General Internists Research Articles

Development and validation of an image-based questionnaire ARTROVIS to identify risk factors for the articular syndrome and related conditions

Background: The importance of timely diagnosis of rheumatic diseases is beyond any doubt. However, in the real practice the time from manifestation of the first symptoms to the assessment by a rheumatologist and treatment administration often exceeds the window of opportunity for disease control. At the moment, there has been no Russian-language questionnaire that would allow a primary care physician to suspect a rheumatic disease manifesting with an articular syndrome. Aim: To develop, validate and test a questionnaire to identify risk factors for joint disorders and related conditions. Methods: From November 2022 to April 2024, we performed the study on the image-based questionnaire on identification of the risk factors for joint syndromes and associated conditions (ARTROVIS), which we have developed for early detection of both joint syndromes, as well as comorbid conditions associated with elevated serum uric acid levels (hyperuricemia). The initial test version of the questionnaire was tested in a focus group of respondents (n = 20) who came for regular medical examination. Based on the results of this face validity assessment, we corrected the wording of 10 questionnaire items. At the second study step, we assessed the primary validity and reliability of the questionnaire in a group of 41 rheumatology patients. The third study step involved 828 respondents (408 men and 420 women, median age 19 [18,0; 20,0] years; 21% with joint syndromes), who came for routine medical examination. The reliability of the questionnaire, its face and discriminant validity, as well as sensitivity and specificity (the ROC analysis) were assessed from 827 questionnaires included in the final processing (one was excluded due to questionnaire completion defects). Results: The self-report questionnaire for patients (ARTROVIS) has 24 items aimed at collecting social and demographic data, identifying risk factors for non-communicable diseases, assessing genetic aspects, identifying complaints from various organ systems, providing information on medical treatments taken by the patient (non-steroid anti-inflammatory agents, diuretics, antihypertensives, glucocorticosteroids, chemotherapy and radiation therapy), as well as an additional question for women on current pregnancy pathology. The questionnaire contains visual aids (colored photos) that facilitate the detection of clinical signs of autoimmune (psoriatic arthritis, Reynolds’s syndrome) and inflammatory rheumatic disease (gout), as well as the differential diagnosis of the joint syndrome. The assessment of face validity of the questionnaire showed the total number of missed answers of 3.42%; 62.85% of the respondents gave their full answers to all items. Good discriminant validity was demonstrated. The ROC analysis showed high correlation between the questionnaire score and the presence of a joint syndrome: the area under the curve was 0.884. The Cronbach’s alfa was 0.798, which is sufficient for a medical questionnaire. Conclusion: We have performed the approbation and standardization of the questionnaire to identify risk factors for the joint syndrome and related comorbidities by assessing its validity and reliability. The ARTROVIS as a self-report questionnaire can be used in primary care as a tool enabling general practitioners and internists to decide on further patient routing to corresponding specialists.

The Organization of Academic General Internal Medicine Practice at the Top Primary Care Schools.

While prior studies have explored staffing infrastructure for primary care practices in general, little is known about the range of academic primary care practice models and supports available for academic general internists. To characterize the range of practice arrangements and expectations for attending academic physicians in general internal medicine (GIM) practices at the top 22 medical schools across the USA. Cross-sectional survey administered electronically between October 30, 2022, and December 28, 2022. Clinical leaders in GIM at the top 22 primary care medical schools, as identified by the 2023 US News and World Report Rankings. Clinical load, productivity expectations, cross-coverage, and team-based care models. Twenty-two leaders responded, representing 68% (15/22) of medical schools surveyed. The practices were mostly in urban locations (18/22, 82%) and 86% (19/22) included residents. Practices ranged from 7 to 200 PCPs and from 3 to 112 clinical FTEs. A full-time (1.0 FTE) clinical role for academic attending GIM physicians entailed a median of 9 (IQR 8, 10) weekly half-day clinic sessions, with a median panel size expectation of 1600 (IQR 1450, 1850) patients and a median yearly RVU expectation of 5200 (IQR 4161, 5891) yearly RVUs generated. Staff support was most commonly present for prescription refills and patient portal message checks. It was less commonly available for time sensitive form completion. Occasional clinical coverage for other physicians was an expectation at all practices. In this study, we characterize the organization of and supports available in academic GIM practices affiliated with the top primary care medical schools. Our findings provide comparative information for leaders of academic GIM practices seeking to enhance primary care delivery for their faculty and trainees. They also highlight areas where standardization may be beneficial across academic GIM.

Methodological characteristics of the academic competition for general practitioners, family doctors and internists as a type of informal education

The article analyzes the results of the All-Russian competition for general practitioners, family doctors and internists held over five years by the National Medical Research Center for Therapy and Preventive Medicine with the support of the Russian Society for the Prevention of Non communicable Diseases.Aim. To determine the methodological characteristics of managing the academic competition as a type of informal education.Material and methods. To conduct the competition, practice-oriented tasks corresponding to professional tasks of a general practitioner were developed. In addition, we developed an original questionnaire to assess the impact of participation in the academic competition on the professional development. Family doctors and general practitioners with 1-10 years of experience, as well as internists, were included.Results. The methodological characteristics of the academic competition management as a type of informal education were determined: practice-oriented goals aimed at improving the knowledge, skills and abilities, competencies of the participants; the content of tasks based on the theory-practice relationship; compliance of tasks and real situations in the practice of a general practitioner; a systematic approach to competition management. Conclusion. The effectiveness of the academic competition as a type of informal education contributes to the professional development of participants, promotes the development of long-term attitudes towards improving professional knowledge, skills, abilities and competencies necessary for solving professional problems.

Incorporating Anti-racist Principles Throughout the Research Lifecycle: A Position Statement from the Society of General Internal Medicine (SGIM).

Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism's impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.

The diagnostic and triage accuracy of the GPT-3 artificial intelligence model: an observational study

Artificial intelligence (AI) applications in health care have been effective in many areas of medicine, but they are often trained for a single task using labelled data, making deployment and generalisability challenging. How well a general-purpose AI language model performs diagnosis and triage relative to physicians and laypeople is not well understood. We compared the predictive accuracy of Generative Pre-trained Transformer 3 (GPT-3)'s diagnostic and triage ability for 48 validated synthetic case vignettes (<50 words; sixth-grade reading level or below) of both common (eg, viral illness) and severe (eg, heart attack) conditions to a nationally representative sample of 5000 lay people from the USA who could use the internet to find the correct options and 21 practising physicians at Harvard Medical School. There were 12 vignettes for each of four triage categories: emergent, within one day, within 1 week, and self-care. The correct diagnosis and triage category (ie, ground truth) for each vignette was determined by two general internists at Harvard Medical School. For each vignette, human respondents and GPT-3 were prompted to list diagnoses in order of likelihood, and the vignette was marked as correct if the ground-truth diagnosis was in the top three of the listed diagnoses. For triage accuracy, we examined whether the human respondents' and GPT-3's selected triage was exactly correct according to the four triage categories, or matched a dichotomised triage variable (emergent or within 1 day vs within 1 week or self-care). We estimated GPT-3's diagnostic and triage confidence on a given vignette using a modified bootstrap resampling procedure, and examined how well calibrated GPT-3's confidence was by computing calibration curves and Brier scores. We also performed subgroup analysis by case acuity, and an error analysis for triage advice to characterise how its advice might affect patients using this tool to decide if they should seek medical care immediately. Among all cases, GPT-3 replied with the correct diagnosis in its top three for 88% (42/48, 95% CI 75-94) of cases, compared with 54% (2700/5000, 53-55) for lay individuals (p<0.0001) and 96% (637/666, 94-97) for physicians (p=0·012). GPT-3 triaged 70% correct (34/48, 57-82) versus 74% (3706/5000, 73-75; p=0.60) for lay individuals and 91% (608/666, 89-93%; p<0.0001) for physicians. As measured by the Brier score, GPT-3 confidence in its top prediction was reasonably well calibrated for diagnosis (Brier score=0·18) and triage (Brier score=0·22). We observed an inverse relationship between case acuity and GPT-3 accuracy (p<0·0001) with a fitted trend line of -8·33% decrease in accuracy for every level of increase in case acuity. For triage error analysis, GPT-3 deprioritised truly emergent cases in seven instances. A general-purpose AI language model without any content-specific training could perform diagnosis at levels close to, but below, physicians and better than lay individuals. We found that GPT-3's performance was inferior to physicians for triage, sometimes by a large margin, and its performance was closer to that of lay individuals. Although the diagnostic performance of GPT-3 was comparable to physicians, it was significantly better than a typical person using a search engine. The National Heart, Lung, and Blood Institute.

Current and future workforce of general internal medicine in Switzerland: a cross-sectional study.

General internal medicine is a crucial element in healthcare systems. Understanding how many people are and will be working in this field is important to maintain and improve quality for patients in healthcare systems. This can provide a basis for political decisions. We conducted a cross-sectional study to analyse the current and future workforce of generalists (general practitioners and internists in hospitals) in Switzerland. The Swiss Society of General Internal Medicine (SSGIM) distributed a survey to all members. Respondents were asked about their current average workload in 2023 and planned workload in 2033. The responses were used to calculate full-time equivalent (FTE) for the current and future workforce of generalists and to extrapolate FTE for all active SSGIM members. To model the demand by 2033, we derived different scenarios. Of all 6,232 active SSGIM members, 2,030 (33%) participated: 46% female, 25% (largest age group) 56-65 years old, 19% still in postgraduate training. The average workload in 2023 was 78% for female and 87% for male generalists; the FTE extrapolated to all active SSGIM members in 2023 was 5,246. By 2033, 1,935 FTEs (36%) will retire, 502 FTEs (10%) will reduce their workload, 116 FTEs (2%) will increase their workload and 2,800 FTEs (53%) will remain in the workforce with the same workload as in 2023. To maintain the same workforce as in 2023, 2,321 new FTEs (44%) will be needed by 2033. To fill this gap of 232 FTE new generalists per year, we modelled different scenarios with assumptions of interest, workload, migration and dropouts. Within only one decade, 44% of the current workforce of generalists will disappear, mainly due to retirement and decreased workload. To fill this gap, various scenarios need to be incorporated. Politicians are called upon to create the political framework to create attractive training and working conditions for generalists to address the future demand for healthcare services.

Characteristics and feedback of adult survivors of childhood cancer seen in Swiss comprehensive follow-up clinics led by general internists: a prospective cohort study

ObjectivesIn our study, we aimed to characterise adult childhood cancer survivors (ACCS), assess their health issues, gauge health-related quality of life (HRQOL) and evaluate visit satisfaction.DesignProspective cohort study using data...

Regional Disparities in Atrial Fibrillation Management: An IMPACT-AF Substudy

BackgroundIn rural regions, atrial fibrillation (AF) management is performed predominately by local primary care professionals (PCPs). Prior work has suggested that a disparity in outcomes in AF occurs for those patients living in a rural, vs urban, location. MethodsThis post hoc analysis of the cluster randomized trial Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) compared a clinical decision support system to standard of care. Patients were classified as living in a rural (population < 10,000) or urban location. The outcomes were as follows: AF-related emergency department (ED) visits, unplanned cardiovascular (CV) hospitalizations, AF-related referrals and guideline adherence for AF treatment. ResultsA total of 1133 patients were enrolled from 2016 to 2018; 54.1% (n = 613) were classified as living in a rural location. No differences were present in age (mean, 72 ± 9.63 vs 72.5 ± 10.42 years) or Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score (mean, 2.1 ± 1.36 vs 2.16 ± 1.34). Referral rates to general internists were higher in the rural population (13.4% vs 3.9%, P < 0.001), whereas the rate of cardiology referrals was higher in the urban population (10% vs 15%, P = 0.0098). At 12 months, no difference in the composite outcome of AF-related ED visits and CV hospitalizations was seen. Fewer recurrent AF-related ED visits and CV hospitalizations occurred in the urban group (incidence rate ratio [IRR], 0.65 [95% confidence interval (0.44, 0.95), P = 0.0262). The incidence of guideline adherence was similar between the rural (IRR, 3.7 ± 1.2) and urban (IRR, 3.6 ± 1.2; P = 0.11) groups. ConclusionsAF patients living in rural locations had higher rates of recurrent AF-related ED visits and unplanned CV hospitalizations. Further research to optimize AF-related outcomes is needed to ensure equitable delivery of care to all Canadians, irrespective of geography. Clinical Trial RegistrationNCT01927367.

Physician and Patient Preferences for Treatment of Anemia Associated with Chronic Kidney Disease in Japan: A Survey Including Best-Worst Scaling.

Several treatment options are available for anemia associated with chronic kidney disease (CKD); however, there remains a lack of awareness of physician and patient preferences regarding these treatments. We aimed to explore physicians' and patients' perceptions and preferences regarding the management of anemia of CKD in Japan. A web-based survey, including best-worst scaling (BWS), was conducted with physicians who had treated ≥1 patient with anemia of CKD in the preceding year, and with patients with CKD who self-reported a clinical diagnosis of anemia of CKD or low hemoglobin levels. A three-step approach was used comprising cognitive interviews, a pilot survey, and a main survey. The BWS survey results were analyzed using multinomial logit and hierarchical Bayesian models. The survey was completed by 906 participants: 103 patients (average age 60.6 years; 77.7% male) and 803 physicians (166 nephrologists, 214 cardiologists, 137 diabetologists, and 286 general internists). Almost all (96.0%) physicians surveyed considered anemia of CKD to be an important condition to treat. Hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitors had the highest treatment satisfaction among physicians, whereas patients had the highest satisfaction with both erythropoietin-stimulating agent therapy and HIF-PH inhibitors. Approximately one-third (35.9%) of patients surveyed indicated that they were receiving treatment. When comparing the relative importance of attributes and levels, physicians favored efficacy (particularly improvement in hemoglobin levels), whereas patients favored safety (particularly a lower rate of severe adverse events). Although a majority of physicians consider treatment of CKD-related anemia important, differences in the perceptions and usage of medications exist between medical specialties. Preferences for the management of anemia of CKD vary between physicians and patients; therefore, patient involvement in treatment decisions may help optimize outcomes.

Brain check-up: a structured approach diagnosing mild cognitive impairment in the primary care setting

The reason-related identification of mild cognitive impairment (MCI) in primary care is helpful to treat reversible causes or decelerate progression to dementia by optimal management of existing risk factors. In this process general practitioners are in akey position. The present feasibility study investigated the practicability of adiagnostic algorithm (brain check-up), comprising neuropsychological examinations, differential diagnoses and follow-up measures. By means of astandardized questionnaire, the utilization and practicability of the brain check-up was surveyed in n = 37 medical practices of general practitioners and internists in Germany. The brain check-up was performed by n = 37physicians in 389 patients (66%). The main barriers to implementation included patients' fear of facing the results, the professionals' lack of time, and costs. Overall, 73% of the participants agreed that the brain check-up was practical in everyday treatment. Long waiting times for an appointment with aneurological/psychiatric specialist were perceived as abarrier for optimal care. The structured algorithm is convenient in physician's everyday practice and can contribute to identify patients with MCI more easily. Therefore, it appears to be ahelpful tool in primary care. To achieve sustainability in everyday use, identified barriers need to be addressed during the implementation phase.

Examining Linguistic Differences in Electronic Health Records for Diverse Patients With Diabetes: Natural Language Processing Analysis.

Individuals from minoritized racial and ethnic backgrounds experience pernicious and pervasive health disparities that have emerged, in part, from clinician bias. We used a natural language processing approach to examine whether linguistic markers in electronic health record (EHR) notes differ based on the race and ethnicity of the patient. To validate this methodological approach, we also assessed the extent to which clinicians perceive linguistic markers to be indicative of bias. In this cross-sectional study, we extracted EHR notes for patients who were aged 18 years or older; had more than 5 years of diabetes diagnosis codes; and received care between 2006 and 2014 from family physicians, general internists, or endocrinologists practicing in an urban, academic network of clinics. The race and ethnicity of patients were defined as White non-Hispanic, Black non-Hispanic, or Hispanic or Latino. We hypothesized that Sentiment Analysis and Social Cognition Engine (SEANCE) components (ie, negative adjectives, positive adjectives, joy words, fear and disgust words, politics words, respect words, trust verbs, and well-being words) and mean word count would be indicators of bias if racial differences emerged. We performed linear mixed effects analyses to examine the relationship between the outcomes of interest (the SEANCE components and word count) and patient race and ethnicity, controlling for patient age. To validate this approach, we asked clinicians to indicate the extent to which they thought variation in the use of SEANCE language domains for different racial and ethnic groups was reflective of bias in EHR notes. We examined EHR notes (n=12,905) of Black non-Hispanic, White non-Hispanic, and Hispanic or Latino patients (n=1562), who were seen by 281 physicians. A total of 27 clinicians participated in the validation study. In terms of bias, participants rated negative adjectives as 8.63 (SD 2.06), fear and disgust words as 8.11 (SD 2.15), and positive adjectives as 7.93 (SD 2.46) on a scale of 1 to 10, with 10 being extremely indicative of bias. Notes for Black non-Hispanic patients contained significantly more negative adjectives (coefficient 0.07, SE 0.02) and significantly more fear and disgust words (coefficient 0.007, SE 0.002) than those for White non-Hispanic patients. The notes for Hispanic or Latino patients included significantly fewer positive adjectives (coefficient -0.02, SE 0.007), trust verbs (coefficient -0.009, SE 0.004), and joy words (coefficient -0.03, SE 0.01) than those for White non-Hispanic patients. This approach may enable physicians and researchers to identify and mitigate bias in medical interactions, with the goal of reducing health disparities stemming from bias.

Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative Inquiry

BackgroundRepeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care.AimThis qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital.MethodsThe FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics.ResultsThematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling.ConclusionThis study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.

Frequency of office blood pressure measurements and the seasonal variability of blood pressure: results of the Hungarian Hypertension Registry

Purpose Hypertension is a major public health problem, thus, its timely and appropriate diagnosis and management are crucial for reducing cardiovascular morbidity and mortality. The aim of the new Hungarian Hypertension Registry is to evaluate the blood pressure measurement practices of general practitioners (GPs), internists and cardiologists in outpatient clinics, as well as to assess the seasonal variability of blood pressure. Materials and methods Omron M3 IT devices were used during four-month periods between October 2018 and April 2023 in GP practices and in hypertension clinics. The blood pressure data were then transmitted online from the monitors’ cuffs to a central database using the Medistance system of Omron. Results Family physicians (n = 2491), and internists/cardiologists (n = 477) participated in the study. A total of 4804 821 blood pressure measurements were taken during 10 four-month evaluation periods. In the ten periods, the daily average number of measurements was between 3.0 and 5.6. Following ESH diagnostic criteria, the proportion of subjects in optimal, normal and high-normal blood pressure categories were 14, 13.4 and 16.7%, respectively. Altogether 56% of the measurements belonged to stage 1, stage 2 or stage 3 hypertension categories (31.6, 17.1 and 7.4%, respectively). On average, a difference of 5/2 mmHg was observed between winter and summer data in systolic and diastolic blood pressures, respectively. The average systolic blood pressure values were higher in GP practices with more than 2000 patients than in the ones with less than 1500 patients (141.86 mmHg versus 140.02 mmHg, p < 0.05). Conclusion In conclusion, the low daily average number of blood pressure measurements indicates a limited blood pressure screening awareness/capacity in the case of Hungarian family physicians. In GP practices with more patients, blood pressure is usually less well-controlled. These results suggest that the further promotion of home blood pressure monitoring is necessary.

High Hepatitis C Cure Rates Among Patients With Alcohol Use at a Safety-Net Hepatitis C Clinic.

We set out to examine several aspects of the relationship between alcohol use and hepatitis C virus (HCV) among a cohort of patients treated at an HCV clinic within a safety net hospital. We examined (1) the prevalence of alcohol use among patients treated for HCV, (2) the likelihood of being started on treatment among patients who reported drinking alcohol compared with those who did not, and (3) the associations between alcohol use and HCV cure. We performed a retrospective chart abstraction study using data from the Grady Liver Clinic, a specialty HCV clinic colocated in Grady Memorial Hospital's primary care clinic and run by general internists. Nine hundred fifty-four patients were included. The sustained virologic response rate among those with 12-week posttreatment measurement was 99.2%, with only 5 patients experiencing virologic failure. None of the alcohol use indicators significantly impacted sustained virologic response or loss to follow-up. Estimates of alcohol use ranged from 28.9% (by International Classification of Diseases, Tenth Revision , code) to 48.9% (clinician documentation). Treatment initiation rates were the same among those who did and did not report alcohol use. Alcohol use was not associated with decreased HCV cure rates. Our findings validate the inclusion of patients with alcohol use in HCV treatment programs.

A235 INFLAMMATORY BOWEL DISEASE AND PREECLAMPSIA: A PHYSICIAN SURVEY

Abstract Background Preeclampsia is a disorder of pregnancy recognized as the second cause of maternal mortality worldwide. The association between IBD and preeclampsia remains unclear, but the significant comorbid profile, and lack of treatment aside from urgent delivery, make primary prevention a priority. Aspirin was shown to halve preeclampsia rates and is recommended for primary prevention for women at risk. Despite high-quality evidence supporting Aspirin use and its well tolerated side effect profile, studies in non-IBD patients have demonstrated a knowledge-to-practice gap. Aims While there are no studies reported in women with IBD, prescribing rates may be even lower in this population, given that it may be incorrectly perceived to increase the risk of an IBD flare. Understanding physician perceptions could allow for a targeted educational approach to increase patient and physician awareness of the indications for Aspirin prophylaxis and its safety profile. Methods This is a cross-sectional survey study assessing physician perceptions and Aspirin prescribing patterns for preeclampsia prevention conducted from Mount Sinai Hospital. Demographic information, information on perceptions of preeclampsia risk in pregnant women with IBD, and on the perceived clinical benefit and risk of Aspirin prescribing were collected. Results A total of 38 Canadian healthcare professionals (HCPs) (15 Gastroenterologists, 14 Obstetricians, 5 General Practitioners, 2 General Internists, 1 nurse practitioner, and 1 midwife) were surveyed. Most HCPs were practicing for over 10 years (71%). In total, 68% of HCPs were comfortable with pregnancy-specific management of IBD. Most HCPs correctly identified all comorbidities associated with a high risk of preeclampsia including a history of preeclampsia (95%), renal disease (87%), and autoimmune disease (68%). A total of 55% of HCPs believed that pregnant patients with IBD were at increased risk of placental related diseases, and 56% agreed that these patients were at increased risk of preeclampsia specifically. Thirty-five percent of HCPs believed that IBD in remission, in the absence of other risk factors, was an indication for Aspirin prophylaxis. More so, 45% believed that IBD, with poor disease control, was an indication. Only 8% of HCPs believed that Aspirin, when used for preeclampsia prevention, was associated with an IBD flare. In patients whom Aspirin prophylaxis was indicated, 77% agreed with its use, even in patients in whom disease control was poor. Finally, 63% agreed that the Aspirin dose should be 162 mg daily, and more than half (58%) agreed that the prescriber should be the patient’s obstetrician. Conclusions Most HCPs agreed that IBD was a risk factor for preeclampsia and that Aspirin prophylaxis was effective and safe for primary prevention. High quality studies are needed to evaluate risk of preeclampsia in IBD, especially in patients with active disease. Funding Agencies CAG

Von Willebrand disease: A guide for the internist.

von Willebrand disease (VWD), the most common inherited bleeding disorder, results when patients either do not make enough von Willebrand factor (VWF) or make defective VWF. The pathophysiology of this disorder is complex but needs to be understood to interpret the diagnostic tests. Most patients have mild to moderate symptoms and can be adequately counseled and managed by a general internist, but some need to consult a hematologist. We review the pathophysiology of VWD, its subtypes, common presentations of each subtype, diagnostic testing, and management of mild as well as severe clinical manifestations of VWD.

Renal Manifestations of IgG4‐Related Disease: A Concise Review

IgG4‐related disease (IgG4‐RD) is an immune‐mediated disorder marked by fibro‐inflammatory masses that can infiltrate multiple organ systems. Due to its relatively recent discovery and limited understanding of its pathophysiology, IgG4‐related disease may be difficult to recognize and is consequently potentially underdiagnosed. Renal involvement is becoming regarded as one of the key features of this disease. To date, the most well‐recognized renal complication of IgG4‐related disease is tubulointerstitial nephritis, but membranous glomerulonephritis, renal masses, and retroperitoneal fibrosis have also been reported. This concise review has two objectives. First, it will briefly encapsulate the history, epidemiology, and presentation of IgG4‐related disease. Second, it will examine the reported renal manifestations of IgG4‐related disease, exploring the relevant histology, imaging, clinical features, and treatment considerations. This synthesis will be highly relevant for nephrologists, rheumatologists, general internists, and renal pathologists to raise awareness and help improve early recognition of IgG4‐related kidney disease (IgG4‐RKD).

What Bedside Skills Could the Modern Rheumatologist Possess? Part II. "Certain Technical Procedures".

Rheumatologists have never been reluctant to adopt procedures that might enhance their diagnostic or therapeutic powers. Their propensity to penetrate the joints of the patients they were treating set them apart from the general internist. Since the 1980s, when a chance to look inside the joints they were treating attracted a few rheumatologists, other things that could be done at the bedside emerged with now an array of bedside procedures that could be part of a rheumatologist's skill set. Besides gains in diagnosis and/or therapy, each constitutes a chance to restore the physical contact between physician and patient, riven by factors of the last decade, such as electronic medical records and COVID. With such contact so important to satisfaction of the patient and physician alike, acquisition of proficiency in certain technical procedures described herein offers one path to begin restoring rheumatology to the richly fulfilling practice it once was.

Conversation starters: Understanding the facilitators and barriers to physician-initiated secure firearm storage conversations

ObjectiveThis paper aims to understand what general practice physicians (GPs) perceive as facilitators and barriers to initiating anticipatory guidance around firearm safety. MethodsWe employ qualitative interviewing to have in-depth conversations with 18 GPs. Participants were randomly selected from a national panel of physicians and screened for specialty (general practice or internist), practice setting (not hospital-based), and time spent on direct patient care (80% +). The sample was stratified at the state level by the presence of safe storage or child access protection laws, with half of the participants selected from each stratum. ResultsWe identify five physician-perceived barriers to providing secure firearm storage counseling, including inadequate screening mechanisms to trigger conversations, physician perceptions of who is at risk for firearm injury, time pressures, concerns about patient receptivity, and a need for training. ConclusionPrior to focusing on how to have conversations about firearm safety, interventions designed to increase the incidence of physician-initiated guidance need to address the structural issues of why those conversations typically do not occur. Practice implicationsFindings indicate the need for revised screening tools and improved physician education as to who is at risk for gun injury and how to best approach firearm safety conversations.

The Associations Between United States Medical Licensing Examination Performance and Outcomes of Patient Care.

The United States Medical Licensing Examination (USMLE) comprises a series of assessments required for the licensure of U.S. MD-trained graduates as well as those who are trained internationally. Demonstration of a relationship between these examinations and outcomes of care is desirable for a process seeking to provide patients with safe and effective health care. This was a retrospective cohort study of 196,881 hospitalizations in Pennsylvania over a 3-year period (January 1, 2017 to December 31, 2019) for 5 primary diagnoses: heart failure, acute myocardial infarction, stroke, pneumonia, or chronic obstructive pulmonary disease. The 1,765 attending physicians for these hospitalizations self-identified as family physicians or general internists. A converted score based on USMLE Step 1, Step 2 Clinical Knowledge, and Step 3 scores was available, and the outcome measures were in-hospital mortality and log length of stay (LOS). The research team controlled for characteristics of patients, hospitals, and physicians. For in-hospital mortality, the adjusted odds ratio was 0.94 (95% confidence interval [CI] = 0.90, 0.99; P < .02). Each standard deviation increase in the converted score was associated with a 5.51% reduction in the odds of in-hospital mortality. For log LOS, the adjusted estimate was 0.99 (95% CI = 0.98, 0.99; P < .001). Each standard deviation increase in the converted score was associated with a 1.34% reduction in log LOS. Better provider USMLE performance was associated with lower in-hospital mortality and shorter log LOS for patients, although the magnitude of the latter is unlikely to be of practical significance. These findings add to the body of evidence that examines the validity of the USMLE licensure program.