Internal Medicine Research Articles

Peer Review: Insights Gleaned From Observing the Editorial Process at Annals of Internal Medicine

Peer Review: Insights Gleaned From Observing the Editorial Process at <i>Annals of Internal Medicine</i>

Medical Diseases in Pregnancy: An Acute on Chronic Focus

In the last decade or so obstetric care has evolved and become more complex. This can be attributed to a combination of factors including rising obesity rates, maternal age and medical treatment advances. Clinicians are caring for more pregnant women with chronic medical disease in addition to any de novo presentations which may occur, emphasising the need for the general medicine body to feel confident and skilled in the management of medical problems before, during and after pregnancy. One of the difficulties faced by clinicians in the assessment and management of pregnant women is the differentiation between symptoms of a normal pregnancy vs symptoms of clinical significance which warrant further investigation, particularly in mothers with background medical disease. Careful consideration and knowledge of normal pregnancy physiology is required when assessing a pregnant women/birthing person to avoid closed thinking and adverse outcomes. Unfortunately, clinician inertia around the care of pregnant women is a common feature in maternal mortality reviews. The most recent maternal mortality report discusses common themes around cardiovascular disease in pregnancy, alongside management of acute and acute-on-chronic presentations in the context of common endocrine, gastrointestinal and neurological disease in pregnancy. This article discusses some of these themes and the management of common medical problems in pregnancy.

Accuracy of Mentzer index for predicting iron deficiency anemia in adults

Background: It is of great clinical significance to differentiate between causes of microcytic, hypo chromatic anemias, iron deficiency anemia being one of them as it will improve with iron supplements. Complete blood picture is unable to differentiate. Iron studies and Hemoglobin electrophoresis are expensive tests. This necessitates the need of a cost-effective test and therefore we tried to determine the effectiveness of mentzer index in predicting iron deficiency anemia. Methods: It was an Observational, Cross-sectional study, conducted in Department of General Medicine, Federal government polyclinic hospital, Islamabad. Patients with microcytic hypochromic anemia, both from indoor and outdoor were included in study. Iron deficiency Anemia was diagnosed by iron studies (serum ferritin, Serum Iron, TIBC and transferrin saturation) and then mentzer index was calculated to check accuracy. Patient with normocytic or macrocytic anemia or other cell lines deficiency, patients with infectious diseases or inflammatory process were excluded from study. Results: A total of 155 patients were included in the study. Out of all the patients 145(93.5%) had mentzer index of &gt; 13 while 10(6.5%) had mentzer index of &lt;13. All of 150 patients (100%) had transferrin saturation lessthan 20 % indicating iron deficiency anemia against 93.5% picked up by Mentzer index. The receiver operator curves (ROC) showed that the MCV was the most important predictor of anemia while calculating mentzer index. The AUC value for MCV was 0.886(CI: 95%, 0.806-0.966, p value &lt;0.000). MCV value between 52.6 to 63.5 fl predicted that the Mentzer index would be above 13, thus suggesting iron deficiency anemia with a sensitivity of more than 86%. Conclusion: Study findings support the use of Mentzer index, particularly MCV, as a valuable tool for predicting iron deficiency anemia.

Protective Potential of Sodium-Glucose Cotransporter 2 Inhibitors in Internal Medicine (Part 1)

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have emerged as a revolutionary class of drugs with far-reaching protective effects in multiple organs. The protective potential of SGLT2i is much broader than that of the classical concept of glucose control and consists of an entire conglomerate of associated pleiotropic effects. This study aims to provide a descriptive review of the pleiotropic therapeutic potential of SGLT2i. The first part of the literature review examined the use of SGLT2i in cardiology and nephrology. The use of SGLT2i represents an innovative approach to improving patients’ quality of life and course of heart failure and chronic kidney disease, regardless of left ventricular ejection fraction and type 2 diabetes.

Dermatological manifestations in diabetes mellitus and its relation with HbA1c levels – An observational study

Diabetes Mellitus is a chronic, metabolic disease characterised by elevated levels of blood glucose, which over time leads to serious damage. The most common is type 2 diabetes which occurs when body becomes resistant to insulin or doesn’t make enough insulin. Skin manifestations are seen generally in pre-diabetes, undiagnosed, long-term and uncontrolled diabetes mellitus. Skin symptoms may help in diagnosing a denovo case and may give an insight into the patient's diabetic status. This is a cross-sectional, observational study conducted in patients attending the outpatient departments of Dermatology, General Medicine and those admitted under these departments over a period of four months. Clearance from Institutional Ethics Committee was taken before the start of the study. A sample population of 100 was selected randomly based on inclusion and exclusion criteria. Glycaemic profiles including HbA1c were done. Infections (35%) were the most common cutaneous symptoms, followed by papulosquamous illnesses (19%), autoimmune diseases (7%), obesity-related (6%), diabetic vasculopathy-related (5%) and miscellaneous conditions (28%), which included generalised pruritus and xerosis etc. The majority of infections were superficial fungal infections, followed by bacterial and viral infections. Dermatophytosis accounted for a majority of superficial fungal infections. Significant correlation was found between higher HbA1c levels and infections, papulo-squamous diseases, auto-immune diseases, obesity-related manifestations.Higher HbA1c levels were found to be significantly associated with a variety of cutaneous symptoms such as infections, papulosquamous illnesses, autoimmune disorders, and obesity-related manifestations.

Implementation and Assessment of a Curriculum for Renal Point of Care Ultrasound (POCUS) Training

Purpose: Renal ultrasound is a non-invasive method to assess for obstructive acute kidney injury (AKI). Point of care ultrasound (POCUS) has been shown to be a good screening tool for obstructive AKI, and with formal training, has high sensitivity and specificity. We aimed to evaluate the effectiveness and feasibility of integrating a novel renal POCUS curriculum into an existing two-week nephrology rotation for internal medicine residents. Methods: We enrolled internal medicine residents rotating on a two-week nephrology rotation between September 2022 and June 2023. Pre-recorded online lectures and a hands-on session on image acquisition were provided. Pre-and post-rotation confidence questionnaires and knowledge tests were collected. At the end of the rotation, participants were evaluated using a skills checklist. Evaluation for knowledge retention was assessed 6–12-months post-rotation with a post-survey and knowledge test. Results: Of the 16 residents that were enrolled, 12 residents completed pre- and post-rotation questionnaires and tests, and 15 residents completed the 6–12-month follow-up. The confidence level showed significant improvement post-test and at 6–12-month follow-up. Knowledge test scores showed a trend towards improvement that did not achieve statistical significance (pre- 6.0 [5.0-7.25], post- 6.5 [5.75-8.0], 6–12-months 7.0 [6.0-8.0] p=0.40). On the skills checklist, an average of 16.8 out of 18 steps were done correctly. Conclusion: Our study showed confidence improvement and a trend towards knowledge improvement after integrating a novel Renal POCUS curriculum into a nephrology rotation. Further iterative changes, such as deliberate practice, or practice with immediate feedback, should be considered.

Inside the November 2024 Issue

Dear Readers, We are thrilled to bring you the second issue of the ninth volume of POCUS Journal. Published since 2016, POCUS Journal is the only multi-disciplinary, peer-reviewed, POCUS-focused journal that is free for authors and readers alike. This issue features a variety of POCUS articles from around the world: from North America, South America, Europe, Asia, and even Australia. In addition to novel cases with striking POCUS images and video clips, this issue boasts a great deal of educational research at all levels: Danila et al. (page 80) report on their study of how POCUS can augment a medical student preclinical cardiovascular course while Piro et al. (page 93) studied the impact of just-in-time POCUS curriculum on internal medicine residents; Janjigian et al. (page 109) studied the longitudinal impact of a faculty POCUS training course. POCUS is a powerful tool with a wide range of applications: for example, it can be used both to diagnose musculoskeletal conditions (Doblinger et al. page 15 and Mack et al. page 27) and to treat musculoskeletal conditions (Bowling et al page 12, and McCreary et al. page 30). POCUS can also be used to predict heart failure readmission (Malagón et al. page 125). We are so excited to showcase pivotal POCUS scholarship like this in the November issue. I hope you enjoy this issue of POCUS Journal as much as I have. A huge thank you to our authors, editorial board, and publisher. Sincerely , Benjamin T. Galen, MD Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA

Just In Time! Assessment of Internal Medicine Resident Point of Care Ultrasound (POCUS) Attitudes and Behaviors After Spaced Intervention at Two Residency Programs

Point of care ultrasound (POCUS) is a complex psychomotor skill that requires scaffolded support for skill acquisition. However, the effect of spaced curricular elements on learner POCUS behaviors are not clearly understood. Using a multi-site observational cross-sectional survey study, we measured resident baseline POCUS use, behaviors, and attitudes and then implemented POCUS workflow and just-in-time POCUS curricula during internal medicine resident ward rotations and assessed changes. Self-reported personal and team POCUS use and documentation habits all improved between baseline and the just-in-time teaching. Personal POCUS use correlated with team POCUS use (ρ=0.431; p&lt;0.001) and co-resident POCUS use (ρ=0.242; p=0.035). Attending POCUS use correlated with team POCUS use (ρ=0.523; p&lt; 0.001), but not personal use. Overall, we found moderate, but statistically significant, improvements in reported resident and team performance of POCUS and documentation habits, suggesting that just-in-time interventions may promote POCUS use. Co-learning also appears to be a key influencer for POCUS use.

Knowledge and Confidence Among Five Cohorts of Faculty Learners in a Point of Care Ultrasound (POCUS) Program: Factors Defining Learner Success

Background: The availability of faculty proficient in point of care ultrasound (POCUS) has emerged as a barrier to the ongoing expansion of POCUS across the field of internal medicine. We sought to examine the faculty graduates of our institutional POCUS program to identify characteristics associated with long-term proficiency to inform curricula and guide institutional support. Methods: We emailed a test and survey to the 89 faculty graduates of the annual POCUS course we have run from 2018-2023. Results: Of the 46 participants (52%) who completed the test and survey, the overall median test score was 72%. Graduates were most confident with image acquisition of the lung, and were most likely to use ultrasound to evaluate ascites and dyspnea. All 11 participants reporting completion of an image portfolio were actively teaching POCUS, whereas only 54% of non-completers were teaching. Portfolio completers scored higher on the test compared to non-completers (median 92% and 68%, respectively, p &lt;0.01) and were more confident in image acquisition and interpretation (p&lt;0.001). Conclusions: In this long-term, single-institutional study of faculty graduates of an annual POCUS program, those who reported completing an image portfolio scored significantly higher on a knowledge test, reported higher confidence with image acquisition and interpretation, and reported using and teaching POCUS more frequently compared to graduates who did not complete the portfolio. POCUS education programs should be designed to foster continuous scanning practice and image portfolio completion.

Effectiveness of General Medicine in the Management of Rheumatoid Arthritis in Rural Settings: A Systematic Review and Meta-Ethnography

Effectiveness of General Medicine in the Management of Rheumatoid Arthritis in Rural Settings: A Systematic Review and Meta-Ethnography

Thromboprophylaxis of venous thromboembolism in internal medicine

Thromboprophylaxis of venous thromboembolism in internal medicine

Cost-Effectiveness of Computer-Assisted Cognitive Behavioral Therapy for Depression Among Adults in Primary Care.

Approximately 1 in 5 adults are diagnosed with depression in their lifetime. However, less than half receive help from a health professional, with the treatment gap being worse for individuals with socioeconomic disadvantage. Computer-assisted cognitive behavioral therapy (CCBT) is an effective and convenient strategy to treat depression; however, its cost-effectiveness in a sociodemographically diverse population remains unknown. To evaluate the cost-effectiveness of clinician-supported CCBT compared with treatment as usual (TAU) in a primary care population with a substantial number of patients with low income, limited computer or internet access, and lack of college education. This economic evaluation was a randomized clinical trial-based cost-effectiveness analysis. The trial was conducted at the Departments of Family and Geriatric Medicine and Internal Medicine at the University of Louisville. Enrollment occurred from June 24, 2016, to May 13, 2019. Participants had mild to moderate depression and were followed up for 6 months after treatment completion. The last follow-up assessment was conducted on January 30, 2020. Statistical analysis was performed from August 2023 to August 2024. CCBT intervention was provided for 12 weeks and included 9 modules ranging from behavioral activation and cognitive restructuring to relapse prevention strategies, supported by telephonic sessions with a clinician, in addition to TAU, which included standard clinical management in primary care. The primary health outcome was quality-adjusted life years (QALYs), estimated using the Short-Form 12 questionnaire (SF-12). The secondary outcome was treatment response, defined as at least 50% improvement in the Patient Health Questionnaire. The intervention cost included sessions with mental health clinicians and the cost of the CCBT software, plus the cost of loaner computer and internet data plan for low-resource households. An incremental cost-effectiveness ratio (ICER) was computed, while adjusting for baseline scores, age, and sex. The cost-effectiveness acceptability curve presented the probability of CCBT being cost-effective for a range of willingness-to-pay values. Among the 175 primary care patients included in this study, 148 (84.5%) were female; 48 (27.4%) were African American, 2 (1.2%) were American Indian or Alaska Native, 4 (2.5%) were Hispanic, 106 (60.5%) were White, and 15 (8.6%) were multiracial; and the mean (SD) age was 47.03 (13.15) years. CCBT was associated with better quality of life and higher chance of treatment response at the posttreatment and 6-month time points, compared with the TAU group. The ICER for CCBT was $37 295 (95% CI, $22 724-$66 546) per QALY, with a probability of 89.4% of being cost-effective at a willingness-to-pay threshold of $50 000/QALY. The ICER per case of treatment response was $3623 (95% CI, $2617-$5377). In this trial-based economic evaluation, CCBT was found to be cost-effective, compared with TAU, in primary care patients with depression. As this study included individuals with low income and with limited internet access who are underrepresented in cost-effectiveness studies, it has important policy implications for addressing unmet needs in sociodemographically diverse populations.

Effect of goal-directed mobilisation versus standard care on physical functioning among medical inpatients: the GoMob-in randomised, controlled trial

ObjectiveTo assess the effect of goal-directed mobilisation (GDM) on physical functioning in medical inpatients.DesignRandomised, controlled, single-centre, parallel, superiority trial with a 3-month follow-up and blinded outcome assessment.SettingGeneral internal medicine wards...

The Center for Health Outcomes in Medicine Scholarship and Service (HOMES): Fostering and Supporting Physician-Initiated Research

Abstract Problem The U.S. physician scholar workforce, currently comprising less than 1.5% of U.S. physicians, continues to decrease, threatening national status as a global biomedical research leader. Academic medical center (AMC) trends away from tenure-track physician faculty appointments toward clinical faculty appointments have contributed to this decrease, but AMCs have limited strategies to equip clinical faculty to conduct research. Infrastructure fostering clinical faculty research may establish new mechanisms for expanding physician scholar workforce and supporting academic goals of clinical faculty. This article presents one such model, the Center for Health Outcomes in Medicine Scholarship and Service (HOMES), from the Department of Internal Medicine, The Ohio State University College of Medicine. Approach Established in 2019, HOMES provides research infrastructure, support, and mentorship tailored to clinical faculty needs. Multidisciplinary core faculty support research across 5 cores: clinical networks, biostatistics and secondary data, qualitative methods, mixed methods, and research ethics. HOMES services include research consultation, mentorship, microgrants, a training toolkit, and symposia. Outcomes In 4 years, HOMES supported 50 faculty on 99 projects. Forty-five (90%) of these faculty have reported scholarly output, including 127 national presentations, authorship on 41 peer-reviewed articles, and 53 grant submissions. Forty HOMES-supported grant submissions have received funding, and 4 HOMES-supported physicians in training have pursued or plan to pursue AMC research careers. Next Steps HOMES has fostered scholarly productivity among AMC physicians, competitive grant applications, and research focus among physicians in training. As demand for HOMES services increases, HOMES will prioritize projects based on their innovation and research skill development potential. Academic medical centers can apply HOMES lessons through fostering clinical faculty collaboration with multidisciplinary research teams and increasing research training opportunities for residents and fellows. National expansion of funding opportunities dedicated to building biomedical research capacity and expertise among clinical faculty can facilitate sustainable scaling of HOMES-like models.

Prevalence, associated factors, and impact of vitamin B12 deficiency in older medical inpatients.

This retrospective cohort study aims to explore the prevalence of vitamin B12 deficiency in older hospitalized adults and identify key factors associated with this deficiency, as well as its impact on frailty and functional decline. Data were collected from older adults (≥65years) sequentially admitted to the Internal Medicine Department of a tertiary university hospital. Clinical and laboratory characteristics, including age, sex, somatometric data, cause of admission, past medical history, chronic medication use, and laboratory tests, were recorded. Frailty and functional status were assessed using the Fried Frailty Scale (FFS), Clinical Frailty Scale (CFS), Barthel Index, and Katz Index. Vitamin B12 levels on admission were categorised as deficient (<200pg/ml), borderline (200-300pg/ml), normal (300-999pg/ml), and high (≥1000pg/ml). A total of 894 patients were included. The median age was 83years and 487 (54.5%) were females. The prevalence of vitamin B12 deficiency was found in 9.1%, while 17.3% of the sample had borderline levels. Multivariate analysis identified polypharmacy (≥5 drugs), low albumin levels/Geriatric Nutritional Risk Index (GNRI), and nursing home residency as independent factors associated with low B12 levels. Multivariate analyses showed that B12 deficiency was significantly associated with higher frailty rates and lower functional status. Vitamin B12 deficiency is prevalent among hospitalized older patients and is significantly associated with increased frailty and reduced functional status. These findings underscore the importance of routine screening for B12 deficiency in this vulnerable population to improve clinical outcomes and quality of life.

The Association Between Elevated Thyroid-Stimulating Hormone Levels and Prolonged Length of Stay Among Adult Diabetic Patients Hospitalized in Internal Medicine Departments: A Large Historical Cohort Study

Background/Objectives: Type 2 diabetes mellitus (DM2) and hypothyroidism are two of the most common endocrine disorders in clinical practice. Hospital length of stay (LOS) is a quality metric of the health systems. We evaluated the association between elevated thyroid-stimulating hormone (TSH) levels and prolonged LOS among all adult patients (age ≥ 18 years) with DM admitted to our Internal Medicine departments between 2014 and 2022. Methods: Data on patient characteristics, LOS, and in-hospital mortality were collected. A TSH level &gt; 4.7 μIU/mL was considered as being elevated. A LOS &gt; 75th percentile and in-hospital mortality were defined as being prolonged. Univariate and multivariable analyses were applied, and propensity score matching controlled for differences between patients with normal and those with elevated TSH levels. Results: Of the 19,066 study participants (median age 75.6 years, IQR 75.9–83.3), 1524 (7.9%) had elevated TSH levels, and prolonged LOS was significantly more common among them (before matching: 38.6% vs. 29.1%, p &lt; 0.001; after matching: 38.7% vs. 32.6%, p = 0.001). After adjustment for potential confounders, elevated TSH levels were also associated with prolonged LOS (OR = 1.22, 95% CI 1.07–1.39, p = 0.002). Conclusions: Elevated TSH levels in diabetic patients hospitalized in Internal Medicine departments are associated with prolonged LOS, emphasizing the importance of identifying hypothyroidism among them.

Patients' preferences for virtual outpatient consultations and health care professionals' assessment of suitability for their patients: A single-centre survey.

To explore patients' preferences regarding virtual consultations (via telephone or video) and to explore healthcare professionals' assessment of whether virtual consultations can maintain the same clinical quality as in-person consultations for outpatient care. A cross-sectional survey was conducted among patients with an in-person consultation at the outpatient clinic for internal medicine and among healthcare professionals who treated the patients. The prevalence of preference was determined using descriptive statistics based on cross-tabulated frequencies. Percentages are presented with 95% confidence intervals (95%CI). In total, 218 patients (response rate 67%) completed the questionnaire; 79 patients (36%) preferred a virtual consultation (95%CI: 30%-43%); telephones were the most popular and preferred by 72 patients (33%; 95%CI: 27%-39%) followed by video preferred by 54 patients (25%; 95%CI: 19%-31%). Regarding contextual factors, male gender and previous experiences with telephone or video consultations were statistically significant predictors in favour of virtual consultations. Healthcare professionals estimated that 58 consultations (21%; 95%CI: 17%-26%) could have been conducted virtually with the same professional and clinical quality as the current in-person consultations. Current practice does not fully align with patient preferences for virtual visits in internal medicine outpatient clinics. Patients should be given the choice of virtual consultations whenever they are deemed professionally and clinically possible to enhance patient autonomy and satisfaction, while being mindful of speciality-specific considerations.

Examining dimensions of career intentions: insights from medical and nursing students at a private not-for profit university in Vietnam.

Understanding students' career intentions through evidence-based approaches is crucial for developing effective career guidance and intervention strategies. Although there has been considerable attention in this field, research remains limited, particularly in low- and middle-income countries (LMICs) in Asia. These regions have unique socioeconomic conditions and cultural norms that potentially shape decision-making processes. This study provides insights into the career intentions of medical and nursing students and identifies the key determinants influencing their choices at a newly established private institution (VinUniversity) in Vietnam. This study employs a mixed-methods design. The quantitative phase involved a survey of all undergraduate medical and nursing students. The qualitative phase consisted of in-depth 11 individual interviews with a purposive sample until data saturation. A total of 198 students (77%) participated in the quantitative phase. The majority of students (75.8%) expressed interest in clinical practice, with preferences notably high for surgical specialties (30.9%), internal medicine (10.1%), and pediatrics (10.1%). 22.7% of students expressed a desire to work overseas, and a significant number (70.7%) indicated the lack of a career guidance program. Qualitative data revealed that personal interest, family influence, financial stability, and societal appreciation were primary influencers in career choice. The study underscores the complex interplay between personal interests, family influence, financial considerations, and societal expectations in shaping career choices. The persistent low interest in family medicine and primary care continued to be a concern. This study provides further insights into the career intentions and influencing factors among medical and nursing students at VinUniversity. The implications for practice include implementing tailored career guidance programs, offering diverse elective tracks that incorporate global health experiences, and establishing structured mentorship programs. It is also recommended to measure the impact of these interventions through longitudinal follow-up studies to enhance career satisfaction, better prepare future healthcare professionals, and contribute to the improvement of healthcare systems.

Putting skin in the game: a descriptive study of lower extremity ulcers in general medical inpatients.

Lower extremity ulcers contribute a significant burden to patient care. Targeted investigation and management are pertinent to improving patient outcomes. We evaluated the aetiology, risk factors, investigations and management of lower extremity ulcers in general medicine patients. There was evidence of under-ordering of appropriate investigations, and over-treatment for infection. We proposed a quality improvement initiative to optimise lower extremity ulcer care.

Knowledge, Attitude, and Practice of the Lebanese University Medical Students and Junior Doctors on Basic Life Support Practices

Background: Basic life support (BLS) is the recognition of sudden cardiac arrest and activation of emergency response system, followed by cardiopulmonary resuscitation (CPR), and rapid defibrillation. Aim: Our study aimed to determine the level of awareness of the Lebanese University medical students and trainees on BLS, by assessing the association between knowledge, attitude, and practice on BLS, and between the demographic variables and KAP scores. Methods: This was a cross-sectional study including 330 medical students enrolled at Lebanese University, from year four of general medicine till year five of residency. An online survey was used to collect data about demographic characteristics, knowledge (K), attitudes (A), and practice (P) about BLS. Data was analyzed using SPSS version 25. Results: Participants were 52.7% females, 47.3% males, and their mean age was 24 ± 2 years. Of the 330 participants, 38.8% received formal training regarding BLS. Medical students had low knowledge (90%), moderate to good attitudes (71.5%), and low practice (93%) regarding BLS. Multiple linear regression showed that knowledge was positively associated with age (p = 0.001), knowledge and information regarding BLS (p = 0.016), and any formal training/workshop regarding BLS (p = 0.021). Attitude was positively associated with academic year (p = 0.002) and knowledge (p = 0.003). Practice was positively associated with age (p &lt; 0.001) and knowledge (p &lt; 0.001). Conclusion: Most Lebanese University medical students showed low knowledge, moderate to good attitudes, and low practice regarding BLS. We recommend that CPR/BLS should be a core competency across all health care professional programs.