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Displaying 661 - 670 of 7510 in ACP Online
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Peer Perspectives: Sean E. Greenhalgh, MD, FACP, FHM
Sean E. Greenhalgh, MD, FACP, FHM Academic Hospitalist, Division Chief, and Regional Medical Director of Hospital Medicine at Loyola University Medical Center, Maywood, IL 1. What is your current professional position?
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Neeladri Misra, MD, FACP Academic Hospitalist and Core Faculty at the Sutter Roseville Medical Center Internal Medicine Residency Program, Roseville, CA Clinical Associate Professor of Medicine at California Northstate University College of Medicine in Elk Grove, California
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Maruti Sharma, MDInternal Medicine PhysicianSharma and Sharma Medical, PLLCMount Vernon, NY1. What is your current professional position?
Displaying 661 - 670 of 6736 in Annals of Internal Medicine
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Implications of the Use of Artificial Intelligence Predictive Models in Health Care Settings: A Simulation Study: Annals of Internal Medicine: Vol 176, No 10
Background: Substantial effort has been directed toward demonstrating uses of predictive models in health care. However, implementation of these models into clinical practice may influence patient outcomes, which in turn are captured in electronic health record data. As a result, deployed models may affect the predictive ability of current and future models. Objective: To estimate changes in predictive model performance with use through 3 common scenarios: model retraining, sequentially implementing 1 model after another, and intervening in response to a model when 2 are simultaneously implemented. Design: Simulation of model implementation and use in critical care settings at various levels of intervention effectiveness and clinician adherence. Models were either trained or retrained after simulated implementation. Setting: Admissions to the intensive care unit (ICU) at Mount Sinai Health System (New York, New York) and Beth Israel Deaconess Medical Center (Boston, Massachusetts). Patients: 130 000 critical care admissions across both health systems. Intervention: Across 3 scenarios, interventions were simulated at varying levels of clinician adherence and effectiveness. Measurements: Statistical measures of performance, including threshold-independent (area under the curve) and threshold-dependent measures. Results: At fixed 90% sensitivity, in scenario 1 a mortality prediction model lost 9% to 39% specificity after retraining once and in scenario 2 a mortality prediction model lost 8% to 15% specificity when created after the implementation of an acute kidney injury (AKI) prediction model; in scenario 3, models for AKI and mortality prediction implemented simultaneously, each led to reduced effective accuracy of the other by 1% to 28%. Limitations: In real-world practice, the effectiveness of and adherence to model-based recommendations are rarely known in advance. Only binary classifiers for tabular ICU admissions data were simulated. Conclusion: In simulated ICU settings, a universally effective model-updating approach for maintaining model performance does not seem to exist. Model use may have to be recorded to maintain viability of predictive modeling. Primary Funding Source: National Center for Advancing Translational Sciences.
Fatal Drug Overdose Risks of Health Care Workers in the United States: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 176, No 8
Background: Despite an unprecedented increase in drug overdose deaths in the United States, the risks faced by U.S. health care workers, who often have access to controlled prescription drugs, are not known. Objective: To estimate risks for drug overdose death among health care workers relative to non–health care workers. Design: Prospective cohort study. Setting: United States. Participants: Health care workers (n = 176 000) and non–health care workers (n = 1 662 000) aged 26 years or older surveyed in 2008 and followed for cause of death through 2019. Measurements: Age- and sex-standardized drug overdose deaths were determined for 6 health care worker groups (physicians, registered nurses, other treating or diagnosing health care workers, health technicians, health care support workers, and social or behavioral health workers) and non–health care workers. Adjusted drug overdose death hazards (and 95% CIs) were also evaluated, with adjustment for age, sex, race/ethnicity, marital status, education, income, urban or rural residence, and region. Results: Approximately 0.07% of our study sample died of a drug overdose during follow-up. Among health care workers, annual standardized rates of drug overdose death per 100 000 persons ranged from 2.3 (95% CI, 0 to 4.8) for physicians to 15.5 (CI, 9.8 to 21.2) for social or behavioral health workers. Compared with those for non–health care workers, the adjusted hazards of total drug overdose death were significantly increased for social or behavioral health workers (adjusted hazard ratio, 2.55 [CI, 1.74 to 3.73]), registered nurses (adjusted hazard ratio, 2.22 [CI, 1.57 to 3.13]), and health care support workers (adjusted hazard ratio, 1.60 [CI, 1.19 to 2.16]), but not for physicians (adjusted hazard ratio, 0.61 [CI, 0.19 to 1.93]), other treating or diagnosing health care workers (adjusted hazard ratio, 0.93 [CI, 0.44 to 1.95]), or health technicians (adjusted hazard ratio, 1.13 [CI, 0.75 to 1.68]). Results were generally similar for opioid-related overdose deaths and unintentional overdose deaths. Limitation: Unmeasured confounding, uncertain validity of cause of death, and one-time assessment of occupation. Conclusion: Registered nurses, social or behavioral health workers, and health care support workers were at increased risk for drug overdose death, suggesting the need to identify and intervene on those at high risk. Primary Funding Source: National Heart, Lung, and Blood Institute.
Risk for Congenital Anomalies in Children Conceived With Medically Assisted Fertility Treatment: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 176, No 10
Background: More than 2 million children are conceived annually using assisted reproductive technologies (ARTs), with a similar number conceived using ovulation induction and intrauterine insemination (OI/IUI). Previous studies suggest that ART-conceived children are at increased risk for congenital anomalies (CAs). However, the role of underlying infertility in this risk remains unclear, and ART clinical and laboratory practices have changed drastically over time, particularly there has been an increase in intracytoplasmic sperm injection (ICSI) and cryopreservation. Objective: To investigate the role of underlying infertility and fertility treatment on CA risks in the first 2 years of life. Design: Propensity score–weighted population-based cohort study. Setting: New South Wales, Australia. Participants: 851 984 infants (828 099 singletons and 23 885 plural children) delivered between 2009 and 2017. Measurements: Adjusted risk difference (aRD) in CAs of infants conceived through fertility treatment compared with 2 naturally conceived (NC) control groups—those with and without a parental history of infertility (NC-infertile and NC-fertile). Results: The overall incidence of CAs was 459 per 10 000 singleton births and 757 per 10 000 plural births. Compared with NC-fertile singleton control infants (n = 747 018), ART-conceived singleton infants (n = 31 256) had an elevated risk for major genitourinary abnormalities (aRD, 19.0 cases per 10 000 births [95% CI, 2.3 to 35.6]); the risk remained unchanged (aRD, 22 cases per 10 000 births [CI, 4.6 to 39.4]) when compared with NC-infertile singleton control infants (n = 36 251) (that is, after accounting for parental infertility), indicating that ART remained an independent risk. After accounting for parental infertility, ICSI in couples without male infertility was associated with an increased risk for major genitourinary abnormalities (aRD, 47.8 cases per 10 000 singleton births [CI, 12.6 to 83.1]). There was some suggestion of increased risk for CAs after fresh embryo transfer, although estimates were imprecise and inconsistent. There were no increased risks for CAs among OI/IUI-conceived infants (n = 13 574). Limitations: This study measured the risk for CAs only in those children who were born at or after 20 weeks' gestation. Observational study design precludes causal inference. Many estimates were imprecise. Conclusion: Patients should be counseled on the small increased risk for genitourinary abnormalities after ART, particularly after ICSI, which should be avoided in couples without problems of male infertility. Primary Funding Source: Australian National Health and Medical Research Council.
Moving Naloxone Over the Counter Is Necessary but Not Sufficient
Naloxone is an opioid antagonist that is available in numerous formulations and can be easily administered to avert death from opioid overdose. Amid a historic overdose crisis in the United States, naloxone has a crucial role in stemming the loss of life. However, it remains largely inaccessible to the public. Recently, the U.S. Food and Drug Administration announced the approval of the first over-the-counter formulation of naloxone. Although this historic change provides an important opportunity to increase distribution of naloxone, we must take careful steps during this transition so that it does not paradoxically threaten overall access to this life-saving medication. Specifically, we must ensure that a larger supply of naloxone will meet the newly increased demand at a sustainable price for consumers who are most in need. We must also continue to prioritize comprehensive methods of distribution, such as overdose education and naloxone distribution programs, that serve as important tools to reach the most vulnerable populations. In addition, simultaneous investment in harm-reduction strategies, such as supervised consumption spaces, is critical to ensure that naloxone is available in settings where its life-saving potential can be most fully realized.
Gabapentinoids and Risk for Severe Exacerbation in Chronic Obstructive Pulmonary Disease: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 177, No 2
Background: North American and European health agencies recently warned of severe breathing problems associated with gabapentinoids, including in patients with chronic obstructive pulmonary disease (COPD), although supporting evidence is limited. Objective: To assess whether gabapentinoid use is associated with severe exacerbation in patients with COPD. Design: Time-conditional propensity score–matched, new-user cohort study. Setting: Health insurance databases from the Régie de l’assurance maladie du Québec in Canada. Patients: Within a base cohort of patients with COPD between 1994 and 2015, patients initiating gabapentinoid therapy with an indication (epilepsy, neuropathic pain, or other chronic pain) were matched 1:1 with nonusers on COPD duration, indication for gabapentinoids, age, sex, calendar year, and time-conditional propensity score. Measurements: The primary outcome was severe COPD exacerbation requiring hospitalization. Hazard ratios (HRs) associated with gabapentinoid use were estimated in subcohorts according to gabapentinoid indication and in the overall cohort. Results: The cohort included 356 gabapentinoid users with epilepsy, 9411 with neuropathic pain, and 3737 with other chronic pain, matched 1:1 to nonusers. Compared with nonuse, gabapentinoid use was associated with increased risk for severe COPD exacerbation across the indications of epilepsy (HR, 1.58 [95% CI, 1.08 to 2.30]), neuropathic pain (HR, 1.35 [CI, 1.24 to 1.48]), and other chronic pain (HR, 1.49 [CI, 1.27 to 1.73]) and overall (HR, 1.39 [CI, 1.29 to 1.50]). Limitation: Residual confounding, including from lack of smoking information. Conclusion: In patients with COPD, gabapentinoid use was associated with increased risk for severe exacerbation. This study supports the warnings from regulatory agencies and highlights the importance of considering this potential risk when prescribing gabapentin and pregabalin to patients with COPD. Primary Funding Source: Canadian Institutes of Health Research and Canadian Lung Association.