Hospitalist perspective on pandemic related clinical and administrative changes: a cross sectional survey study

OBJECTIVE

Hospitalists have played a leading role in caring for hospitalized COVID-19 patients. Many clinical and administrative changes occurred in hospitals to meet the varied pandemic needs. We surveyed hospitalists to understand their perspective on pandemic-related changes in technology, models of care, administration and leadership, impact on personal lives, and which of these changes should be continued versus reverting to pre-pandemic practices.

METHODS

A 30-question survey was distributed to hospitalists working across the United States between April 6, 2022 to May 16, 2022. Baseline demographics were measured, and post-pandemic perspectives related to changes were analyzed. Perspectives were measured using a 5-point Likert scale and responses were categorized into "agree" and "did not agree" for analysis. Variation was assessed using Chi-square or Fisher exact tests. Open-ended questions were reported following qualitative content analysis organized into themes and reported as frequency.

RESULTS

177 respondents (39%) completed the survey. Nearly three-fourths favored hybrid meetings, and two-thirds preferred to continue new models of care. Nearly 90% desired more family and leisure time, continued wellness, and support services, and resumption of social gatherings. No major differences in perspectives were noted between hospitalists at teaching facilities and non-teaching facilities except for resuming protected time for non-clinical activities in those from teaching facilities (83.0% vs 62.5%). Respondents less than age 50 were more likely to prefer virtual meetings (59.0% vs 31.3%). Content analysis of open-ended questions resulted in different themes for each question. Respondents favored more work-life balance and less administrative and logistical work burden.

CONCLUSIONS

Hospitalists preferred to continue the use of technology and new models of care even in the post-pandemic period and express a desire for more work-life balance and less administrative and logistical work burden.

SPEAKers at the National Society of Hospital Medicine Meeting: A Follow-UP Study of Gender Equity for Conference Speakers from 2015 to 2019. The SPEAK UP Study

Women continue to be underrepresented as speakers at national conferences, and research has shown similar trends in hospital medicine. The Society of Hospital Medicine (SHM) Annual Meeting has historically had an open call peer review process for workshop speakers and, in 2019, expanded the process for didactic speakers. We aimed to assess the overall conference trends for women speakers and whether the systematic processes in recruitment procedures (ie, open call) resulted in improved representation of women speakers. We also sought to understand how the proportion of women speakers might affect overall scores of the conference. From 2015 to 2019, the overall representation of women speakers increased, as did evaluation scores during the same time period. When selection processes included the open call peer review process, there were higher proportions of women speakers. An open call process with peer review for speakers may be a systematic process that national meetings could replicate to reduce gender inequities.

Short communication: Predictors of time to dairy calf bucket training

The time required to adequately bucket-train a dairy calf to drink its milk allotment is unknown. Additionally, factors that could predict calves who are slow to learn have not been identified. A prospective observational study was conducted to describe timing of bucket training and possible calf birth and colostrum quality factors that might predict calves requiring extra time to train. On one dairy farm, 1,235 calves were enrolled at birth in a prospective cohort study. Calving ease score, calf presentation at birth, twinning, calf sex, and dam parity were recorded by farm personnel. An as-fed colostrum sample for each calf was collected and evaluated for total solids, total plate bacterial count, and coliform bacterial count. Calf serum total protein values were obtained by d 2 to 3 of life. Calves were observed before the morning milk feeding for attitude/posture, and after feeding for assistance needed to drink milk from their bucket. Attitude/posture was significantly associated with whether a calf required assistance or not. Almost 60% (n = 724) of calves consumed their morning milk allotment (2 L) after d 3 of life without assistance. Significant factors associated with the odds of requiring assistance with drinking after 3 d of age included calf sex, being born a twin, and the week the calf was enrolled. Knowing how long it takes to train a calf to drink from a bucket could be useful in allocating the time or labor required to successfully train calves.

Remote monitoring of nuclear power plants in Baden-Wuerttemberg

As part of its responsibilities as nuclear supervisory authority, the Ministry of the Environment, Climate Protection and the Energy Sector Baden-Wuerttemberg (UM) operates a computer-based system for remote monitoring of nuclear power plants (NPPs) (KFUe, Kernreaktor-Fernüberwachung). In addition to the Baden-Wuerttemberg NPPs located at Philippsburg, Neckarwestheim and the disused Obrigheim, those in foreign locations close to the border area, i.e. Fessenheim in France, and Leibstadt and Beznau in Switzerland, are monitored. The KFUe system provides several methods to evaluate and present the measured data as well as to ensure compliance of threshold limits and safety objectives. For the UM, it serves as an instrument of the nuclear supervision. In case of a radioactive release, the authorities responsible for civil protection can use dispersion calculations in order to identify potentially affected areas and to initiate protective measures for the population. Beyond the data collected at the plant sites, various international radiation and meteorological measuring networks are integrated in the KFUe. The State Institute for Environment, Measurements and Nature Protection (LUBW), the technical operator of the KFUe, runs its own special monitoring network for ambient gamma dose rate and nuclide specific activity concentration measurements in the vicinity of each NPP. This article gives an overview of the solution to combine data of different sources on a single screen: dose rate networks, dose rate traces measured by car, airborne gamma spectra of helicopters, mobile dose rate probes, grid data of weather forecasts, dispersion calculations, etc.

Determination and evaluation of the radiological situation using mobile measurements during the ground phase

The nuclear reactor remote monitoring system of the state of Baden-Württemberg (Kernreaktor-Fernüberwachung Baden-Württemberg – KFÜ BW) is implemented according to the recently renewed “recommendations for remote monitoring of nuclear power plants”. In Baden-Württemberg, the application area of the system covers both, the surveillance of internal procedures on one hand, and the handling of incidents or accidents on the other. The following paper shows the role of the KFÜ regarding the determination and evaluation of the radiological situation in the range of off-site emergency response. Progress is reported on the measurement conception and the technical possibilities for the investigation of the radiological situation after the end of the deposition of radio nuclides (ground phase).

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

OBJECTIVE

To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence.

METHODS

71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging.

RESULTS

Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%).

CONCLUSION

The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.

ADVANCES IN KNOWLEDGE

Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

Comparison of image quality, diagnostic confidence and interobserver variability in contrast enhanced MR angiography and 2D time of flight angiography in evaluation of carotid stenosis

The aim of this study was to compare image quality, level of diagnostic confidence and interobserver agreement in assessment of carotid stenosis with contrast enhanced MR angiography (CE MRA) in comparison with 2D time of flight MR angiography (2D TOF MRA). 60 carotid arteries in 30 patients were examined by three observers. Image quality and diagnostic confidence were assessed on the basis of a visual analogue scale. Interobserver variability was assessed with the help of intraclass correlation coefficient. Median values on the visual analogue scale for image quality and diagnostic confidence were higher for CE MRA compared with 2D TOF MRA for all three observers. Higher intraclass correlation values were recorded for interobserver variability for CE MRA compared with 2D TOF MRA both for visual estimation of carotid stenosis as well as for measurement of carotid stenosis on the basis of North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) criteria. CE MRA provides better image quality, higher level of diagnostic confidence and more interobserver agreement compared with 2D TOF MRA.

Crustacean hyperglycaemic hormone (CHH)-like peptides and CHH-precursor-related peptides from pericardial organ neurosecretory cells in the shore crab, Carcinus maenas, are putatively spliced and modified products of multiple genes

About 24 intrinsic neurosecretory neurons within the pericardial organs (POs) of the crab Carcinus maenas produce a novel crustacean hyperglycaemic hormone (CHH)-like peptide (PO-CHH) and two CHH-precursor-related peptides (PO-CPRP I and II) as identified immunochemically and by peptide chemistry. Edman sequencing and MS revealed PO-CHH as a 73 amino acid peptide (8630 Da) with a free C-terminus. PO-CHH and sinus gland CHH (SG-CHH) share an identical N-terminal sequence, positions 1-40, but the remaining sequence, positions 41-73 or 41-72, differs considerably. PO-CHH may have different precursors, as cDNA cloning of PO-derived mRNAs has revealed several similar forms, one exactly encoding the peptide. All PO-CHH cDNAs contain a nucleotide stretch coding for the SG-CHH(41-76) sequence in the 3'-untranslated region (UTR). Cloning of crab testis genomic DNA revealed at least four CHH genes, the structure of which suggest that PO-CHH and SG-CHH arise by alternative splicing of precursors and possibly post-transcriptional modification of PO-CHH. The genes encode four exons, separated by three variable introns, encoding part of a signal peptide (exon I), the remaining signal peptide residues, a CPRP, the PO-CHH(1-40)/SG-CHH(1-40) sequences (exon II), the remaining PO-CHH residues (exon III) and the remaining SG-CHH residues and a 3'-UTR (exon IV). Precursor and gene structures are more closely related to those encoding related insect ion-transport peptides than to penaeid shrimp CHH genes. PO-CHH neither exhibits hyperglycaemic activity in vivo, nor does it inhibit Y-organ ecdysteroid synthesis in vitro. From the morphology of the neurons it seems likely that novel functions remain to be discovered.

Antioxidant nutrient supplementation reduces the susceptibility of low density lipoprotein to oxidation in patients with coronary artery disease

OBJECTIVE

This study sought to determine the effect of antioxidant supplementation on the susceptibility of low density lipoprotein (LDL) to oxidation in patients with established cardiovascular disease (CVD).

BACKGROUND

Data are inconsistent regarding the role of antioxidant nutrients in the prevention of CVD.

METHODS

The study design was a 12-week, double-blind, placebo-controlled clinical trial. Patients with CVD (n = 45) were randomized to 1) placebo control; 2) 400 IU of vitamin E, 500 mg of vitamin C, 12 mg of beta-carotene (mid-dose); or 3) 800 IU of vitamin E, 1,000 mg of vitamin C, 24 mg of beta-carotene (high dose) daily. Reduced susceptibility of LDL to oxidation was estimated by an increase in lag phase (minutes). Baseline and 6- and 12-week measurements of lipoproteins and lag phase were obtained. Plasma levels of antioxidants were measured at baseline and 12 weeks.

RESULTS

Concentrations of alpha-tocopherol, vitamin C and beta-carotene significantly increased in the mid- and high dose groups during the trial. Lag phase significantly increased from baseline (190.1 +/- 63.8 min [mean +/- SD]) to 12 weeks (391.1 +/- 153.0 min) in the high dose group (p < 0.01). A nonsignificant increase in lag phase in the mid-dose group was observed during the same time interval. A dose response was found for mean percent change from baseline to 12 weeks for lag phase for the placebo, mid- and high dose groups (p = 0.004 for trend).

CONCLUSIONS

A high dose combination of antioxidant nutrients reduces the susceptibility of LDL to oxidation in patients with CVD and may be useful in secondary prevention.

Influence of spontaneous calcium intake and physical exercise on the vertebral and femoral bone mineral density of children and adolescents

Peak bone mass is determined mainly by genetic-ethnic factors, but environmental factors such as calcium intake and physical activity during childhood and adolescence could play a role. We have measured the bone mineral density (BMD) of 151 healthy children and adolescents, ages 7-15.3 years. Density was measured by dual X-ray absorptiometry (DXA) at two sites (lumbar verterbrae L1-L4 and the upper femur), and the data were analyzed in terms of the height, weight, sexual maturation, spontaneous calcium intake, and physical activity. Of the children, 57-71% had calcium intakes below 1000 mg/day. BMD increased with pubertal maturation from 0.68 +/- 0.08 to 0.92 +/- 0.09 g/cm2 (vertebral bone density, VBD) and from 0.87 +/- 0.10 to 1.03 +/- 0.09 g/cm2 (femoral bone density, FBD) between Tanner stage 1 and 5. Multiple regression analysis showed that body weight and Tanner stage were main determinants of bone density when expressed as g/cm2. The weekly duration of sports activity also influenced both the vertebral (p < 0.001) and femoral (p = 0.01) sites, especially in girls and during puberty. Dietary calcium appeared to be another independent determinant of BMD, especially before puberty, at the vertebral (p = 0.02) site. Most important, dietary calcium was found to be the main determinant of vertebral mineral density, when expressed as z score, in both sexes. Moreover, 93% of the 28 children with low vertebral z score values (below -1) and 84% of the 31 children with low femoral z score values (below -1) had dietary calcium intakes below 1000 mg/day.

Case report: fatal pulmonary Kaposi's sarcoma and Castleman's disease in a renal transplant recipient

Two unusual complications of immunosuppression, Castleman's disease and Kaposi's sarcoma, occurring in a renal transplant recipient, are reported. Kaposi's sarcoma is a potentially curable condition in immunosuppressed patients if recognized and treated appropriately. In this patient, the pulmonary Kaposi's sarcoma was not diagnosed and this lead to the patient's death.

[Aptitude for sports in children operated on for aortic coarctation. Contribution of the exercise test]

Pronouncing on the fitness of children operated upon for coarctation of the aorta to practise sports, as well as on the nature and level of this activity, depends, to a great extent, upon their blood pressure profile at exercise (BPE) as measured by an exercise test on an ergometric bicycle. We studied thi profile in 43 children aged 11.7 +/- 2.5 years who had undergone surgery for coarctation of the aorta (isolated in 93 p. 100 of the cases) at the age of 3.8 +/- 3.2 years Systolic arterial pressure (SAP) in the upper limbs was normal at rest in 80p. 100 of the children but reached abnormal values at exercise in 81 p. 100 and even exceeded 200 mmHg in 16 p. 100. Diastolic arterial pressure (DAP) in the upper limbs was sometimes slightly elevated at rest, but it clearly decreased at exercise and became normal in all cases. This suggested that systolic hypertension at exercise was due to low peripheral resistance and either to an exercise-induced isthmic gradient or to a poor vascular impedance. As a result of this study, we warn such children against playing sports with a strong static stress (e.g. martial sports) or with a risk of thoracic trauma (e.g. rugby). For the other sports, we make no reservation when the BPE is normal, and we forbid competitions when the BPE is abnormal but the SAP at exercise remains below 200 mmHg. Beyond this value, children must be investigated for residual coarctation of the aorta which may be amenable to a specific treatment.

[Acute leukemia in Fanconi's anemia. Report of a patient and review of the literature]

A case is reported of a 7 years old boy with Fanconi's Anemia (FA). The aplastic anemia has been treated with androgens. Six years after the confirmation of the diagnosis FA a (pre-)leukemia occurred. Because of the known complications of cytostatics in FA and the bad prognosis, the leukemia has not been treated. The boy died 4 months later. An overview of the literature shows 31 patients with acute non-lymphocytic leukemia in FA, of which the clinical course, chromosomal investigations and therapy are discussed.

[Left ventricular function and cardiovascular adaptation to exercise in young sportsmen]

In order to find out whether the expression "sports heart" can be used in children and if so, to give an objective definition of it, we studied a group of 40 young people (mean age 12.2 +/- 1.6 years) subjected to intensive training and practising sports regularly, i.e. about 12 hours of physical activity per weeks on average. The sports practised were mainly tennis among boys and ice-skating among girls. A group of 40 subjects with similar characteristics but no particular physical training was studied simultaneously and served as control. These 80 young people had normal heart structure. All underwent routine cardiovascular examinations (physical, radiological, electrocardiographic), complete one - and two - dimensional echocardiography to evaluate left ventricular function and an exercise-test on ergometric bicycle. No difference was found between the left ventricle of sportsmen and that of controls; in particular, there was neither dilatation nor parietal thickening in sportsmen, so that all functional values were the same. During exercise-tests sportsmen performed better than controls, with significantly longer duration of effort and greater maximal oxygen consumption. However, heart rate at rest, then during exercise and recovery, and variations in systolic blood pressure during exercise and in the 10 minutes which followed were identical in both groups. The only notable difference was a deeper fall in diastolic blood pressure in sportsmen, indicating a better opening of the peripheral vascular bed during exercise. It is concluded that there are few cardiovascular differences between trained sporting children and children with normal physical activity, probably because the relatively short training undergone does not leave sufficient time for most of the adaptation systems to become established.