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Halalau A, Roy S, Hegde A, Khanal S, Langnas E, Raja M, Homayouni R. Risk factors associated with glycated hemoglobin A1c trajectories progressing to type 2 diabetes. Ann Med 2023; 55:371-378. [PMID: 36621941 PMCID: PMC9833406 DOI: 10.1080/07853890.2022.2164347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The notion of prediabetes, defined by the ADA as glycated hemoglobin A1c (HbA1c) of 5.7-6.4%, implies increased vascular inflammatory and immunologic processes and higher risk for developing diabetes mellitus and major cardiovascular events. We aimed to determine the risk factors associated with rapid progression of normal and prediabetes patients to type 2 diabetes mellitus (T2DM). METHODS Retrospective cohort study in a single 8-hospital health system in southeast Michigan, between 2006 and 2020. All patients with HbA1c <6.5% at baseline and at least 2 other HbA1c measurements were clustered in five trajectories encompassing more than 95% of the study population. Multivariate linear regression analysis was performed to examine the association of demographic and comorbidities with HbA1c trajectories progressing to diabetes. RESULTS A total of 5,347 prediabetic patients were clustered based on their HbA1c progression (C1: 4,853, C2: 253, C66: 102, C12: 85, C68: 54). The largest cluster (C1) had a baseline median HbA1c value of 6.0% and exhibited stable HbA1c levels in prediabetic range across all subsequent years. The smallest cluster (C68) had the lowest median baseline HbA1c value and also remained stable across subsequent years. The proportion of normal HbA1c in each of the pre-diabetic trajectories ranged from 0 to 12.7%, whereas 81.5% of the reference cluster (C68) were normal HbA1c at baseline. The C2 (steady rising) trajectory was significantly associated with BMI (adj OR 1.10, 95%CI 1.03-1.17), and family history of DM (adj OR 2.75, 95%CI 1.32-5.74). With respect to the late rising trajectories, baseline BMI was significantly associated with both C66 and C12 trajectory (adj OR 1.10, 95%CI 1.03-1.18) and (adj OR 1.13, 95%CI 1.05-1.23) respectively, whereas, the C12 trajectory was also significantly associated with age (adj OR 1.62, 95%CI 1.04-2.53) and history of MACE (adj OR 3.20, 95%CI 1.14-8.93). CONCLUSIONS We suggest that perhaps a more aggressive preventative approach should be considered in patients with a family history of T2DM who have high BMI and year-to-year increase in HbA1c, whether they have normal hemoglobin A1c or they have prediabetes.KEY MESSAGESProgression to diabetes from normal or prediabetic hemoglobin A1c within four years is associated with baseline BMI.A steady rise in HbA1c during a four-year period is associated with age and family history of T2DM, whereas age and personal history of MACE are associated with a rapid rise in HbA1c.A more aggressive preventative approach should be considered in patients with a family history of T2DM who have high BMI and year-to-year increase in HbA1c.
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Affiliation(s)
- Alexandra Halalau
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Sujoy Roy
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Arpitha Hegde
- Department of Electrical and Computer Engineering, Oakland University, Rochester, MI, USA
| | - Sumesh Khanal
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Emily Langnas
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Maidah Raja
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Ramin Homayouni
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Verhoef PA, Spicer AB, Lopez-Espina C, Bhargava A, Schmalz L, Sims MD, Palagiri AV, Iyer KV, Crisp MJ, Halalau A, Maddens N, Gosai F, Syed A, Azad S, Espinosa A, Davila F, Davila H, Evans NR, Smith S, Reddy B, Sinha P, Churpek MM. Analysis of Protein Biomarkers From Hospitalized COVID-19 Patients Reveals Severity-Specific Signatures and Two Distinct Latent Profiles With Differential Responses to Corticosteroids. Crit Care Med 2023; 51:1697-1705. [PMID: 37378460 DOI: 10.1097/ccm.0000000000005983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVES To identify and validate novel COVID-19 subphenotypes with potential heterogenous treatment effects (HTEs) using electronic health record (EHR) data and 33 unique biomarkers. DESIGN Retrospective cohort study of adults presenting for acute care, with analysis of biomarkers from residual blood collected during routine clinical care. Latent profile analysis (LPA) of biomarker and EHR data identified subphenotypes of COVID-19 inpatients, which were validated using a separate cohort of patients. HTE for glucocorticoid use among subphenotypes was evaluated using both an adjusted logistic regression model and propensity matching analysis for in-hospital mortality. SETTING Emergency departments from four medical centers. PATIENTS Patients diagnosed with COVID-19 based on International Classification of Diseases , 10th Revision codes and laboratory test results. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Biomarker levels generally paralleled illness severity, with higher levels among more severely ill patients. LPA of 522 COVID-19 inpatients from three sites identified two profiles: profile 1 ( n = 332), with higher levels of albumin and bicarbonate, and profile 2 ( n = 190), with higher inflammatory markers. Profile 2 patients had higher median length of stay (7.4 vs 4.1 d; p < 0.001) and in-hospital mortality compared with profile 1 patients (25.8% vs 4.8%; p < 0.001). These were validated in a separate, single-site cohort ( n = 192), which demonstrated similar outcome differences. HTE was observed ( p = 0.03), with glucocorticoid treatment associated with increased mortality for profile 1 patients (odds ratio = 4.54). CONCLUSIONS In this multicenter study combining EHR data with research biomarker analysis of patients with COVID-19, we identified novel profiles with divergent clinical outcomes and differential treatment responses.
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Affiliation(s)
- Philip A Verhoef
- Hawaii Permanente Medical Group, Honolulu, HI
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Pratik Sinha
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO
| | - Matthew M Churpek
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
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Hess AL, Halalau A, Dokter JJ, Paydawy TS, Karabon P, Bastani A, Baker RE, Balla AK, Galens SA. High-dose intravenous vitamin C decreases rates of mechanical ventilation and cardiac arrest in severe COVID-19. Intern Emerg Med 2022; 17:1759-1768. [PMID: 35349005 PMCID: PMC8961256 DOI: 10.1007/s11739-022-02954-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 02/22/2022] [Indexed: 12/24/2022]
Abstract
Intravenous vitamin C (IV-VitC) has been suggested as a treatment for severe sepsis and acute respiratory distress syndrome; however, there are limited studies evaluating its use in severe COVID-19. Efficacy and safety of high-dose IV-VitC (HDIVC) in patients with severe COVID-19 were evaluated. This observational cohort was conducted at a single-center, 530 bed, community teaching hospital and took place from March 2020 through July 2020. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes in patients with severe COVID-19 treated with and without HDIVC. Patients were enrolled if they were older than 18 years of age and were hospitalized secondary to severe COVID-19 infection, indicated by an oxygenation index < 300. Primary study outcomes included mortality, mechanical ventilation, intensive care unit (ICU) admission, and cardiac arrest. From a total of 100 patients enrolled, 25 patients were in the HDIVC group and 75 patients in the control group. The average time to death was significantly longer for HDIVC patients (P = 0.0139), with an average of 22.9 days versus 13.7 days for control patients. Patients who received HDIVC also had significantly lower rates of mechanical ventilation (52.93% vs. 73.14%; ORIPTW = 0.27; P = 0.0499) and cardiac arrest (2.46% vs. 9.06%; ORIPTW = 0.23; P = 0.0439). HDIVC may be an effective treatment in decreasing the rates of mechanical ventilation and cardiac arrest in hospitalized patients with severe COVID-19. A longer hospital stay and prolonged time to death may suggest that HDIVC may protect against clinical deterioration in severe COVID-19.
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Affiliation(s)
- Andrea L Hess
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Alexandra Halalau
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
- Internal Medicine Department, Beaumont Hospital, 3711 W. 13 Mile Rd, Royal Oak, MI, 48073, USA.
| | - Jonathan J Dokter
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Tania S Paydawy
- Department of Pharmaceutical Services, Beaumont Hospital, Troy, MI, USA
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Aveh Bastani
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Emergency Medicine Department, Beaumont Hospital, Troy, MI, USA
| | - Rebecca E Baker
- Department of Pharmaceutical Services, Beaumont Hospital, Troy, MI, USA
| | - Abdalla Kara Balla
- Internal Medicine Department, Beaumont Hospital, 3711 W. 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Stephen A Galens
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Internal Medicine Department, Pulmonary and Critical Care Division, Beaumont Hospital, Troy, MI, USA
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Madanat L, Sager M, O'Connor D, Thapa B, Aggarwal N, Ghimire B, Lauter C, Maine GN, Sims M, Halalau A. Prognostic Value of SARS-CoV-2 Anti-RBD IgG Antibody Quantitation on Clinical Outcomes in Hospitalized COVID-19 Patients. Int J Gen Med 2022; 15:5693-5700. [PMID: 35755860 PMCID: PMC9215841 DOI: 10.2147/ijgm.s370080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Antibody levels against SARS-CoV-2 can be used as an indicator of recent or past vaccination or infection. However, the prognostic value of antibodies targeting the receptor binding protein (anti-RBD) in hospitalized patients is not widely reported. Purpose Determine prognostic impact of SARS-CoV-2 antibody quantification at the time of admission on clinical outcomes in hospitalized COVID-19 patients. Methods We conducted a pilot observational study on patients hospitalized with SARS-CoV-2 infection to determine the prognostic impact of antibody quantitation within the first two days of admission. Anti-nucleocapsid IgG (anti-N) and Anti-RBD levels were measured. Anti-RBD level of 500 AU/mL was used as a cutoff to stratify patients. Spearman’s rank Coefficient (rs) was used to demonstrate association. Results Of the 26 patients included, those who were vaccinated more frequently tested positive for Anti-RBD (100% vs 46.2%, P = 0.005) with higher median titer level (623 vs 0, P = 0.011) compared to unvaccinated patients. Anti-N positivity was more frequently seen in unvaccinated patients (53.9% vs 7.7%, P = 0.03). Anti-RBD levels >500 were associated with lower overall hospital length of stay (LOS)(5 vs 10 days, P = 0.046). The analysis employing a Spearman Rank coefficient demonstrated a strong negative correlation between anti-S titer and LOS (rs=−.515, p = 0.007) and a moderate negative correlation with oxygen needs (rs =−.401, p = 0.042). Conclusion Anti-RBD IgG levels were associated with lower LOS and oxygen needs during hospitalization. Further studies are needed to determine if levels on admission can be used as a prognostic indicator.
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Affiliation(s)
- Luai Madanat
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Melinda Sager
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Daniel O'Connor
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Bijaya Thapa
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Nishant Aggarwal
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Bipin Ghimire
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Carl Lauter
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Infectious Diseases, William Beaumont Hospital, Royal Oak, MI, USA.,Allergy and Immunology, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Gabriel N Maine
- Pathology and Laboratory Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Pathology, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Matthew Sims
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Infectious Diseases, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Alexandra Halalau
- Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Halalau A, Sonmez M, Uddin A, Karabon P, Scherzer Z, Keeney S. Efficacy of a pharmacist-managed diabetes clinic in high-risk diabetes patients, a randomized controlled trial - "Pharm-MD" : Impact of clinical pharmacists in diabetes care. BMC Endocr Disord 2022; 22:69. [PMID: 35296307 PMCID: PMC8925057 DOI: 10.1186/s12902-022-00983-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetes mellitus affects 13% of American adults. To address the complex care requirements necessary to avoid diabetes-related morbidity, the American Diabetes Association recommends utilization of multidisciplinary teams. Research shows pharmacists have a positive impact on multiple clinical diabetic outcomes. METHODS Open-label randomized controlled trial with 1:1 assignment that took place in a single institution resident-run outpatient medicine clinic. Patients 18-75 years old with type 2 diabetes mellitus and most recent HbA1c ≥9% were randomized to standard of care (SOC) (continued with routine follow up with their primary provider) or to the SOC + pharmacist-managed diabetes clinic PMDC group (had an additional 6 visits with the pharmacist within 6 months from enrollment). Patients were followed for 12 months after enrollment. Data collected included HbA1c, lipid panel, statin use, blood pressure control, immunization status, and evidence of diabetic complications (retinopathy, nephropathy, neuropathy). Intention-to-treat and per-protocol analysis were performed. RESULTS Forty-four patients were enrolled in the SOC + PMDC group and 42 patients in the SOC group. Average decrease in HbA1c for the intervention compared to the control group at 6 months was - 2.85% vs. -1.32%, (p = 0.0051). Additionally, the odds of achieving a goal HbA1c of ≤8% at 6 months was 3.15 (95% CI = 1.18, 8.42, p = 0.0222) in the intervention versus control group. There was no statistically significant difference in the remaining secondary outcomes measured. CONCLUSIONS Addition of pharmacist managed care for patients with type 2 diabetes mellitus is associated with significant improvements in HbA1c compared with standard of care alone. Missing data during follow up limited the power of secondary outcomes analyses. TRIAL REGISTRATION ClinicalTrials.gov , ID: NCT03377127 ; first posted on 19/12/2017.
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Affiliation(s)
- Alexandra Halalau
- General Internal Medicine Division, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, USA.
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
| | - Melda Sonmez
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Ahsan Uddin
- Medicine- Pediatrics Department, Beaumont Health, Royal Oak, MI, USA
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Zachary Scherzer
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Giovanatti A, Elassar H, Karabon P, Wunderlich-Barillas T, Halalau A. Social Determinants of Health Correlating with Mechanical Ventilation of COVID-19 Patients: A Multi-Center Observational Study. Int J Gen Med 2021; 14:8521-8526. [PMID: 34848998 PMCID: PMC8612671 DOI: 10.2147/ijgm.s334593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/29/2021] [Indexed: 01/30/2023] Open
Abstract
Importance Several studies have relayed the disproportionate impact of COVID-19 on marginalized communities; however, few have specifically examined the association between social determinants of health and mechanical ventilation (MV). Objective To determine which demographics impact MV rates among COVID-19 patients. Design This observational study included COVID-19 patient data from eight hospitals’ electronic medical records (EMR) between February 25, 2020, to December 31, 2020. Associations between demographic data and MV rates were evaluated using uni- and multivariate analyses. Setting Multicenter (eight hospitals), largest health system in Southeast Michigan. Participants Inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab. Exclusion criteria were missing demographic data or non-permanent Michigan residents. Exposure Patients were divided into two groups: MV and non-MV. Main Outcome and Measures The primary outcome was MV rate per demographic. A multivariate model then predicted the odds of MV per demographic descriptor. Hypotheses were formulated prior to data collection. Results Among 11,304 COVID-19 inpatients investigated, 1621 (14.34%) were MV, and 49.96% were male with a mean age of 63.37 years (17.79). Significant social determinants for MV included Black race (40.19% MV vs 31.31% non-MV, p<0.01), poverty (14.60% vs. 13.21%, p<0.01), and disability (12.65% vs 9.14%; p<0.01). Black race (AOR 1.61 (CI 1.41–1.83; p<0.01)), median income (AOR 0.99 (CI 0.99–0.99; p<0.01)), disability (AOR 1.55 (CI 1.26, 1.90; p<0.01)), and non-English-speaking status (AOR 1.26 (CI 1.05, 1.53)) had significantly higher odds of MV. Conclusions and Relevance Black race, low socioeconomic status, disability, and non-English-speaking status were significant risk factors for MV from COVID-19. An urgent need remains for a pandemic response program that strategizes care for marginalized communities.
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Affiliation(s)
- Alexa Giovanatti
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Heba Elassar
- Internal Medicine Department, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | | | - Alexandra Halalau
- Internal Medicine Department, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Farrukh Mustafa S, Zafar MR, Vira A, Halalau A, Rabah M, Dixon S, Hanson I. In-hospital outcomes of patients with chronic kidney disease undergoing percutaneous coronary intervention for chronic total occlusion: a systematic review and meta-analysis. Coron Artery Dis 2021; 32:681-688. [PMID: 33587359 DOI: 10.1097/mca.0000000000001026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relative safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in patients with chronic kidney disease (CKD) have not been well defined. We performed a systematic review and meta-analysis of observational studies to assess in-hospital outcomes in this population. METHODS We searched MEDLINE, EMBASE, and Cochrane Library databases from inception to April 2020 for all clinical trials and observational studies. Five observational studies with a total of 6769 patients met our inclusion criteria. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR <60 ml/min/1.73m2 in CKD group and ≥ 60 ml/min/1.73m2 in non-CKD group). The primary outcome was in-hospital mortality. Secondary outcomes were acute kidney injury, coronary injury (perforation, dissection or tamponade), stroke and procedural success. Mantel-Haenszel random-effects model was used to calculate the odds ratio (OR) and 95% confidence intervals (CI). RESULTS In-hospital mortality was significantly higher among patients with CKD undergoing PCI for CTO (OR: 5.16, 95% CI: 2.60-10.26, P < 0.00001). Acute kidney injury (OR: 2.54, 95% CI: 1.89-3.40, P < 0.00001) and major bleeding (OR: 2.58, 95% CI: 1.20-5.54, P < 0.01) were also more common in the CKD group. No significant difference was observed in the occurrence of stroke (OR: 2.36, 95% CI: 0.74-7.54, P < 0.15) or coronary injury (OR: 1.38, 95% CI: 0.98-1.93, P < 0.06) between the two groups. Non-CKD patients had a higher likelihood of procedural success compared to CKD patients (OR: 0.66, 95% CI: 0.57-0.77, P < 0.00001). CONCLUSION Patients with CKD undergoing PCI for CTO have a significantly higher risk of in-hospital mortality, acute kidney injury and major bleeding when compared to non-CKD patients. They also have a lower procedural success rate.
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Affiliation(s)
| | - Meer R Zafar
- Division Cardiology, Department of Medicine, Jacob's School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Amit Vira
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Maher Rabah
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Simon Dixon
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Ivan Hanson
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak
- Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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Halalau A, Imam Z, Karabon P, Mankuzhy N, Shaheen A, Tu J, Carpenter C. External validation of a clinical risk score to predict hospital admission and in-hospital mortality in COVID-19 patients. Ann Med 2021; 53:78-86. [PMID: 32997542 PMCID: PMC7877986 DOI: 10.1080/07853890.2020.1828616] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/20/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Identification of patients with novel coronavirus disease 2019 (COVID-19) requiring hospital admission or at high-risk of in-hospital mortality is essential to guide patient triage and to provide timely treatment for higher risk hospitalized patients. METHODS A retrospective multi-centre (8 hospital) cohort at Beaumont Health, Michigan, USA, reporting on COVID-19 patients diagnosed between 1 March and 1 April 2020 was used for score validation. The COVID-19 Risk of Complications Score was automatically computed by the EHR. Multivariate logistic regression models were built to predict hospital admission and in-hospital mortality using individual variables constituting the score. Validation was performed using both discrimination and calibration. RESULTS Compared to Green scores, Yellow Scores (OR: 5.72) and Red Scores (OR: 19.1) had significantly higher odds of admission (both p < .0001). Similarly, Yellow Scores (OR: 4.73) and Red Scores (OR: 13.3) had significantly higher odds of in-hospital mortality than Green Scores (both p < .0001). The cross-validated C-Statistics for the external validation cohort showed good discrimination for both hospital admission (C = 0.79 (95% CI: 0.77-0.81)) and in-hospital mortality (C = 0.75 (95% CI: 0.71-0.78)). CONCLUSIONS The COVID-19 Risk of Complications Score predicts the need for hospital admission and in-hospital mortality patients with COVID-19. Key points: Can an electronic health record generated risk score predict the risk of hospital admission and in-hospital mortality in patients diagnosed with coronavirus disease 2019 (COVID-19)? In both validation cohorts of 2,025 and 1,290 COVID-19, the cross-validated C-Statistics showed good discrimination for both hospital admission (C = 0.79 (95% CI: 0.77-0.81)) and in-hospital mortality (C = 0.75 (95% CI: 0.71-0.78)), respectively. The COVID-19 Risk of Complications Score may help predict the need for hospital admission if a patient contracts SARS-CoV-2 infection and in-hospital mortality for a hospitalized patient with COVID-19.
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Affiliation(s)
- Alexandra Halalau
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Zaid Imam
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nikhil Mankuzhy
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Aciel Shaheen
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - John Tu
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Clinical Informatics, Beaumont Health, Southfield, MI, USA
| | - Christopher Carpenter
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Section of Infectious Disease, Beaumont Health, Royal Oak, MI, USA
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9
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Abstract
INTRODUCTION Type II diabetes mellitus (DM) is a proinflammatory process and a known risk factor for major adverse cardiac events (MACE). The same inflammatory markers may be present in prediabetes (pDM); however, the relationship between pDM by HbA1c and MACE is not well studied. We sought to see if pDM increases one's risk for MACE. METHODS We retrospectively studied patients at Beaumont Health, Michigan between 2006 and 2020. We divided patients into groups (G1-G5) based on haemoglobin A1c (HbA1c) trends over the study period as follows: G1: pDM patients who remained pDM; G2: pDM who progressed into DM; G3: pDM who normalized their HbA1c; G4: patients who maintained a normal HbA1c; and G5: patients with HbA1c persistently in the DM range. We compared MACE between the groups by univariate and multivariate regression analyses. RESULTS A total of 119,271 patients were included in the study (G1: N = 13,520, G2: N = 6314, G3: N = 1585, G4: N = 15,018, G5: N = 82,834). Pairwise comparison revealed a statistically significant increase in the odds of MACE in all groups compared to those with normal HbA1c values (G4; p < .001). After adjusting for baseline characteristics, multivariate regression revealed elevated odds of MACE in patients with persistent pDM (G1; aOR = 1.087, p = .002) and diabetes (G2/G5; aOR = 1.25 and aOR = 1.18, p < .001) compared to individuals with normal HbA1c values. CONCLUSION Prediabetes is a risk factor for MACE. Normalization of HbA1c values appears to decrease the adjusted risk for MACE and should be the goal in patients with pDM.KEY MESSAGESPatients with prediabetes (pDM) are at increased risk for major cardiovascular events.Normalization of HbA1c in pDM patients may have a clinically significant benefit, in terms of lowering the MACE risk.Prediabetes patients who progress into diabetes mellitus may represent a particularly high-risk group.
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Affiliation(s)
- Ramy Mando
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Muhammad Waheed
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Adrian Michel
- Department of Internal Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Alexandra Halalau
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.,Department of Internal Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
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10
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McCrohan M, Nierenberg L, Karabon P, Wunderlich-Barillas T, Halalau A. The Impact of Disparities in Social Determinants of Health on Hospitalization Rates for Patients with COVID-19 in Michigan (USA). Int J Gen Med 2021; 14:7681-7686. [PMID: 34764681 PMCID: PMC8572739 DOI: 10.2147/ijgm.s328663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/20/2021] [Indexed: 11/24/2022] Open
Abstract
Importance The COVID-19 pandemic continues to impact the health-care system in the United States and has brought further light on health disparities within it. However, only a few studies have examined hospitalization risk with regard to social determinants of health. Objective We aimed to identify how health disparities affect hospitalization rates among patients with COVID-19. Design This observational study included all individuals diagnosed with COVID-19 from February 25, 2020 to December 31, 2020. Uni- and multivariate analyses were utilized to evaluate associations between demographic data and inpatient versus outpatient status for patients with COVID-19. Setting Multicenter (8 hospitals), largest size health system in Southeast Michigan, a region highly impacted by the pandemic. Participants All outpatients and inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab were included. Exclusion criteria included missing demographic data or status as a non-permanent Michigan resident. Exposure Patients who met inclusion and exclusion criteria were divided in 2 groups: outpatients and inpatients. Main Outcome and Measures We described the comparative demographics and known disparities associated with hospitalization status. Results Of 30,292 individuals who tested positive for SARS-CoV-2, 34.01% were admitted to the hospital. White or Caucasian race was most prevalent (57.49%), and 23.35% were African-American. The most common ethnicity was non-Hispanic or Latino (70.48%). English was the primary language for the majority of patients (91.60%). Private insurance holders made up 71.11% of the sample. Within the hospitalized patients, lower socioeconomic status, African-American race and Hispanic and Latino ethnicity, non-English speaking status, and Medicare and Medicaid were more likely to be admitted to the hospital. Conclusions and Relevance Several health disparities were associated with greater rates of hospitalization due to COVID-19. Addressing these inequalities from an individual to system level may improve health-care outcomes for those with health disparities and COVID-19.
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Affiliation(s)
- Megan McCrohan
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Linnea Nierenberg
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | | | - Alexandra Halalau
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.,Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
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11
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Madanat L, Saleh M, Maraskine M, Halalau A, Bukovec F. Congestive Heart Failure 30-Day Readmission: Descriptive Study of Demographics, Co-morbidities, Heart Failure Knowledge, and Self-Care. Cureus 2021; 13:e18661. [PMID: 34786247 PMCID: PMC8579470 DOI: 10.7759/cureus.18661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
Background Congestive heart failure (CHF) readmissions are associated with substantial financial and medical implications. We performed a descriptive study to determine demographic, clinical, and behavioral factors associated with 30-day readmission. Materials and methods Patients hospitalized with CHF at William Beaumont Hospital in Royal Oak, MI, from March 2019-May 2019 were studied. Response to heart failure knowledge and self-care questionnaires along with the patients' demographic and clinical factors were collected. Thirty-day readmission to any of the eight hospitals in the Beaumont Health System was documented. Results One-hundred ninety-six (196) patients were included. The all-cause 30-day readmission rate was 23%. A numerical higher rate of readmissions was observed among males (23.7% vs 22.2%), current smokers (27.3% vs 22.9%), and patients with peripheral vascular disease (PVD; 28.9% vs 21.2%), diabetes mellitus (DM; 26.4% vs 18.9%), hypertension (HTN; 26.4% vs 10%), coronary artery disease (CAD; 24.6% vs 19%), and prior history of cerebrovascular accident (CVA; 28.9% vs 21.2%) (p>0.05). Reduced left ventricular ejection fraction (LVEF) was associated with higher readmissions (24.4% vs 20.5%, p=0.801). Patients with the highest reported questionnaire scores corresponding to better heart failure knowledge and self-care behaviors at home were readmitted at a similar rate compared to those scoring in the lowest interval (25%, p=0.681). Conclusion Though statistically insignificant due to the limitations of sample size, a higher percentage of readmissions was observed in male patients, current smokers, reduced LVEF, and higher comorbidity burden. Better reported patient self-care behavior, medication compliance, and heart failure knowledge did not correlate with reduced readmission rates. While the impact of medical comorbidities on 30-day readmissions is better established, the role of socioeconomic factors remains unclear and might suggest a focus for future work.
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Affiliation(s)
- Luai Madanat
- Internal Medicine, Beaumont Hospital, Royal Oak, USA
| | - Monique Saleh
- Internal Medicine, Beaumont Hospital, Royal Oak, USA
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12
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Harvey R, Hermez M, Schanz L, Karabon P, Wunderlich-Barillas T, Halalau A. Healthcare Disparities Correlated with In-Hospital Mortality in COVID-19 Patients. Int J Gen Med 2021; 14:5593-5596. [PMID: 34548810 PMCID: PMC8449643 DOI: 10.2147/ijgm.s326338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/16/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Increasing age, male gender, African American race, and medical comorbidities have been reported as risk factors for COVID-19 mortality. We aimed to identify health-care disparities associated with increased mortality in COVID-19 patients. Methods We performed an observational study of all hospitalized patients with SARS-CoV2 infection from within the largest multicenter healthcare system in Southeast Michigan, from February to December, 2020. Results From 11,304 hospitalized patients, 1295 died, representing an in-hospital mortality rate of 11.5%. The mean age of hospitalized patients was 63.77 years-old, with 49.96% being males. Older age (AOR = 1.05, p < 0.0001), male gender (AOR = 1.43, p < 0.0001), divorced status (AOR = 1.25, p = 0.0256), disabled status (AOR = 1.42, p = 0.0091), and homemakers (AOR = 1.96, p = 0.0216) were significantly associated with in-hospital mortality. Conclusion Older age, male gender, divorced and disabled status and homemakers were significantly associated with in-hospital mortality if they developed COVID-19. Further research should aim to identify the underlying factors driving these disparities in COVID-19 in-hospital mortality.
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Affiliation(s)
- Rachel Harvey
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Maryan Hermez
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Luke Schanz
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Patrick Karabon
- Office of Research, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | | | - Alexandra Halalau
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.,Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
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13
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Sigua-Arce P, Mando R, Spencer L, Halalau A. Treatment of May-Thurner's Syndrome and Associated Complications: A Multicenter Experience. Int J Gen Med 2021; 14:4705-4710. [PMID: 34447265 PMCID: PMC8384425 DOI: 10.2147/ijgm.s325231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/02/2021] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To assess the treatment options and associated complications in patients with May-Thurner's syndrome (MTS). METHODS We retrospectively reviewed the charts of patients diagnosed with MTS. Thorough review was completed and data relevant to methods of diagnosis, treatment, complications, hospital readmission, and mortality were extracted from patient charts. The patients were followed for two years after diagnosis. RESULTS Of the 47 patients identified as having "MTS", 32 (70%) were diagnosed formally with either magnetic resonance venography, computed tomography venography, or ultrasound. Two patients were excluded for insufficient availability of follow-up records. Mean age of the population included (N = 30) was 50.24 ±15.33 years and 83% (N = 25) had female gender. The majority (40%) of patients were treated with anticoagulation, thrombolysis, and stent placement, and 13.3% received a combination of anticoagulation, antiplatelet agent, thrombolysis, and stent placement. Overall, we found 28 patients (93%) who underwent endovascular stenting. However, 39.3% (11/28) had stent-related complications that included stent thrombosis, stenosis, and migration. One patient underwent open heart surgery for stent retrieval. Duration of anticoagulation therapy ranged from 6 months to lifelong. Two patients (6.7%) suffered major bleeds requiring transfusion. Fourteen patients (46.6%) developed post-thrombotic syndrome. Seven (23.3%) patients required MTS-related readmission within 30 days. No mortality was noted at two-year follow-up. CONCLUSION Although our study only included 30 patients, it was evident to us that there is no consensus in the management of MTS. Furthermore, endovascular stenting, which has a major role in the management of MTS, has complication rates that hover close to 40%. Further research is needed to help develop a standardized evidence-based approach in the management of MTS that ensures a decreased risk of immediate and long-term complications.
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Affiliation(s)
| | - Ramy Mando
- Department of Internal Medicine, Beaumont Health System, Royal Oak, MI, USA
| | - Lisa Spencer
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health System, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
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14
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Hanna A, Gill I, Imam Z, Halalau A, Jamil LH. Low yield of head CT in cirrhotic patients presenting with hepatic encephalopathy. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000609. [PMID: 34083228 PMCID: PMC8174513 DOI: 10.1136/bmjgast-2021-000609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/16/2022] Open
Abstract
Goals and background The utility of routine head CT (HCT) in hepatic encephalopathy (HE) evaluation is unclear. We investigated HCT yield in detecting acute intracranial abnormalities in cirrhotic patients presenting with HE. Study Retrospective review of cirrhotic patient encounters with HE between 2016 and 2018 at Beaumont Health, in Michigan was performed. A low-risk (LR) indication for HCT was defined as altered mental status (AMS), which included dizziness and generalised weakness. A high-risk (HR) indication was defined as trauma/fall, syncope, focal neurological deficits (FNDs) or headache. Descriptive statistics and univariate/multivariate analyses by logistic regression were performed using SPSS to identify HCT abnormality correlates. Results Five hundred twenty unique encounters were reviewed. Mean age was 63.4 (12.1) years, 162 (37.5%) had alcoholic cirrhosis and median Model for End-Stage Liver Disease (MELD)-score was 17 (13–23). LR indication was reported in 408 (78.5%) patients and FNDs reported in 24 (4.6%) patients. Only 13 (2.5%) patients were found to have an acute intracranial pathology (seven haemorrhagic stroke, two ischaemic stroke, four subdural haematoma). Aspirin use prior to presentation (aOR 4.6, 95% CI 1.1 to 19.2), and HR indication (aOR 7.3, 95% CI 2.3 to 23.8) were independent correlates of acute intracranial pathology on HCT. Age, sex, MELD-score, haemoglobin, platelet count, race and cirrhosis aetiology did not correlate with HCT abnormalities. Number needed to screen to identify one acute pathology was 14 in HR indications versus 82 for LR indications. Conclusion Routine HCTs in cirrhotic patients presenting with HE with AMS in the absence of history of trauma, headache, syncope, FNDs or aspirin use is of low diagnostic yield.
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Affiliation(s)
- Angy Hanna
- Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Inayat Gill
- Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Zaid Imam
- Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Alexandra Halalau
- Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA.,Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Laith H Jamil
- Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, Michigan, USA.,Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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15
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Imam Z, Gill I, Antonios B, Hasan L, Aneese A, Kakked G, Halalau A. Hyperlipasemia does not confer worse clinical outcomes in a retrospective cohort of novel coronavirus patients. Minerva Gastroenterol (Torino) 2021; 69:312-314. [PMID: 34078033 DOI: 10.23736/s2724-5985.21.02929-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Zaid Imam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA -
| | - Inayat Gill
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
| | - Bana Antonios
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
| | - Leen Hasan
- Department of Internal Medicine, University of Connecticut, Farmington, CT, USA
| | - Andrew Aneese
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
| | - Gaurav Kakked
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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16
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Halalau A, Holmes B, Rogers-Snyr A, Donisan T, Nielsen E, Cerqueira TL, Guyatt G. Evidence-based medicine curricula and barriers for physicians in training: a scoping review. Int J Med Educ 2021; 12:101-124. [PMID: 34053914 PMCID: PMC8411338 DOI: 10.5116/ijme.6097.ccc0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/09/2021] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To describe the published literature on EBM curricula for physicians in training and barriers during curriculum implementation. METHODS We performed a systematic search and review of the medical literature on PubMed, Embase, ERIC, Scopus and Web of Science from the earliest available date until September 4, 2019. RESULTS We screened 9,042 references and included 29 full-text studies and 14 meeting abstracts. Eighteen studies had moderate validity, and 6 had high validity. The EBM curricular structure proved highly variable in between studies. The majority of the EBM curricula was longitudinal with different lengths. Only five studies reported using Kern's six-step approach for curriculum development. Twenty-one articles reported on EBM skills and knowledge, and only 5/29 full-text articles used a validated assessment tool. Time was the main barrier to EBM curriculum implementation. All the included studies and abstracts, independent of the EBM curriculum structure or evaluation method used, found an improvement in the residents' attitudes and/or EBM skills and knowledge. CONCLUSIONS The current body of literature available to guide educators in EBM curriculum development is enough to constitute a strong scaffold for developing any EBM curriculum. Given the amount of time and resources needed to develop and implement an EBM curriculum, it is very important to follow the curriculum development steps and use validated assessment tools.
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Affiliation(s)
- Alexandra Halalau
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan, USA
| | - Brett Holmes
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan, USA
| | | | - Teodora Donisan
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan, USA
| | - Eric Nielsen
- University of Michigan, Ann Arbor, Michigan, USA
| | - Tiago Lemos Cerqueira
- Dresden International University, Division of Health Care Sciences Center for Clinical Research and Management Education Dresden, Germany
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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17
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Halalau A, Halalau M, Carpenter C, Abbas AE, Sims M. Vestibular neuritis caused by severe acute respiratory syndrome coronavirus 2 infection diagnosed by serology: Case report. SAGE Open Med Case Rep 2021; 9:2050313X211013261. [PMID: 34035914 PMCID: PMC8127789 DOI: 10.1177/2050313x211013261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/07/2021] [Indexed: 12/25/2022] Open
Abstract
Vestibular neuritis is a disorder selectively affecting the vestibular portion of the eighth cranial nerve generally considered to be inflammatory in nature. There have been no reports of severe acute respiratory syndrome coronavirus 2 causing vestibular neuritis. We present the case of a 42-year-old Caucasian male physician, providing care to COVID-19 patients, with no significant past medical history, who developed acute vestibular neuritis, 2 weeks following a mild respiratory illness, later diagnosed as COVID-19. Physicians should keep severe acute respiratory syndrome coronavirus 2 high on the list as a possible etiology when suspecting vestibular neuritis, given the extent and implications of the current pandemic and the high contagiousness potential.
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Affiliation(s)
- Alexandra Halalau
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,William Beaumont School of Medicine, Oakland University, Rochester, MI, USA
| | | | - Christopher Carpenter
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,William Beaumont School of Medicine, Oakland University, Rochester, MI, USA.,Infectious Disease Department, Beaumont Health, Royal Oak, MI, USA
| | - Amr E Abbas
- William Beaumont School of Medicine, Oakland University, Rochester, MI, USA.,Cardiovascular Department, Beaumont Health, Royal Oak, MI, USA
| | - Matthew Sims
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,William Beaumont School of Medicine, Oakland University, Rochester, MI, USA.,Infectious Disease Department, Beaumont Health, Royal Oak, MI, USA
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18
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19
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Halalau A, Odish F, Imam Z, Sharrak A, Brickner E, Lee PB, Foglesong A, Michel A, Gill I, Qu L, Abbas AE, Carpenter CF. Epidemiology, Clinical Characteristics, and Outcomes of a Large Cohort of COVID-19 Outpatients in Michigan. Int J Gen Med 2021; 14:1555-1563. [PMID: 33953603 PMCID: PMC8089468 DOI: 10.2147/ijgm.s305295] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/15/2021] [Indexed: 01/08/2023] Open
Abstract
Background Most outpatients with coronavirus disease 2019 (COVID-19) do not initially demonstrate severe features requiring hospitalization. Understanding this population’s epidemiological and clinical characteristics to allow outcome anticipation is crucial in healthcare resource allocation. Methods Retrospective, multicenter (8 hospitals) study reporting on 821 patients diagnosed with COVID-19 by real-time reverse transcriptase–polymerase chain reaction assay of nasopharyngeal swabs and discharged home to self-isolate after evaluation in emergency departments (EDs) within Beaumont Health System in March, 2020. Outcomes were collected through April 14, 2020, with a minimum of 12 day follow-up and included subsequent ED visit, admission status, and mortality. Results Of the 821 patients, mean age was 49.3 years (SD 15.7), 46.8% were male and 55.1% were African-American. Cough was the most frequent symptom in 78.2% of patients with a median duration of 3 days (IQR 2–7), and other symptoms included fever 62.1%, rhinorrhea or nasal congestion 35.1% and dyspnea 31.2%. ACEI/ARBs usage was reported in 28.7% patients and 34.0% had diabetes mellitus. Return to the ED for re-evaluation was reported in 19.2% of patients from whom 54.4% were admitted. The patients eventually admitted to the hospital were older (mean age 54.4 vs 48.7 years, p=0.002), had higher BMI (35.4 kg/m2 vs 31.9 kg/m2, p=0.004), were more likely male (58.1% vs 45.4%, p=0.026), and more likely to have hypertension (52.3% vs 29.4%, p<0.001), diabetes mellitus (74.4% vs 29.3%, p<0.001) or prediabetes (25.6% vs 8.4%, p<0.001), COPD (39.5% vs 5.4%, p<0.001), and OSA (36% vs 19%, p<0.001). The overall mortality rate was 1.3%. Conclusion We found that 80.8% of patients did not return to the ED for re-evaluation. Sending patients with COVID-19 home if they experience mild symptoms is a safe approach for most patients and might mitigate some of the financial and staffing pressures on healthcare systems.
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Affiliation(s)
- Alexandra Halalau
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Fadi Odish
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Wright State University, Dayton, OH, USA
| | - Zaid Imam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
| | - Aryana Sharrak
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Evan Brickner
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Paul Bumki Lee
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Adam Foglesong
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Adrian Michel
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Inayat Gill
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Lihua Qu
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.,Outcome Research Department, Research Institute Beaumont Health, Royal Oak, MI, USA
| | - Amr E Abbas
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.,Cardiovascular Department, Beaumont Health, Royal Oak, MI, USA
| | - Christopher F Carpenter
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA.,Infectious Disease Section, Beaumont Health, Royal Oak, MI, USA
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20
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Yu L, Halalau A, Dalal B, Abbas AE, Ivascu F, Amin M, Nair GB. Machine learning methods to predict mechanical ventilation and mortality in patients with COVID-19. PLoS One 2021; 16:e0249285. [PMID: 33793600 PMCID: PMC8016242 DOI: 10.1371/journal.pone.0249285] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/15/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The Coronavirus disease 2019 (COVID-19) pandemic has affected millions of people across the globe. It is associated with a high mortality rate and has created a global crisis by straining medical resources worldwide. OBJECTIVES To develop and validate machine-learning models for prediction of mechanical ventilation (MV) for patients presenting to emergency room and for prediction of in-hospital mortality once a patient is admitted. METHODS Two cohorts were used for the two different aims. 1980 COVID-19 patients were enrolled for the aim of prediction ofMV. 1036 patients' data, including demographics, past smoking and drinking history, past medical history and vital signs at emergency room (ER), laboratory values, and treatments were collected for training and 674 patients were enrolled for validation using XGBoost algorithm. For the second aim to predict in-hospital mortality, 3491 hospitalized patients via ER were enrolled. CatBoost, a new gradient-boosting algorithm was applied for training and validation of the cohort. RESULTS Older age, higher temperature, increased respiratory rate (RR) and a lower oxygen saturation (SpO2) from the first set of vital signs were associated with an increased risk of MV amongst the 1980 patients in the ER. The model had a high accuracy of 86.2% and a negative predictive value (NPV) of 87.8%. While, patients who required MV, had a higher RR, Body mass index (BMI) and longer length of stay in the hospital were the major features associated with in-hospital mortality. The second model had a high accuracy of 80% with NPV of 81.6%. CONCLUSION Machine learning models using XGBoost and catBoost algorithms can predict need for mechanical ventilation and mortality with a very high accuracy in COVID-19 patients.
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Affiliation(s)
- Limin Yu
- Department of Pathology, Beaumont Health System, Royal Oak, MI, United States of America
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health System, Royal Oak, MI, United States of America
| | - Bhavinkumar Dalal
- Division of Pulmonary and Critical Care Medicine, Beaumont Health System, Royal Oak, MI, United States of America
| | - Amr E. Abbas
- Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, MI, United States of America
| | - Felicia Ivascu
- Department of General Surgery, Beaumont Health System, Royal Oak, MI, United States of America
| | - Mitual Amin
- Department of Pathology, Beaumont Health System, Royal Oak, MI, United States of America
| | - Girish B. Nair
- Division of Pulmonary and Critical Care Medicine, Beaumont Health System, Royal Oak, MI, United States of America
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21
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Halalau A, Fuller W, Wheeler S. Canagliflozin Reduces the Risk of Kidney Failure in Patients with Type 2 Diabetes Mellitus and Nephropathy: The CREDENCE Randomized Trial. J Gen Intern Med 2021:10.1007/s11606-020-06216-z. [PMID: 33547569 DOI: 10.1007/s11606-020-06216-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Alexandra Halalau
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA.
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
| | - William Fuller
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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22
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Trang A, Bushman J, Halalau A. Effect of Long-Term Proton Pump Inhibitor Use on Glycemic Control in Patients with Type Two Diabetes Mellitus. J Diabetes Res 2021; 2021:5578265. [PMID: 34368365 PMCID: PMC8346311 DOI: 10.1155/2021/5578265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/04/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022] Open
Abstract
There have been conflicting results regarding the effect of proton pump inhibitors (PPIs) as an adjunctive therapy to oral antidiabetic medication (OAM) in those with type 2 diabetes (T2DM). PPIs increase gastrin levels, causing a rise in insulin. No studies have evaluated the duration of PPI therapy and its effect on glycemic control. Medical records across 8 hospitals between 2007 and 2016 were reviewed for 14,602 patients with T2DM (not on insulin therapy) taking PPIs. Values of HbA1c (baseline, follow-up, and the difference between the two) in those prescribed with PPIs and years of therapy were compared to HbA1c values of those who had no record of PPI use. Baseline and follow-up HbA1c for patients on PPIs were 6.8 and 7.0, respectively, compared to 7.1 and 7.2 in their untreated counterparts (p < 0.001 in both comparisons). For both groups, an increase in baseline HbA1c was seen with time. Those on PPI had an increase in HbA1c of 0.16 compared to 0.08 in those not prescribed PPI. Our results show no relationship between the length of PPI therapy and HbA1c reduction.
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Affiliation(s)
- Amy Trang
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jordan Bushman
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Alexandra Halalau
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
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Said A, Keeney S, Matka M, Hafeez A, George J, Halalau A. Concomitant use of direct oral anticoagulants and aspirin versus direct oral anticoagulants alone in atrial fibrillation and flutter: a retrospective cohort. BMC Cardiovasc Disord 2020; 20:263. [PMID: 32487114 PMCID: PMC7268433 DOI: 10.1186/s12872-020-01509-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
Background The benefit of combining aspirin and direct oral anticoagulants on the reduction of cardiovascular events in atrial fibrillation or flutter is not well studied. We aimed to assess whether concurrent aspirin and direct oral anticoagulant therapy for atrial fibrillation or flutter will result in less coronary, cerebrovascular and systemic ischemic events compared to direct oral anticoagulant therapy alone. Methods Retrospective study of adult patients between 18 and 100 years old who have nonvalvular atrial fibrillation or flutter and were started on a direct oral anticoagulant (apixaban, rivaroxaban, or dabigatran), between January 1, 2010 and September 1, 2015 within the Beaumont Health System. Exclusions were history of venous thromboembolic disease and use of other antiplatelet therapies such as P2Y12 inhibitors. Patients were classified into two groups based on concurrent aspirin use and observed for a minimum of 2 years. Primary outcome was major adverse cardiac events, defined as acute coronary syndromes, ischemic strokes, and embolic events. Secondary outcomes were bleeding and death. Results Six thousand four patients were in the final analysis, 57% males and 80% Caucasians, median age 71, interquartile range (63–80). The group exposed to aspirin contained 2908 subjects, and the group unexposed to aspirin contained 3096 subjects. After using propensity scores to balance the baseline characteristics in both groups, the analysis revealed higher rate of major adverse cardiac events in the exposed group compared to the unexposed group, (HR 2.11, 95% CI (1.74–2.56)) with a number needed to harm of 11 (95% CI [9–11]). The rate of bleeding was also higher in the exposed group, (HR 1.30, 95% CI (1.11–1.52)). The rate of death was not statistically different between the groups, (HR 0.87, 95% CI (0.61–1.25)). Conclusions In this observational analysis of patients with atrial fibrillation and flutter, the concomitant use of direct oral anticoagulants and aspirin was associated with an increased risk of both major adverse cardiac and bleeding events when compared to the use of direct oral anticoagulants alone. These findings underscore the potential harm of this combination therapy when used without a clear indication.
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24
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Imam Z, Odish F, Gill I, O'Connor D, Armstrong J, Vanood A, Ibironke O, Hanna A, Ranski A, Halalau A. Older age and comorbidity are independent mortality predictors in a large cohort of 1305 COVID-19 patients in Michigan, United States. J Intern Med 2020; 288:469-476. [PMID: 32498135 PMCID: PMC7300881 DOI: 10.1111/joim.13119] [Citation(s) in RCA: 218] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Higher comorbidity and older age have been reported as correlates of poor outcomes in COVID-19 patients worldwide; however, US data are scarce. We evaluated mortality predictors of COVID-19 in a large cohort of hospitalized patients in the United States. DESIGN Retrospective, multicenter cohort of inpatients diagnosed with COVID-19 by RT-PCR from 1 March to 17 April 2020 was performed, and outcome data evaluated from 1 March to 17 April 2020. Measures included demographics, comorbidities, clinical presentation, laboratory values and imaging on admission. Primary outcome was mortality. Secondary outcomes included length of stay, time to death and development of acute kidney injury in the first 48-h. RESULTS The 1305 patients were hospitalized during the evaluation period. Mean age was 61.0 ± 16.3, 53.8% were male and 66.1% African American. Mean BMI was 33.2 ± 8.8 kg m-2 . Median Charlson Comorbidity Index (CCI) was 2 (1-4), and 72.6% of patients had at least one comorbidity, with hypertension (56.2%) and diabetes mellitus (30.1%) being the most prevalent. ACE-I/ARB use and NSAIDs use were widely prevalent (43.3% and 35.7%, respectively). Mortality occurred in 200 (15.3%) of patients with median time of 10 (6-14) days. Age > 60 (aOR: 1.93, 95% CI: 1.26-2.94) and CCI > 3 (aOR: 2.71, 95% CI: 1.85-3.97) were independently associated with mortality by multivariate analyses. NSAIDs and ACE-I/ARB use had no significant effects on renal failure in the first 48 h. CONCLUSION Advanced age and an increasing number of comorbidities are independent predictors of in-hospital mortality for COVID-19 patients. NSAIDs and ACE-I/ARB use prior to admission is not associated with renal failure or increased mortality.
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Affiliation(s)
- Z Imam
- From the, Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Internal Medicine Residents, Beaumont Hospital, Royal Oak, MI, USA
| | - F Odish
- From the, Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Internal Medicine Residents, Beaumont Hospital, Royal Oak, MI, USA
| | - I Gill
- From the, Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Internal Medicine Residents, Beaumont Hospital, Royal Oak, MI, USA
| | - D O'Connor
- From the, Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Internal Medicine Residents, Beaumont Hospital, Royal Oak, MI, USA
| | - J Armstrong
- From the, Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Internal Medicine Residents, Beaumont Hospital, Royal Oak, MI, USA
| | - A Vanood
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - O Ibironke
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - A Hanna
- From the, Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Internal Medicine Residents, Beaumont Hospital, Royal Oak, MI, USA
| | - A Ranski
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - A Halalau
- From the, Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA.,Department of Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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Tice JA, Halalau A, Burke H. Vitamin D Does Not Prevent Cancer or Cardiovascular Disease: The VITAL Trial : Manson JE, Cook NR, Lee IM, Christen W, Bassuk SS, Mora S, Gibson H, Gordon D, Copeland T, D'Agostino D, Friedenberg G, Ridge C, Bubes V, Giovannucci EL, Willett WC, Buring JE (2019) Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease. N Engl J Med 380 (1):33-44. J Gen Intern Med 2020:10.1007/s11606-020-05648-x. [PMID: 32789616 DOI: 10.1007/s11606-020-05648-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Jeffrey A Tice
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Alexandra Halalau
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Harry Burke
- Division of General Internal Medicine, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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26
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Halalau A, Ditkoff J, Hamilton J, Sharrak A, Vanood A, Abbas A, Ziadeh J. Emergency Center Curbside Screening During the COVID-19 Pandemic: Retrospective Cohort Study. JMIR Public Health Surveill 2020; 6:e20040. [PMID: 32619184 PMCID: PMC7404008 DOI: 10.2196/20040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/02/2020] [Accepted: 07/02/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19) is a global pandemic that has placed a significant burden on health care systems in the United States. Michigan has been one of the top states affected by COVID-19. OBJECTIVE We describe the emergency center curbside testing procedure implemented at Beaumont Hospital, a large hospital in Royal Oak, MI, and aim to evaluate its safety and efficiency. METHODS Anticipating a surge in patients requiring testing, Beaumont Health implemented curbside testing, operated by a multidisciplinary team of health care workers, including physicians, advanced practice providers, residents, nurses, technicians, and registration staff. We report on the following outcomes over a period of 26 days (March 12, 2020, to April 6, 2020): time to medical decision, time spent documenting electronic medical records, overall screening time, and emergency center return evaluations. RESULTS In total, 2782 patients received curbside services. A nasopharyngeal swab was performed on 1176 patients (41%), out of whom 348 (29.6%) tested positive. The median time for the entire process (from registration to discharge) was 28 minutes (IQR 17-44). The median time to final medical decision was 15 minutes (IQR 8-27). The median time from medical decision to discharge was 9 minutes (IQR 5-16). Only 257 patients (9.2%) returned to the emergency center for an evaluation within 7 or more days, of whom 64 were admitted to the hospital, 11 remained admitted, and 4 expired. CONCLUSIONS Our curbside testing model encourages the incorporation of this model at other high-volume facilities during an infectious disease pandemic.
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Affiliation(s)
| | | | | | - Aryana Sharrak
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Aimen Vanood
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Amr Abbas
- Beaumont Health, Royal Oak, MI, United States
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27
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Gomez‐Rojas O, Hafeez A, Gandhi N, Berghea R, Halalau A. Bilateral Vertebral Artery Dissection: A Case Report with Literature Review. Case Rep Med 2020; 2020:8180926. [PMID: 33101417 PMCID: PMC7568148 DOI: 10.1155/2020/8180926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/24/2020] [Accepted: 04/13/2020] [Indexed: 12/20/2022] Open
Abstract
Vertebral artery dissection (VAD) is a rare cause of ischemic stroke in young patients. The largely nonspecific symptoms and delayed presentation pose a serious diagnostic challenge. Medical management with either anticoagulation or antiplatelet therapy is recommended, but there are no reports of successful dual therapy. We report a case of spontaneous bilateral vertebral artery dissections (VADs) treated with both anticoagulation and antiplatelet therapy and a literature review on clinical presentation and the current medical and surgical management options. A 37-year-old healthy female presented to the emergency department with worsening neck pain and headache for two weeks despite over-the-counter medication, block therapy, yoga, and deep tissue neck massage. She denied any trauma but admitted to multiple roller coaster rides over the past few months. CT angiography was concerning for VADs, and MRI brain revealed multiple strokes in the left posterior inferior cerebellar artery (PICA) territory. Cerebral arteriography confirmed the diagnosis of VADs. The patient was initiated on warfarin, along with atorvastatin and aspirin. She was discharged home with no complications and followed up with neurology as an outpatient. MR angiography after three months revealed complete resolution of the dissection. The patient did not report any bleeding complications from dual therapy.
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Affiliation(s)
- Olga Gomez‐Rojas
- Office of Occupational Health, Alexander von Humboldt Peruvian German School, Lima, Peru
| | - Adam Hafeez
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Nikhil Gandhi
- Internal Medicine Department, Ascension Health, St.John Hospital, Detroit, MI, USA
| | - Ramona Berghea
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Alexandra Halalau
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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28
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Bastola S, Kc O, Khanal S, Halalau A. Hepatitis-associated aplastic anemia from workout supplement: Rare but potentially fatal entity. SAGE Open Med Case Rep 2020; 8:2050313X20901937. [PMID: 32030129 PMCID: PMC6977214 DOI: 10.1177/2050313x20901937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 12/31/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatitis-associated aplastic anemia (HAAA) is a rare clinical syndrome characterized by bone marrow failure 1–3 months after development of hepatitis. Untreated, hepatitis-associated aplastic anemia has poor outcome and the mainstay of treatment remains either bone marrow transplant or immunosuppressive therapy. A previously healthy 21-year-old man presented with a 1-week history of right upper quadrant pain and jaundice. Admission labs revealed mixed hyperbilirubinemia and elevated transaminases ranging in 2000s IU/dl. Extensive workup for etiologies of acute hepatitis including viruses, autoimmune, toxins etc. were negative. He admitted to taking “Dust V2,” a workout supplement, for 4 months prior to the presentation. His liver function tests started to improve after conservative treatment. Two months after his discharge, he was found to have severe pancytopenia on routine labs. Bone marrow biopsy revealed hypocellular marrow consistent with aplastic anemia. Extensive workup for etiologies of aplastic anemia were negative. On literature review, none of the components of the supplement were found to cause aplastic anemia. A diagnosis of hepatitis-associated aplastic anemia was made as there was a lag time before development of anemia. His counts failed to improve despite treatment with filgrastim and he was referred for hematopoietic cell transplant.
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Affiliation(s)
- Sanjog Bastola
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Ojbindra Kc
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Sumesh Khanal
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Alexandra Halalau
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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29
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Ahmed N, Mauad VAQ, Gomez-Rojas O, Sushea A, Castro-Tejada G, Michel J, Liñares JM, Pedrosa Salles L, Candido Santos L, Shan M, Nassir R, Montañez-Valverde R, Fabiano R, Danyi S, Hassan Hosseyni S, Anand S, Ahmad U, Casteleins WA, Sanchez AT, Fouad A, Jacome A, Moura de Oliveira Paiva MS, Saavedra Ruiz AG, Grochowski RA, Toyama M, Nagi H, Sarvodelli MZ, Halalau A. The Impact of Rehabilitation-oriented Virtual Reality Device in Patients With Ischemic Stroke in the Early Subacute Recovery Phase: Study Protocol for a Phase III, Single-Blinded, Randomized, Controlled Clinical Trial. J Cent Nerv Syst Dis 2020; 12:1179573519899471. [PMID: 32009828 PMCID: PMC6974741 DOI: 10.1177/1179573519899471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 12/08/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND RATIONALE Stroke is considered the most common cause of adult disability. Intensive rehabilitation protocols outperform nonintensive counterparts. The subacute stroke phase represents a potential window to recovery. Virtual reality (VR) has been shown to provide a more stimulating environment, allowing for increased patient compliance. However, the quality of current literature comparing VR with standard therapies is limited. Our aim is to measure the impact of VR versus standard therapy on the recovery of the upper limb motor function in patients with stroke in the early subacute recovery phase. METHOD This is a randomized, controlled trial that will assign 262 patients to tailor-made standard rehabilitation (TMSR) or TMSR plus immersive VR device. The trial will be conducted in an urban rehabilitation clinic in the United States with expertise in the management of poststroke patients. Patients will be 18 to 70 years of age and in the early subacute period (30-90 days post ischemic stroke). The primary outcome will be the change of Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score, measured at baseline and 13 weeks after randomization. The secondary outcome will be the change in the UK Functional Independence Measure and Functional Assessment Measure (UK FIM-FAM) score at the same time points. DISCUSSION If the use of VR in the rehabilitation of patients with stroke proves to have a significant impact on their motor recovery, it will constitute an extremely important step into decreasing the functional impairment associated with stroke and the related health care expense burden.
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Affiliation(s)
- Nima Ahmed
- Neurology Department, Hamad Medical
Corporation, Doha, Qatar
| | | | - Olga Gomez-Rojas
- Occupational Health Department,
Alexander von Humboldt School, Lima, Peru
| | - Ammu Sushea
- Department of Anesthesia and Critical
Care, Harvard Medical School Teaching Hospital, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Gelanys Castro-Tejada
- Regional University Hospital Jose Maria
Cabral y Baez (HRUJMCB), Biomedical and Clinical Research Center (CINBIOCLI),
Santiago, Dominican Republic
| | - Janet Michel
- Health Systems and Policy Department,
University of Basel, Swiss TPH, Basel, Switzerland
| | - Juan Manuel Liñares
- Department of Pediatric Neurosurgery,
SAMIC Pediatric Hospital “Prof. Dr. Juan Pedro Garrahan,” Buenos Aires,
Argentina
| | - Loise Pedrosa Salles
- Dentistry Department, Faculty of Health
Sciences, University of Brasilia, Brasilia, Brazil
| | | | - Ming Shan
- Translational Research &
Development, TESARO, Inc., Waltham, MA, USA
| | - Rami Nassir
- Department of Pathology, School of
Medicine, Umm Al-Qura University, Mecca, Saudi Arabia
| | | | | | - Sofia Danyi
- Lusíada University Centre’s Medical
School, Santos, Brazil
| | | | - Seerat Anand
- Jawaharlal Nehru Medical College,
Belgaum, India
| | - Usman Ahmad
- Department of Pharmacology &
Therapeutics, Hamdard University, Karachi, Pakistan
| | | | | | - Ahmed Fouad
- Clinical Pharmacy Department, Hamad
Medical Corporation, Doha, Qatar
| | | | | | | | | | - Mayumi Toyama
- School of Public Health, Department of
Health Informatics, Kyoto University, Kyoto, Japan
| | - Hibatalla Nagi
- Neurology Department, Hamad Medical
Corporation, Doha, Qatar
| | | | - Alexandra Halalau
- Internal Medicine Department, Beaumont
Hospital, Royal Oak, MI, USA
- Oakland University William Beaumont
School of Medicine, Rochester, MI, USA
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30
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Farshad S, Halalau A, Townsend W, Schiopu E. Utility of Coronary Calcium Scoring (CCS) in Connective Tissue Disorders (CTDs) for the Evaluation of Subclinical Coronary Atherosclerosis - A Systematic Review. ACR Open Rheumatol 2020; 2:84-91. [PMID: 32043830 PMCID: PMC7011425 DOI: 10.1002/acr2.11107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/07/2019] [Indexed: 12/19/2022] Open
Abstract
Objective To assess the current state of knowledge for the utility of coronary calcium scoring (CCS) in connective tissue disorders (CTDs) as it relates to the presence and quantification of coronary atherosclerosis. Methods Following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, a literature search via PubMed, Embase, Scopus, Web of Science Core Collection, CINAHL, and Cochrane Database of Systematic Review retrieved 1019 studies (since database inception on May 7, 2018) from which 121 manuscripts were eligible for review. Inclusion criteria consisted of studies that investigated CCS in adults with respective CTDs. Studies were excluded if a complete manuscript was not written in English or was a case report. Results Thirty‐one studies were included (27 with healthy age‐/gender‐matched control group for comparison and 4 without). CTDs analyzed in articles with control group: 11 rheumatoid arthritis (RA), 14 systemic lupus erythematosus (SLE), 4 systemic sclerosis (SSc), 1 idiopathic inflammatory myopathies (IIM), 1 Takayasu arteritis, and 1 psoriasis. Nine out of 11 RA studies, 12 out of 14 SLE studies, and 2 out of 4 SSc studies showed statistically significant increased CCS when compared with the control group. CTDs analyzed in studies without control group: two Kawasaki disease, one juvenile idiopathic arthritis (JIA), and one antiphospholipid syndrome (APS) article, which demonstrated increased coronary arterial calcium burden, however, without statistically significant data. Conclusion CTDs, especially SLE and RA, are associated with higher CCS compared with the control group, indicating increased risk of coronary atherosclerosis. Our search did not elicit sufficient publications or statistically significant results in many other CTDs.
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Affiliation(s)
| | - Alexandra Halalau
- Beaumont Health System, Royal Oak, Michigan, and Oakland University William Beaumont School of Medicine, Rochester, Michigan
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31
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Edupuganti S, Bushman J, Maditz R, Kaminoulu P, Halalau A. A quality improvement project to increase compliance with diabetes measures in an academic outpatient setting. Clin Diabetes Endocrinol 2019; 5:11. [PMID: 31367465 PMCID: PMC6651972 DOI: 10.1186/s40842-019-0084-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 07/08/2019] [Indexed: 11/10/2022] Open
Abstract
Background American Diabetes Association (ADA) sets annual guidelines on preventative measures that aim to delay the onset of severe diabetes mellitus complications. Compared to private internal medicine clinics, resident clinics provide suboptimal diabetic preventative care as evidenced by decreased compliance with ADA guidelines. The purpose of our study is to improve diabetic care in resident clinics through quality improvement (QI) projects, with A1C value as primary outcome and other ADA guidelines as secondary outcomes. Methods Our resident clinic at Beaumont Hospital, Royal Oak consists of 76 residents divided in 8 teams. In November 2016, baseline data on ADA guideline measures was obtained on 538 patients with diabetes mellitus. A root cause analysis was conducted. 5 teams developed a QI intervention plan to improve their diabetes care and 3 teams served as comparisons without intervention plans. In November 2017, post-intervention data was collected. Results Baseline characteristics demonstrate mean age of intervention groups at 60.9 years and of comparison groups at 58.9 years. The change in A1C value from baseline to post-intervention was + 0.09 vs. + 0.322 in the intervention and comparison groups respectively (p = 0.174). As a group, the changes in secondary outcome measures were as follows: eye examinations (+ 5% in intervention vs. -7% in comparison, p < 0.01), foot examinations (+ 13% vs. + 5%, p = 0.09), lipid panel testing (+ 7% vs. -5%, p < 0.01), micro-albumin/creatinine ratio testing (+ 4% vs. + 1%, p = 0.03), and A1C testing (+8% vs. + 5%, p = 0.24). Conclusions While the QI project did not improve A1C value, it did have significant improvement in several secondary outcomes within intervention groups. One resident team implemented an intervention involving protected half-day blocks to identify overdue examinations and consequently had the largest improvements, thus serving as a potential intervention to further study. Given our study results, we believe that QI interventions improve preventative care for patients with diabetes in resident clinics.
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Affiliation(s)
- Subhash Edupuganti
- 1Oakland University William Beaumont School of Medicine, 3601 W 13 Mile Rd, Royal Oak, Michigan, Rochester Hills, MI 48073 USA
| | - Jordan Bushman
- 2Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI USA
| | - Rhyan Maditz
- 3Department of Nephrology, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Pradeep Kaminoulu
- 1Oakland University William Beaumont School of Medicine, 3601 W 13 Mile Rd, Royal Oak, Michigan, Rochester Hills, MI 48073 USA.,2Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI USA
| | - Alexandra Halalau
- 1Oakland University William Beaumont School of Medicine, 3601 W 13 Mile Rd, Royal Oak, Michigan, Rochester Hills, MI 48073 USA.,2Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI USA
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Yadav S, Hartkop S, Cardenas PY, Ladkany R, Halalau A, Shoichet S, Maddens M, Zakalik D. Utilization of a breast cancer risk assessment tool by internal medicine residents in a primary care clinic: impact of an educational program. BMC Cancer 2019; 19:228. [PMID: 30871497 PMCID: PMC6416938 DOI: 10.1186/s12885-019-5418-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2019] [Indexed: 01/11/2023] Open
Abstract
Background Despite strong evidence of benefit, breast cancer risk assessment and chemoprevention are underutilized by primary care physicians. This study evaluates the impact of an educational program on knowledge and utilization of the NCI Breast Cancer Risk Assessment Tool (BCRAT) by internal medicine residents. Methods Internal medicine residents at the primary care clinic at William Beaumont Hospital participated in an educational program on breast cancer risk assessment and chemoprevention. A questionnaire was used to assess knowledge and practice before and after participation. Electronic health records of women between the ages of 35 and 65 who were seen by participating residents for annual health exams between Dec 15, 2015 and Dec 14, 2016 were reviewed. Utilization of BCRAT by the residents was compared pre- and post-educational program. Results A total of 43 residents participated in the study. 31 (72.1%) residents reported no prior knowledge about BCRAT. The remaining 12 (27.9%) reported limited knowledge of BCRAT, but the majority of these (n = 10, 83.3%) had not used it in the last six months. For each question on the pre-educational knowledge assessment, fewer than 10% of the residents responded correctly. After implementation of the educational program, there was a significant increase in the proportion of residents who answered correctly (Range: 67 to 100%, p < 0.001). Electronic health records of 301 clinic patients were reviewed, 118 (39.2%) in the pre-educational program group and 183 (60.8%) in the post-educational program group. There was a higher use of BCRAT in the post-educational program group compared to the pre-intervention group (3.8% vs. 0%, p < 0.05). However, a majority (n = 294, 98.7%) of eligible patients from both groups did not undergo breast cancer risk assessment. Conclusions Our study demonstrates that an educational intervention improved residents’ knowledge of BCRAT. Despite this improvement, a significant proportion of patients did not undergo breast cancer risk assessment. Expanding the scope and duration of this intervention and combining it with innovative use of technology to improve utilization should be the subject of future investigation. Electronic supplementary material The online version of this article (10.1186/s12885-019-5418-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Siddhartha Yadav
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sarah Hartkop
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Paola Yumpo Cardenas
- Nancy and James Grosfeld Cancer Genetics Center, Beaumont Cancer Institute, Beaumont Health, 3577 W 13 Mile Rd, Suite 140, Royal Oak, MI, 48073, USA
| | - Rand Ladkany
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Nancy and James Grosfeld Cancer Genetics Center, Beaumont Cancer Institute, Beaumont Health, 3577 W 13 Mile Rd, Suite 140, Royal Oak, MI, 48073, USA
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA
| | - Sandor Shoichet
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA
| | - Michael Maddens
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA
| | - Dana Zakalik
- Nancy and James Grosfeld Cancer Genetics Center, Beaumont Cancer Institute, Beaumont Health, 3577 W 13 Mile Rd, Suite 140, Royal Oak, MI, 48073, USA. .,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA.
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Aneese AM, Nasr JA, Halalau A. A prospective mixed-methods study evaluating the integration of an evidence based medicine curriculum into an internal medicine residency program. Adv Med Educ Pract 2019; 10:533-546. [PMID: 31413652 PMCID: PMC6659792 DOI: 10.2147/amep.s203334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/08/2019] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Evidence based medicine (EBM) skills are often lacking in the general internal medicine physician population. Our aim is to evaluate the impact of our internal medicine EBM curriculum on the residents' EBM skills and knowledge through mixed methods. METHODS A prospective study was performed that evaluated the EBM curriculum: quantitatively, with pre/posttests and qualitatively through a focus group that addressed residents' opinion on the educational and clinical impact of each aspect of the curriculum. RESULTS A total of 60 internal medicine residents were surveyed. Short-term EBM skills: therapy workshops (N=25) median pretest score of 8 (IQR): [6-9]) vs posttest 8 (IQR: [8-9]), (p=0.006); diagnosis (N=16) pretest score of 6 (IQR: [3-6]) vs posttest 7 (IQR: [6-9]), (p=0.006); systematic review (N=13) pretest score of 4 (IQR: [4-6]) vs posttest 7 (IQR: [6-8]), (p=0.002); and harm (N=16) pretest score of 6 (IQR: [5-7]) vs posttest 7 (IQR: [7-8]), (p=0.004). Long-term EBM skills: Fresno test of competence in EBM, pretest median score of 110.5/212 (IQR: 96.0-124.0) and a median posttest score of 115/212 (IQR: 100.0-130.0) (p=0.60). Having previous EBM training, being actively involved in research and being the first author on a publication was associated with higher Fresno test scores. Focus group provided qualitative feedback on the residents' EBM curriculum perception. CONCLUSION This curriculum adds a significant contribution to the current field of medical education as it fills an important educational gap, through defining ways of effectively delivering EBM concepts which led to improvement in residents' ability to evaluate and apply medical literature. The EBM curriculum was overall well received by the residents.
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Affiliation(s)
- Andrew M Aneese
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI48073, USA
| | - Justine A Nasr
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI48073, USA
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI48309, USA
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI48073, USA
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI48309, USA
- Correspondence: Alexandra HalalauDepartment of Internal Medicine, Beaumont Health, 3601 W 13 Mile Road, Royal Oak, Michigan, USATel +1 248 551 3481Email
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Halalau A, Shelden D, Keeney S, Hehar J. Pharm-MD; an open-label, randomized controlled, phase II study to evaluate the efficacy of a pharmacist-managed diabetes clinic in high-risk diabetes patients - study protocol for a randomized controlled trial. Trials 2018; 19:458. [PMID: 30143033 PMCID: PMC6109355 DOI: 10.1186/s13063-018-2836-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 08/02/2018] [Indexed: 11/26/2022] Open
Abstract
Background Millions of Americans are currently living with diabetes and approximately 1.5 million cases are being diagnosed each year. Diabetes is now the seventh leading cause of death in the United States. In addition, the economic burden of the disease has resulted in billions of dollars in health care costs. In spite of these investments, the United States lags behind other developed countries on diabetes life expectancy and disease-related deaths. The purpose of this study is to assess the impact of a pharmacist-managed diabetes clinic (PMDC) model on diabetes core measures. Our hypothesis is that a PMDC would have a significant positive impact on the diabetes measures and will result in higher-quality care at a lower price. Methods This study is a randomized, open-label, controlled, parallel-group trial which will be conducted in the outpatient clinic at Beaumont Hospital, Royal Oak, Michigan. Patients will be randomly assigned to one of two groups: standard of care (SOC) or standard of care plus PMDC (SOC + PMDC). Included in the study will be patients older than 18 years of age with a diagnosis of type 2 diabetes mellitus and a hemoglobin A1c ≥ 9%, who are established with a primary care resident and who have not been seen in the PMDC within the last 3 months. The primary outcome is the change in hemoglobin A1c, measured at 6 and 12 months. Secondary outcomes include the impact on all diabetes core measures, patient quality of life, harms, and cost impact related to the intervention. Discussion If the results of this trial are consistent with the previous retrospective analysis that a pharmacy clinic has a significant impact in controlling hemoglobin A1c levels as well as other diabetes core measures to improve clinical outcomes, it will constitute a scaffold for a future multicenter, randomized controlled trial. In addition, these results may influence future diabetes guidelines, leading to the inclusion of a PMDC as the standard of care. The impact of these results on the economic burden, life expectancy, and diabetes-related deaths are needed and have yet to be studied. Trial registration ClinicalTrials.gov, ID: NCT03377127. Protocol version: registered on 10 February 2018; version #1. Electronic supplementary material The online version of this article (10.1186/s13063-018-2836-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra Halalau
- Beaumont Health, Royal Oak, MI, USA. .,Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | | | - Scott Keeney
- Beaumont Health, Royal Oak, MI, USA.,Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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Nasr JA, Falatko J, Halalau A. The impact of critical appraisal workshops on residents' evidence based medicine skills and knowledge. Adv Med Educ Pract 2018; 9:267-272. [PMID: 29713212 PMCID: PMC5912372 DOI: 10.2147/amep.s155676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To assess the impact of four evidence based medicine (EBM) critical appraisal education workshops in improving residents' EBM knowledge and skills. METHODS The eligible participants in the workshops were 88 residents-in-training, postgraduate years one through four, rotating through the outpatient internal medicine clinic. Four EBM workshops, consisting of 3 days each (30 minutes daily), were taught by our faculty. Topics covered included critical appraisal of randomized controlled trials, case-control and cohort studies, diagnosis studies, and systematic reviews. RESULTS As a program evaluation, anonymous pre-workshop and post-workshop tests were administered. Each of the four sets of tests showed improvement in scores: therapy from 58% to 77% (42% response rate), harm from 65% to 73% (38% response rate), diagnosis from 49% to 68% (49% response rate), and systematic review from 57% to 72% (30% response rate). CONCLUSION We found that teaching EBM in four short workshops improved EBM knowledge and critical appraisal skills related to the four topics.
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Affiliation(s)
- Justine A Nasr
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
- Internal Medicine Department, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - John Falatko
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
| | - Alexandra Halalau
- Internal Medicine Department, Beaumont Hospital, Royal Oak, MI, USA
- Internal Medicine Department, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Aneese NJ, Halalau A, Muench S, Shelden D, Fett J, Lauster C. Impact of a pharmacist-managed diabetes clinic on quality measures. Am J Manag Care 2018; 24:SP116-SP119. [PMID: 29689147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Aultman W, Fett J, Lauster C, Muench S, Halalau A. Urine Drug Test Interpretation: An Educational Program's Impact on Resident Knowledge and Comfort Level. MedEdPORTAL 2018; 14:10684. [PMID: 30800884 PMCID: PMC6342351 DOI: 10.15766/mep_2374-8265.10684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/10/2018] [Indexed: 06/09/2023]
Abstract
Introduction Following the release of the Centers for Disease Control and Prevention guidelines in 2016, institutions are encouraged to have controlled substance agreements that require the use of drug screens for appropriate opioid prescribing. Correct evaluation of urine drug tests (UDTs) is essential for appropriate chronic prescribing of controlled substances. Anticipating the increase in use of these tests, our institution developed and implemented an educational program to improve knowledge of and comfort level with UDT interpretation. Methods The educational program was 30 minutes in duration and consisted of a PowerPoint presentation followed by informal discussion. All internal medicine and medicine/pediatrics residents were encouraged to attend. A survey assessing knowledge of and comfort level with interpreting UDTs before, immediately after, and 2 months following the educational program was used as an assessment tool. Results A total of 44 out of 76 residents at our institution attended the educational program. The majority (81.8%) had no prior education on UDT interpretation; however, most (97.7%) stated they interpreted UDTs monthly, and 22.7% had refused refills within the prior month based on UDT results. Change in residents' knowledge and change in residents' comfort were both found to be significantly increased following the educational program (p < .0001 for both variables). Discussion Significant increases in both comfort with and knowledge of UDT interpretation occurred following the educational program provided for medical residents, which supports its expansion to other institutions as an easy and effective means of promoting appropriate UDT evaluation.
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Affiliation(s)
- Whitney Aultman
- Clinical Pharmacist, State of Franklin Healthcare Associates
- Assistant Professor, East Tennessee University Bill Gatton College of Pharmacy
| | - Janna Fett
- Ambulatory Care Residency Director, Department of Pharmaceutical Services, Beaumont Hospital
- Ambulatory Care Clinical Pharmacy Specialist, Department of Pharmaceutical Services, Beaumont Hospital
| | - Colleen Lauster
- Ambulatory Care Clinical Pharmacy Specialist, Department of Pharmaceutical Services, Beaumont Hospital
| | - Sarah Muench
- Ambulatory Care Clinical Pharmacy Specialist, Department of Pharmaceutical Services, Beaumont Hospital
| | - Alexandra Halalau
- Internal Medicine Section Head, Beaumont Hospital
- Research Director, Beaumont Hospital
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Abstract
A 39-year-old woman with a history of chronic back pain due to spinal haemangiomas, multiple malignancies and depression was brought by Emergency medical servicesS to the emergency centre (EC) after being found unresponsive on the bathroom floor. The patient had an exacerbation of her back pain the previous day for which she admitted to taking double her usual dose of oxycodone, in addition to alprazolam, lorazepam, diphenhydramine and a glass of wine. She reported that she lost consciousness and was down for over 8 hours. In the EC, she complained of right forearm pain which was accompanied by mild diffuse soft-tissue swelling and decreased sensation in the right hand. Radial pulse was intact. Creatine kinase was found to be at 4663 U/L. The patient was found to have acute compartment syndrome and underwent emergent forearm fasciotomy. She eventually regained full function of the right arm.
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Affiliation(s)
- Ahmad Said
- Internal Medicine, Beaumont Health System, Royal Oak, Michigan, USA
| | - Alexandra Halalau
- Internal Medicine, Beaumont Health System, Royal Oak, Michigan, USA
- Internal Medicine, Oakland University, Rochester, Michigan, USA
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Rezaee ME, Ward CE, Nuanez B, Rezaee DA, Ditkoff J, Halalau A. Examining 30-day COPD readmissions through the emergency department. Int J Chron Obstruct Pulmon Dis 2017; 13:109-120. [PMID: 29343950 PMCID: PMC5749550 DOI: 10.2147/copd.s147796] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Thirty-day readmission in COPD is common and costly, but potentially preventable. The emergency department (ED) may be a setting for COPD readmission reduction efforts. Objective To better understand COPD readmission through the ED, ascertain factors associated with 30-day readmission through the ED, and identify subgroups of patients with COPD for readmission reduction interventions. Patients and methods A retrospective cohort study was conducted from January 2009 to September 2015 in patients with COPD of age ≥18 years. Electronic health record data were abstracted for information available to admitting providers in the ED. The primary outcome was readmission through the ED within 30 days of discharge from an index admission for COPD. Logistic regression was used to examine the relationship between potential risk factors and 30-day readmission. Results The study involved 1,574 patients who presented to the ED within 30 days on an index admission for COPD. Of these, 82.2% were readmitted through the ED. Charlson score (odds ratio [OR]: 3.6; 95% CI: 2.9–4.4), a chief complaint of breathing difficulty (OR: 1.6; 95% CI: 1.1–2.6), outpatient utilization of albuterol (OR: 4.1; 95% CI: 2.6–6.4), fluticasone/salmeterol (OR: 2.3; 95% CI: 1.3–4.2), inhaled steroids (OR: 3.8; 95% CI: 1.3–10.7), and tiotropium (OR: 1.8; 95% CI: 1.0–3.2), as well as arterial blood gas (OR: 4.4; 95% CI: 1.3–15.1) and B-type natriuretic peptide (OR: 2.2; 95% CI: 1.4–3.5) testing in the ED were associated with readmission (c-statistic =0.936). Seventeen-point-eight percent of patients with COPD presented to the ED and were discharged home; 56% presented with a complaint other than breathing difficulty; and 16% of those readmitted for breathing difficulty had a length of stay <48 hours. Conclusion Intensive outpatient monitoring, evaluation, and follow-up after discharge are needed to help prevent re-presentation to the ED, as practically all patients with COPD who represent to the ED within 30 days are readmitted to the hospital and for a variety of clinical complaints. Among those patients with COPD who present with breathing difficulty, improved decision support algorithms and alternative management strategies are needed to identify and intervene on the subgroup of patients who require <48-hour length of stay.
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Affiliation(s)
- Michael E Rezaee
- Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Charlotte E Ward
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University.,Center for Health Statistics, University of Chicago, Chicago, IL
| | - Bonita Nuanez
- Oakland University William Beaumont School of Medicine, Rochester, MI
| | | | - Jeffrey Ditkoff
- Oakland University William Beaumont School of Medicine, Rochester, MI.,Emergency Medicine
| | - Alexandra Halalau
- Oakland University William Beaumont School of Medicine, Rochester, MI.,Internal Medicine, Beaumont Health, Royal Oak, MI, USA.,Internal Medicine, Beaumont Health, Royal Oak, MI, USA
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Lohani S, Golenbiewski J, Swami A, Halalau A. A unique case of nephrogenic systemic fibrosis from gadolinium exposure in a patient with normal eGFR. BMJ Case Rep 2017; 2017:bcr-2017-221016. [PMID: 29025775 PMCID: PMC5652398 DOI: 10.1136/bcr-2017-221016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2017] [Indexed: 11/04/2022] Open
Abstract
A 57-year-old woman presented with swelling and thickening of the skin of the lower extremities. Three months prior to presentation, patient had MRI with gadolinium as part of an evaluation for suspected pancreatic malignancy. Creatinine levels at the time of gadolinium exposure were 0.9-1.2 mg/dL, with a corresponding estimated glomerular filtration rate of 64 mL/min/1.73m2 by modification of diet in renal disease equation. Twenty-four-hour urine creatinine clearance was performed as an outpatient following development of symptoms. This revealed a creatinine clearance of 23 mL/min, suggestive of advanced chronic kidney disease despite an estimated glomerular filtration rate of 64 mL/min/1.73m2 Skin biopsy was positive for sclerosing dermopathy. These findings, in addition to the temporal association with gadolinium exposure, led to the diagnosis of nephrogenic systemic fibrosis.
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Affiliation(s)
- Sadichhya Lohani
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Jon Golenbiewski
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Abhishek Swami
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
- Department of Nephrology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Alexandra Halalau
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
- Oakland University, William Beaumont School of Medicine, Rochester, Michigan, USA
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Affiliation(s)
- Scott Keeney
- Internal Medicine, Beaumont Health System, Royal Oak, Michigan, USA
| | - Alexandra Halalau
- Beaumont Health System, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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Merchan-Del Hierro X, Halalau A. Cytomegalovirus-related transverse myelitis in an immunocompetent host: a subacute onset of an immune-mediated disease? BMJ Case Rep 2017; 2017:bcr-2017-220563. [PMID: 28801328 DOI: 10.1136/bcr-2017-220563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of transverse myelitis in an immunocompetent host with an atypical long onset of symptoms. A 56-year-old man was admitted to the hospital reporting 5 months of progressive ascending lower extremity weakness and numbness, inability to walk, bowel incontinence,urinary retention and several episodes of nausea and vomiting. MRI showed moderate spinal swelling and multiple hyperintense signal changes on cervical levels C2-C5 and thoracic levels T1-T3. Cerebrospinal fluid (CSF) showed pleocytosis and was positive for anti-cytomegalovirus (CMV) IgG intrathecal antibodies, but the CSF PCR for CMV was negative. The diagnosis of immune-mediated CMV-related transverse myelitis was established and the patient was treated with methylprednisolone and valgancyclovir. The patient had poor recovery and remained paraplegic at discharge.
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Affiliation(s)
| | - Alexandra Halalau
- Internal Medicine Department, Beaumont Hospital, Royal Oak, Michigan, USA
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Mi M, Halalau A. A pilot study exploring the relationship between lifelong learning and factors associated with evidence-based medicine. Int J Med Educ 2016; 7:214-9. [PMID: 27372836 PMCID: PMC4939218 DOI: 10.5116/ijme.576f.a2ca] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 02/25/2016] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To explore possible relationships between residents' lifelong learning orientation, skills in practicing evidence-based medicine (EBM), and perceptions of the environment for learning and practicing EBM. METHODS This was a pilot study with a cross-sectional survey design. Out of 60 residents in a medical residency program, 29 participated in the study. Data were collected using a survey that comprised three sections: the JeffSPLL Scale, EBM Environment Scale, and an EBM skill questionnaire. Data were analyzed using SPSS and were reported with descriptive and inferential statistics (mean, standard deviation, Pearson's correlation, and a two-sample t-test). RESULTS Mean scores on the JeffSPLL Scale were significantly correlated with perceptions of the EBM Scale and use of EBM resources to keep up to date or solve a specific patient care problem. There was a significant correlation between mean scores on the EBM Scale and hours per week spent in reading medical literature to solve a patient care problem. Two-sample t-tests show that residents with previous training in research methods had significantly higher scores on the JeffSPLL Scale (p=0.04), EBM Scale (p=0.006), and self-efficacy scale (p =0.024). CONCLUSIONS Given the fact that physicians are expected to be lifelong learners over the course of their professional career, developing residents' EBM skills and creating interventions to improve specific areas in the EBM environment would likely foster residents' lifelong learning orientation.
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Affiliation(s)
- Misa Mi
- Department of Biomedical Sciences, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Alexandra Halalau
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
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