Southern Medical Journal最新文献

[This corrects the article DOI: 10.14423/SMJ.0000000000001965.].

Objectives: The opioid epidemic has increasingly affected the U.S. population, posing significant public health challenges. We aimed to examine factors associated with opioid use disorder (OUD) among hospitalized adults in the United States using a multilevel modeling approach and to identify distinct patterns of co-occurring clinical conditions using latent class analysis (LCA).

Methods: We analyzed a random sample of 100,000 hospital discharge records from the 2000-2020 North Carolina State Inpatient Database, including equal numbers with and without OUD. Adult patients (18 years and older) with complete sociodemographic and clinical data were included. Diagnoses were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification codes, grouped via Clinical Classifications Software. Mixed-effects logistic regression models assessed associations with OUD, incorporating random effects for area-level income. LCA classified hospitalizations into two distinct clinical profiles based on cooccurring conditions related to OUD.

Results: Patients diagnosed as having OUD were younger, more frequently male, and predominantly White compared with those without OUD. Mental health diagnoses ranged from 2% for attention-deficit/hyperactivity disorder/adjustment/eating disorders to 22% for depression/bipolar disorder, whereas comorbidities such as hypertension was present in nearly half of hospitalizations. LCA identified two distinct clinical profiles: class 1, characterized by less obesity and psychiatric comorbidities (63.3% of records), and class 2, with higher obesity and psychiatric morbidities (36.7%). Mixed-effects logistic regression showed that male sex, White race, emergency department admission, and insurance type (Medicaid/self-pay) were independently linked to OUD, whereas hepatitis B or C was the strongest (odds ratio [OR] 5.62) and tobacco use was the weakest (OR 1.28) clinical correlate. In a mixed-effects logistic regression model, patients in class 2 versus class 1 had a nearly threefold higher odds of OUD (OR 2.83), after adjustment for sociodemographic factors.

Conclusions: This study highlights important sociodemographic and clinical factors associated with OUD, including higher odds among male, White, and publicly insured patients. LCA identified distinct clinical profiles with varying psychiatric and obesity-related comorbidities linked to OUD risk. Key comorbidities such as hepatitis B/hepatitis C strongly predicted OUD, underscoring the need for integrated care. These findings inform targeted interventions for hospitalized populations facing complex medical and psychosocial challenges.

Objectives: Transgender and gender-diverse (TGD) individuals represent a growing demographic in the United States. This population, however, faces many health inequities, in part attributable to a lack of education for physicians in training on transgender health care at both the graduate and undergraduate medical education levels. We developed a curriculum on gender-affirming care for Internal Medicine (IM) residents to fill this educational gap.

Methods: We created a virtual, asynchronous, case-based curriculum on gender-affirming care for IM residents at a large urban academic medical center. To address gaps in prior curricula, we included attitudinal, knowledge, and skills-based material and assessments. We used precurriculum, immediate postcurriculum, and delayed 1-month postcurriculum surveys to assess curriculum efficacy, learner satisfaction, and knowledge retention.

Results: We found that 77.8% of IM resident participants had cared for a TGD patient but had received little prior training in gender-affirming care, and residents reported low levels of confidence in caring for this patient population. After completing the curriculum, performance on knowledge-based questions improved significantly, and residents reported significantly higher confidence in providing gender-affirming care. These improvements were durable on the delayed posttest.

Conclusions: A virtual, asynchronous, case-based curriculum on gender-affirming care in a primary care setting was effective at increasing residents' knowledge and confidence in transgender health, a topic that learners believed was important to their practice. These benefits persisted at 1 month, demonstrating knowledge retention. These findings support the importance of expanding education on gender-affirming care for TGD individuals, and interleaving material over time to promote retention.

Objectives: Using the most recent US population projections data, we sought to update the estimated number of women who will undergo surgery for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in the United States from 2025 through 2060. We hypothesize that the number of pelvic floor surgeries will increase in the upcoming decades.

Methods: We used the 2017 National Population Projections from the US Census Bureau, which provides age-specific estimates on the number of women in the US from 2025 to 2060. We used previously published age-specific rates of surgery for women undergoing SUI-only surgery, POP-only surgery, and either SUI or POP surgery. These rates were applied to the population estimates of women aged 18 to 89 years to determine the projected surgeries from 2025 to 2060 in 5-year increments.

Results: From 2025 to 2060, the population of women in the United Sates ages 18 to 89 years is projected to increase 17%, from 136.0 million to 158.5 million. Correspondingly, the total number of either SUI or POP surgeries will increase from 469,460 in 2025 to 553,858 in 2060.

Conclusions: From 2025 to 2060, there will be an 18% increase in the projected number of surgeries for SUI or POP, from 469,460 to 553,858. Our field should be proactive in ensuring that enough specialists and fellowship-trained subspecialists are available to meet the future surgical demands of women with pelvic floor disorders.

Objectives: In rural Appalachian Kentucky, managing chronic conditions presents a challenge due to limited healthcare access, inadequate health education, and poor dietary resources. This study explores factors contributing to healthcare barriers and examines how social support may help individuals better manage chronic illness.

Methods: We interviewed residents of rural Appalachian Kentucky and asked them to describe resources that helped or hindered their access to adequate health care and identify qualities essential for an effective healthcare leader. Thematic analysis was used to identify recurring patterns related to healthcare barriers, resources needed for self-management, and social support and its role in managing chronic illness.

Results: Among the 79 interviewees, most were long-term residents of the region, and approximately half were currently employed. Barriers to chronic disease management included distrust of medical professionals, limited health education, restricted access to care, and challenges with affordability and transportation. Participants cited a need for both general health education and diabetes mellitus-specific education.

Conclusions: This study highlighted significant barriers to the management of chronic illness in Appalachian Kentucky. Strong existing community bonds present an opportunity to improve outcomes. Such programs could leverage local support networks to enhance self-management for chronic diseases, including type 2 diabetes mellitus.

Objectives: The purpose of this study was to investigate the efficacy of various assessment tools in accurately evaluating resident proficiency in bedside procedures and to determine the potential value of incorporating self-assessment as a means to bridge the "competency gap" between perceived and actual procedural skill.

Methods: This retrospective, observational study evaluated resident performance of two common bedside procedures using evidence-based global rating scales (GRSs) and procedural checklists. We additionally compared supervisor assessments with resident self-assessments to identify discrepancies. Residents were assessed by a small group of expert faculty on a medicine procedure service at Virginia Commonwealth University from June 2016 to July 2020.

Results: Most residents (94% and 79%) performed all of the procedural checklist items. Only 79% and 48% of residents achieved both a GRS score ≥4 and completed all of the items on the checklist for each respective procedure. Residents were significantly more likely to perform all items on the checklist than obtain a GRS score ≥4 (P < 0.001) for both procedures. The mean number of procedures needed for resident and supervisor assessment to agree was 1.34 and 1.28.

Conclusions: The combined use of comprehensive performance checklists and GRSs, coupled with deliberate self-evaluation coaching and timely feedback, provides a more comprehensive and precise evaluation of procedural performance.

Objectives: This study examined the use of inhaled nitrous oxide as a pain management option during labor. Nitrous oxide offers a noninvasive, self-administered pain relief option that allows patients greater autonomy compared with other methods such as epidural analgesia or intravenous opioids. Its effectiveness and patient satisfaction remain a debated topic, however, with mixed results from previous studies. The primary aim of this cohort study was to analyze nitrous oxide utilization by focusing on identifying factors influencing its continued use during labor.

Methods: This was a retrospective cohort study of information collected from patient charts of those who used nitrous oxide between January 1, 2020 and July 1, 2023. Demographic and clinical characteristics were reviewed to assess patterns in continued nitrous oxide usage.

Results: There were 267 women who selected nitrous oxide for pain relief during labor. The study showed that the type of healthcare provider (certified nurse midwives vs doctors of medicine) (adjusted odds ratio [aOR] 2.45, 95% confidence interval [CI] 1.22-4.89, P=0.0115), and race relative to Hispanic patients, that non-Hispanic White women had a lower odds of remaining on nitrous oxide (aOR 0.27, 95% CI 0.11-0.68), as did non-Hispanic Black women (aOR 0.39, 95% CI 0.16-0.93) were significantly associated with continued nitrous oxide use during labor. The factors of maternal age, gestational age (term vs preterm), marital status, type of insurance, and parity were not significantly associated.

Conclusions: Women who selected and continued using nitrous oxide until delivery were more likely to have a certified nurse midwife managing their labor/delivery and were more likely to be Hispanic. The study underscores the potential use of nitrous oxide to enhance patient autonomy during labor. Further research is needed to clarify the use of nitrous oxide for pain management during labor.

Hemoglobin A1c (HbA1c) remains a cornerstone of glycemic assessment in diabetes mellitus care, yet discordance between HbA1c and measured glucose values is common in clinical practice. Failure to recognize this discordance can lead to inappropriate treatment escalation, increased hypoglycemia risk, and patient distress. This article reviews the biological and clinical factors that contribute to HbA1c-glucose discordance and translates these findings into practical strategies for routine care. Common causes include iron deficiency, chronic kidney disease, altered red blood cell turnover, hemoglobin variants, and rapid changes in glycemia. A stepwise, practice-oriented framework is presented to guide clinicians in evaluating discordant glycemic data using targeted laboratory testing and continuous glucose monitoring metrics. Emphasis is placed on avoiding reflexive medication intensification and using glucose monitoring data to individualize treatment decisions. The role of interdisciplinary care and patient-centered communication is also highlighted.

Objective: Teaching cultural competency is a critical but challenging task for clinician educators. Immersive experiential learning in the local community through the arts and humanities remains underexplored in medical education. To address this gap, a novel arts and humanities-based cultural competency workshop was developed.

Methods: This half-day cultural competency workshop was a collaborative effort between a center for humanities in medicine and an Internal Medicine residency program at an academic institution in the southeastern United States. The workshop incorporated a walking tour to sites in the historic downtown area near the institution's Community Health Collaborative to highlight local artists and the intersection of art, history, community, and health. Facilitators provided prompts to help guide discussion. Residents were asked to complete an anonymous, pre- and postintervention survey comprising five questions about arts and humanities-based learning and several aspects of cultural competency. Likert scale responses ranged from 1 (strongly disagree/extremely uncomfortable) to 5 (strongly agree/extremely comfortable).

Results: A total of 43 residents participated in the workshop, 35 of whom (82%) completed the presurvey and 26 (60%) completed the postsurvey. Pre- and postintervention surveys demonstrated statistically significant improvements across all five learning outcomes assessed. The findings indicate improved awareness and self-perceived readiness to engage with cultural issues in clinical practice, demonstrating the value of humanities in facilitating experiential understanding of such concepts.

Conclusions: This pilot study highlights the significant potential of immersive arts and humanities-based learning to enhance cultural competency in medical education. This approach can effectively complement traditional clinical training to enhance culturally responsive care. Future studies should implement this model across a broader range of training environments and specialties. By investing in such innovative educational approaches, we can better prepare the next generation of physicians to navigate the complexities of patients and deliver better care.