Internal Medicine Research Articles

Antipsychotic, benzodiazepine and Z-drug prescriptions in a Swiss hospital network in the Choosing Wisely and COVID-19 eras: a longitudinal study.

Physicians frequently prescribe antipsychotics off-label to treat, among others, insomnia and anxiety. The Swiss "smarter medicine - Choosing Wisely" campaign has tried to raise awareness about the risks and to limit benzodiazepine and Z-drug prescriptions. In the Italian-speaking part of Switzerland, our network of public hospitals joined the campaign with the aim of avoiding unnecessary benzodiazepine and Z-drug treatments, with prescription monitoring, benchmarking and educational contributions. Considering the risks of a possible shift towards the prescription of antipsychotics, and aware of the potential role of the COVID-19 pandemic, we decided to analyse the prescription trends of antipsychotics and benzodiazepines/Z-drugs before, during (2016-2017) and after the intervention. For this longitudinal study, we reactivated a continuous monitoring of inpatient benzodiazepine/Z-drug and antipsychotics prescriptions/deprescriptions, paused in 2018 after the end of the internal Choosing Wisely campaign, based on routinely collected observational health data. We screened all demographic, administrative and prescription data of patients admitted to the internal medicine department of the four teaching hospitals (H1-H4) belonging to the EOC (Ente Ospedaliero Cantonale) network, from the fourth quarter of 2014 to the second quarter of 2023. We analysed 74,659 hospital stays (14,645 / 16,083 / 24,285 / 19,646 at hospitals H1 / H2 / H3 / H4 respectively). The mean (± SD) case mix (a metric that reflects the diversity, complexity and severity of the treated patients) and patient age were 1.08 ± 0.14 and 73 ± 2 years. 10.6% and 12.1% of patients received antipsychotics prior to admission and at discharge respectively (new prescriptions 3.3 ± 0.7%; deprescriptions 13.3 ± 5.2%). New prescriptions showed an upward trend, with +0.20% per year (p <0.001). Patients admitted with ongoing antipsychotics therapy increased 0.36% per year (p <0.001). New benzodiazepine/Z-drug prescriptions showed a 0.20% per year decrease (p = 0.01). Patients admitted with ongoing benzodiazepine/Z-drug therapy decreased 0.32% per year (p <0.001). New antipsychotics prescriptions showed differences between hospitals, with H3 above and H2 below the average. The increase in antipsychotics quantitatively matched the decrease in benzodiazepine/Z-drug prescribing, suggesting a shift from one to the other sedative therapy. The same trend was visible in the ongoing prescriptions at admission revealing a similar out-of-hospital approach. This suggests a change in sedative prescribing strategy rather than the choice of alternative, non-pharmacological approaches. Furthermore, the variation between similar services of different hospitals points out the consequences of local prescribing cultures and the importance of continuously monitoring and benchmarking medication prescriptions.

Clinical characteristics and influencing factors of serious fall injuries among older inpatients: A secondary analysis of multicenter cross-sectional administrative data

BackgroundInpatient falls are common adverse events in hospitals, particularly among older adults. However, current research on falls in the older population is limited by small sample sizes and reliance on single-center designs without distinguishing the different levels of fall injuries. ObjectiveTo examine the circumstances of falls in older inpatients and investigate the factors influencing serious fall injuries. DesignA secondary analysis of multicenter cross-sectional administrative data from the China National Database of Nursing Quality (CNDNQ). Setting(s)67 hospitals in Hunan, China. Participants5143 fall incidents from 5048 older inpatients were included from January 2019 to December 2022. MethodsDescriptive statistics (means, standard deviations, frequencies, and percentages) were used to describe fall characteristics. Given the multilevel data structure, a Generalized Linear Mixed Model (GLMM) with a Logistic link function was employed, treating hospitals and wards as random effects. Univariate and multivariate analyses were conducted. ResultsThe prevalences of fall-related injuries and serious fall injuries in this study were 63.3 % and 25.0 %, respectively. Nurse-to-patient ratio at the time of fall ≤0.04 (aOR = 1.522, 95 % CI: 1.297–1.785), female gender (aOR = 1.304, 95 % CI: 1.137–1.497), a lengthy hospital stay (aOR = 1.009, 95 % CI: 1.001–1.018) were associated with an increased risk of serious fall injuries. Surgical (aOR = 0.655, 95 % CI: 0.482–0.889) and orthopedic wards (aOR = 0.649, 95 % CI: 0.449–0.939) exhibited lower risks of serious fall injuries than internal medicine wards. The time period from 8:00 to 15:59 was associated with a higher risk of serious fall injuries compared to the period from 0:00 to 7:59 (aOR = 1.416, 95 % CI: 1.171–1.713). Compared to lying, standing (aOR = 2.594, 95 % CI: 1.733–3.883), getting in/out of bed (aOR = 1.403, 95 % CI: 1.009–1.951), walking or rehabilitating (aOR = 3.039, 95 % CI: 2.194–4.208), toileting (aOR = 1.411, 95 % CI: 1.038–1.917), and showering (aOR = 2.170, 95 % CI: 1.391–3.385) were associated with an increased risk of serious fall injuries. ConclusionsFall-related injuries and serious fall injuries are highly prevalent among older inpatients. The study provides insights for targeted fall prevention strategies, improving nursing management and patient safety. RegistrationNot registered.

ВИКТОР АЛЕКСАНДРОВИЧ СНЕЖИЦКИЙ: ПРЕДАННОСТЬ И ВДОХНОВЕНИЕ В СЕРДЦЕ НАУКИ (К 65-ЛЕТИЮ СО ДНЯ РОЖДЕНИЯ)

The article is dedicated to the anniversary of an outstanding scientist, a highly qualified specialist and a true professional in the field of cardiology, a beloved mentor and simply a wonderful person, professor of the 1st Department of Internal Medicine of the Grodno State Medical University, Doctor of Medical Sciences, Professor, Corresponding Member of the National Academy of Sciences of Belarus V. A. Snezhitsky.

Retinal vascular events and relationship to CANCER development

BackgroundCentral retinal vein occlusion (CRVO) is a frequent and clinically relevant vascular pathology. The main risk factors are the same as systemic cardiovascular risk factors, but recently other significant risk factors have been studied. The aim of this study is to analyse the risk factors for retinal venous thrombosis and their relationship with the development of cancer. Methods710 patients with retinal vascular pathology were included, of whom 527 had suffered retinal venous thrombosis. Patients were followed up in internal medicine outpatient clinics between September 24, 1999, and April 30, 2022. The incidence of cancer during that time was collected. ResultsOf 527 patients evaluated, 448 (86.7 %) presented cardiovascular risk factors, and 89 (17.2 %) developed some neoplasm, being the most frequent: prostate (19.1 %), colon (16.9 %), skin (12.4 %), breast (9.0 %). Retinal venous thrombosis was related to the development of neoplasms during follow-up time (Log Rank = 5.28, p = 0.022; Breslow = 4.84, p = 0.028). Other significant factors were age above the median, smoking, HbA1c levels, and homocysteine levels higher than the median, and cholesterol and LDL-Cholesterol lower than the median. Age above the median (p < 0.001), smoking (p = 0.003) and levels of cholesterol below the median (p = 0.026) were independently related to the development of neoplasms. ConclusionsRetinal venous thrombosis is associated with the development of cancer. Other factors related to its development have been identified. If this is confirmed, the implications for the diagnosis, control, and treatment of these patients should be evaluated.

Enfant présentant une allergie alimentaire en crèche : quelle est la place du Projet d’Accueil Individualisé ? Quels ressentis pour le personnel ?

ContextThe nursery welcomes children from a few months to the age of 3 years, age range where there is an increase in cases of anaphylaxis related to food allergies (FA). ObjectivesTo draw up an inventory of the training and knowledge of staff with regard to FA. Observe the organization of the Individualized Reception Project (IRP) in the nursery. Take stock of the feelings and possible apprehensions of professionals to work on a daily basis with a child with FA. MethodsSurvey conducted in 2023 with 50 staff working in different childcare facilities. ResultsSeventy-four per cent had initial training on FA, 64% had no training on FA since taking a position in nursery and 66% never handled an adrenaline auto-injector (AAI). Twenty-one per cent of the structures have an internal medicine cabinet to support an inaugural reaction of FA and 14% are equipped with AAI (internal stock not taking into account the AAI of possible IRP). Sixty-eight per cent know that they are allowed to apply the IRP themselves in emergency situations in the nursery, in connection with the ministerial circular of 2021. Sixty-six per cent are comfortable in the daily reception of the child with FA, 38% are comfortable with the handling of the AAI. ConclusionGiven the increasing frequency of FA in small children, it is necessary for early childhood professionals to be better trained and informed during their studies and in the nursery, especially on the administration of AAI. It is desirable that an in-house pharmacy be equipped with AAI for the management of inaugural FA.

Rare neurological and neuropsychiatric manifestations of scrub typhus: a case series of 10 cases

IntroductionScrub typhus is a potentially life-threatening but curable disease that can produce multi-organ failure. Neurological manifestations in scrub typhus have gained attention recently, where the entire neural axis except the myoneural junction can be involved. Although the pathogenesis of neurological involvement has not been established, immune-mediated mechanisms are suspected. This article reports the clinicopathological features of scrub typhus cases presenting several rare neurological and neuropsychiatric manifestations. MethodsThree hundred fifty-four serologically confirmed scrub typhus cases were admitted to the Department of General Medicine of Burdwan Medical College and Hospital (West Bengal, India) between May 2018 and May 2022. There were 50 patients who had predominantly neurological manifestations. Of these 50 cases, ten patients presented with extremely rare neurological manifestations. ResultsWe report 10 cases of scrub typhus (four men and six women) who presented with complex neurological pictures (posterior reversible encephalopathy syndrome, Opalski syndrome, parkinsonism, cerebellitis, isolated opsoclonus, acute transverse myelitis, myositis, polyradiculoneuropathy with cranial neuropathy, acute transient behavioral changes, and fibromyalgia). Immune-mediated mechanisms might have mediated the pathogenesis of most cases following scrub typhus infection. ConclusionFrom a clinicopathological point of view, each case was unique in its presentation and treatment response. In any acute onset neurological disorders associated with febrile illness in the tropics or subtropics, scrub typhus infection should be included in the differential diagnosis, despite the absence of eschar and unremarkable neuroimaging findings. This otherwise curable disease may result in multi-organ dysfunction syndrome and death if the diagnosis is delayed.

Triggerpunkt-Behandlungs-Tool zur Selbsttherapie von Myogelosen im Berufsumfeld – eine Anwendungsbeobachtung

Trigger point treatment tool for self-therapy of myogelosis in the professional environment – An observational study Aim: There is a large number of occupations where workplace-associated movement patterns and/or forced postures lead to muscle tension in the shoulders and back. These tensions have a direct detrimental impact on the quality of life and capacity for work of those affected. In the medium to long term, they also promote the development of structural degeneration of the musculoskeletal system. If employees in the healthcare sector are affected, this impairs high-quality patient care. The trigger point self-treatment tool “TensionTerminator” (ErgoPhysion, Innsbruck, Austria) was developed for the self-therapy of such tension conditions in the workplace. The use of this device was evaluated as part of an application observation in six departments at Vienna General Hospital (AKH). Methods: Six departments at Vienna General Hospital from the areas of surgery, laboratory medicine, internal medicine and radiology were each provided with a “TensionTerminator” device for independent use for 4 months between May 2023 and March 2024. A contact person in each department was trained in the use of the device and how to handle the documentation. As part of the observation, users were asked to independently enter their user ID, the duration of use and their subjective assessment of the effect (“better”/”worse”/”no change”) in a list each time they used the device. Results: During the test period, a total of 430 uses by 145 users were documented in the six departments, i.e. an average of almost 3 uses per person. The average application duration was 6.5 minutes. In 85.1% of all uses, the patient’s condition after use was described as “better”, and in 14% of all cases as “no change”. One of the 430 uses received a negative rating (“worse”). Conclusion: The trigger point self-treatment tool “TensionTerminator” has proven to be an effective device against workplace-associated muscle tension. It was received very well in the hospital setting and was used regularly. Keywords: workplace health promotion – back pain – myogelosis – myofascial trigger points

Enhancing Patient Safety: The Role of Interdisciplinary Teams in Reducing Blood Culture Contamination.

Blood cultures are vital to diagnostic workups among many hospitalized patients, providing valuable information about bloodstream infections (BSIs), which cause roughly 250 000 deaths annually between North America and Europe. Despite advances in health care, blood culture contamination remains a substantial problem, with deleterious effects on patient mortality, patient and hospital costs, and microbial resistance. This article reviews the repercussions of blood culture contamination on the health care system and delineates evidence-based strategies to decrease contamination rates. To reduce blood culture contamination rates, our health care facility undertook a quality improvement initiative. A task force was created, consisting of leadership from the laboratory, phlebotomy, nursing, pathology, internal medicine teams, emergency medical services, and others. Measures included comprehensive staff training, standardization of protocols and supplies across facilities, and the introduction of waste tubes and smaller-volume chlorhexidine applicators for skin preparation. Data on blood culture contamination rates were collected before and after implementation. Prior to the intervention, the average monthly blood culture contamination rate across our facilities was 3.76%. Following the intervention, this rate decreased significantly to 2.07%, representing a reduction of 44.95%. Statistical analysis revealed a strong association between the implemented interventions and the decreased contamination rates, with a chi-square value of 62.3, 1 degree of freedom, and a P value of less than .001. These results indicate that the interventions were highly effective. Furthermore, the reduced contamination rates were sustained in the subsequent months, consistently remaining below 2%. The study demonstrated a substantial reduction in blood culture contamination rates through targeted interventions, highlighting the efficacy of combining evidence-based strategies with interdisciplinary teamwork to improve patient care outcomes.

The Efficacy of a Combination of Milk Thistle, Artichoke, and Green Tea in the Treatment of Biliary Sludge: An Interventional Prospective Open Study

Background: In Western countries, 10–20% of adults have gallstones, of which about 1–3% of patients are symptomatic for biliary colic. The treatment with ursodeoxycholic acid is debated. Silymarin is emerging nowadays as a natural substance with choleretic and beneficial properties, useful in the case of gallbladder sludge. Aim: The aim of our study was to evaluate the efficacy of supplementation with a mix of natural compounds (milk thistle 150 mg, artichoke 150 mg, and green tea 150 mg) in patients affected by biliary sludge in reducing biliary colic and biliary sludge and improving lipid profiles after 3 months of treatment compared to a control group. Patients and Methods: This was an interventional open study on 65 consecutive adult patients (23 M/42 F; mean age 61.0 ± 18.7 years) affected by biliary sludge without indication for surgery, admitted to the Internal Medicine Department of San Carlo di Nancy Hospital Rome. Forty patients were treated with milk thistle 150 mg, artichoke 150 mg, and green tea 150 mg, 2 capsules/day for three months, and followed up for abdominal ultrasound, the frequency of occurrence of biliary colic, and blood tests. Twenty-five control group patients were followed up for abdominal ultrasound, the frequency of occurrence of biliary colic, and blood tests after 3 months. Results: In Group A, we observed a disappearance of biliary sludge in 32.4% (12/37) of patients compared to 8.7% in the control group (p &lt; 0.05). In 32.4% of treated patients, we report a reduction in biliary sludge. There were no side effects during treatment. In both groups, we registered a significant reduction in transaminases and gamma-glutamyl transferase (γ-GT) (p &lt; 0.05). No significant modification of the lipid profile was observed. Conclusions: The treatment with a mix of natural compounds (milk thistle, artichoke, and green tea) in patients affected by symptomatic biliary colic resulted in efficacy and safety in reducing biliary sludge, biliary colic, and transaminases levels after three months of treatment. The limitations of this study include a small number of patients and the absence of long-term follow up after the end of treatment.

Appropriateness of Empirical Antibiotic Use and Concordence with the WHO Aware Classification in Hospitalized Patients

Background: Antibiotic prescription trends analysis is essential for monitoring the sensitivity and resistance patterns of microorganisms discovered, regularly generating and updating antibiograms, and providing the context for antibiotic usage and prevalence. Specifically, consistent prescription patterns and antibiotic therapy practices with the WHO AWaRe (Access, Watch, and Reserve) classification of antibiotics and the national or WHO essential medicine list would enhance the prudent use of antibiotics, prevent the emergence and spread of antimicrobial resistance, and preserve antibiotic efficacy for future requirements. Objective: This study aimed to analyze selection of antibiotics for empirical use and definitive therapy and to evaluate rational use of antibiotics according to the WHO-AWaRe (Access, Watch, and Reserve) categories in hospitalized patients. Methodology: An observational and cross-sectional study was conducted in a 300 bedded multispecialty tertiary care hospital from October 2022 to March 2023 for a period of six months. Evaluation of demographic data based on antimicrobial susceptibility reports, pathogen characteristics, and infection site; evaluation of antibiotics administered before and after AST reports; and classification of antibiotics using WHO AWaRe metrics from the WHO essential medicines list. Descriptive statistics were applied for the data collected using Microsoft Excel. Results are expressed as total count, frequency, and percentages. Results: Antimicrobial susceptibility results from 162 patients were gathered from the laboratory. Of these 138 (85.18%) patients had positive results for Gram-negative bacteria and 24 (14.81%) for Gram-positive bacteria. The mean (SD) age of patients was 55 ± 28 years; predominantly male patients 92 (56.79%). 107 (66%) patients were hospitalized for 1-5 days. Monotherapy was given in 17 (10.5%) patients, Most of the patients were admitted into the general medicine 94 (58.02%), Bacteria were mainly isolated from urine (65 isolates, 40.1%), and a total of 36 organisms were isolated. The proportions of appropriate empirical therapy use were 84.05% for Gram-negative bacteria. A total of 706 antibiotics were prescribed out of which 334 are prescribed before AST and 372 are prescribed after AST. More prescribed empirical antibiotics were from the ‘Watch’ group (55.69%), followed by the ‘Access’ group (25.75%). ‘Reserve’ category (8.38%) and ‘not-recommended’ category (10.18%) antibiotics were also prescribed. A greater number of prescribed definitive antibiotics were from the ‘Watch’ group (48.11%). ‘Access’ group antibiotics should be preferable to the ‘Watch’ group. ‘Reserve’ antibiotics are always used as the last option when “Access” and “Watch” group antibiotics don’t work. Conclusion: The high use of empirical antibiotics especially from the ‘Watch’ category is a disturbing trend as observed in our study. . Increasing the use of ‘Access' antibiotics while limiting the use of ‘Watch' and ‘Reserve' antibiotics at the same time is the highest priority for preserving effectiveness of important antibiotics and minimizing the danger of AMR. Conducting such studies and analysis of such data periodically would pave the way for promotion of rational use of antimicrobials and help restrict the emergence of resistant strains of bacteria.

10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score Calculation in Out-Patient Department

Objective: To calculate 10-year Atherosclerotic Cardiovascular Disease risk score in outdoor department of a tertiary care hospital and identify individuals at high risk of cardiovascular disease. Study Design: Cross-sectional study. Place and Duration of Study: Combined Military Hospital, Malir, Pakistan, from Oct 2020 to Mar 2021. Methodology: 116 patients presenting to Out-Patient Department of General Medicine of CMH, Malir, Pakistan, without previous evidence of cardiovascular disease were included. Previous history of diabetes, smoking, use of anti-hypertensives, Aspirin and statins was recorded. Systolic and diastolic blood pressures, waist circumference, HbA1c, fasting blood sugar, fasting LDL, HDL and total cholesterol were tested for each patient. 10-year ASCVD risk score was calculated using online ASCVD Risk Estimator calculator. Results: Mean age of the patients was 58.6±9.92 years with 62.1% being males and 37.9% being females. Mean 10-year ASCVD risk score was 13.37±7.1, of which 21 patients (18.1%) had Very High, 66(56.9%) had Intermediate and 29(25%) had Low 10-year ASCVD risk score. Among Very High cases, 80.9% were males, all were in age group 50-79 years, 61.9% were diabetic, 33.3% were smokers and 66.7% were obese. Conclusion: A very high percentage of study group had Intermediate or Very High 10-year ASCVD risk score. Identifying those individuals at high risk early and controlling the modifiable risk factors can help lessen the morbidity and mortality associated with cardiovascular diseases.

Regional Distribution of Foreign-Born Medical Graduates in US Primary Care Specialty Residencies from 2010 to 2022.

The United States has more foreign-born (FB) individuals than any other country and a large international medical graduate (IMG) workforce. Yet little is known about the trends of FB IMGs matching into primary care specialties residency programs or the alignment between FB individuals and FB IMGs. This study examined the recent trends in FB IMGs entry into primary care specialty residency programs and their distribution in relation to the US FB population. In this retrospective study, we used archives of National Resident Matching Program (NRMP) data on the main residency match from 2010 to 2022. We extracted match data and program directors' policies for internal medicine, pediatrics, family medicine, and internal medicine/pediatrics. We also extracted data on the total population and FB individuals from the US Census Bureau for each US state from 2010 to 2022. From 2010 to 2022, 17.2% of primary care specialty positions were filled by FB IMGs, with 22.1% for internal medicine, 11.3% for pediatrics, 10.7% for family medicine, and 3.2% for internal medicine/pediatrics. The percentage of primary care specialty positions filled by FB IMGs was significantly higher than the percentage of FB people in the US overall and 7 of 9 US regions (p < 0.001) (excepting Pacific and Mountain). The percentage of family medicine, pediatrics, and internal medicine/pediatrics positions filled by FB IMGs was significantly lower than the proportion of FB people (p < 0.001). Internal medicine had a higher proportion of positions filled by FB IMGs compared to the proportion of FB individuals in the general population (p < 0.001). Distribution of FB IMGs varies in primary care specialties compared to FB people in the US. Given the importance of aligning medical education with patients' needs, programs could take into account population demographics while assessing and admitting the applicants.

Interprofessional meetings, organization, and interactive practices: the reflexive achievement of patient-centeredness

ABSTRACT Interprofessional meetings are crucial for achieving patient-centeredness in healthcare. Exactly how patient-centeredness is reached during these meetings remains underexamined. Adopting an Ethnomethodology and Conversation Analysis (hereafter EMCA) perspective, this contribution looks at video-recordings of interprofessional meetings in two distinct healthcare settings: rehabilitation and internal medicine. It aims to provide new insight into how investigations of patient-centeredness as a reflexive achievement allow us to better understand the organizational and relational efforts required to achieve it in practice. This contribution outlines how different healthcare contexts result in variety in the meeting frequency, duration, aims, participants, and agendas, which in turn means that the opportunities for patient-centeredness are not the same. But it also illustrates how patient-centeredness depends on the ways the various opportunities are seized and play out in the interprofessional interactions. It is therefore argued here that research on how patient-centeredness is reached in interprofessional meetings and the development of recommendations for enhancing it both require consideration of context-specific conditions and how participants adapt to and simultaneously modify them to achieve patient-centeredness in practice.

Malnutrition and Fall Risk in Older Adults: A Comprehensive Assessment Across Different Living Situations.

Malnutrition among older adults is associated with numerous adverse effects, including increased morbidity, mortality, prolonged hospital stays, and a heightened risk of falls. This study aims to investigate the prevalence of malnutrition in different groups of older adults using the F-MNA, anthropometry, and s-albumin and the association between nutritional status and fall risk. A total of 228 participants aged 60 years and older were divided into three groups: (1) patients in an internal medicine ward, (2) individuals living in family homes, and (3) residents of care homes. Disease profiles, nutritional status (assessed using the F-MNA and SNAQ), body composition, fall risk, and biochemical markers were evaluated. The results indicated the highest prevalence of malnutrition among hospitalized individuals. Fall risk was associated with age, calf circumference, the F-MNA, the SNAQ, serum albumin levels, residence in a care home, comorbidities, and the number of medications taken daily. Regression analysis revealed that age, calf circumference, and residence in a care home were independent predictors of fall risk in older adults. Older adults are at significant risk of malnutrition, with the risk notably increasing during hospitalization and long-term stays in care homes. Hospitalized individuals had the poorest nutritional status and were at significant risk of further weight loss, underscoring the importance of post-discharge care and rehabilitation.

Effect of integrated medicines management on quality of discharge medication information - a secondary endpoint in a randomized controlled trial.

High-quality discharge information is important to promote patient safety when patients are transferred from hospital to primary care. Patients with multiple long-term conditions are especially vulnerable to insufficient transfer of medication information, as they use many medications and have complex interactions with the healthcare services. The aim of this study was to investigate the effect of integrated medicines management provided to hospitalized multimorbid patients on the quality of the discharge medication information. Multimorbid patients ≥18 years, using a minimum of four regular medications from a minimum of two therapeutic medication classes were recruited from the Internal Medicine ward, Oslo University Hospital, Norway, from August 2014 to March 2016 and randomly assigned, 1:1, to the intervention or control group. Intervention patients received integrated medicines management throughout the hospital stay. Control patients received standard care. This paper reports the results of a pre-specified secondary endpoint analysis of a randomized controlled trial; the difference between the intervention and control group in the quality of discharge medication information. The analysis population comprised 384 patients. Integrated medicines management improved the discharge summary quality score of the medication information from 5.8 ± 1.5 to 8.6 ± 2.6 (mean difference 2.7, 95% CI 2.3-3.2, p < 0.001). In total 171 intervention patients (89%) received a patient discharge information letter, compared to 66 control patients (35%), p < 0.001. The quality score of the medication information in the patient discharge information letter was improved from 6.0 ± 1.8 in the control group to 10.0 ± 1.3 in the intervention group (mean difference 4.0, 95% CI 3.6-4.4, p < 0.001). Integrated medicines management delivered to multimorbid patients during a hospital stay improved the quality of the medication information in discharge summaries as well as patient discharge information letters and ensured that a discharge information letter in lay language was prepared for almost all patients who were involved in the management of their medications after discharge.

Clinical Staff Perceptions of Pay-for-Performance Financial Incentives for HPV Vaccine Promotion.

The purpose was to investigate clinical staff perceptions of pay-for-performance human papillomavirus (HPV) vaccination financial incentives. In 2022, the authors conducted a national survey of clinical staff (N = 2527; response rate = 57%). Respondents were (1) certified to practice in the United States; (2) practiced as a physician, physician assistant, nurse practitioner, advanced practice nurse, registered nurse, licensed practical/vocational nurse, medical assistant, or certified nursing assistant; (3) worked in pediatrics, family medicine, or general medicine specialties; and (4) had a role in HPV vaccination for children ages 9 through 12 years. The team used ordered regressions to model whether respondents agreed with (ie, "Strongly agreed" or "Agreed" on a 5-point Likert scale) each of the 9 statements. The statements were mapped to domains based on the theory of planned behavior: attitudes (5 statements), perceived behavioral control (2), and norms (2). Favorable responses to 9 statements ranged from 32% to 85%; 5/9 items had more than 50% favorable responses. The following example odds ratios (ORs) are for "agree" versus "neutral" or "disagree" to change their behavior to obtain the incentive. Clinical staff with prior experience with incentives were more likely to agree with 8/9 positive statements about incentives (eg, OR = 1.32 [95% confidence interval {CI}: 1.12-1.57]). Family medicine clinics were more likely than pediatric clinics to agree with 5/9 statements (eg, OR = 1.42 [95% CI: 1.18-1.70]). Clinical staff with more years of experience were less likely to agree with 6/9 statements (eg, OR = 0.97 [95% CI: 0.97-0.98]). Clinical staff's perceptions of pay-for-performance HPV vaccination financial incentives were generally favorable.

A longitudinal observational study on activated partial thromboplastin time in hypothyroidism and effect of thyroxine supplementation

Background: Hypothyroidism is a common condition characterized by thyroid hormone deficiency, which, if untreated, can lead to severe health consequences and even death. Due to the wide range of clinical presentations and non-specific symptoms, hypothyroidism is primarily diagnosed biochemically. It can result from congenital thyroid abnormalities or iodine deficiency. Aims and objectives: Aim: To evaluate the correlation between hypothyroidism and Activated Partial Thromboplastin Time (aPTT) and assess the effect of thyroxine supplementation. Objective: To study the impact of levothyroxine supplementation on aPTT in hypothyroid patients. Materials and methods: This observational study was conducted at the General Medicine outpatient clinic and inpatient wards at Al-Ameen Medical College and Hospital, Vijayapura, from September 2022 to March 2024. A total of 80 hypothyroid patients of both sexes were included. TSH, Free T4, and aPTT levels were measured with appropriate aseptic precautions. Results: The majority of subjects were females (90%), with the highest proportion (31.3%) aged 26-35 years. The mean ± SD of pre-thyroxine TSH was 25.453 ± 19.9073, which significantly decreased to 4.299 ± 0.6738 post-thyroxine. aPTT values also decreased significantly post-treatment. A positive correlation was found between TSH and aPTT, while aPTT had a negative correlation with T3 and T4 levels. Conclusion: aPTT is significantly elevated in hypothyroid patients and shows a positive correlation with TSH levels. Regular monitoring of aPTT should be included in the follow-up of hypothyroid patients.

Trainee's Perceptions on Simulation-Based Education and Its Impact on Transitioning to the Role of Medical Registrar: A Qualitative Study.

Background and aim In 2019, a three-year internal medicine training (IMT) program replaced the two-year core medical training program in the United Kingdom, incorporating the first year of medical registrar (MR) training into the same curriculum. In light of the considerable evidence supporting the effectiveness of simulation-based education (SBE) and the challenges inherent in transitioning, the design and delivery of SBE are now ideally positioned to facilitate this transition process and assess its impact. However, trainees' perceptions regarding the effectiveness of SBE in the IMT curriculum for transitioning to the MR role are not well-documented. This study aimed to explore and examine trainees' views on SBE in the IMT curriculum to prepare them to transition to the role of the MR. It sought to identify the critical qualities and skills that IMT trainees believe SBE should address to enable them to successfully fulfill the MR role, as well as to assess the extent to which internal medicine year three trainees perceive that SBE in its current form within the IMT curriculum has prepared them for the role of MR. Methods This qualitative study employed focus groups to explore individuals' perspectives on SBE in the IMTcurriculum and its role in preparing them for the transition to the MR position. Four focus groups were conducted, two with core trainees (CTs) and two with MRs. Sessions were recorded, transcribed verbatim, and analyzed using a thematic analysis approach. Results Eleven trainees participated in the study. Seven of them were CTs, with the remaining four in their first year as a MR. Six main themes emerged from the data, grouped into two main headings. The heading titled "Perceptions of SBE" included the themes "Valuable Teaching Tool," "A Squandered Resource," and "Avoid Over-Reliance." In contrast, the heading "Areas/Suggestions for Improving SBE" included the themes "Quantity and Scheduling," "Feedback," and "Draw on Others' Experiences." Conclusion The value of SBE was recognized, alongside the vital role of high-quality feedback. Other medical specialties and industries were highlighted for their effective implementation of SBE, offering a possible standard for educators involved in the IMT curriculum to pursue. There was a perception that SBE did not adequately supportthe ongoing maintenance of skills, placing considerable reliance on real-world clinical practice to fulfill this need. The limitations inherent in SBE were acknowledged, and educators are encouraged to explore ways to optimize the use of all educational tools at their disposal, which may include the formal introduction of a shadowing period for trainees.

Utilization patterns of Chiranjeevi Swasthya Bima Yojana in Rajasthan during financial year 2023 to 2024: a cross-sectional study at a tertiary care hospital

Background: Publicly funded health insurance (PFHI) is considered a key policy tool to provide financial protection to households seeking healthcare. The state government of Rajasthan has launched Mukhya Mantri Chiranjeevi Swasthya Bima Yojana (CSBY), with a cover of 25,00,000 INR per family per year, that makes it one of the largest PFHI in world by cost-coverage. However, there is an evidence-gap on utilization patterns and consequent need of higher-rate packages in state-PFHIs. A study was designed with the objective to describe the utilization pattern of CSBY in Rajasthan. Methods: The cross-sectional study was conducted at Sawai Man Singh Hospital in Jaipur, the highest public tertiary care institute of Rajasthan. The data on CSBY hospitalisations was collected from Chiranjeevi portal for financial year 2023-2024. Summary statistics were used to describe the variables such as age and gender of beneficiaries and medical specialities and cost details of packages utilised. Results: The mean age of patients was 45.9 (±20.0) years and 62.1% were males. The top specialty by volume of admission was general medicine (14.2%) and by cumulative cost of packages utilized was cardiology (22.0%). The median cost of packages utilized per hospitalization was 12,200 INR. 96.8% of beneficiaries utilized the services at a cumulative cost of up to 1 lakh INR and only 0.01% patients utilized more than 5 lakh INR. Conclusions: The study found higher utilisation of highly-specialised services over broad-specialties and an underutilisation of higher-rate packages, demonstrating a gap in perceived need of higher-rate packages in the state.

Using implementation science to encourage Serious Illness Conversations on general medicine inpatient services: An interrupted time series.

Serious Illness Conversations (SICs) are not consistently integrated into existing inpatient workflows. We assessed the implementation of multiple interventions aimed at encouraging SICs with hospitalized patients. We used the Consolidated Framework for Implementation Research to identify determinants for conducting SICs by interviewing providers and the Expert Recommendations for Implementing Change to develop a list of interventions. Adult patient encounters with a Readmission Risk Score (RRS) > 28% admitted to a general medicine service from January 2019 to October 2021 and without standardized SIC documentation in the prior year were included. A multivariable segmented logistic regression model, suitable for an interrupted time series analysis, was used to assess changes in the odds of standardized SIC documentation. Barriers included those associated with the COVID-19 pandemic, such as extreme census. Facilitators included the presence of the Speaking About Goals and Expectations program and palliative care consultations. Key interventions included patient identification via the existing Quality and Safety Dashboard (QSD), weekly emails, in-person outreach, and training for faculty and trainees. There was no significant change in the odds of standardized SIC documentation despite interventions (change in temporal trend odds ratio (OR) 1.16, 95% Confidence Interval (CI) 0.98-1.39). The lack of significant change in standardized SIC documentation may be attributed to insufficient or ineffective interventions and COVID-19-related challenges. Although patient identification is a known barrier to SICs, this issue was minimized with the use of the QSD and RRS. Further research is needed to enhance the implementation of SICs in inpatient settings.