Publications by authors named "Anna Chang"

154 Publications

COVID-19 treatment combinations and associations with mortality in a large multi-site healthcare system.

PLoS One 2021 11;16(6):e0252591. Epub 2021 Jun 11.

Division of Infectious Diseases, Department of Medicine, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA, United States of America.

Introduction: During the early months of the COVID-19 pandemic, mortality associated with the disease declined in the United States. The standard of care for pharmacological interventions evolved during this period as new and repurposed treatments were used alone and in combination. Though these medications have been studied individually, data are limited regarding the relative impact of different medication combinations. The objectives of this study were to evaluate the association of COVID-19-related mortality and observed medication combinations and to determine whether changes in medication-related practice patterns and measured patient characteristics, alone, explain the decline in mortality seen early in the COVID-19 pandemic.

Methods: A retrospective cohort study was conducted at a multi-hospital healthcare system exploring the association of mortality and combinations of remdesivir, corticosteroids, anticoagulants, tocilizumab, and hydroxychloroquine. Multivariable logistic regression was used to identify predictors of mortality for both the overall population and the population stratified by intensive care and non-intensive care unit admissions. A separate model was created to control for the change in unmeasured variables over time.

Results: For all patients, four treatment combinations were associated with lower mortality: Anticoagulation Only (OR 0.24, p < 0.0001), Anticoagulation and Remdesivir (OR 0.25, p = 0.0031), Anticoagulation and Corticosteroids (OR 0.53, p = 0.0263), and Anticoagulation, Corticosteroids and Remdesivir (OR 0.42, p = 0.026). For non-intensive care unit patients, the same combinations were significantly associated with lower mortality. For patients admitted to the intensive care unit, Anticoagulation Only was the sole treatment category associated with decreased mortality. When adjusted for demographics, clinical characteristics, and all treatment combinations there was an absolute decrease in the mortality rate by 2.5% between early and late periods of the study. However, when including an additional control for changes in unmeasured variables overtime, the absolute mortality rate decreased by 5.4%.

Conclusions: This study found that anticoagulation was the most significant treatment for the reduction of COVID-related mortality. Anticoagulation Only was the sole treatment category associated with a significant decrease in mortality for both intensive care and non-intensive care patients. Treatment combinations that additionally included corticosteroids and/or remdesivir were also associated with decreased mortality, though only in the non-intensive care stratum. Further, we found that factors other than measured changes in demographics, clinical characteristics or pharmacological interventions accounted for an additional decrease in the COVID-19-related mortality rate over time.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252591PLOS
June 2021

Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes.

Popul Health Manag 2021 May 17. Epub 2021 May 17.

Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

This study explored the relationship between trust in physicians and telehealth use during the COVID pandemic in 162 African Americans with diabetes. More than 90% of patients had internet-capable devices and internet service but only 61 patients (39%) had a telehealth visit. Compared to the latter, participants with no telehealth visits had less trust in physicians' ability to diagnose COVID, less trust in physicians' ability to treat via telehealth, and resided in more deprived neighborhoods. There were no differences in age, sex, education, nor literacy. For African Americans with diabetes, health disparities may increase unless fundamental issues such as trust are addressed.
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http://dx.doi.org/10.1089/pop.2021.0094DOI Listing
May 2021

Lessons From Learners: Adapting Medical Student Education During and Post-COVID-19.

Acad Med 2021 May 4. Epub 2021 May 4.

M.R.H. Castro is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California; ORCID: https://orcid.org/0000-0002-2085-4893. L.M. Calthorpe is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California; ORCID: https://orcid.org/0000-0002-0496-9471. S.E. Fogh is associate professor, Department of Radiation Oncology, University of California San Francisco School of Medicine, San Francisco, California. S. McAllister is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California. C.L Johnson is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California. E.D. Isaacs is professor of emergency medicine, Department of Emergency Medicine, University of California San Francisco, San Francisco, California. A. Ishizaki is manager, Clinical Microsystems Clerkship, University of California San Francisco School of Medicine, San Francisco, California. A. Kozas is curriculum coordinator, Clinical Microsystems Clerkship, University of California San Francisco School of Medicine, San Francisco, California. D. Lo is assistant professor of medicine, Division of Geriatrics, Department of Medicine, University of California San Francisco School of Medicine; and Department of Geriatrics and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California. S. Rennke is professor of medicine, Division of Hospital Medicine, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California. J. Davis is professor of medicine and associate dean for curriculum, University of California San Francisco School of Medicine, San Francisco, California. A. Chang is professor of medicine, Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California.

In response to the COVID-19 pandemic, many medical schools suspended clinical clerkships and implemented newly adapted curricula to facilitate continued educational progress. While the implementation of these new curricula has been described, an understanding of the impact on student learning outcomes is lacking. In 2020, the authors followed Kern's 6-step approach to curricular development to create and evaluate a novel COVID-19 curriculum for medical students at the University of California San Francisco School of Medicine and evaluate its learning outcomes. The primary goal of the curriculum was to provide third- and fourth-year medical students an opportunity for workplace learning in the absence of clinical clerkships, specifically for students to develop clerkship-level milestones in the competency domains of practice-based learning and improvement, professionalism, and systems-based practice. The curriculum was designed to match students with faculty-mentored projects occurring primarily in virtual formats. A total of 126 students enrolled in the curriculum and completed a survey about their learning outcomes (100% response rate). Of 35 possible clerkship-level milestones, there were 12 milestones for which over half of students reported development, in competency domains including practice-based learning and improvement, professionalism, and interpersonal and communication skills. Thematic analysis of students' qualitative survey responses demonstrated 2 central motivations for participating in the curriculum: identity as physicians-in-training, and patient engagement. Six central learning areas were developed during the curriculum: interprofessional teamwork, community resources, technology in medicine, skill-building, quality improvement, and specialty-specific learning. This analysis demonstrates that students can develop competencies and achieve rich workplace learning through project-based experiential learning, even in virtual clinical workplaces. Furthermore, knowledge of community resources, technology in medicine, and quality improvement were developed through the curriculum more readily than in traditional clerkships, and could be considered as integral learning objectives in future curricular design.
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http://dx.doi.org/10.1097/ACM.0000000000004148DOI Listing
May 2021

Urgent and non-emergent telehealth care for seniors: Findings from a multi-site impact study.

J Telemed Telecare 2021 Apr 17:1357633X211004321. Epub 2021 Apr 17.

West Health Institute, La Jolla, CA, USA.

Introduction: The global pandemic has raised awareness of the need for alternative ways to deliver care, notably telehealth. Prior to this study, research has been mixed on its effectiveness and impact on downstream utilization, especially for seniors. Our multi-institution study of more than 300,000 telehealth visits for seniors evaluates the clinical outcomes and healthcare utilization for urgent and non-emergent symptoms.

Methods: We conducted a retrospective cohort study from November 2015 to March 2019, leveraging different models of telehealth from three health systems, comparing them to in-person visits for urgent and non-emergent needs of seniors based on International Classification of Diseases, 10th edition diagnoses. The study population was adults aged 60 years or older who had access to telehealth and were affiliated with and resided in the geographic region of the healthcare organization providing telehealth. The primary outcomes of interest were visit resolution and episodes of care for those that required follow-up.

Results: In total, 313,516 telehealth visits were analysed across three healthcare organizations. Telehealth encounters were successful in resolving urgent and non-emergent needs in 84.0-86.7% of cases. When visits required follow-up, over 95% were resolved in less than three visits for both telehealth and in-person cohorts.

Discussion: While in-person visits have traditionally been the gold standard, our results suggest that when deployed within the confines of a patient's existing primary care and health system provider, telehealth can be an effective alternative to in-person care for urgent and non-emergent needs of seniors without increasing downstream utilization.
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http://dx.doi.org/10.1177/1357633X211004321DOI Listing
April 2021

Guiding Academic Clinician Educators at Research-Intensive Institutions: a Framework for Chairs, Chiefs, and Mentors.

J Gen Intern Med 2021 Apr 12. Epub 2021 Apr 12.

Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco School of Medicine (UCSF), San Francisco, CA, USA.

Department chairs and division chiefs at research-intensive academic medical centers often find mentoring clinician educators challenging. These faculty constitute the majority of academic physicians. Supporting excellent clinician educators is key to ensuring high-quality patient care and developing tomorrow's physicians. Little has been written for leaders on strategies to advance academic clinician educators' career success. We present a framework to guide chairs, chiefs, and mentors seeking to address clinician educator retention and satisfaction in academic medical centers.
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http://dx.doi.org/10.1007/s11606-021-06713-9DOI Listing
April 2021

Medical students are accurate in interpreting the presence of pathologic interstitial edema on focused lung ultrasound compared to expert reviewers.

AEM Educ Train 2021 Apr 1;5(2):e10584. Epub 2021 Apr 1.

Nazareth Hospital (previously Thomas Jefferson University Hospital) Philadelphia Pennsylvania USA.

Background: Over the past two decades, studies have demonstrated that lung ultrasound is useful in diagnosing alveolar interstitial syndrome, which is seen in patients with decompensated congestive heart failure (CHF).

Methods: We studied medical students performing lung ultrasound on patients admitted to the hospital with a presumed diagnosis of decompensated CHF in a prospective convenience observation study. Two ultrasound fellowship-trained emergency medicine attendings independently reviewed the lung ultrasounds at a later date, blinded to the students' interpretation and other clinical information, to confirm ultrasound findings and assess for inter-rater reliability of the lung ultrasound using intraclass correlation coefficients (ICCs).

Results: Thirty-six patients were enrolled in the study resulting in 653 unique lung zones scanned. The zones were imaged and classified as being normal (B-lines < 3) or pathologic (B-lines ≥ 3). The novice scanners' interpretation was compared to expert reviews using ICCs. The ICC was 0.88, with a 95% confidence interval of 0.87 to 0.90, for all lung zones scanned.

Conclusion: There was almost perfect agreement between novice practitioners and experts when determining the presence of pathologic B-lines in individual patients.
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http://dx.doi.org/10.1002/aet2.10584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015726PMC
April 2021

Sex-related differences in D-dimer levels for venous thromboembolism screening.

Acad Emerg Med 2021 Jan 26. Epub 2021 Jan 26.

Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA.

Background: D-dimer is generally considered positive above 0.5 mg/L irrespective of sex. However, women have been shown to be more likely to have a positive D-dimer after controlling for other factors. Thus, differences may exist between males and females for using D-dimer as a marker of venous thromboembolic (VTE) disease. We hypothesized that the accuracy of D-dimer tests may be enhanced by using appropriate cutoff values that reflect sex-related differences in D-dimer levels.

Methods: This research is a secondary analysis of a multicenter, international, prospective, observational study of adult (18+ years) patients suspected of VTE, with low-to-intermediate pretest probability based on Wells criteria ≤ 6 for pulmonary embolism (PE) and ≤ 2 for deep vein thrombosis (DVT). VTE diagnoses were based on computed tomography, ventilation perfusion scanning, or venous ultrasound. D-dimer levels were tested for statistical difference across groups stratified by sex and diagnosis. Multivariable regression was used to investigate sex as a predictor of diagnosis. Sex-specific optimal D-dimer thresholds for PE and DVT were calculated from receiver operating characteristic analyses. A Youden threshold (D-dimer level coinciding with the maximum of sensitivity plus specificity) and a cutoff corresponding to 95% sensitivity were calculated. Statistical difference for cutoffs was tested via 95% confidence intervals from 2,000 bootstrapped samples.

Results: We included 3,586 subjects for analysis, of whom 61% were female. Race demographics were 63% White, 27% Black/African American, and 6% Hispanic. In the suspected PE cohort, 6% were diagnosed with PE, while in the suspected DVT cohort, 11% were diagnosed with DVT. D-dimer levels were significantly higher in males than females for the PE-positive group and the DVT-negative group, but males had significantly lower D-dimer levels than females in the PE-negative group. Regression models showed male sex as a significant positive predictor of DVT diagnosis, controlling for D-dimer levels. The Youden thresholds for PE patients were 0.97 (95% CI = 0.64 to 1.79) mg/L and 1.45 (95% CI = 1.36 to 1.95) mg/L for females and males, respectively; 95% sensitivity cutoffs for this group were 0.64 (95% CI = 0.20 to 0.89) and 0.55 (95% CI = 0.29 to 1.61). For DVT, the Youden thresholds were 0.98 (95% CI = 0.84 to 1.56) mg/L for females and 1.25 (95% CI = 0.65 to 3.33) mg/L for males with 95% sensitivity cutoffs of 0.33 (95% CI = 0.2 to 0.61) and 0.32 (95% CI = 0.18 to 0.7), respectively.

Conclusion: Differences in D-dimer levels between males and females are diagnosis specific; however, there was no significant difference in optimal cutoff values for excluding PE and DVT between the sexes.
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http://dx.doi.org/10.1111/acem.14220DOI Listing
January 2021

Classification and prediction of post-trauma outcomes related to PTSD using circadian rhythm changes measured via wrist-worn research watch in a large longitudinal cohort.

IEEE J Biomed Health Inform 2021 Jan 22;PP. Epub 2021 Jan 22.

Post-Traumatic Stress Disorder (PTSD) is a psychiatric condition resulting from threatening or horrifying events. We hypothesized that circadian rhythm changes, measured by a wrist-worn research watch are predictive of post-trauma outcomes.

Approach: 1618 post-trauma patients were enrolled after admission to emergency departments (ED). Three standardized questionnaires were administered at week eight to measure post-trauma outcomes related to PTSD, sleep disturbance, and pain interference with daily life. Pulse activity and movement data were captured from a research watch for eight weeks. Standard and novel movement and cardiovascular metrics that reflect circadian rhythms were derived using this data. These features were used to train different classifiers to predict the three outcomes derived from week-eight surveys. Clinical surveys administered at ED were also used as features in the baseline models.

Results: The highest cross-validated performance of research watch-based features was achieved for classifying participants with pain interference by a logistic regression model, with an area under the receiver operating characteristic curve (AUC) of 0.70. The ED survey-based model achieved an AUC of 0.77, and the fusion of research watch and ED survey metrics improved the AUC to 0.79.

Significance: This work represents the first attempt to predict and classify post-trauma symptoms from passive wearable data using machine learning approaches that leverage the circadian desynchrony in a potential PTSD population.
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http://dx.doi.org/10.1109/JBHI.2021.3053909DOI Listing
January 2021

Prognostic neuroimaging biomarkers of trauma-related psychopathology: resting-state fMRI shortly after trauma predicts future PTSD and depression symptoms in the AURORA study.

Neuropsychopharmacology 2021 06 21;46(7):1263-1271. Epub 2021 Jan 21.

Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA.

Neurobiological markers of future susceptibility to posttraumatic stress disorder (PTSD) may facilitate identification of vulnerable individuals in the early aftermath of trauma. Variability in resting-state networks (RSNs), patterns of intrinsic functional connectivity across the brain, has previously been linked to PTSD, and may thus be informative of PTSD susceptibility. The present data are part of an initial analysis from the AURORA study, a longitudinal, multisite study of adverse neuropsychiatric sequalae. Magnetic resonance imaging (MRI) data from 109 recently (i.e., ~2 weeks) traumatized individuals were collected and PTSD and depression symptoms were assessed at 3 months post trauma. We assessed commonly reported RSNs including the default mode network (DMN), central executive network (CEN), and salience network (SN). We also identified a proposed arousal network (AN) composed of a priori brain regions important for PTSD: the amygdala, hippocampus, mamillary bodies, midbrain, and pons. Primary analyses assessed whether variability in functional connectivity at the 2-week imaging timepoint predicted 3-month PTSD symptom severity. Left dorsolateral prefrontal cortex (DLPFC) to AN connectivity at 2 weeks post trauma was negatively related to 3-month PTSD symptoms. Further, right inferior temporal gyrus (ITG) to DMN connectivity was positively related to 3-month PTSD symptoms. Both DLPFC-AN and ITG-DMN connectivity also predicted depression symptoms at 3 months. Our results suggest that, following trauma exposure, acutely assessed variability in RSN connectivity was associated with PTSD symptom severity approximately two and a half months later. However, these patterns may reflect general susceptibility to posttraumatic dysfunction as the imaging patterns were not linked to specific disorder symptoms, at least in the subacute/early chronic phase. The present data suggest that assessment of RSNs in the early aftermath of trauma may be informative of susceptibility to posttraumatic dysfunction, with future work needed to understand neural markers of long-term (e.g., 12 months post trauma) dysfunction. Furthermore, these findings are consistent with neural models suggesting that decreased top-down cortico-limbic regulation and increased network-mediated fear generalization may contribute to ongoing dysfunction in the aftermath of trauma.
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http://dx.doi.org/10.1038/s41386-020-00946-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134491PMC
June 2021

Concerns about Using Sex-Specific Cutoffs for Cardiac Troponin Testing.

Authors:
Anna Marie Chang

Clin Chem 2021 Jan;67(1):201-203

Thomas Jefferson University, Philadelphia, PA, USA.

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http://dx.doi.org/10.1093/clinchem/hvaa289DOI Listing
January 2021

Effect of a Self-care Intervention on 90-Day Outcomes in Patients With Acute Heart Failure Discharged From the Emergency Department: A Randomized Clinical Trial.

JAMA Cardiol 2021 Feb;6(2):200-208

Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: Up to 20% of patients who present to the emergency department (ED) with acute heart failure (AHF) are discharged without hospitalization. Compared with rates in hospitalized patients, readmission and mortality are worse for ED patients.

Objective: To assess the impact of a self-care intervention on 90-day outcomes in patients with AHF who are discharged from the ED.

Design, Setting, And Participants: Get With the Guidelines in Emergency Department Patients With Heart Failure was an unblinded, parallel-group, multicenter randomized trial. Patients were randomized 1:1 to usual care vs a tailored self-care intervention. Patients with AHF discharged after ED-based management at 15 geographically diverse EDs were included. The trial was conducted from October 28, 2015, to September 5, 2019.

Interventions: Home visit within 7 days of discharge and twice-monthly telephone-based self-care coaching for 3 months.

Main Outcomes And Measures: The primary outcome was a global rank of cardiovascular death, HF-related events (unscheduled clinic visit due to HF, ED revisit, or hospitalization), and changes in the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) summary score (SS) at 90 days. Key secondary outcomes included the global rank outcome at 30 days and changes in the KCCQ-12 SS score at 30 and 90 days. Intention-to-treat analysis was performed for the primary, secondary, and safety outcomes. Per-protocol analysis was conducted including patients who completed a home visit and had scheduled outpatient follow-up in the intervention arm.

Results: Owing to slow enrollment, 479 of a planned 700 patients were randomized: 235 to the intervention arm and 244 to the usual care arm. The median age was 63.0 years (interquartile range, 54.7-70.2), 302 patients (63%) were African American, 305 patients (64%) were men, and 178 patients (37%) had a previous ejection fraction greater than 50%. There was no significant difference in the primary outcome between patients in the intervention vs usual care arm (hazard ratio [HR], 0.89; 95% CI, 0.73-1.10; P = .28). At day 30, patients in the intervention arm had significantly better global rank (HR, 0.80; 95% CI, 0.64-0.99; P = .04) and a 5.5-point higher KCCQ-12 SS (95% CI, 1.3-9.7; P = .01), while at day 90, the KCCQ-12 SS was 2.7 points higher (95% CI, -1.9 to 7.2; P = .25).

Conclusions And Relevance: The self-care intervention did not improve the primary global rank outcome at 90 days in this trial. However, benefit was observed in the global rank and KCCQ-12 SS at 30 days, suggesting that an early benefit of a tailored self-care program initiated at an ED visit for AHF was not sustained through 90 days.

Trial Registration: ClinicalTrials.gov Identifier: NCT02519283.
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http://dx.doi.org/10.1001/jamacardio.2020.5763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675219PMC
February 2021

Safety-Net Hospitals as Community Anchors in COVID-19.

J Patient Exp 2020 Aug 13;7(4):436-438. Epub 2020 Aug 13.

Department of Medicine, University of California, San Francisco, School of Medicine, CA, USA.

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http://dx.doi.org/10.1177/2374373520949800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534120PMC
August 2020

Use of the color Doppler twinkle artifact for teaching ultrasound guided peripheral vascular access.

J Vasc Access 2020 Sep 22:1129729820959907. Epub 2020 Sep 22.

Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA.

Background: The optimal method for teaching ultrasound guided peripheral IV (USGPIV) insertion is unknown. Poor needle tip visualization has been cited for USGPIV failure. Twinkle artifact (TA), visualized with color Doppler, is used in other clinical settings. Our objective was to investigate whether teaching students USGPIV placement utilizing TA would enhance needle tip visualization and improve first pass success.

Methods: This was a prospective, randomized study of premedical and preclinical medical students without prior USGPIV experience. Students were given a standardized didactic session on USGPIV placement before being randomized and separated to learn and practice USGPIV with or without TA (control). The students were given 5 min to perform USGPIV on phantom models. The primary outcome was the rate of first pass success. Secondary outcomes included total time to cannulation, rate of posterior venous wall puncture, and total number of attempts.

Results: Rates of first pass success were similar in both the TA (82%) and control groups (57%),  = 0.095. There was a difference in the mean time to cannulation. The TA group achieved success at 50.76 s (SD 26.93) while the control group achieved success at 85.30 s (SD 65.47),  = 0.048.

Conclusion: In this study of utilizing TA to aid in USGPIV placement, students were able to achieve successful cannulation in a shorter amount of time. There was no significant difference in first pass success. Future studies should utilize a larger sample size and evaluate the utility of TA when placing USGPIV on patients.
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http://dx.doi.org/10.1177/1129729820959907DOI Listing
September 2020

An analysis of Twitter for an Academic Emergency Medicine Ultrasound Division.

Eur J Emerg Med 2021 Jan;28(1):70-71

Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1097/MEJ.0000000000000698DOI Listing
January 2021

A randomized clinical trial of a collaborative home-based diabetes intervention to reduce emergency department visits and hospitalizations in black individuals with diabetes.

Contemp Clin Trials 2020 08 16;95:106069. Epub 2020 Jun 16.

Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, United States of America.

The prevalence of diabetes mellitus (DM) in black individuals (blacks) is twice that of white individuals (whites), and blacks are more likely to have worse glycemic control, less optimal medication regimens, and higher levels of mistrust in the medical system. These three factors account for higher rates of acute medical care use in blacks with DM. To address this disparity, we developed DM I-TEAM (Diabetes Interprofessional Team to Enhance Adherence to Medical Care), a home-based multidisciplinary behavioral intervention that integrates care from a community health worker (CHW), the participant's primary care physician (PCP), a DM nurse educator, and a clinical pharmacist. Treatment is delivered during 9 sessions over 1 year, and includes diabetes education and goal setting, telehealth visits with participants' PCP and a DM nurse educator, and comprehensive medication reviews by a pharmacist. We describe the rationale and methods for a randomized controlled trial to test the efficacy of DM I-TEAM to reduce emergency department (ED) visits and hospitalizations. We are enrolling 200 blacks with DM during an ED visit. Participants are randomized to DM I-TEAM or Usual Medical Care (UMC). Follow-up assessments are conducted at 6 and 12 months. The primary outcome is the number of ED visits and hospitalizations over 12 months, and is measured by participant self-report and medical record review. Secondary outcomes include hemoglobin A1c (HbA1c), number of potentially inappropriate medications (PIMs), and trust in health care.
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http://dx.doi.org/10.1016/j.cct.2020.106069DOI Listing
August 2020

Dopamine brain single-photon emission computed tomography (SPECT) imaging helps to determine the alternative effect of dopamine agonist in treating patients with rapid eye movement sleep behavior disorder (RBD).

Sleep Med 2020 Jul 7;71:37-38. Epub 2020 May 7.

Graduate Institute of Biomedical and Pharmaceutical Science, Fu-Jen Catholic University, New Taipei City, Taiwan; Department of Chest, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Electronic address:

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http://dx.doi.org/10.1016/j.sleep.2020.04.028DOI Listing
July 2020

The Accuracy of Interqual Criteria in Determining the Observation versus Inpatient Status in Older Adults with Syncope.

J Emerg Med 2020 Aug 11;59(2):193-200. Epub 2020 Apr 11.

Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Background: McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown.

Objective: We sought to determine whether InterQual criteria accurately predicted length of stay (LOS) in older patients with syncope.

Methods: We conducted a secondary analysis of a cohort study of adults ≥60 years of age who had syncope. We calculated InterQual criteria and classified the patient as observation or inpatient status. Outcomes were whether LOS were less than or greater than 2 midnights.

Results: We analyzed 2361 patients; 1227 (52.0%) patients were male and 1945 (82.8%) were white, with a mean age of 73.2 ± 9.0 years. The median LOS was 32.6 h (interquartile range 24.2-71.8). The sensitivity of InterQual criteria for LOS was 60.8% (95% confidence interval 57.9-63.6%) and the specificity was 47.8% (95% confidence interval 45.0-50.5%).

Conclusions: In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction.
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http://dx.doi.org/10.1016/j.jemermed.2020.02.020DOI Listing
August 2020

Health Systems Science in Medical Education: Unifying the Components to Catalyze Transformation.

Acad Med 2020 09;95(9):1362-1372

D.R. Wolpaw is professor of medicine and humanities, Penn State University College of Medicine, Hershey, Pennsylvania.

Medical education exists in the service of patients and communities and must continually calibrate its focus to ensure the achievement of these goals. To close gaps in U.S. health outcomes, medical education is steadily evolving to better prepare providers with the knowledge and skills to lead patient- and systems-level improvements. Systems-related competencies, including high-value care, quality improvement, population health, informatics, and systems thinking, are needed to achieve this but are often curricular islands in medical education, dependent on local context, and have lacked a unifying framework. The third pillar of medical education-health systems science (HSS)-complements the basic and clinical sciences and integrates the full range of systems-related competencies. Despite the movement toward HSS, there remains uncertainty and significant inconsistency in the application of HSS concepts and nomenclature within health care and medical education. In this Article, the authors (1) explore the historical context of several key systems-related competency areas; (2) describe HSS and highlight a schema crosswalk between HSS and systems-related national competency recommendations, accreditation standards, national and local curricula, educator recommendations, and textbooks; and (3) articulate 6 rationales for the use and integration of a broad HSS framework within medical education. These rationales include: (1) ensuring core competencies are not marginalized, (2) accounting for related and integrated competencies in curricular design, (3) providing the foundation for comprehensive assessments and evaluations, (4) providing a clear learning pathway for the undergraduate-graduate-workforce continuum, (5) facilitating a shift toward a national standard, and (6) catalyzing a new professional identity as systems citizens. Continued movement toward a cohesive framework will better align the clinical and educational missions by cultivating the next generation of systems-minded health care professionals.
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http://dx.doi.org/10.1097/ACM.0000000000003400DOI Listing
September 2020

Becoming outstanding educators: What do they say contributed to success?

Adv Health Sci Educ Theory Pract 2020 08 15;25(3):655-672. Epub 2020 Jan 15.

Departments of Medicine and Surgery, University of California, San Francisco, San Francisco, CA, USA.

Aspiring medical educators and their advisors often lack clarity about career paths. To provide guidance to faculty pursuing careers as educators, we sought to explore perceived factors that contributed to the career development of outstanding medical educators. Using a thematic analysis, investigators at two institutions interviewed 39 full or associate professor physician faculty with prominent roles as medical educators in 2016. The social cognitive career theory (SCCT) informed the interview guide. Investigators developed the codebook and performed iterative analysis using qualitative methods. Extensive team discussion generated the final themes. Eight themes emerged related to preparation, early successes, mentors, networks, faculty development, balance, work environment, and multiple identities. Preparation led to early successes, which served as "launch points," while mentors, networks, and faculty development programs served as career accelerators to open more opportunities, and a supportive work environment was an additional enabler of this pathway. Educators who reported balance between work and outside interests described boundary setting as well as selectively choosing new opportunities to establish boundaries in mid-career. Participants described multiple professional identities, and clinician and educator identities tended to merge and reinforce each other as careers progressed. This study revealed common themes describing trajectories of success among medical educators. These themes aligned with the SCCT, and typically replayed and spiraled over the course of the educators' careers. These findings resonate with other studies, lending credence to an approach to career development that can be shared with junior faculty who are exploring careers in medical education.
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http://dx.doi.org/10.1007/s10459-019-09949-7DOI Listing
August 2020

Chest pain: Should we be scared or take a heart felt approach?

Emergencias 2020 02;32(1):5-6

Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, EE.UU.

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February 2020

The AURORA Study: a longitudinal, multimodal library of brain biology and function after traumatic stress exposure.

Mol Psychiatry 2020 02 19;25(2):283-296. Epub 2019 Nov 19.

Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, postconcussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/treatment interventions. Progress in overcoming these limitations has been challenging because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large-scale (n = 5000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for 1 year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.
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http://dx.doi.org/10.1038/s41380-019-0581-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6981025PMC
February 2020

Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics.

Acad Emerg Med 2020 02 26;27(2):139-147. Epub 2019 Dec 26.

Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, and National Academic Center for Telehealth, Philadelphia, PA.

Objectives: More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures.

Methods: We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program.

Results: Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%).

Conclusions: Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.
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http://dx.doi.org/10.1111/acem.13890DOI Listing
February 2020

Jump-Starting Faculty Development in Quality Improvement and Patient Safety Education: A Team-Based Approach.

Acad Med 2019 11;94(11):1728-1732

S.M. van Schaik is professor of pediatrics and director of faculty development, Bridges Curriculum, University of California, San Francisco School of Medicine, San Francisco, California. A. Chang is professor of medicine and director, Clinical Microsystems Clerkships, University of California, San Francisco School of Medicine, San Francisco, California. S. Fogh is associate professor of radiation oncology and site director, Clinical Microsystems Clerkships, University of California, San Francisco School of Medicine, San Francisco, California. M. Haehn is assistant professor of anesthesiology and associate quality director, Department of Anesthesiology, University of California, San Francisco School of Medicine, San Francisco, California. A. Lyndon is associate professor of nursing and chair, Family Health Care Nursing, University of California, San Francisco, San Francisco, California. B. O'Brien is associate professor of medicine, University of California, San Francisco School of Medicine, and director, Fellowship in Health Professions Education Evaluation and Research, San Francisco Veterans Affairs Medical Center, San Francisco, California. P. O'Sullivan is professor, Department of Medicine, and director, Research and Development in Medical Education, Center for Faculty Educators, University of California, San Francisco School of Medicine, San Francisco, California. S. Ranji is professor of medicine, University of California, San Francisco School of Medicine, and chief, Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California. G. Rosenbluth is professor of pediatrics and director, Quality and Safety Programs, Office of Graduate Medical Education, University of California, San Francisco School of Medicine, San Francisco, California. N. Sehgal is professor of medicine, University of California, San Francisco School of Medicine, and vice president and chief quality officer, UCSF Health, San Francisco, California. J. Tabas is professor of emergency medicine and director, Outcomes and Innovations, Office of Continuing Medical Education, University of California, San Francisco School of Medicine, San Francisco, California. R.B. Baron is professor of medicine and associate dean for graduate and continuing medical education, University of California, San Francisco School of Medicine, San Francisco, California.

Problem: Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners.

Approach: The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a "Teach-for-UCSF" certificate program in teaching QIPS.

Outcomes: Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS.

Next Steps: Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.
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http://dx.doi.org/10.1097/ACM.0000000000002784DOI Listing
November 2019

Cognitive Deficits in African Americans With Diabetes in an Emergency Department.

Am J Geriatr Psychiatry 2020 04 6;28(4):503-504. Epub 2019 Aug 6.

Sidney Kimmel Medical College at Thomas Jefferson University (BWR, RJC, AMC, JH, KLR), Philadelphia, PA.

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http://dx.doi.org/10.1016/j.jagp.2019.07.018DOI Listing
April 2020

Effect of single-session transcranial direct current stimulation on cognition in Parkinson's disease.

CNS Neurosci Ther 2019 11 19;25(11):1237-1243. Epub 2019 Aug 19.

Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.

Aims: Nonmotor symptoms (NMS) such as cognitive impairment and impulse-control disorders in Parkinson's disease (PD) remain a therapeutic challenge. Transcranial direct current stimulation (tDCS) has emerged as a promising alternative, although its immediate effects on NMS have been less well defined. In this randomized, sham-controlled, crossover study, we aimed to explore the single-session tDCS effects on cognitive performance in PD.

Methods: Ten nondemented patients with PD completed two sessions in counterbalanced order, receiving 20 minutes of either 2 mA anodal or sham tDCS over the left dorsolateral prefrontal cortex (DLPFC). During stimulation, they performed the visual working memory and go/no-go tasks. Performance of the tasks was compared between the two conditions.

Results: Single-session anodal tDCS over the left DLPFC did not significantly improve cognitive tasks in PD compared with sham (P > .05).

Conclusion: Single-session tDCS is ineffective in improving visual working memory and inhibitory control in PD. Further research may worth exploring alternative tDCS parameters, ideally with repeated sessions and concomitant training.
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http://dx.doi.org/10.1111/cns.13210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834682PMC
November 2019

Recurrent neurologic symptoms complicating venom immunotherapy in a patient with systemic mastocytosis and severe Hymenoptera allergy.

J Allergy Clin Immunol Pract 2020 Feb 12;8(2):780-782. Epub 2019 Aug 12.

Division of Clinical Immunology & Allergy, Department of Medicine, St Michael's Hospital & University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1016/j.jaip.2019.07.040DOI Listing
February 2020

"A Friendly Place to Grow as an Educator": A Qualitative Study of Community and Relationships Among Medical Student Coaches.

Acad Med 2020 Feb;95(2):293-300

L. Sheu is assistant professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. K.E. Hauer is associate dean for assessment and professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. K. Schreiner is a medical student, George Washington University School of Medicine, Washington, DC. S.M. van Schaik is Baum Presidential Chair of Experiential Learning and professor of pediatrics, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California. A. Chang is professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. B.C. O'Brien is associate professor of medicine, Department of Medicine, and education scientist, Center for Faculty Educators, University of California, San Francisco, School of Medicine, San Francisco, California.

Purpose: The rise of coaching programs in medical education sparks questions about ways to support physician coaches in learning new educational practices specific to coaching. How coaches learn from one another is of particular interest considering the potential value of social learning. Using communities of practice as a conceptual framework, the authors examine the sense of community and relationships among coaches in a new medical student coaching program, the value of this community, and the facilitators and barriers influencing community development.

Method: In this qualitative study, investigators conducted 34 interviews with physician coaches at 1 institution over 2 years (2017-2018) and observed 36 coach meetings. Investigators analyzed interview transcripts using thematic analysis and used observation field notes for context and refinement of themes.

Results: Coaches described a sense of community based on regular interactions; shared commitment to medical education; and new roles with similar experiences, joys, and challenges. They valued the sense of camaraderie and support, learning from one another, and opportunities for professional growth that strengthened their identities as educators and enhanced job satisfaction. Facilitators of community included regular meetings, leadership and administrative support, and informal opportunities to interact outside of meetings. Barriers included time constraints and geographic challenges for coaches at off-site locations.

Conclusions: The sense of community among coaches was a valued and beneficial part of their coaching experience. Coaches' interactions and relationships promoted skill acquisition, knowledge transfer, professional development, and career satisfaction. Thus, incorporating support for social learning in coaching programs promotes coach faculty development.
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http://dx.doi.org/10.1097/ACM.0000000000002900DOI Listing
February 2020

Dose-dependent glycometabolic effects of sotagliflozin on type 1 diabetes over 12 weeks: The inTandem4 trial.

Diabetes Obes Metab 2019 11 1;21(11):2440-2449. Epub 2019 Aug 1.

Lexicon Pharmaceuticals, Inc., The Woodlands, Texas.

Aims: To assess the dose-related effects of sotagliflozin, a novel dual inhibitor of sodium-glucose co-transporters-1 and -2, in type 1 diabetes (T1D).

Materials And Methods: In this 12-week, multicentre, randomized, double-blind, placebo-controlled dose-ranging trial, adults with T1D were randomized to once-daily placebo (n = 36) or sotagliflozin 75 mg (n = 35), 200 mg (n = 35) or 400 mg (n = 35). Insulin was maintained at baseline doses. The primary endpoint was least squares mean (LSM) change in glycated haemoglobin (HbA1c) from baseline. Other endpoints included proportion of participants with ≥0.5% HbA1c reduction and assessments of 2-hour postprandial glucose (PPG), weight, and urinary glucose excretion (UGE).

Results: From a mean baseline of 8.0% ± 0.8% (full study population), placebo-adjusted LSM HbA1c decreased by 0.3% (P = .07), 0.5% (P < .001) and 0.4% (P = .006) with sotagliflozin 75 mg, 200 mg and 400 mg, respectively, at week 12. In the placebo and sotagliflozin 75 mg, 200 mg and 400 mg groups, 33.3%, 37.1%, 80.0% and 65.7% of participants achieved an HbA1c reduction ≥0.5%. Placebo-adjusted PPG decreased by 22.2 mg/dL (P = .28), 28.7 mg/dL (P = .16) and 50.2 mg/dL (P = .013), UGE increased by 41.8 g/d (P = .006), 57.7 g/d (P < .001) and 70.5 g/d (P < .001), and weight decreased by 1.3 kg (P = .038), 2.4 kg (P < .001) and 2.6 kg (P < .001) with sotagliflozin 75 mg, 200 mg and 400 mg, respectively. One case of severe hypoglycaemia occurred in each sotagliflozin group and one case of diabetic ketoacidosis (DKA) occurred with sotagliflozin 400 mg.

Conclusions: Combined with stable insulin doses, sotagliflozin 200 mg and 400 mg improved glycaemic control and weight in adults with T1D. Sotagliflozin 400 mg reduced PPG levels. UGE increased with all sotagliflozin doses. Rates of severe hypoglycaemia and DKA were low (NCT02459899).
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http://dx.doi.org/10.1111/dom.13825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851757PMC
November 2019