Pub Date : 2025-07-18DOI: 10.1016/j.ajmo.2025.100112
Mohamad R. Taha , Harrison P. Nguyen , Stephen K. Tyring
Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis that results in progressive, painful ulcers most commonly affecting the lower extremities. Although immunosuppressants are frequently used for therapy, there is no standard treatment approach, and recurrences are common. The pathogenesis of PG is believed to involve dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway, supporting the potential use of JAK/STAT inhibitors as a treatment option. This case series describes the successful use of upadacitinib, a selective JAK inhibitor, in the management of PG.
{"title":"Upadacitinib Monotherapy for Treatment of Pyoderma Gangrenosum","authors":"Mohamad R. Taha , Harrison P. Nguyen , Stephen K. Tyring","doi":"10.1016/j.ajmo.2025.100112","DOIUrl":"10.1016/j.ajmo.2025.100112","url":null,"abstract":"<div><div>Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis that results in progressive, painful ulcers most commonly affecting the lower extremities. Although immunosuppressants are frequently used for therapy, there is no standard treatment approach, and recurrences are common. The pathogenesis of PG is believed to involve dysregulation of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway, supporting the potential use of JAK/STAT inhibitors as a treatment option. This case series describes the successful use of upadacitinib, a selective JAK inhibitor, in the management of PG.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100112"},"PeriodicalIF":0.0,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144827127","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-18DOI: 10.1016/j.ajmo.2025.100113
Austin Drysch , Kathryn Fink , Nikhil Sriram , Marianne Kanaris , Scott Wu , Deep Upadhyay , Katherine Welter , Lisa Blankenship , Melissa Bregger , Kelli Scott , Brent Schnipke , Ashti Doobay-Persaud
Hospitalization presents a critical opportunity to initiate medications for opioid use disorder (MOUD) and improve long-term outcomes for patients with opioid use disorder (OUD). While inpatient MOUD initiation significantly reduces mortality and relapse, many patients lack appropriate follow-up care after discharge. This scoping review synthesizes evidence from 52 studies on hospital discharge practices for patients with OUD initiated on MOUD to identify best practices that support continued treatment and recovery. Inpatient addiction consultation services, standardized protocols, and clinician education emerged as key facilitators of MOUD initiation. Transitional care strategies, such as bridge clinics, peer navigation, telemedicine, and structured discharge planning, were associated with increased outpatient linkage, reduced readmissions, and improved retention in treatment. Despite policy advances including X-waiver elimination, systemic barriers persist and disproportionately affect rural and minoritized populations. Multidisciplinary, patient-centered discharge pathways that integrate medical treatment with social support are critical. Effective linkage strategies must address both structural and individual barriers to care. We propose six pillars of MOUD continuity, including early initiation, warm handoffs, peer support, bridge care models, telemedicine integration, and attention to social determinants. Implementing these strategies is essential to closing care gaps and improving outcomes in the evolving landscape of MOUD treatment.
{"title":"Initiating Medications During Hospitalization and Strategies for Ensuring Linkage at Discharge for Patients With Opioid Use Disorder: A Scoping Review","authors":"Austin Drysch , Kathryn Fink , Nikhil Sriram , Marianne Kanaris , Scott Wu , Deep Upadhyay , Katherine Welter , Lisa Blankenship , Melissa Bregger , Kelli Scott , Brent Schnipke , Ashti Doobay-Persaud","doi":"10.1016/j.ajmo.2025.100113","DOIUrl":"10.1016/j.ajmo.2025.100113","url":null,"abstract":"<div><div>Hospitalization presents a critical opportunity to initiate medications for opioid use disorder (MOUD) and improve long-term outcomes for patients with opioid use disorder (OUD). While inpatient MOUD initiation significantly reduces mortality and relapse, many patients lack appropriate follow-up care after discharge. This scoping review synthesizes evidence from 52 studies on hospital discharge practices for patients with OUD initiated on MOUD to identify best practices that support continued treatment and recovery. Inpatient addiction consultation services, standardized protocols, and clinician education emerged as key facilitators of MOUD initiation. Transitional care strategies, such as bridge clinics, peer navigation, telemedicine, and structured discharge planning, were associated with increased outpatient linkage, reduced readmissions, and improved retention in treatment. Despite policy advances including X-waiver elimination, systemic barriers persist and disproportionately affect rural and minoritized populations. Multidisciplinary, patient-centered discharge pathways that integrate medical treatment with social support are critical. Effective linkage strategies must address both structural and individual barriers to care. We propose six pillars of MOUD continuity, including early initiation, warm handoffs, peer support, bridge care models, telemedicine integration, and attention to social determinants. Implementing these strategies is essential to closing care gaps and improving outcomes in the evolving landscape of MOUD treatment.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100113"},"PeriodicalIF":0.0,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144878295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sleep is now recognized as a key factor in cardiovascular health by the American Heart Association's Life’s Essential 8. However, the relationship between sleep duration and stable angina remains unexplored.
Methods
This nationally representative cross-sectional study analyzed data from 18,385 U.S. adults aged 40 and older using the National Health and Nutrition Examination Survey (2005-2018). Daily sleep duration was categorized as <7 hours, 7-8 hours (reference), and >8 hours. Angina was assessed with the Rose Angina Questionnaire and classified by severity (Grade 1 or 2) and pain location (typical vs atypical). Covariates were identified a priori based on previous literature, and clinical relevance.
Results
Our study included 18,385 adults with a mean age of 57.6 years (SE 0.16). Out of these, 48.6% were female and 70% were non-Hispanic Whites. A total of 954 (5.2 %) participants reported experiencing angina. Among those with angina, 109 (11%) reported atypical symptoms. Univariate analysis revealed that both short (<7 hours) and long (>8 hours) sleep durations were associated with higher odds of Grade 2 angina compared to adequate sleep (7-8 hours). Adjusted analysis showed significantly higher odds of Grade 2 angina in individuals sleeping >8 hours (OR [95% CI]: 2.16 [1.08-4.32] for females; 2.69 [1.15-6.29] for males). Additionally, sleep <7 hours was associated with a greater likelihood of atypical angina presentation (OR: 1.77 [1.21-3.05]).
Conclusion
Our findings suggest that sleeping over 8 hours increases the likelihood of Grade 2 angina, while under 7 hours is linked to atypical presentations, complicating diagnosis. Clinicians could incorporate brief sleep assessments—asking about duration and quality—alongside angina tools like the ROSE questionnaire to identify potential sleep-related factors. While promising, these associations require further research before being translated into definitive clinical guidelines for angina management.
{"title":"Association Between Sleep Duration and Angina Characteristics in United States Adults","authors":"Maslahuddin HA Alhaque Roomi MD , Nehal Eid MBBCh , Aayush Visaria MD","doi":"10.1016/j.ajmo.2025.100109","DOIUrl":"10.1016/j.ajmo.2025.100109","url":null,"abstract":"<div><h3>Background</h3><div>Sleep is now recognized as a key factor in cardiovascular health by the American Heart Association's Life’s Essential 8. However, the relationship between sleep duration and stable angina remains unexplored.</div></div><div><h3>Methods</h3><div>This nationally representative cross-sectional study analyzed data from 18,385 U.S. adults aged 40 and older using the National Health and Nutrition Examination Survey (2005-2018). Daily sleep duration was categorized as <7 hours, 7-8 hours (reference), and >8 hours. Angina was assessed with the Rose Angina Questionnaire and classified by severity (Grade 1 or 2) and pain location (typical vs atypical). Covariates were identified a priori based on previous literature, and clinical relevance.</div></div><div><h3>Results</h3><div>Our study included 18,385 adults with a mean age of 57.6 years (SE 0.16). Out of these, 48.6% were female and 70% were non-Hispanic Whites. A total of 954 (5.2 %) participants reported experiencing angina. Among those with angina, 109 (11%) reported atypical symptoms. Univariate analysis revealed that both short (<7 hours) and long (>8 hours) sleep durations were associated with higher odds of Grade 2 angina compared to adequate sleep (7-8 hours). Adjusted analysis showed significantly higher odds of Grade 2 angina in individuals sleeping >8 hours (OR [95% CI]: 2.16 [1.08-4.32] for females; 2.69 [1.15-6.29] for males). Additionally, sleep <7 hours was associated with a greater likelihood of atypical angina presentation (OR: 1.77 [1.21-3.05]).</div></div><div><h3>Conclusion</h3><div>Our findings suggest that sleeping over 8 hours increases the likelihood of Grade 2 angina, while under 7 hours is linked to atypical presentations, complicating diagnosis. Clinicians could incorporate brief sleep assessments—asking about duration and quality—alongside angina tools like the ROSE questionnaire to identify potential sleep-related factors. While promising, these associations require further research before being translated into definitive clinical guidelines for angina management.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100109"},"PeriodicalIF":0.0,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144631130","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-15DOI: 10.1016/j.ajmo.2025.100110
Masis Perk
{"title":"Can Statistical Data Replace Pathophysiologic Rationale?: A Belated Question for the Second Quarter of the 21st Century","authors":"Masis Perk","doi":"10.1016/j.ajmo.2025.100110","DOIUrl":"10.1016/j.ajmo.2025.100110","url":null,"abstract":"","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100110"},"PeriodicalIF":0.0,"publicationDate":"2025-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144634096","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-06-01DOI: 10.1016/j.ajmo.2025.100107
Jack Keegan , William Peppard , Rebecca Bauer , Mary Beth Alvarez , Kimberly Stoner , Jennifer McNeely
Background
Despite their efficacy, medications for opioid use disorder (MOUD) remain underutilized in patients with infections from intravenous opioid use (I-IOU). This study evaluates the impact of an Expanded MOUD Access Initiative (EMAI) on MOUD uptake and other clinical outcomes in patients hospitalized for I-IOU at an institution without addiction medicine consultation.
Methods
We performed a retrospective pre-post study of hospital admissions for I-IOU before (January 2019-June 2021) and after (January 2022-December 2023) EMAI introduction. Data was collected via chart review. The EMAI eliminated restrictions on methadone use and established a new order set for buprenorphine inductions. The primary outcome was MOUD receipt; secondary outcomes included patient directed discharge (PDD) and 30-day re-hospitalization.
Results
There were 129 hospitalizations prior to the intervention (control) and 98 after (EMAI). MOUD receipt was significantly higher in the EMAI group (75.5% vs 31.0%; OR, 6.86 [95% CI, 3.84-12.61]). In patients not receiving MOUD prior to admission (n = 176), new inductions occurred more frequently in the EMAI group (68.0% vs 11.9%; OR, 15.76 [95% CI, 7.50-35.78]). PDD was lower in the EMAI group (23.5% vs 48.8%; OR, 0.32 [95% CI, 0.10-0.57]), as was 30-day re-hospitalization (12.2% vs 22.5%; OR, 0.48 [95% CI, 0.22-0.98]). In a multivariable logistic regression model, the EMAI was the only variable to show a statistically significant association with MOUD receipt (aOR, 6.89 [95% CI, 3.75-13.11]).
Conclusions
The EMAI was associated with increased MOUD uptake, reduced PDD, and fewer 30-day re-hospitalizations despite the lack of addiction medicine consultation.
背景：尽管阿片类药物使用障碍（mod）药物有效，但在静脉阿片类药物使用（I-IOU）感染的患者中，药物使用率仍然不足。本研究评估了扩展mod访问倡议（EMAI）对在没有成瘾药物咨询的机构住院的I-IOU患者的mod吸收和其他临床结果的影响。方法对引入EMAI之前（2019年1月- 2021年6月）和之后（2022年1月- 2023年12月）因I-IOU入院的患者进行回顾性研究。通过图表审查收集数据。EMAI取消了对美沙酮使用的限制，并建立了丁丙诺啡诱导的新命令集。主要结局为mode接收；次要结局包括患者直接出院（PDD）和30天再住院。结果干预前（对照组）住院129例，干预后（EMAI）住院98例。EMAI组的mod接收率明显更高（75.5% vs 31.0%； OR, 6.86 [95% CI, 3.84-12.61]）。在入院前未接受mod治疗的患者（n = 176）中，EMAI组的新诱导发生率更高（68.0% vs 11.9%； OR, 15.76 [95% CI, 7.50-35.78]）。EMAI组PDD较低（23.5% vs 48.8%； OR, 0.32 [95% CI, 0.10-0.57]）， 30天再住院率较低（12.2% vs 22.5%； OR, 0.48 [95% CI, 0.22-0.98]）。在多变量logistic回归模型中，EMAI是唯一显示与mod接收有统计学显著关联的变量（aOR, 6.89 [95% CI, 3.75-13.11]）。结论：尽管缺乏成瘾药物咨询，EMAI与mod摄取增加、PDD减少和30天再住院次数减少有关。
{"title":"Clinical Impact of an Expanded MOUD Access Initiative for Patients Hospitalized With Infections From Intravenous Opioid Use","authors":"Jack Keegan , William Peppard , Rebecca Bauer , Mary Beth Alvarez , Kimberly Stoner , Jennifer McNeely","doi":"10.1016/j.ajmo.2025.100107","DOIUrl":"10.1016/j.ajmo.2025.100107","url":null,"abstract":"<div><h3>Background</h3><div>Despite their efficacy, medications for opioid use disorder (MOUD) remain underutilized in patients with infections from intravenous opioid use (I-IOU). This study evaluates the impact of an Expanded MOUD Access Initiative (EMAI) on MOUD uptake and other clinical outcomes in patients hospitalized for I-IOU at an institution without addiction medicine consultation.</div></div><div><h3>Methods</h3><div>We performed a retrospective pre-post study of hospital admissions for I-IOU before (January 2019-June 2021) and after (January 2022-December 2023) EMAI introduction. Data was collected via chart review. The EMAI eliminated restrictions on methadone use and established a new order set for buprenorphine inductions. The primary outcome was MOUD receipt; secondary outcomes included patient directed discharge (PDD) and 30-day re-hospitalization.</div></div><div><h3>Results</h3><div>There were 129 hospitalizations prior to the intervention (control) and 98 after (EMAI). MOUD receipt was significantly higher in the EMAI group (75.5% vs 31.0%; OR, 6.86 [95% CI, 3.84-12.61]). In patients not receiving MOUD prior to admission (n = 176), new inductions occurred more frequently in the EMAI group (68.0% vs 11.9%; OR, 15.76 [95% CI, 7.50-35.78]). PDD was lower in the EMAI group (23.5% vs 48.8%; OR, 0.32 [95% CI, 0.10-0.57]), as was 30-day re-hospitalization (12.2% vs 22.5%; OR, 0.48 [95% CI, 0.22-0.98]). In a multivariable logistic regression model, the EMAI was the only variable to show a statistically significant association with MOUD receipt (aOR, 6.89 [95% CI, 3.75-13.11]).</div></div><div><h3>Conclusions</h3><div>The EMAI was associated with increased MOUD uptake, reduced PDD, and fewer 30-day re-hospitalizations despite the lack of addiction medicine consultation.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100107"},"PeriodicalIF":0.0,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145095207","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-05-31DOI: 10.1016/j.ajmo.2025.100106
Nicholaus J. Christian MD, MBA , Amber Baysinger MD, PhD , Richard Bottner DHA, PA-C , Cody Cowley MD , Rebecca Nekolaichuk MD , Phil Owen RSPS , Blake Smith MD , Kimberly L. Sue MD, PhD
Background
Individuals with opioid use disorder (OUD) commonly face stigma when receiving healthcare. Although experienced stigma of patients with OUD in hospital settings is linked to worse treatment outcomes, less is known about the stigmatizing care practices of hospital-based providers that result in experienced stigma.
Objective
This study aimed to explore hospital-based stigma experiences and positive care experiences of people with OUD to identify stigmatizing and nonstigmatizing care practices to inform hospital-based care.
Design
This was a qualitative study based on semi-structured, in-person focus groups.
Participants
Participants were people who self-identified as being in recovery from opioid use disorder recruited through a community recovery organization in Austin, TX.
Approach
Focus groups followed a semi-structured interview guide encouraging discussion of stigmatizing healthcare experiences. We used applied thematic analysis in a systematic, inductive approach to categorize themes around hospital-based care experiences.
Key Results
Among participants (n = 18), stigmatizing experiences reflected the following hospital-based care practice themes: using non-person-first language, ignoring pain, labeling as “drug-seeking,” and not valuing the lived expertise of patients. These practices resulted in fear/avoidance of care, distrust of the care team, and internalized stigma. On the other hand, using recovery-oriented language, being polite, and engaging in shared decision making resulted in open communication with providers and trust of the care team.
Conclusions
Stigma experienced in hospital settings has significant consequences for patients with OUD. Hospital systems must implement policies that promote patient-centered practices and avoid stigmatizing practices to improve hospital-based care delivery for people with OUD.
{"title":"Hospital-Based Stigma Practices Towards Individuals With Opioid Use Disorder: A Qualitative Study in Austin, Texas","authors":"Nicholaus J. Christian MD, MBA , Amber Baysinger MD, PhD , Richard Bottner DHA, PA-C , Cody Cowley MD , Rebecca Nekolaichuk MD , Phil Owen RSPS , Blake Smith MD , Kimberly L. Sue MD, PhD","doi":"10.1016/j.ajmo.2025.100106","DOIUrl":"10.1016/j.ajmo.2025.100106","url":null,"abstract":"<div><h3>Background</h3><div>Individuals with opioid use disorder (OUD) commonly face stigma when receiving healthcare. Although experienced stigma of patients with OUD in hospital settings is linked to worse treatment outcomes, less is known about the stigmatizing care practices of hospital-based providers that result in experienced stigma.</div></div><div><h3>Objective</h3><div>This study aimed to explore hospital-based stigma experiences and positive care experiences of people with OUD to identify stigmatizing and nonstigmatizing care practices to inform hospital-based care.</div></div><div><h3>Design</h3><div>This was a qualitative study based on semi-structured, in-person focus groups.</div></div><div><h3>Participants</h3><div>Participants were people who self-identified as being in recovery from opioid use disorder recruited through a community recovery organization in Austin, TX.</div></div><div><h3>Approach</h3><div>Focus groups followed a semi-structured interview guide encouraging discussion of stigmatizing healthcare experiences. We used applied thematic analysis in a systematic, inductive approach to categorize themes around hospital-based care experiences.</div></div><div><h3>Key Results</h3><div>Among participants (n = 18), stigmatizing experiences reflected the following hospital-based care practice themes: using non-person-first language, ignoring pain, labeling as “drug-seeking,” and not valuing the lived expertise of patients. These practices resulted in fear/avoidance of care, distrust of the care team, and internalized stigma. On the other hand, using recovery-oriented language, being polite, and engaging in shared decision making resulted in open communication with providers and trust of the care team.</div></div><div><h3>Conclusions</h3><div>Stigma experienced in hospital settings has significant consequences for patients with OUD. Hospital systems must implement policies that promote patient-centered practices and avoid stigmatizing practices to improve hospital-based care delivery for people with OUD.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100106"},"PeriodicalIF":0.0,"publicationDate":"2025-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145095206","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Increased bone turnover is associated with use of SGLT2i. Patients with diabetes experience adverse effects on bone metabolism. Our aim was to evaluate if SGLT2i was associated with fractures vs DPP4i as add-on therapy to diabetes regimens.
Methods
We assembled a retrospective cohort of Veterans with diabetes combining Veterans Administration, Medicare, and National Death Index databases. Using an active comparator new user design, patients starting on SGLT2i or DPP4i were followed from prescription fill until a fracture event, death, stopping medication, loss of follow-up, or study end. Fractures included: face/skull, spine, ribs, long bones, hand/feet/digits, or hip. Fractures were identified based on a validated algorithm with positive predictive value 91.3% (86.8, 94.4). Cox models compared the association of fractures between SGLT2i and DPP4i in a propensity score-weighted cohort that balanced 70+ covariates including comorbidities, vital signs, labs, vitamin D levels, smoking, and medications.
Results
The unweighted sample included 115,124 SGLT2i episodes (104,086 Veterans; 94% empagliflozin; 4% canagliflozin; 2% dapagliflozin) and 213,095 DPP4i episodes (173,724 Veterans; 45% saxagliptin; 15% sitagliptin; 34% alogliptin; 6% Linagliptin). After propensity score calculation and matched weighting, the cohort included 76,072 SGLT2i and 75,833 DPP4i episodes. Median age was 69.3 years and diabetes duration 9.7 (6.1, 14.0) years. In the matched weighted analyses, there were 1431 and 1564 fractures among SGLT2i and DPP4i users, respectively. There were no clinical differences in fractures per 1000 person-years: 18.2 (17.4, 19.1) vs 19.8 (19.0, 20.6). The adjusted hazard ratio (adjusted hazard ratio 0.93 [0.87, 0.99]) excluded increased risk of fractures (adjusted hazard ratio > 1) in SGLT2i users.
Conclusions
SGLT2i use as add-on treatment for diabetes was not associated with increased fracture outcomes compared to DPP4i.
{"title":"The Association of SGLT2i vs DPP4i on Fracture: A Cohort Study in Veterans with Diabetes","authors":"Kathryn Snyder MD, MPH , Katherine Griffin MPH , Amber Hackstadt PhD , Amir Javid PhD , Adriana Hung MD, MPH , Robert Greevy PhD , Christianne L. Roumie MD, MPH","doi":"10.1016/j.ajmo.2025.100105","DOIUrl":"10.1016/j.ajmo.2025.100105","url":null,"abstract":"<div><h3>Background</h3><div>Increased bone turnover is associated with use of SGLT2i. Patients with diabetes experience adverse effects on bone metabolism. Our aim was to evaluate if SGLT2i was associated with fractures vs DPP4i as add-on therapy to diabetes regimens.</div></div><div><h3>Methods</h3><div>We assembled a retrospective cohort of Veterans with diabetes combining Veterans Administration, Medicare, and National Death Index databases. Using an active comparator new user design, patients starting on SGLT2i or DPP4i were followed from prescription fill until a fracture event, death, stopping medication, loss of follow-up, or study end. Fractures included: face/skull, spine, ribs, long bones, hand/feet/digits, or hip. Fractures were identified based on a validated algorithm with positive predictive value 91.3% (86.8, 94.4). Cox models compared the association of fractures between SGLT2i and DPP4i in a propensity score-weighted cohort that balanced 70+ covariates including comorbidities, vital signs, labs, vitamin D levels, smoking, and medications.</div></div><div><h3>Results</h3><div>The unweighted sample included 115,124 SGLT2i episodes (104,086 Veterans; 94% empagliflozin; 4% canagliflozin; 2% dapagliflozin) and 213,095 DPP4i episodes (173,724 Veterans; 45% saxagliptin; 15% sitagliptin; 34% alogliptin; 6% Linagliptin). After propensity score calculation and matched weighting, the cohort included 76,072 SGLT2i and 75,833 DPP4i episodes. Median age was 69.3 years and diabetes duration 9.7 (6.1, 14.0) years. In the matched weighted analyses, there were 1431 and 1564 fractures among SGLT2i and DPP4i users, respectively. There were no clinical differences in fractures per 1000 person-years: 18.2 (17.4, 19.1) vs 19.8 (19.0, 20.6). The adjusted hazard ratio (adjusted hazard ratio 0.93 [0.87, 0.99]) excluded increased risk of fractures (adjusted hazard ratio > 1) in SGLT2i users.</div></div><div><h3>Conclusions</h3><div>SGLT2i use as add-on treatment for diabetes was not associated with increased fracture outcomes compared to DPP4i.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100105"},"PeriodicalIF":0.0,"publicationDate":"2025-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144313389","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-05-19DOI: 10.1016/j.ajmo.2025.100104
De-Vaughn Williams MD, Scott Keller MHA, Jennifer Mcentee MD, MPH, MAEd, Escher Howard-Williams MD, Cristin M. Colford MD
Provider notes serve as a critical component of physician workflow, documenting essential aspects of patient care while also fulfilling regulatory and billing requirements. With increasing documentation complexity introduced by the Centers for Medicare and Medicaid Services and the 2021 mandate for open access to clinical notes, physicians in training must develop skills to accurately document patient complexity. This quality improvement initiative aimed to enhance inpatient note documentation by internal medicine residents, focusing on improving the capture of medical complexity in coding and billing standards.
Our intervention included the development and implementation of a standardized progress note template, a structured scoring rubric, multidisciplinary rounds and curriculum integrating faculty and peer-led feedback. The study measured documentation improvements through rubric scores, Length of Stay Index (LOSi), and complications or comorbidities (CC) and major complications or comorbidities (MCC) capture rates.
Results demonstrated improvements in LOSi and enhanced CC/MCC capture, leading to improved institutional performance metrics. This initiative highlights the necessity of integrating formal note-writing training within residency curricula to meet evolving documentation demands.
提供者笔记是医生工作流程的重要组成部分，记录了患者护理的基本方面，同时也满足了法规和计费要求。随着医疗保险和医疗补助服务中心（Centers for Medicare and Medicaid Services）引入的文件复杂性日益增加，以及2021年对临床记录开放获取的要求，接受培训的医生必须培养准确记录患者复杂性的技能。这一质量改进举措旨在加强内科住院医师的住院病历记录，重点是改进编码和计费标准中对医疗复杂性的捕捉。我们的干预措施包括开发和实施标准化的进度记录模板、结构化的评分标准、多学科轮次和整合教师和同行主导反馈的课程。该研究通过标题评分、住院时间指数（LOSi）、并发症或合并症（CC）和主要并发症或合并症（MCC）捕获率来衡量文献的改善。结果表明，LOSi得到改善，CC/MCC捕获得到加强，从而改善了机构绩效指标。这项倡议强调必须将正式的笔记写作训练纳入住院医师课程，以满足不断变化的文件需求。
{"title":"Enhancing Resident Note Documentation: A Quality Improvement Initiative to Accurately Capture Patient Complexity","authors":"De-Vaughn Williams MD, Scott Keller MHA, Jennifer Mcentee MD, MPH, MAEd, Escher Howard-Williams MD, Cristin M. Colford MD","doi":"10.1016/j.ajmo.2025.100104","DOIUrl":"10.1016/j.ajmo.2025.100104","url":null,"abstract":"<div><div>Provider notes serve as a critical component of physician workflow, documenting essential aspects of patient care while also fulfilling regulatory and billing requirements. With increasing documentation complexity introduced by the Centers for Medicare and Medicaid Services and the 2021 mandate for open access to clinical notes, physicians in training must develop skills to accurately document patient complexity. This quality improvement initiative aimed to enhance inpatient note documentation by internal medicine residents, focusing on improving the capture of medical complexity in coding and billing standards.</div><div>Our intervention included the development and implementation of a standardized progress note template, a structured scoring rubric, multidisciplinary rounds and curriculum integrating faculty and peer-led feedback. The study measured documentation improvements through rubric scores, Length of Stay Index (LOSi), and complications or comorbidities (CC) and major complications or comorbidities (MCC) capture rates.</div><div>Results demonstrated improvements in LOSi and enhanced CC/MCC capture, leading to improved institutional performance metrics. This initiative highlights the necessity of integrating formal note-writing training within residency curricula to meet evolving documentation demands.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100104"},"PeriodicalIF":0.0,"publicationDate":"2025-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144262157","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-05-15DOI: 10.1016/j.ajmo.2025.100103
Alexandra M. Cruz Pabón , Eric Pyles , Daniel Peach , Sarfraz Ahmad , Paul Blake O’Brien , Michael Kuhlman , Sarah Steiner , Lara Crown , Elizabeth Purinton , James Priano
Background/Purpose
Chest pain is a common reason for ED visits. Implementing a HEART score-based algorithm previously increased early discharges by 99%. This study aims to determine if the transition from cTnT to hs-cTnT assays affected patient disposition rates.
Methods
This retrospective observational study was conducted in a multi-site hospital system. Adults presenting to the ED with chest pain and a low HEART score (≤3) between November 9, 2020, and November 10, 2022, were included. The primary outcome was the change in patient disposition. Secondary outcomes included length-of-stay (LOS), rates of provocative testing, ED returns, and major adverse cardiovascular events (MACE).
Results
We evaluated 32,968 patients (17,173 in the cTnT group and 15,795 in the hs-cTnT group). Both groups had a similar median age, but the hs-cTnT group had a higher proportion of patients with baseline troponin elevations. The ED discharge rate was higher in the hs-cTnT group (87.5%) compared to the cTnT group (85.3%; P < .001), with a corresponding decrease in observation and inpatient admissions. Additionally, the implementation of hs-cTnT was associated with a reduced LOS and a decrease in patients undergoing further testing. Finally, there was a reduction in ED re-visits without a difference in 30- or 60-day MACE after the implementation of hs-cTnT.
Conclusions
Integration of hs-cTnT into our chest pain clinical pathway resulted in increased ED discharges, reduced LOS, and fewer additional tests without a change in MACE. This translates to a savings of almost 7,000 ED hours annually without compromising safety.
{"title":"Implementation of High-Sensitivity Troponin for Early Rule-Out of Acute Myocardial Infarction in Emergency Department","authors":"Alexandra M. Cruz Pabón , Eric Pyles , Daniel Peach , Sarfraz Ahmad , Paul Blake O’Brien , Michael Kuhlman , Sarah Steiner , Lara Crown , Elizabeth Purinton , James Priano","doi":"10.1016/j.ajmo.2025.100103","DOIUrl":"10.1016/j.ajmo.2025.100103","url":null,"abstract":"<div><h3>Background/Purpose</h3><div>Chest pain is a common reason for ED visits. Implementing a HEART score-based algorithm previously increased early discharges by 99%. This study aims to determine if the transition from cTnT to hs-cTnT assays affected patient disposition rates.</div></div><div><h3>Methods</h3><div>This retrospective observational study was conducted in a multi-site hospital system. Adults presenting to the ED with chest pain and a low HEART score (≤3) between November 9, 2020, and November 10, 2022, were included. The primary outcome was the change in patient disposition. Secondary outcomes included length-of-stay (LOS), rates of provocative testing, ED returns, and major adverse cardiovascular events (MACE).</div></div><div><h3>Results</h3><div>We evaluated 32,968 patients (17,173 in the cTnT group and 15,795 in the hs-cTnT group). Both groups had a similar median age, but the hs-cTnT group had a higher proportion of patients with baseline troponin elevations. The ED discharge rate was higher in the hs-cTnT group (87.5%) compared to the cTnT group (85.3%; <em>P < .</em>001), with a corresponding decrease in observation and inpatient admissions. Additionally, the implementation of hs-cTnT was associated with a reduced LOS and a decrease in patients undergoing further testing. Finally, there was a reduction in ED re-visits without a difference in 30- or 60-day MACE after the implementation of hs-cTnT.</div></div><div><h3>Conclusions</h3><div>Integration of hs-cTnT into our chest pain clinical pathway resulted in increased ED discharges, reduced LOS, and fewer additional tests without a change in MACE. This translates to a savings of almost 7,000 ED hours annually without compromising safety.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100103"},"PeriodicalIF":0.0,"publicationDate":"2025-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144313321","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-05-12DOI: 10.1016/j.ajmo.2025.100102
Julia Loewen , Paul Salow BBA, MBA , Patricia Andreski MA , David J Brown MD , Kanakadurga Singer MA, MD
Faculty retention provides a competitive advantage in an academic medical center. Faculty surveys show that lack of career advancement and leadership opportunities are primary reasons faculty seek employment elsewhere. Leadership roles for faculty are frequently locally maintained and not available for institutional leaders to assess leadership opportunities and gaps, especially for women and race/ethnicity groups underrepresented in academic medicine.
Offices of Faculty Affairs, Faculty Development and Health Equity & Inclusion launched a collaboration to frame and define the current state of faculty leadership at one institution. A desired faculty leadership philosophy, best practices, role descriptions, and overall title framework were developed and reviewed with department leaders. Departments identified all current faculty leaders using the title framework, and titles were entered as additional appointments into our human resource database at the faculty level.
Baseline demographic analysis of faculty leadership appointments demonstrated a gender and race/ethnicity disparity between the population of faculty and those in leadership roles. With the expanded tracking, the number of faculty leadership roles increased approximately sevenfold. While gender and race/ethnicity gaps closed substantially, the data revealed differences in higher-level leadership roles with more equity in mid-level and emerging roles.
Results enhanced awareness of the importance of tracking and evaluating leadership roles at all levels. Consequently, faculty leadership data were translated into real-time data visualizations. Tracking of who holds leadership positions increases accountability for initiatives designed to diversify leadership in an academic medical center, and demonstrates a commitment to diversity, equity, and inclusion.
{"title":"Institutional Accountability for Developing the Next Generation of Faculty Leaders","authors":"Julia Loewen , Paul Salow BBA, MBA , Patricia Andreski MA , David J Brown MD , Kanakadurga Singer MA, MD","doi":"10.1016/j.ajmo.2025.100102","DOIUrl":"10.1016/j.ajmo.2025.100102","url":null,"abstract":"<div><div>Faculty retention provides a competitive advantage in an academic medical center. Faculty surveys show that lack of career advancement and leadership opportunities are primary reasons faculty seek employment elsewhere. Leadership roles for faculty are frequently locally maintained and not available for institutional leaders to assess leadership opportunities and gaps, especially for women and race/ethnicity groups underrepresented in academic medicine.</div><div>Offices of Faculty Affairs, Faculty Development and Health Equity & Inclusion launched a collaboration to frame and define the current state of faculty leadership at one institution. A desired faculty leadership philosophy, best practices, role descriptions, and overall title framework were developed and reviewed with department leaders. Departments identified all current faculty leaders using the title framework, and titles were entered as additional appointments into our human resource database at the faculty level.</div><div>Baseline demographic analysis of faculty leadership appointments demonstrated a gender and race/ethnicity disparity between the population of faculty and those in leadership roles. With the expanded tracking, the number of faculty leadership roles increased approximately sevenfold. While gender and race/ethnicity gaps closed substantially, the data revealed differences in higher-level leadership roles with more equity in mid-level and emerging roles.</div><div>Results enhanced awareness of the importance of tracking and evaluating leadership roles at all levels. Consequently, faculty leadership data were translated into real-time data visualizations. Tracking of who holds leadership positions increases accountability for initiatives designed to diversify leadership in an academic medical center, and demonstrates a commitment to diversity, equity, and inclusion.</div></div>","PeriodicalId":72168,"journal":{"name":"American journal of medicine open","volume":"14 ","pages":"Article 100102"},"PeriodicalIF":0.0,"publicationDate":"2025-05-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144212635","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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