Internal Medicine Research Articles

NIDA and FDA call for new pathways for smoking cessation

The National Institute on Drug Abuse (NIDA) and the Food and Drug Administration (FDA), in a commentary published last week in the Annals of Internal Medicine, call for innovations in research and development of smoking cessation therapies. Cigarette smoking, while decreasing, kills nearly 500,000 Americans each year. The opioid overdose epidemic kills one‐fifth of that. More than 28 million adults currently smoke in the United States. Most of them say they want to quit, but only 31% of those receive counseling and/or medications to do so. Less than 8% quit a year.

Peripheral Ischemia and Necrosis Revealing Buerger's Disease in an Internal Medicine Department

Buerger's disease is a systemic vasculitis strongly correlated with tobacco use. It entails a heavy socio-occupational impact. We report the case of a 26-year-old patient with ischemia of the lower limbs revealing Buerger’s disease. He is known smoker with passive exposure to Indian hemp. He was seen for ischemic foot pain that had been progressing for a year. Involvement began in the left big toe. Subsequently, hyperalgesic necrotic lesions were observed on the 3rd, 4th and 5th toes of the foot. Biological investigations revealed an inflammatory syndrome with normocytic anemia and increased C-reactive protein. Retroviral, syphilitic, Hepatitis B and C viruses and SARS-CoV-2 serologies were negative. Antinuclear antibodies were initially borderline at 100 IU with speckled fluorescence, then negative on control. Neutrophil cytoplasmic antibodies and antiphospholipid antibodies were negative. Investigation of thrombophilia was non-contributory, notably factor V mutation testing, antithrombin III assay, proteins C and S and fibrinogen. An arterial ultrasound revealed extensive arterial thrombosis with thickening of the femoral arterial vessel walls. Thromboangiitis obliterans was confirmed and the patient was put on corticosteroids and adjuvant therapy. Surgical treatment was performed 4 months later. Buerger's disease is a serious vascular disorder which must be diagnosed very early in order to prevent complications. Early smoking cessation leads to remission in the early phase.

A Study on Veterinary Faculty Students' Opinions on Ethics Education and Career Choices: A Case of Ondokuz Mayıs University.

Veterinary ethics is a multifaceted element of the veterinary profession as it deals with various ethical issues related to medical practice, animal welfare, professional behaviour and societal expectations. By focusing on teaching ethics in veterinary medicine education, it will be possible to guide future veterinarians through the ethical dilemmas and conflicts they may encounter in their careers. To evaluate the opinions of the Ondokuz Mayıs University Faculty of Veterinary Medicine intern students about ethics education in veterinary medicine. Evaluation and comparison of the perspective on ethics education and career choice. A cross-sectional descriptive survey design was used to collect data via a questionnaire. Data obtained from 87 out of 119 students in the intern programme were evaluated. Responses were analysed by statistical methods. In the study, it was determined that pet veterinary services (private sector) and government veterinary services (public sector) were the leading career choices of intern veterinary students; female and male students wanted to turn to different fields of work; and the difference in career preferences did not change the views on ethics education. It was observed that students needed applied teaching and measurement-evaluation methods in ethics education and sought role models in developing ethical attitudes and behaviours. In addition to gaining ethical knowledge in veterinary education, it was observed that they attach importance to professional and legal obligations. This study is one of the few studies on veterinary ethics education and career choice in Turkey. The study results provide information to guide the development of veterinary ethics education to prepare future veterinarians for the complex ethical issues they will face in their careers.

Factors influencing the choice of specialization - a cross-sectional study with civilian medical students and prospective medical officers in Germany

BackgroundThe recruitment of physicians is an increasing challenge. The aim of the study was to explore factors that might influence future civilian and military doctors’ choice of specialization.MethodsA 28 item author developed questionnaire was used to survey civilian medical students and prospective medical officers. The questionnaire consisted of 20 items addressing choice of specialization, and eight socio-demographic factors. Response options were available in the form of open and closed questions as well as in the form of a Likert scale (1 ‘not at all’ to 6 ‘very much’). The questionnaire was completed online by prospective medical officer from June to September 2021 and by civilian students from November 2020 to March 2021.ResultsIn total, 2,030 students (56.1% female, mean age = 24, mean semester 6.5) participated in the survey, 1,553 civilian students and 477 prospective medical officers. Regular feedback and clear structures (mean = 5.35) followed by good teamwork (mean = 5.33) during postgraduate training was rated particularly important. Moreover, a secure job after graduation (mean = 5.23) and a compatibility of family and job (mean = 5.14) were important parameters for career choice. The specializations most frequently chosen were surgery (32.0%), internal medicine (27.1%) and anesthesiology (22.1%). The regression models showed that the choice depends on own attitude concerning the specialty would be a patient-orientation job, or a job with more manual work or more career option within in the job preferred.ConclusionsConsidering the value students place on receiving feedback and the structure of their specialist training, this seems to be a promising strategy for future recruitment. Good team dynamics and job security are key concerns for prospective physicians.

"Doctor, would it surprise you if there were prescribing errors in this patient's medication?" Identifying eligible patients for in-hospital pharmacotherapeutic stewardship: A matched case-control study.

Evaluating a patient's medication list is critical to reduce prescribing errors (PEs), but is a labour- and time-intensive process. Identification of patients at risk of PEs could improve the allocation of scarce time and resources, but currently available prediction tools are not effective. To investigate whether ward doctors can identify patients at risk of PEs. This prospective matched case-control study was conducted on three clinical wards in an academic hospital. Otolaryngology and oncology ward doctors used clinical intuition to select patients requiring a clinical medication review (CMR) (cases). These patients were then matched 1:1 on age (±10years) and number (±1) of prescriptions with patients not selected for CMRs on the internal medicine and upper gastrointestinal surgery ward (controls). A multidisciplinary in-hospital pharmacotherapeutic stewardship team assessed the prevalence of PEs. A total of 387 patients with 5191 prescriptions were included. Overall, 799 PEs affecting 279 patients (72.1%) were identified. Most PEs (58.8%) occurred during hospitalization. There were no significant differences in age, number of prescriptions, sex, renal function or documented allergies or intolerances between the cases and controls or between controls and other patients who did not receive a CMR. The incidence of PEs was higher in cases than in controls (97.5% vs 72.5%, odds ratio= 14.8, 95% confidence interval [CI] 1.8-121.1, P= .002)). The rate of PEs was three times higher in cases than in controls (incidence rate ratio=3.0, 95% CI 2.3-4.0, P< .001). Ward doctors can effectively identify patients with PEs, and thus at risk of medication-related harm, using clinical intuition.

Response to tigilanol tiglate in dogs with mast cell tumors.

Information regarding response rate to tigilanol tiglate for mast cell tumors in dogs is limited. Report the response rate and durability of tigilanol tiglate intratumoral treatment in dogs with mast cell tumors presented to veterinary oncologists. One hundred forty-nine dogs; 151 individual tumors. Multicenter, retrospective survey-based study. Veterinary oncologists subscribed to the American College of Veterinary Internal Medicine (ACVIM) oncology listserv were solicited for information from dogs treated with tigilanol tiglate. An electronic survey was used to collect information at initial treatment, 1 month and 1 year after treatment. Most tumors were cutaneous, occurred on the limbs and were cytologically low grade. Seventy-five percent of dogs achieved a complete response after 1 dose of tigilanol tiglate 1 month after treatment. This response was durable at 1 year in 64% of dogs for which data were available (n = 88). Wound formation, an expectation after treatment, occurred after a median of 7 days (range, 1-91 days), with a median wound area of 4.71 cm2 (range, 0.09-100 cm2). Wounds took a median of 30 days to heal completely (range, 14-154 days). A moderate association between tumor volume and wound size was confirmed. Tigilanol tiglate is an effective local treatment option for mast cell tumors in dogs with a predictable clinical course and response. Because of the unique mode of action and clinical course, client education and careful case selection is necessary before electing tigilanol tiglate for local treatment.

Sticky Floor, Broken Ladder, and Glass Ceiling in Internal Medicine Academic Ranking, Leadership, and Research Productivity.

Despite more women entering medicine, substantial gender disparities remain in various medical disciplines. This study explores the extent of these disparities in Canadian academic internal medicine, particularly in academic ranks, leadership positions, and research productivity. Cross-sectional. Faculty physicians within internal medicine and subspecialties. Data on faculty physicians with Medical Doctorate (MD), Doctor of Osteopathic Medicine (DO), or Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees were compiled from 17 internal medicine programs listed in the Canadian Resident Matching Service (CaRMS). Research metrics were obtained using Elsevier's Scopus, and analyses were performed with Stata v14.2. Among 5099 physician faculty members in internal medicine, 34% were women, and 66% were men. Among the faculty members holding leadership positions, 68% were men, and 32% were women. There was a significant difference in h-index between men and women physician faculty members (p ≤ 0.001), with men having a higher research output. Across all academic ranks, men faculty had higher median h-index values: Assistant Professor (12 vs. 9), Associate Professor (20 vs. 16), and Professor (40 vs. 30). Women were underrepresented in the procedural specialties, while only a few internal medicine subspecialties, such as palliative medicine and geriatrics, had a women predominance. Our study underscores existing gender disparity within academic internal medicine in Canada, aligning with global trends. Women remain disproportionately underrepresented in academic ranks, leadership positions, and research productivity. Addressing these disparities necessitates a systemic and multifaceted approach, encompassing policy reforms, mentorship, and fostering an inclusive work environment.

Mitigating overuse of antinuclear antibody (ANA) testing through educational intervention: a study in internal medicine and neurology departments.

Overuse of antinuclear antibody (ANA) tests leads to increased costs, false positives, and unnecessary treatments. This study evaluated ANA overuse in internal medicine and neurology departments and assessed the impact of an educational intervention. This quality improvement educational intervention study examined ANA test overuse in five internal medicine departments and one neurology department at a university-affiliated medical center. The educational intervention included a session focusing on ANA testing appropriateness. Outcome measures comprised the ANA/new patient ratio (APR) and the percentage of positive ANA test results. Outcomes were compared between the pre- and post-intervention periods (both 6months). The intervention took place in December 2021. The APR decreased from 43% in the pre-educational intervention period to 27% in the post-intervention period in the neurology department (odds ratio [OR] 0.49, confidence interval [95% CI] 0.37-0.63, P < 0.0001) and from 2.6% to 2.2% in the internal medicine departments (OR 0.89, 95% CI 0.73-1.10, P = 0.28). The percentage of positive ANA tests increased from 43% pre-intervention to 53% in the post-intervention period (OR 1.49, 95% CI 0.90-2.46, P = 0.12) in the neurology department and from 48% to 59% (OR 1.56, 95% CI 0.99-2.44, P = 0.0543) in the internal medicine departments. A simple educational intervention reduced unnecessary ANA testing in the neurology department but not in internal medicine departments, improving patient selection and potential cost savings. The results underscore the importance of targeted education to promote evidence-based behavior among healthcare professionals. Further research with longer follow-up is needed to assess the sustainability of these improvements.

Process Groups for Supporting Resident Wellbeing: Factors Influencing Resident Wellness amid the COVID-19 Pandemic.

Background: Burnout is a well-recognized problem among resident physicians. The COVID-19 pandemic impacted the dynamics of the patient/resident relationship and introduced new stressors for medical trainees, such as new restrictions in the hospital, increased patient death, and uncertainty around safety. There is limited research on the implementation of group therapy for residents to address issues of wellbeing and burnout during the pandemic. Method: In response to perceived burnout amongst internal medicine residents, a university-based internal medicine residency program in the Northeast United States implemented process groups, a form of group therapy, in the curriculum. These sessions were held hourly once every five weeks for each cohort of twelve residents during the academic year. We sought to measure resident burnout and identify themes that impacted wellbeing to facilitate the intervention of process groups during the pandemic. In 2021 and 2022, internal medicine residents were invited to complete the Maslach Burnout Inventory (MBI) and answer two open-ended questions about the factors that most negatively and positively influenced their wellness. Results: Of the 134 participants, 82% had high emotional exhaustion or depersonalization. The most prevalent themes hindering wellness were negative personal interactions at work, most notably rude behavior by patients, unsupportive attendings, residency program expectations, and work intensity. Findings unique to the pandemic include social isolation from family, distress from poor outcomes, and fear of contracting or spreading the virus. The most prevalent themes for supporting wellness were personal life, camaraderie, professional satisfaction, and program structured support. Conclusions: Our findings suggest that programs can tailor structured support to improve wellness, despite the presence of significant stressors.

Effects of a Gender-Balancing Strategy on Resident Panels in a Primary Care Setting.

Patients oftenprefergender concordance when choosing a primary care practitioner. In a trainee setting, this may lead to unequal training opportunities for male and female resident physicians. Residency leadershipmay be interested in ways to promotebalance in patient empanelment. To assess the efficacy of an intervention to equalize imbalance in patient gender on resident primary care panels. Observational cohort study. Categorial internal medicine residents beginning residency in 2020. The panels of internal medicine residents were manually rebalanced at the beginning of training for a new cohort of residents with the goal of having similar numbers of male and female patients on each resident's panel. Panel data was observed for 2 years following intervention. Number of male patients, number of female patients, and overall panel size were compared between male and female residents at baseline, 6 months, and 24 months. The analysis included 28 female residents and 20 male residents. After rebalancing, baseline panels had similar numbers of male patients (median of 50 on both male and female residents' panels; average panel 54.7% male) and female patients (median of 41.5 on female residents' panels and 41 on male residents' panels; average panel 45.3% female). At the end of the follow-up period, a significant difference was observed in the median number of male patients (59.5 and 43.5; p < 0.001) and female patients (33.5 and 48.5; p < 0.001) between male and female residents, but no difference was observed in overall panel size. A steady drift towards gender concordance was observed over 2 years following a rebalancing intervention. Program leadership overseeing primary care empanelment for resident physicians may consider periodic rebalancing of panels in addition to other interventions to ensure equal training opportunities and best prepare residents for future practice.

Contact Dermatitis in the United States: A Population-Based Study on Patient Visit Characteristics and Treatment Prescription Patterns.

Background: Contact dermatitis (CD) affects ∼15% of the general population over a lifetime. However, there is a lack of epidemiological studies on treatment patterns for CD. Objective: We aim to analyze the patient characteristics and prescribing patterns among dermatologists and general practitioners (GPs) (internal medicine [IM] and family medicine [FM]) for CD in the United States. Methods: We conducted a population-based study using the National Ambulatory Medical Care Survey. Results: We identified 178,017,680 weighted patient visits for CD from 2001 to 2016. Dermatologists saw more white and non-Hispanic patients than GPs. GPs were less likely to prescribe ultrahigh potency topical corticosteroids (FM OR 0.27; P < 0.001, IM OR 0.41; P < 0.001) and more likely to prescribe oral antihistamines (FM OR 3.71; P < 0.001, IM OR 3.56; P < 0.001), oral corticosteroids (FM OR 5.35; P < 0.001, IM OR 6.87; P < 0.001), and injectable corticosteroids (FM OR 3.42; P = 0.006, IM OR 5.68; P < 0.001) than dermatologists. Conclusions: Across CD visits, GPs were less likely than dermatologists to prescribe ultrahigh potency topical corticosteroids and more likely than dermatologists to prescribe oral antihistamines and systemic corticosteroid therapy.

Outcomes of Accelerated 3-Year MD Graduates at NYU Grossman School of Medicine During Medical School and Early Residency.

For accelerated 3-year MD (3YMD) pathways to be fully adopted in medical education, a comprehensive analysis of outcome data is needed. This study includes 7 accelerated 3YMD graduating classes at NYU Grossman School of Medicine (NYUGSOM) and reports on outcomes from both medical school and internship compared to their 4-year MD (4YMD) counterparts. Outcomes across the undergraduate-graduate medical education continuum for the first 7 classes of NYUGSOM graduates (matriculated from 2013-2019) from the accelerated 3YMD (n = 136) and 4YMD pathways (n = 681) were compared. For the internship outcomes, 3YMD interns were compared with 4YMD interns who graduated from NYUGSOM and all 4YMD interns (4YMD graduates from NYUGSOM and any other medical school) at NYUGSOM residencies. Accelerated 3YMD students were approximately 5 months older at admission and had higher multiple mini-interview scores than 4YMD students. Overall, accelerated 3YMD students performed similarly to 4YMD students during medical school and internship. Significant differences included higher performance by 3YMD students on preclerkship exams and lower performance on Steps 1 and 2 (average: 5.6 and 8.3 fewer points, respectively) and the physical examination portion of the NYUGSOM Comprehensive Clinical Skills Exam. Internship data indicated comparable team assessments across all residencies, statistically significant higher performance on Step 3 when compared to all 4YMD interns, and, in internal medicine, comparable clinical reasoning between 3YMD and all 4YMD interns. When comparing 3YMD interns to all 4YMD interns in the internal medicine residency program, 3YMD interns had a statistically significantly higher performance on milestones. The outcomes from 7 years of graduating accelerated 3YMD students at NYUGSOM show similar performance in medical school and early residency to 4YMD graduates. Long-term study of accelerated 3YMD students from NYUGSOM and other medical schools is needed to further validate the success of this innovative medical education pathway.

Testing and Evaluation of Health Care Applications of Large Language Models

Large language models (LLMs) can assist in various health care activities, but current evaluation approaches may not adequately identify the most useful application areas. To summarize existing evaluations of LLMs in health care in terms of 5 components: (1) evaluation data type, (2) health care task, (3) natural language processing (NLP) and natural language understanding (NLU) tasks, (4) dimension of evaluation, and (5) medical specialty. A systematic search of PubMed and Web of Science was performed for studies published between January 1, 2022, and February 19, 2024. Studies evaluating 1 or more LLMs in health care. Three independent reviewers categorized studies via keyword searches based on the data used, the health care tasks, the NLP and NLU tasks, the dimensions of evaluation, and the medical specialty. Of 519 studies reviewed, published between January 1, 2022, and February 19, 2024, only 5% used real patient care data for LLM evaluation. The most common health care tasks were assessing medical knowledge such as answering medical licensing examination questions (44.5%) and making diagnoses (19.5%). Administrative tasks such as assigning billing codes (0.2%) and writing prescriptions (0.2%) were less studied. For NLP and NLU tasks, most studies focused on question answering (84.2%), while tasks such as summarization (8.9%) and conversational dialogue (3.3%) were infrequent. Almost all studies (95.4%) used accuracy as the primary dimension of evaluation; fairness, bias, and toxicity (15.8%), deployment considerations (4.6%), and calibration and uncertainty (1.2%) were infrequently measured. Finally, in terms of medical specialty area, most studies were in generic health care applications (25.6%), internal medicine (16.4%), surgery (11.4%), and ophthalmology (6.9%), with nuclear medicine (0.6%), physical medicine (0.4%), and medical genetics (0.2%) being the least represented. Existing evaluations of LLMs mostly focus on accuracy of question answering for medical examinations, without consideration of real patient care data. Dimensions such as fairness, bias, and toxicity and deployment considerations received limited attention. Future evaluations should adopt standardized applications and metrics, use clinical data, and broaden focus to include a wider range of tasks and specialties.

The refugee and migrant health "global competency standards for health workers": results of a survey in general practitioner trainees in Sicily.

Refugees and migrants may represent the most vulnerable communities in many societies. Health systems should be sensitive to needs of refugees and migrants. The document "The Refugee and Migrant Health: Global Competency Standards for Health Workers (the Standards)" identifies the competencies and areas of practice of health workers working with refugees and migrants. The aim of this study is to provide an analysis of these competences and training needs, identifying the educational priorities for the implementation of the Standards in Sicily, Italy. A cross-sectional analytical pilot study was conducted by administering a questionnaire, in electronic format "Google Form ®," to doctors attending the Medical Training Course for General Practitioners in Sicily (Italy). Data obtained were collected in a Microsoft Excel database and analyzed with IBM SPSS Software 24 version. Absolute and relative frequencies were calculated for relevant categorical variables. Univariate analysis of the selected variables was subsequently carried out. The significance level chosen was a p value <0.05 (two-tailed). A total of 192 General Practitioner (GP) trainees responded to the questionnaire. They were asked if their training course comprised a Global Health Course that included the topic of health protection and social and health care for migrant populations and the 65.4% of them answered "No" or "Do not Know." GP trainees were also asked if they considered useful to include a Global Health Course dedicated to the management of patients with a migratory background within the training course in general medicine. Of the total 192 participants, 81.9% answered "Yes." Overall, in a simple regression model, the perception of having addressed migrants' health needs is positively correlated with having attended a Global Health Course (OR = 3.34 95%CI 1.2-9.1; p = 0.018). This study identified educational priorities for the implementation of the Standards in Sicily for doctors attending the Medical Training Course for General Practitioners. We hope that the results of this study will guide and inform possible future projects to implement the Standards at a national level.

Influencing physician distribution through education: a qualitative study on retention in Japan’s rural hospitals

BackgroundAddressing the shortage of healthcare professionals in rural Japan poses significant challenges. At Sanmu Medical Center, incorporating resident physicians into a general medicine training program has proved effective in retaining them as supervising physicians. This study aims to identify the key factors contributing to the success of such programs.MethodsWe used a qualitative research design to comprehensively understand the factors contributing to physician retention in regional community hospitals in areas with physician shortages. Interviews were conducted with four experienced physicians, including the center director, who participated in the general or family medicine training programs at Sanmu Medical Center. Using a semi-structured questionnaire, we explored the factors influencing physician retention in community-based hospitals experiencing shortages. Two physicians specializing in community medicine conducted a content analysis under the supervision of three experts in community-oriented medical education and qualitative research. This approach helped compare retention factors perceived by physicians and the center director.ResultsContent analysis revealed 10 categories and 47 subcategories. The analysis revealed that “Educational activity” and “Supervising physicians and guidance system” are crucial for physician retention in rural hospitals in Japan. The study highlighted key educational factors contributing to retention: engagement in educational activities led to personal and professional growth, creating a rewarding experience for the physicians. Furthermore, a structured supervising physician system provided essential guidance and mentorship, improving the educational environment. Diverse learning opportunities and protected learning times were identified as critical for fostering a sustainable commitment among physicians to work in rural settings. These findings contribute to existing literature by detailing how structured educational activities and mentorship programs in rural hospital settings can significantly impact physician retention.ConclusionsCommunity-based medical education programs that focus on diverse clinical settings, mentorship, and a supportive work environment can enhance physician retention in rural areas. By fostering such educational and professional environments, healthcare institutions can address physician maldistribution and improve care quality in underserved communities. Our study offers practical insights that can be replicated or adapted by other rural hospitals facing similar challenges. It offers targeted strategies to address the unique challenges faced by female physicians in rural healthcare settings.

Dermatographia in oral cavity unveiled: A case study

Dermatographia is a form of physical urticaria, quite uncommon in oral cavity characterized by elevated skin following localized erythema, oedema, and a flare-up reaction around it. It is usually induced by any blunt object or minor trauma and usually does not affect the routine life of the patient. Here we present a case report of a 20 year old male with the chief complaint of elevation on skin from a blunt object. On his physical examination with the consent of the patient we induced the condition in the department by asking the patient to write the letter ‘D’ on his flexural arm using the blunt end of the pen. After 5 min, the elevations on his skin began to appear which raised drastically with time. It remained on the skin for about an hour and then fainted on it’s own over time. During intraoral examination we also induced similar strokes on his buccal mucosa and surprisingly a linear elevation was produced along the line of blunt pen which was reddish in colou. No treatment was provided as the condition did not affect the quality life of the patient. Pharmacological therapy may include oral antihistamines, such as cetirizine or loratadine, to alleviate pruritus and reduce the frequency of wheal formation. Topical corticosteroids, such as triamcinolone acetonide or betamethasone, can be applied to affected sites for localized anti-inflammatory effects. In Ayurveda, the use of internal Ayurvedic medicines like, ‘Aragwadha amritadi kashaya’, ‘Ayaskriti’, ‘Varanadi kashaya’ and ‘Dashamoola hareetaki’ are recommended along with dietary restrictions and life style changes.

Research Institute of Internal and Preventive Medicine, Branch of the Institute of Cytology and Genetics, Siberian Branch, Russian Academy of Sciences

The purpose of the study was to evaluate the clinical manifestations of osteoarthritis (OA) in combination with MS (OAMS) and their relationship with concentration of several circulating proinflammatory cytokines, the level of lipids in peripheral blood serum. Forty women patients with knee OA were examined: 19 patients from the experimental group in whom OA was combined with metabolic syndrome (MS), 21 patients with OA without MetS. All patients were elderly and overweight. In the first subgroup of patients, the absolute majority of people were obese, while in the second subgroup, overweight patients predominated. Patients in the experimental subgroup showed a statistically significant increase in waist circumference compared to patients without MS. The duration of OA did not differ in both subgroups. It has been established that the metabolic phenotype of gonarthrosis – OA in combination with metabolic syndrome – differs from patients with OA without MS in greater severity of pain, a decrease in the level of daily activity, an increase in the burden of the disease and other symptoms of OA. These core characteristics are associated with poor quality of life and clinically significant symptoms of depression. The metabolic type of gonarthrosis is characterized by more pronounced laboratory signs of systemic low-grade inflammation in comparison with patients without MS, as evidenced by a threefold increase in CRP content and an increase in the level of IL-6, IL-18 in PC serum. In addition, in patients with the metabolic phenotype of OA, a fivefold increase in the level of a specific humoral immune response to type 2 collagen (Col2Ab) and dyslipidemia – an increase in the content of LDL cholesterol and triglycerides, with a comparable reduced level of HDL cholesterol – were revealed. It is concluded that the phenotype of OA in combination with MS is probably due to the pathogenetic similarity of OA and MS (syntropy), which is based on low-grade inflammation. Studying the pathogenesis of the OAMS phenotype and developing new principles for the treatment of multimorbidity should be based on patient-oriented approaches.

Primary Care Informatics: Vitalizing the Bedrock of Health Care.

Primary care informatics (PCI) professionals address workflow and technology solutions in a wide spectrum of health, ranging from optimizing the experience of the individual patient in the clinic room to supporting the health of populations and augmenting the work of frontline primary care clinical teams. PCI overlaps uniquely with 2 disciplines with an impact on societal health-primary care and health informatics. Primary care is a gateway to health care access and aims to synthesize and coordinate numerous, complex elements of patients' health and medical care in a holistic manner. However, over the past 25 years, primary care has become a specialty in crisis: in a post-COVID-19 world, workforce shortages, clinician burnout, and continuing challenges in health care access all contribute to difficulties in sustaining primary care. Informatics professionals are poised to change this trajectory. In this viewpoint, we aim to inform readers of the discipline of PCI and its importance in the design, support, and maintenance of essential primary care services. Although this work focuses on primary care in the United States, which includes general internal medicine, family medicine, and pediatrics (and depending on definition, includes specialties such as obstetrics and gynecology), many of the principles outlined can also be applied to comparable health care services and settings in other countries. We highlight (1) common global challenges in primary care, (2) recent trends in the evolution of PCI (personalized medicine, population health, social drivers of health, and team-based care), and (3) opportunities to move forward PCI with current and emerging technologies using the 4Cs of primary care framework. In summary, PCI offers important contributions to health care and the informatics field, and there are many opportunities for informatics professionals to enhance the primary care experience for patients, families, and their care teams.

Ordering and Utilization of Peripheral Blood Flow Cytometry in an Academic Medical Center

Abstract Introduction/Objective The American Society for Clinical Pathology and the American Board of Internal Medicine’s Choosing Wisely campaign have developed best practice utilization guidelines for laboratory testing. Wisconsin Diagnostic Laboratories and Medical College of Wisconsin leadership noticed an increase in inappropriate peripheral blood flow cytometry testing in the last two years. An intervention was developed to help reduce inappropriate testing requests. Methods/Case Report The laboratory implemented a clinical decision support tool in the electronic medical record system that looked at patient diagnosis, history of stem cell transplant, and recommendations from pathology to help improve utilization of peripheral blood flow cytometry testing. Based on patient history, flow cytometry testing would move forward, or an alternative order of a peripheral blood pathology smear review with reflex to flow cytometry was offered. Pathologists would reflex flow cytometry if abnormalities were present by light microscopy or predetermined reflexing criteria were met. Results (if a Case Study enter NA) 314 cases were included for analysis. The intervention reduced volumes of peripheral blood flow cytometry in patients without a history of hematologic malignancy by 49.1% (p=&amp;lt;0.001). Appropriate utilization increased from 47.0% in the pre-intervention period to 80.4% in the post intervention period (p=&amp;lt;0.001). Significant diagnosis rate increased from 42.5% to 50.0% (p=.261). This resulted in a cost savings of $12,232 for the health system during the intervention period. Conclusion Clinical decision support based utilization efforts provide strong and consistent interventions to reduce the unnecessary and inappropriate ordering of peripheral blood flow cytometry.

Handoffs and Equity: Impact of a Patient Distribution Model on Handoffs for Black Patients.

Hospital medicine patient distribution models (PDM) assign patients to inpatient services on hospital admission. Models balance tradeoffs including patient handoffs, physician wellness, subspecialty care, and other factors to ensure optimal outcomes; however, equity is rarely considered. Handoffs during inpatient care can result in medical error and worse patient outcomes. This study evaluates the impact of a PDM that prioritizes use of specialty care services and an overflow service (OS) during high census on racial inequities in handoff frequency. A single-center retrospective cohort study of inpatient encounters on hospital medicine services from July 2017 to December 2019 was conducted. The primary exposures included being discharged by a general medicine service (GMS) or cared for by an OS. The primary outcome was handoffs per day of stay, analyzed by multivariable regression adjusted for age, gender, race, ethnicity, insurance, discharge from GMS, and care from OS. A total of 4165 inpatient hospitalizations with the majority of their stay on a hospital medicine service were reviewed. Patients discharged by GMS (78.2% vs. 58.1%, p < .001) and cared for by OS (78.7% vs. 67.0%, p < .001) were more likely to identify as Black. Multivariable analysis showed a handoff risk ratio of 1.53 (p < .001) for OS patients and 1.06 (p = .01) if discharged from GMS, but race alone did not significantly affect risk of handoffs. The PDM prioritization drove increased handoffs disproportionately for Black patients. Multivariable analysis showed that race alone did not contribute to increased handoffs suggesting the creation of a systemic bias in patient care.