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.

Medical Student Personality Traits and Clinical Grades in the Internal Medicine Clerkship

BACKGROUND

Third year clerkship grades include subjective evaluations. The purpose of this study is to identify if personality traits and self-esteem predispose students to better clerkship performance.

METHODS

Third-year medical students completed the OCEAN Five Factor Model Personality Test and Rosenberg Self-Esteem Scale. Clerkship grades were matched to survey results. Chi-squared and linear regression analyses assessed the correlation between students' clerkship grades, personality traits, and self-esteem.

RESULTS

There was no association between OCEAN personality domains and any component of clerkship grade. In secondary post hoc analysis, students who are "deep thinking" (OR 2.97, 95% CI 1.26-7.01, p = 0.01), "sophisticated" (OR 2.70, 95% CI 1.12-6.50, p = 0.03), and "outgoing" (OR 2.45, 95% CI 1.02-5.89, p = 0.04) were significantly more likely to get an overall clerkship grade of Honors. "Deep thinking" (OR 3.44, 95% CI 1.47-8.04, p = 0.004) and "efficient" (OR 2.87, 95% CI 1.12-7.36, p = 0.03) students scored better on shelf exams, while "shy" students scored worse (OR 0.30, 95% CI 0.13-0.69, p = 0.004); "aloof" students received worse clinical scores (OR 0.57, 95% CI 0.37-0.89, p = 0.03), and "rude" (OR 5.08, 95% CI 1.03-24.94, p = 0.03) and "sophisticated" (OR 2.47, 95% CI 1.02-6.00, p = 0.04) students received higher preceptor scores. There was no correlation between self-esteem and clerkship grades.

CONCLUSION

Students with certain personality traits may be predisposed to success during clerkships. Medical educators should be cognizant of biases favoring certain personalities and help students maximize success by recognizing their strengths and identifying gaps.

Current updates in the medical management of obesity

Obesity is a chronic medical condition that is expected to become an indirect but leading cause of mortality and morbidity. Obesity results in type 2 diabetes mellitus, insulin resistance, hypertension, dyslipidemia, coronary heart disease. These factors contribute to cardiovascular disease that is a leading cause of death. Therefore, the approach to obesity therapy should be designed to reduce cardiovascular disease risk and mortality. Diet and lifestyle changes remain the cornerstones of therapy for obesity, but the resultant weight loss is often small. For more effective weight loss, individuals have shown to benefit from anti-obesity medications. Anti-Obesity therapy is considered for individuals with a body mass index greater than 30 kg/m2 or ranging from 25 to 30 kg/m2, or individuals with co-morbid conditions. Recent anti-obese medications affect biological mechanisms that suppress appetite and absorb nutrients to regulate body weight. In this review, we discuss the FDA approved anti-obesity drugs and recent patents which include phentermine/topiramate, pramlintide, lorcaserin, AOD9604, oleoyl-estrone, trk-beta antagonists and melanin concentrating hormone that can reduce adiposity at the molecular level.

Carotid artery disease development after traumatic injury inflicted by a Ram's Horn

A 36-year-old man presented for treatment of headache, paresthesis, and weakness of his right arm and leg. Examination revealed an atherosclerotic plaque in the left common carotid artery, lying to the left internal carotid artery and resulting in 99% stenosis. The plaque was removed successfully by carotid endarterectomy. Pathological examination of the tissue confirmed the diagnosis of an atherosclerotic plaque. Detailed investigation of risk factors led to the conclusion that the stenosis of the carotid artery was due to blunt trauma caused by an injury that had occurred 30 years previously when the patient was gored by a ram's horn.

Resveratrol attenuates inflammation and stricture formation in experimental caustic esophageal burns

The purpose of medical treatment in the caustic esophageal burns (CEB) is to decrease inflammatory reaction and to prevent stricture formation. Resveratrol has anti-inflammatory and antifibrotic properties. The aim of this study is to investigate potential therapeutic effects of resveratrol in experimental CEB. We divided 42 male Wistar albino rats into five groups: a control group, caustic groups 4 and 28 (esophageal burns were created), and resveratrol groups 4 and 28 (esophageal burns were created and resveratrol was administered). We used 25% NaOH to form CEB following the method of Gehanno and Guedon as modified by Liu and Richardson. Animals were killed on the 4th and 28th days for biochemical and histopathological examinations. We found that the mean malondialdehyde and nitric oxide assays of the caustic groups were significantly higher than that of the resveratrol groups (P < 0.05). On the other hand, glutathione assay of the resveratrol groups was significantly higher than that of the caustic groups (P < 0.05). Histologically, edema, inflammation and necrosis were found to be significantly lower in the resveratrol 4 group compared with the caustic 4 group (P < 0.05). Submucosal and muscular collagen accumulation were found significantly lower in the resveratrol 28 group compared with the caustic 28 group (P < 0.05). We conclude that resveratrol decreased both the inflammatory reaction and the stricture formation in experimental CEB.

PercuTwist: a new alternative to Griggs and Ciaglia's techniques

BACKGROUND AND OBJECTIVE

Tracheostomy is one of the most common procedures in intensive care units worldwide. In this study we aimed to compare three different tracheostomy techniques with respect to duration of procedure and complications.

METHODS

One hundred and thirty patients requiring endotracheal intubation for more than 10 days due to acute respiratory distress syndrome, infections or cerebrovascular events were consecutively selected to undergo the percutaneous dilatational tracheostomy technique (PDT n = 44), the guide-wire dilating forceps technique group (GWDF n = 41) or the PercuTwist technique (n = 45). The time taken to perform the procedure (skin incision to successful placement of tracheostomy tube) and complications were recorded.

RESULTS

The operating times were found to be 9.9 +/- 1.1, 6.2 +/-1.4 and 5.4 +/- 1.2 min in PDT, GWDF and PercuTwist groups, respectively. The duration of the procedure was significantly shorter in the PercuTwist group as compared to the percutaneous dilatational tracheostomy (P < 0.01) and guide-wire dilating forceps (P < 0.05) groups. During postoperative bronchoscopy, eight cases of longitudinal tracheal abrasion (four in the PDT group, two in the GWDF group and two in the PercuTwist group), two cases of posterior tracheal wall injury (one in PDT and one in GWDF) and one case of tracheal ring rupture in the PDT group were seen.

CONCLUSIONS

Percutaneous tracheostomy techniques have their own advantages and complications. PercuTwist, a new controlled rotating dilatation method, was associated with minimal complications, appears to be easy to perform and a practical alternative to percutaneous dilatational tracheostomy and guide-wire dilating forceps techniques.

Stress distribution associated with loaded acrylic-metal-cement crowns by using finite element method

The axisymmetrical finite element method (FEM) was used to compare stress distribution in a maxillary second premolar restored tooth. The three models were evaluated by crowning the tooth with Au-Pd alloy, Ni-Cr alloy and Ti alloy with acrylic. A longitudinal static force, 200 N in magnitude at an angle of 45 degrees was applied on the occlusal margin of each model. The tooth was assumed isotropic, homogenous and elastic. This numerical study was carried out using axisymmetric finite element models and calculation programmes were prepared by the authors using FORTRAN 77. Comparison of stress distributions was made in four regions of apex, cole, dentin-metal interface and metal-acrylic interface. The highest stress values were obtained when NiCr alloy with acrylic was used.

An investigation of temperature and stress distribution on a restored maxillary second premolar tooth using a three-dimensional finite element method

This paper presents the stress analysis of the maxillary second premolar tooth under thermal loading as a result of hot/cold liquid in the mouth using the three-dimensional (3D) finite element method (FEM). The tooth was considered to be in a restored state with composite resin and amalgam on glass-ionomer as the base material. In the first step of the study, the temperature changes as a result of hot/cold liquid in the mouth were calculated. The thermal stress distributions owing to the temperature changes were then obtained. All calculation programs were prepared by the authors using FORTRAN 77. The tooth was assumed to be isotropic, homogeneous, elastic and unsymmetric. The distribution of temperature and stress were plotted for some critical points.

Side effects of tamoxifen in oophorectomized rats

OBJECTIVE

Our objective was to evaluate the direct effect of tamoxifen citrate (TAM) on the endometrium, liver, breast tissue and the lipid profile in oophorectomized (OX) rats.

STUDY DESIGN

An experimental animal study.

MATERIAL AND METHODS

Forty-one mature rats (33 OX) were randomly divided into four groups and received either TAM (0.4 or 0.8 mg/kg p.o.) therapy or placebo over 60 days as follows: (1) sham; (2) OX + TAM (0.4 mg/kg); (3) OX + TAM (0.8 mg/kg); (4) OX. All histological changes in the endometrium, liver and breast tissue were evaluated under the light microscope by comparing the TAM-treated groups with the OX and sham-operated groups. Blood total cholesterol and low-density lipoprotein cholesterol levels were also analyzed.

RESULTS

TAM-treated rats showed a significant reduction in body weight, blood cholesterol and low-density lipoprotein cholesterol levels, but the wet uterine weight was not affected. Estrogenic effects of TAM were not detected with either dosage on the endometrium. TAM-treated groups showed atrophic breast tissue. No histopathological changes were detected in the liver with TAM treatment.

CONCLUSION

The data suggests that TAM may not act as an estrogen receptor agonist with the given dosage on the endometrium in OX rats. Two different doses of TAM do not cause histological changes in liver over 60 days of treatment.

An investigation of the stress values on a tooth restored by amalgam

The study was carried out in two stages: (1) MOD amalgam cavities were prepared on maxillary second premolars and three strain gauges were attached to the palatal surface of each tooth. The teeth were filled using amalgam with and without base material (glass-ionomer). Stresses occurred during the hardening phase and also through mastication and were measured by strain-gauge rosettes. (2) The stresses which occurred at the same points were calculated by the finite element method and compared with the values obtained experimentally. The highest stress values were observed when no base material was used.

Analysis of a restored maxillary second premolar tooth by using three-dimensional finite element method

In the first part of this study some physical properties of restorative materials, amalgam, glass-ionomer and composite resin were measured experimentally. In the second part a numerical study was carried out, for which the maxillary second premolar tooth was used. The tooth model was restored with composite resin and amalgam on glass-ionomer, which was used as the base material. The stress distribution investigated was the resultant of the stresses which come from the mastication force and those resulting from the contraction and expansion of restorative materials. All calculations were carried out using the finite element method and programs were written using FORTRAN 77. A load of 450 N, at an angle of 45 degrees to the longitudinal axis was applied on the occlusal margin of the tooth. The tooth was assumed isotropic, homogenous, elastic and unsymmetrical. The distribution of compressive, tensile and shear stresses were plotted for the whole tooth structure.

Fracture toughness determination of composite resin and dentin/composite resin adhesive interfaces by laboratory testing and finite element models

OBJECTIVES

The reliability and validity of the adhesive bond toughness of dentin/composite resin interfaces were studied from the standpoint of fracture mechanics.

METHODS

The fracture toughness (KIC) and fracture energy (JIC) values of two different composite resins (Brilliant Dentin and P50) were determined by using single edge notch (SEN) specimens loaded in three point bending and the results were analyzed by the t-test method (p < 0.1). The fracture loads of dentin/composite resin interface with different initial crack lengths were obtained experimentally. The adhesive fracture energy (J(adh)), residual fracture energy (J(res)) and effective (total) fracture energy (J(eff)) for the symmetrical bimaterial (SBM) joint specimen for dentin/composite resin interfaces were calculated and the applied fracture energy (J(appl)) values under the mastication force were obtained for the axisymmetric tooth models. All numerical calculations were carried out by the finite element method and software programs were prepared according to fortran 77.

RESULTS

The fracture toughness and energy values obtained experimentally for Brilliant Dentin were found to be higher than those for P50. It was seen that, calculated J values (J(adh) and J(res)++) changed with the crack length; but the effective fracture energy (J(eff)++) was independent of the crack length, as expected. The applied fracture energy (J(appl)) and effective fracture energy (J(eff)) are considerably smaller than the experimentally determined JIC values of composite resins.

SIGNIFICANCE

The bonded interface tends to produce microscopic flaws which could act as critical stress risers promoting interfacial failures. The initiation and propagation of such flaws under the mastication forces can be followed by fracture toughness (KIC) or fracture energy (JIC) in linear elastic fracture mechanics (LEFM).

The role of prostaglandin synthesis stimulation in the protective effect of captopril on ischaemia-reperfusion arrhythmias in rats in vivo

Attenuation of ischaemia-reperfusion induced arrhythmias by several angiotensin converting enzyme (ACE) inhibitors, such as captopril, has been demonstrated. The role of prostaglandin synthesis stimulation in this protective effect of ACE inhibition was evaluated in an in vivo rat model. To produce arrhythmia, the left main coronary artery was occluded for 7 min, followed by 7 min of reperfusion. Captopril (3 mg kg-1) and a prostaglandin synthesis inhibitor, indomethacin (2 mg kg-1) alone or together were administered by intravenous (i.v.) injection 10 min before occlusion. Captopril reduced the incidence of ventricular tachycardia (VT) and the number of ventricular ectopic beats (VEB) on ischaemia and reperfusion as well as the incidence of reversible ventricular fibrillation (VF) on reperfusion. These protective effects of captopril against ischaemia-reperfusion-induced arrhythmias were prevented by indomethacin. Captopril also caused a sustained decrease of preocclusion values in the arterial blood pressure (BP) and heart rate (HR), whereas in the presence of indomethacin, captopril had no significant effect on either HR or arterial BP values except the heart rate value just before occlusion. Indomethacin alone did not affect either the severity of arrhythmias or the haemodynamic parameters. These results suggest that, in this experimental model, the protective effects of ACE inhibitors on the arrhythmias following ischaemia-reperfusion are mediated by the stimulation of prostaglandin synthesis and the haemodynamic effects of these drugs may have a contributory role in their protective effect.

Protective effect of ACE inhibitors on ischemia-reperfusion-induced arrhythmias in rats: is this effect related to the free radical scavenging action of these drugs?

The antiarrhythmic effects of captopril, a sulphydryl-containing angiotensin converting enzyme (ACE) inhibitor, were compared with those of the nonsulphydryl-containing ACE inhibitor lisinopril and the sulphydryl-containing agent glutathione in an in vivo rat model of coronary artery ligation. To produce arrhythmia, the left main coronary artery was occluded for 7 min, followed by 7 min of reperfusion. Captopril (3 mg kg-1) and lisinopril (0.1, 0.3 or 1 mg kg-1) caused marked decreases in mean arterial blood pressure (BP) and heart rate, whereas glutathione (5 mg kg-1) had no effect on them. The incidence of ventricular tachycardia (VT) on ischemia and reperfusion was significantly reduced by captopril and lisinopril. Captopril and 1 mg kg-1 lisinopril also significantly decreased the number of VEB during occlusion and the duration of VT on reperfusion, respectively. These drugs also attenuated the incidence of reversible ventricular fibrillation (VF) and the number of ventricular ectopic beats (VEB) during reperfusion. However, glutathione only reduced the incidence of VT on reperfusion, significantly. These results suggest that, in this experimental model, ACE inhibitors limit the arrhythmias following ischemia-reperfusion and free radical scavenging action of these drugs does not have a major contributory role in their protective effect.

Effects of captopril on ischaemia-reperfusion-induced arrhythmias in an in vivo rat model

The antiarrhythmic effects of captopril, an angiotensin converting enzyme (ACE) inhibitor, were investigated in an in vivo rat model of coronary artery ligation. Captopril (0.3-3 mg kg-1) or saline were administered by intravenously 10 min before coronary ischaemia. The left main coronary artery was then occluded for 7 min, followed by 7 min of reperfusion. Captopril caused a marked decrease in mean arterial blood pressure which was transient at 0.3 and 1 mg kg-1, and at doses of 1 and 3 mg kg-1, it produced marked bradycardia. The incidence of ventricular tachycardia (VT) on ischaemia was significantly reduced the captopril at a dose of 3 mg kg-1 only and on reperfusion at doses of 1 and 3 mg kg-1. At the same doses, captopril significantly reduced the mean duration of ventricular fibrillation (VF) on reperfusion. The incidence of mortality resulting from reperfusion-induced irreversible VF in the control group decreased from 42.9% to 14.3% (NS), 21.4% (NS) and 7.7% (P < 0.05) in captopril at 0.3, 1 and 3 mg kg-1, respectively. Our results indicate that captopril appears to limit the arrhythmias following reperfusion and this may be due in part to the antiischemic effect associated with bradycardia and vasodepression.