Mirela Feurdean

Integrating a Resident-Driven Longitudinal Quality Improvement Curriculum Within an Ambulatory Block Schedule.

BACKGROUND Quality improvement (QI) is essential in clinical practice, requiring effective teaching in residency. Barriers include lack of structure, mentorship, and time. OBJECTIVE To develop a longitudinal QI curriculum for an internal medicine residency program with limited faculty resources and evaluate its effectiveness. METHODS All medicine residents were provided with dedicated research time every 8 weeks during their ambulatory blocks. Groups of 3 to 5 residents across all postgraduate year levels were formed. Two faculty members and 1 chief resident advised all groups, meeting with each group every 8 weeks, with concrete expectations for each meeting. Residents were required to complete didactic modules from the Institute for Healthcare Improvement. Current residents and alumni were surveyed for feedback. RESULTS Over 3 years, all eligible residents (92 residents per year in 2012-2014, 102 in 2014-2015) participated in the curriculum. Residents worked on 54 quality assessment and 18 QI projects, with 6 QI projects showing statistically significant indicator improvements. About 50 mentoring hours per year were contributed by 2 faculty advisors and a chief resident. No other staff or IT support was needed. A total of 69 posters/abstracts were produced, with 13 projects presented at national or regional conferences. Survey respondents found the program useful; most (75% residents, 63% alumni) reported it changed their practice, and 71% of alumni found it useful after residency. CONCLUSIONS Our longitudinal QI curriculum requires minimal faculty time and resulted in increased QI-related publications and measurable improvements in quality indicators. Alumni reported a positive effect on practice after graduation.

Suicidal ideation among adults with cardiovascular disease: The National Health and Nutrition Examination Survey

OBJECTIVE Previous studies have shown a possible link between cardiovascular disease (CVD) and suicidal ideation (SI). However, limited information exists regarding the association between different subtypes of CVD and SI and the role of depression. METHODS Data were used from the National Health and Nutrition Examination Survey for cycles 2009-2010 and 2011-2012. SI was assessed by item 9 of the Patient Health Questionnaire 9. Data regarding sociodemographic factors, and comorbid conditions were collected and examined as potential correlates. Logistic regression analyses were used to examine the relationship between CVD and subtypes and suicidal ideation. RESULTS Among a total of 11,678 participants, suicidal ideation was significantly higher among patients with CVD compared to participants without a history of CVD (5.4% vs 3.6%, P<0.001). A subset of patients with CVD with a history of congestive heart failure (CHF) and prior myocardial infarction (MI) had the highest percentage of SI (10.6%). The association between CVD and SI remained significant after adjusting for baseline characteristics and associated comorbidities including depression (OR 1.40, 95% CI 1.10-2.09, P=0.006). CONCLUSION CVD is an independent risk factor for SI. The identification of a subset of patients with CVD at greatest risk of SI underlines the importance of screening in this vulnerable population.

Time Trends and Predictors of Acute Gastroenteritis in the United States: Results From National Health and Nutrition Examination Survey 2005-2014

GOALS To investigate the time trends of the prevalence and predictors of acute gastroenteritis (AGE) in the United States from 2005 to 2014 using nationally representative data. BACKGROUND AGE results in numerous visits to emergency departments and outpatient clinics annually in the United States with the estimated attributable cost to the US economy up to

The Association of leptin with severity of non-alcoholic fatty liver disease: A population-based study

145 billion dollars. However, time trends and predictors of AGE are not fully understood. METHODS Data were obtained from the National Health and Nutrition Survey (NHANES) 2005 to 2014, a nationally representative health survey. AGE was defined by a medical question (Do you have a stomach or intestinal illness with vomiting or diarrhea that started during last 30 d?). Prevalence of AGE was estimated in the total population as well as by selected demographic variables. Predictors of AGE and time trends of prevalence over survey periods were also investigated. RESULTS Overall monthly prevalence of AGE was 8.31% (95% confidence interval, 7.81-8.81), corresponding to 22.8 million people. AGE was associated with a younger age group, the highest in ages 0 to 9 years old, females, winter to early spring season, US born, divorced/separated/widowed individuals, current smokers, heavy alcohol users, and low household income. In the trends analyses, the prevalence of AGE significantly decreased over the study periods: 10.23% in 2005 to 2006, 9.89% in 2007 to 2008, 7.58% in 2009 to 2010, 6.44% in 2011 to 2012, and 7.47% in 2013 to 2014 (trend P<0.001). CONCLUSION In the United States from 2005 to 2014, the monthly prevalence of AGE was 8.31% and has been significantly decreasing over time.Goals: To investigate the time trends of the prevalence and predictors of acute gastroenteritis (AGE) in the United States from 2005 to 2014 using nationally representative data. Background: AGE results in numerous visits to emergency departments and outpatient clinics annually in the United States with the estimated attributable cost to the US economy up to

Vitamin D’s Role in Non-Alcoholic Fatty Liver Disease

145 billion dollars. However, time trends and predictors of AGE are not fully understood. Methods: Data were obtained from the National Health and Nutrition Survey (NHANES) 2005 to 2014, a nationally representative health survey. AGE was defined by a medical question (Do you have a stomach or intestinal illness with vomiting or diarrhea that started during last 30 d?). Prevalence of AGE was estimated in the total population as well as by selected demographic variables. Predictors of AGE and time trends of prevalence over survey periods were also investigated. Results: Overall monthly prevalence of AGE was 8.31% (95% confidence interval, 7.81-8.81), corresponding to 22.8 million people. AGE was associated with a younger age group, the highest in ages 0 to 9 years old, females, winter to early spring season, US born, divorced/separated/widowed individuals, current smokers, heavy alcohol users, and low household income. In the trends analyses, the prevalence of AGE significantly decreased over the study periods: 10.23% in 2005 to 2006, 9.89% in 2007 to 2008, 7.58% in 2009 to 2010, 6.44% in 2011 to 2012, and 7.47% in 2013 to 2014 (trend P<0.001). Conclusion: In the United States from 2005 to 2014, the monthly prevalence of AGE was 8.31% and has been significantly decreasing over time.

Obesity, Metabolic Syndrome, and Cardiovascular Risk in Gluten-Free Followers Without Celiac Disease in the United States: Results from the National Health and Nutrition Examination Survey 2009–2014

Background/Aims Leptin is associated with metabolic disorders, which predispose one to non-alcoholic fatty liver disease (NAFLD). The role of leptin in NAFLD pathogenesis is not fully understood. We aim to investigate the association between serum leptin level and severity of NAFLD using U.S. nationally representative data. Methods Data were obtained from the United States Third National Health and Nutrition Examination Survey. NAFLD was defined by ultrasound detection and severity of hepatic steatosis in the absence of other liver diseases. The severity of hepatic fibrosis was determined by NAFLD fibrosis score (NFS). We used multivariate survey-weighted generalized logistic regression to evaluate the association between leptin level and the degree of NAFLD. We also performed subgroup analyses by body mass index (lean vs. classic NAFLD). Results Among 4,571 people, 1,610 (35%) had NAFLD. By ultrasound findings, there were 621 people with mild, 664 with moderate, and 325 with severe steatosis. There were 885 people with low NFS (<-1.455, no significant fibrosis), 596 with intermediate NFS, and 129 with high NFS (>0.676, advanced fibrosis). Leptin levels for normal, mild, moderate and severe steatosis were 10.7±0.3 ng/mL, 12.1±0.7 ng/mL, 15.6±0.8 ng/mL, 16±1.0 ng/mL, respectively (trend P-value<0.001). Leptin levels for low, intermediate, and high NFS were 11.8±0.5 ng/mL, 15.6±0.8 ng/mL, 28.5±3.5ng/mL, respectively (trend P-value<0.001). This association remained significant even after adjusting for known demographic and metabolic risk factors. In the subgroup analysis, this association was only prominent in classic NAFLD, but not in lean NAFLD. Conclusions Serum leptin level is associated with the severity of NAFLD, especially in classic NAFLD patients.

Impact of Hospital Teaching Status on Mortality, Length of Stay and Cost Among Patients With Cardiac Arrest in the United States

appropriately. First, the study design of this study is cross-sectional, which could not disclose any causal relationship. Th e lack of statistical signifi cance may not necessarily imply that vitamin D does not play a role in NAFLD pathogenesis. Rather, it could be interpreted that vitamin D and other metabolic risk factors, especially BMI, are placed on the same causal pathway in the pathogenesis and highly correlated. Earlier this year, in the American Journal of Gastroenterology , Nelson et al. reported contradictory results that vitamin D defi ciency may be involved in pro-infl ammatory pathways of NASH and the degree of defi ciency is associated with increased severity on histology in 190 biopsy-proven NAFLD patients, using the Non-alcoholic Steatohepatitis Clinical Research Network cohort ( 3 ). Second, although the authors mention that there was no statistical diff erence in vitamin D levels between control and NAFLD patients, there is signifi cant diff erence in light skin races (64.1% in controls vs. 83.6% in NAFLD) and proportion of participants involved in metabolic and weight loss surgery program (30.8% in controls vs. 13.5% in NAFLD). Races with lighter skin and people without medical condition requiring metabolic and weight loss surgery programs tend to have higher vitamin D levels, possibly elevating the mean vitamin D level in NAFLD ( 4,5 ). In the methods section, the authors mention that they only used two-sided t -tests or Wilcoxon’s rank-sum tests for continuous predictors and chi-squared tests or Fisher’s exact tests for categorical variables to compare controls and NAFLD demographics without adjustment for these diff erences. Also, the number of patients in the study seems too low to generate enough power to detect any meaningful diff erence, especially in that there were only nine stage 4 fi brosis patients who had the lowest mean vitamin D level. Th ird, it is unclear in the methods section how they generated age, gender, and BMI-matched cohorts. Th is is important since there may be a potential selection bias if the study population is not enrolled consecutively. Given other existing contradictory results over vitamin D’s role in NAFLD and numerous evidence of vitamin D’s role in metabolic risk factors, it may be premature 3. Deshpande A , Pasupuleti V , Th ota P et al. Community-associated Clostridium diffi cile infection and antibiotics: a meta-analysis . J Antimicrob Chemother 2013 ; 68 : 1951 – 61 . 4. Dial S , Alrasadi K , Manoukian C et al. Risk of Clostridium diffi cile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies . Can Med Assoc J 2004 ; 171 : 33 – 8 . 5. Heidelbaugh JJ , Goldberg KL , Inadomi JM . Overutilization of proton pump inhibitors: a review of cost-eff ectiveness and risk [corrected] . Am J Gastroenterol 2009 ; 104 Suppl 2 : S27 – 32 .