Southern Medical Journal最新文献

Objectives: The objective of this study was to describe ethical and professional issues encountered and the ethical and professional values cited by medical students during their critical care clerkship, with a comparison of issues encountered before and during the coronavirus disease 2019 (COVID-19) pandemic.

Methods: In this single-center, retrospective mixed-methods study, two investigators at a midwestern US academic medical center performed qualitative content analysis on reflections written by fourth-year medical students about ethical and professional issues encountered during their critical care rotations between March 2016 and September 2021. We also analyzed the ethical/professional values mentioned in their reflections. Descriptive and inferential (χ²) statistics were performed to examine differences in issues and values cited before and during the pandemic.

Results: Respondents highlighted several key themes identified in prior studies, including decision making (64.1%), communication between clinicians and families (52.2%), and justice-related issues (32.1%), as well as interdisciplinary communication (25.7%) and issues related to the role of students in the intensive care unit (6.1%). Six novel subthemes were identified in this group, predominantly related to resource availability and end-of-life care. Of 343 reflections, 69% were written before the pandemic. Analysis of ethical and professional issues before and during COVID were notable for several significant differences, including increased discussion of inadequate tools/supplies/equipment (1.3% before vs 17.6% during, P = 0.005) and/or access to care (3.9% before vs 17.6% during, P = 0.03) and increased concerns about the tension between law and ethics (21.2% before vs 41.2% during, P = 0.028). Primacy of patient welfare (49.8% before vs 47.2% during, P = 0.659) and patient autonomy (51.1% before vs 38.9% during, P = 0.036) were the most commonly cited ethical principles in both time frames, often discussed concurrently and in tension.

Conclusions: Although the COVID-19 pandemic was associated with increased reflection by medical students about resources in the intensive care unit, their perception of ethical issues arising in critical illness remained largely focused on enduring challenges in shared decision-making. These findings should be considered when developing ethics curricula for critical care rotations.

Objectives: Orthopedic surgery is a highly competitive field. The residency applicant pool is expected to grow with the increasing number of new medical schools in the United States, posing significant challenges for applicants. This study explored the impact of an engaged faculty mentor in an orthopedic surgery interest group (OSIG) at a new medical school and the impact it has on students. The study aimed to uncover the most valuable features of an OSIG at a new medical school to create a blueprint for other student-leaders and/or faculty in future initiatives.

Methods: An observational study was conducted via survey responses from active OSIG members at a new medical school in Texas. Questions were mostly in a "before and after" format asking about students' perspectives of the group before and after the addition of an engaged faculty advisor. Descriptive and inferential statistics were used to analyze the data.

Results: Twenty of 21 (95.2%) eligible OSIG members participated in the study. The survey results revealed that faculty engagement significantly enhanced the OSIG and its members' medical school experience. Following faculty involvement, average OSIG event attendance more than tripled, there was a statistically significant increase in medical student well-being, and confidence in their ability to be a competitive orthopedic surgery applicant nearly doubled. OSIG participation influenced their career interests significantly more after faculty engagement. A total of 93.3% of participants voted that they felt having an engaged faculty advisor is critical for the OSIG.

Conclusions: Mentorship was identified as the most crucial activity for career development, followed by clinical exposure and research. The study provides valuable insights for new medical schools in establishing and optimizing OSIGs and potentially other interest groups, particularly in competitive specialties.

Objectives: Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia.

Methods: This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation.

Results: Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%).

Conclusions: Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.

Objectives: Sling immobilization is commonly used following rotator cuff repair. The purpose of this study was to determine the detrimental impact of sling usage on mobility and balance in an older adult population through validated gait and balance testing. The authors hypothesize that sling use will negatively affect balance and stability.

Methods: This institutional review board-approved and registered randomized prospective clinical trial enrolled patients from 2019 to 2021. Following informed consent, patients were randomized into two groups: a sling worn (group 1) and no sling worn (group 2). Participants were assessed via the Edmonton Frail Scale as well as Tinetti gait and balance scoring.

Results: Fifty patients were included in the study, 23 (46%) men and 27 (54%) women, with a mean age of 72.2 years. The balance score median was 16.00 for participants not wearing a sling and 15.00 for participants wearing a sling. The gait score median was 12.00 for participants not wearing a sling and 11.50 for participants wearing a sling. The balance and gait scores were significantly greater when patients were not wearing a shoulder sling with P values of 0.006 and 0.011, respectively. The overall combined gait and balance score was significantly greater, with median values of 27.00 for participants not wearing a sling and 26.00 for participants wearing a sling (P = 0.001). Patients reported little to no anxiety about falling while wearing the sling, with a score of 0.16.

Conclusions: Postoperative sling immobilization negatively affects balance and gait in the geriatric population, potentially increasing the risk of postoperative falls in an already at-risk population.

Objectives: Rural Hawai'i faces a shortage of physicians specializing in women's health. Improving clinician collaboration and access to the scientific literature are potential strategies for improving physician retention in this community. In 2021, a monthly women's health journal club was established for local clinicians and trainees on Hawai'i Island. Although journal clubs are common in large academic institutions, there are limited data regarding the value of journal clubs in rural and community practices. This study aimed to evaluate the value of a women's health journal club on Hawai'i Island.

Methods: We used an anonymous Web-based survey to evaluate the value of the journal club.

Results: Of the 18 eligible clinicians participating in the women's health journal club, 13 completed a Web-based survey (response rate 72%). The common reasons for attending journal club included wanting to learn about research methods/statistics (100%), seeking opportunities to discuss current best practices (86%), and desiring to practice critical review skills (71%). The majority of respondents (77%) believed that journal club was a valuable activity, and 92% of respondents would recommend this activity to a colleague. This journal club allowed participants to improve their understanding of research methods (85%) and stay up-to-date with medical advancements (85%).

Conclusions: This community-based journal club is a valuable activity for clinicians practicing on Hawai'i Island. Other rural communities may similarly benefit from engaging in structured scholarly discussion.

Objective: The objective of this study was to describe anthropometric measures from internationally adopted children. Internationally adopted children are at risk for poor growth and development and there is no standardized growth chart evaluation for internationally adopted children due to variations in growth, genetics, and environmental exposures.

Methods: This is a retrospective chart review of 882 patients seen in an international adoption clinic between 2010 and 2017. Anthropometric measurements were converted to Z scores for weight, height, head circumference, and body mass index.

Results: A total of 41 countries and 16 subregions were represented. Central America, northern Africa, southern Africa, and southern Europe were the only subregions that had positive mean Z scores for weight, and southeast Asia had the lowest mean Z score for weight (n = 40, -1.76). No subregion had a positive mean Z score for height, and western Asia had the lowest overall mean Z score for height (n = 2, -2.44). Mean Z score for body mass index was positive in several subregions.

Conclusions: Growth is an important predictor of health and development, and this study adds to the literature on growth patterns of internationally adopted children.

Objectives: Sufficient exercise and high-quality sleep are important for good health, and they may be particularly crucial during the coronavirus pandemic. Sleeping difficulties and insufficient exercise are prevalent in the United States, however, and data indicate little to no change-or even worsening-of these health behaviors before the pandemic. This study explores how exercise quantity coincides with sleep quality in the United States during the pandemic and how both ultimately relate to physical health.

Methods: We used logistic regression and multinomial logistic regression to analyze data from the 2021 Crime, Health, and Politics Survey sampled from the National Opinion Research Center's AmeriSpeak panel. Survey responses were collected between May and June 2021.

Results: Results show that more typical weekly exercise and more exercise during the pandemic are significantly associated with higher odds of better current sleep quality and sleep quality during the pandemic, controlling for a variety of sociodemographic factors. Both exercise activity and sleep quality are also significantly associated with higher odds of good physical health.

Conclusions: These findings support the literature that increases in exercise frequency and improved sleep quality are linked and are also associated with better physical health outcomes, even during a global crisis.

Objectives: Internal Medicine (IM) residents have reported dissatisfaction with continuity clinic (CC) training, which may contribute to the increasing shortage of primary care physicians. Studies show balancing inpatient and outpatient duties as a driver of dissatisfaction, but few studies have compared CC with inpatient (IP) training, following transition to an X + Y model, or assessed the impact of show rates, continuity, and telemedicine use on resident perceptions. The aim of this study was to adapt a validated survey to compare residents' perceptions of their CC with their inpatient medicine training and examine the impact of objective clinic measures on training.

Methods: This quantitative cross-sectional study included a survey that was sent to 152 residents at an academic IM program in May-June 2021. Clinic measures such as show versus no-show rates, continuity with the residents' own patients, and visit modality were obtained through the electronic health records at Veterans Affairs and non-Veterans Affairs CCs.

Results: The survey response rate was 78% (118/152). Residents were more satisfied with inpatient general medicine rotations than their CC experience (4.5 vs 3.3 on a 5-point scale, P < 0.001). Residents were more likely to pursue a profession in inpatient IM than in primary care (3.7 vs 2.3, P < 0.001). No correlation was found between higher show rates, continuity with patients, or proportion of visits conducted through telemedicine and resident satisfaction with CC.

Conclusions: This study aligns with previous findings of IM resident dissatisfaction with CC training while adding a side-by-side comparison to inpatient training and including objective CC data. We identified new areas for improvement of CC training, including residents' medical knowledge through review of quality metrics, making CC representative of real-world practice, and mentorship from faculty.