: Of 444 patients, 66.4% were female, 47.1% Hispanic White, 49.1% spoke English, and 63.7% earned <300% of the federal poverty level. More than half were uninsured and 52.5% achieved navigation goals. Insurance status and risk level significantly predicted PN outcomes, with "other insurance" and high-risk patients being 1.9 and 1.7 times more likely to complete navigation.

Conclusions: The program achieved high completion rates, emphasizing the need for resources such as translators and financial assistance. Risk stratification successfully linked acute cases to resources. Navigation success was consistent, demonstrating the effectiveness of the program across diverse patient groups.

Objectives: Parturients are at increased risk for difficult airway management with subsequent fetal complications. Videolaryngoscopy was opined to be the new standard of airway care to facilitate orotracheal intubation under urgent care conditions. We examined in parturients requiring general anesthesia for urgent cesarean delivery the association of the type of laryngoscopy technique and time required to facilitate orotracheal intubation with the incidence of subsequent neonatal intensive care unit (NICU) admission.

Methods: Following institutional review board approval, 431 parturients aged 18 years and older who underwent urgent cesarean section requiring general anesthesia were entered into this study. Patient characteristics, maternal comorbidities, and indications for urgent cesarean delivery were collected from the electronic medical records from January 2013 to November 2018. Orotracheal intubation times by type of laryngoscopy (video or direct) and NICU admission rates also were collected. A measure of effect size, risk differences with 95% confidence intervals (CIs), were calculated for the likelihood of NICU admission by difficult orotracheal intubation and by type of laryngoscopy used to secure the airway.

Results: Videolaryngoscopy as the primary type of laryngoscopy was used in 24.1% (95% CI 20.3%-28.3%) of general anesthetics. The incidence of difficult orotracheal intubation was 4.4% (95% CI 2.8%-6.7%), with a higher incidence observed with videolaryngoscopy (8.7%) than with direct laryngoscopy (3.1%) and a risk difference of 5.6% (95% CI 0.001%-11.3%). The incidence of NICU admission was 38.4% (95% CI 34.0%-43.1%). Times for successful orotracheal intubation were longer with videolaryngoscopy. Videolaryngoscopy had a higher association for NICU admission (47%) than for direct laryngoscopy (36%), with a risk difference of 11.4% (95% CI 0.01%-22.3%).

Conclusions: Videolaryngoscopy did not decrease the incidence of difficult orotracheal intubation, and it did not decrease the time associated with orotracheal intubation. Videolaryngoscopy was associated with a higher association of NICU admission. These results suggest that videolaryngoscopy does not supplant direct laryngoscopy as the standard of care for orotracheal intubation under urgent care conditions of general anesthesia for cesarean section.