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Sickle cell disease is prevalent in large numbers of patients in the United States and has a significant global impact. Its complications span numerous organs and lead to reduced life expectancy. Acute and chronic sickle cell pain is a common cause of patient suffering. The American Society of Hematology published updated guidelines on management of acute and chronic pain from sickle cell disease in 2019. Several of the recommendations are conditional and leave specific decisions to the treating physician. These include conditional recommendations about the use of ketamine for acute pain and the initiation and discontinuation of long-term opioid therapy for chronic pain. Here, 2 hematologists discuss these guidelines and make contrasting recommendations for the management of acute and chronic pain for a patient with sickle cell disease.

Community-acquired pneumonia is a major cause of morbidity and mortality in the United States, leading to 1.5 million hospitalizations and at least 200 000 deaths annually. The 2019 American Thoracic Society/Infectious Diseases Society of America clinical practice guideline on diagnosis and treatment of adults with community-acquired pneumonia provides an evidence-based overview of this common illness. Here, 2 experts, a general internist who served as the co-primary author of the guidelines and a pulmonary and critical care physician, debate the management of a patient hospitalized with community-acquired pneumonia. They discuss disease severity stratification methods, whether to use adjunctive corticosteroids, and when to prescribe empirical treatment for multidrug-resistant organisms such as methicillin-resistant

BACKGROUND: Although the COVID-19 pandemic increased social isolation among hospitalised patients given isolation precautions, visitor restrictions and curtailed interactions with healthcare teams, medical students had limited opportunities for involvement in the care of inpatients. APPROACH: We designed a humanistic and narrative medicine intervention to engage medical students in combating social isolation in hospitalised patients during the COVID-19 pandemic at a tertiary care teaching hospital. In our programme, medical students provided virtual social support to hospitalised patients via phone by providing assistance connecting with family members, having informal conversations and check-ins and writing up patient life narratives. EVALUATION: From April 2020 to March 2021, we received 126 referrals of potentially isolated patients from inpatient medical teams. Fifty patients accepted and received our intervention, including 26 who completed life narratives. Feedback was positive, demonstrating benefit to medical students in learning about humanism and connecting with patients through their life stories. In addition, patients and medical teams felt more supported. We share key operational lessons and resources to facilitate the implementation of this intervention elsewhere. IMPLICATIONS: Our intervention allows medical students to meaningfully contribute to the care of inpatients, support beleaguered inpatient teams and learn important lessons about humanism in medicine. This educational and patient care intervention holds promise in other settings, including beyond the COVID-19 pandemic.

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death in the United States. Reducing ASCVD risk through primary prevention strategies has been shown to be effective; however, the role of aspirin in primary prevention remains unclear. The decision to recommend aspirin has been limited by the difficulty clinicians and patients face when trying to balance benefits and harms. In 2016, the U.S. Preventive Services Task Force addressed this issue by determining the risk level at which prophylactic aspirin generally becomes more favorable, recommending aspirin above a risk cut point (>10% estimated ASCVD risk). In 2019, the American College of Cardiology and the American Heart Association issued a guideline on the primary prevention of CVD that recommends low-dose aspirin might be considered for the primary prevention of ASCVD among select adults aged 40 to 70 years who are at higher ASCVD risk but not at increased risk for bleeding. Here, 2 experts discuss how to apply this guideline in general and to a patient in particular while answering the following questions: How do you assess ASCVD risk, and what is the role, if any, of the coronary artery calcium score?; At what risk threshold of benefits and harms would you recommend aspirin or not?; and How do you help a patient come to a decision about starting or stopping aspirin therapy?

Pulmonary embolism can be acutely life-threatening and is associated with long-term consequences such as recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. In 2020, the American Society of Hematology published updated guidelines on the management of patients with venous thromboembolism. Here, a hematologist and a cardiology and vascular medicine specialist discuss these guidelines in the context of the care of a patient with pulmonary embolism. They discuss advanced therapies such as catheter-directed thrombolysis in the short-term management of patients with intermediate-risk disease, recurrence risk stratification at presentation, and ideal antithrombotic regimens for patients whose pulmonary embolism was associated with a transient minor risk factor.

Because pancreatic cancer is typically advanced at the time of diagnosis, it has a very low 5-year survival rate and may become the second leading cause of cancer death in the United States. A screening program to find early-stage pancreatic cancer is needed but has been challenging to develop because of the lack of an effective screening test. In 2019, the U.S. Preventive Services Task Force performed an evidence review and updated its guidance, confirming its 2004 "D" recommendation against routine screening for average-risk patients. Here, 2 experts review the updated guideline and recent evidence and discuss whether a patient with a family history of pancreatic cancer should undergo screening.

About 15% of adults in the United States-37 million persons-have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts-a nephrologist and a general internist-palliative care physician-reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.

Introduction: Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. Methods: We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. Results: From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). Conclusions: Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

Teaching on physical examination, especially evidence-based physical diagnosis, is at times lacking on general medicine rounds. We created a hospitalist faculty workshop on teaching evidence-based physical diagnosis.The workshop included a systematic approach to teaching evidence-based physical diagnosis, multiple teaching resources, and observed peer teaching. A long-term follow-up session was offered several months after the workshop. Participants completed questionnaires before and after the workshop as well as after the long-term follow-up session.Four workshops were conducted and attended by 28 unique participants. Five hospitalists attended long-term follow-up sessions. Due to the COVID-19 pandemic, repeat sessions and long-term follow-up were limited. In paired analyses compared to preworkshop, respondents after the workshop reported a higher rate of prioritizing ( We created and implemented a workshop to train hospitalists in teaching evidence-based physical diagnosis. This workshop led to improvements in faculty attitudes and teaching skills. Long-term outcomes were limited by low participation due in part to the COVID-19 pandemic.

Nonvariceal upper gastrointestinal bleeding is common, morbid, and potentially fatal. Cornerstones of inpatient management include fluid resuscitation; blood transfusion; endoscopy; and initiation of proton-pump inhibitor therapy, which continues in an individualized manner based on risk factors for recurrent bleeding in the outpatient setting. The International Consensus Group released guidelines on the management of nonvariceal upper gastrointestinal bleeding in 2019. These guidelines provide a helpful, evidence-based roadmap for management of gastrointestinal bleeding but leave certain management details to the discretion of the treating physician. Here, 2 gastroenterologists consider the care of a patient with nonvariceal upper gastrointestinal bleeding from a peptic ulcer, specifically debating approaches to blood transfusion and endoscopy timing in the hospital, as well as the recommended duration of proton-pump inhibitor therapy after discharge.

A 34-year-old woman is admitted to the hospital with dyspnoea, dry cough and left-sided flank pain. Her Legionella urinary test was positive and CT imaging demonstrated multifocal pneumonia with pulmonary abscesses. Although she had initial clinical improvement on appropriate antibiotic therapy, her hospital course was complicated by worsening flank pain, hypoxemia and leucocytosis, prompting clinical re-evaluation and assessment for development of complications involving the pleural space. CT imaging revealed interval development of a loculated complicated parapneumonic effusion. Successful treatment required chest tube drainage assisted by fibrinolytic therapy. This case highlights the importance of considering Legionella in patients with pulmonary abscess, demonstrates an approach to a patient with a non-resolving pneumonia and illustrates the management of parapneumonic effusions.

This cross-sectional study assesses the availability of the direct oral anticoagulant reversal agents idarucizumab and andexanet alfa in US hospitals.

Venous thromboembolism (VTE), which includes both deep venous thrombosis and pulmonary embolism, is a common and potentially fatal condition. Medical inpatients are at high risk for VTE because of immobility as well as acute and chronic illness. Several randomized trials demonstrated that chemoprophylaxis, or low-dose anticoagulation, prevents VTE in selected medical inpatients. The 2018 American Society of Hematology clinical practice guideline on prophylaxis for hospitalized and nonhospitalized medical patients conditionally recommends chemoprophylaxis for non-critically ill medical inpatients, leaving much to the discretion of the treating physician. Here, 2 experts, a hematologist and a hospitalist, reflect on the care of a woman hospitalized with a rheumatologic disorder. They consider the risks and benefits of chemoprophylaxis, discuss VTE risk stratification, and recommend which patients should receive chemoprophylaxis and with which agents.

Objectives. To assess a community health worker (CHW) program’s impact on childhood illness treatment in rural Liberia. Methods. We deployed CHWs in half of Rivercess County in August 2015 with the other half constituting a comparison group until July 2016. All CHWs were provided cash incentives, supply chain support, and monthly clinical supervision. We conducted stratified cluster-sample population-based surveys at baseline (March–April 2015) and follow-up (April–June 2016) and performed a difference-in-differences analysis, adjusted by inverse probability of treatment weighting, to assess changes in treatment of fever, diarrhea, and acute respiratory infection by a qualified provider. Results. We estimated a childhood treatment difference-in-differences of 56.4 percentage points (95% confidence interval [CI] = 36.4, 76.3). At follow-up, CHWs provided 57.6% (95% CI = 42.8, 71.2) of treatment in the intervention group. The difference-in-differences diarrhea oral rehydration therapy was 22.4 percentage points (95% CI = −0.7, 45.5). Conclusions. Implementation of a CHW program in Rivercess County, Liberia, was associated with large, statistically significant improvements treatment by a qualified provider; however, improvements in correct diarrhea treatment were lower than improvements in coverage. Findings from this study offer support for expansion of Liberia’s new National Community Health Assistant Program.

Background The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. Methods and Findings We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March–April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011–June 14, 2014) or EVD period (June 15, 2014–April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48–0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50–0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50–0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36–0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59–1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. Conclusions We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies., John Kraemer and colleagues estimate changes in facility-based delivery during the Ebola virus disease epidemic in rural Liberia using cross-sectional data from a population-based household survey., Author Summary Why was this study done? The 2014–2015 West African Ebola virus disease (EVD) epidemic killed approximately 11,300 people directly, but its effects are magnified by collateral health consequences. Mathematical models and facility-based data provide evidence of substantial health service interruptions, but little population-based survey data has been published from the three principally affected countries. Maternal health services, which are dependent on functioning health systems, are likely to be particularly susceptible to external shocks, such as the EVD epidemic. What did the researchers do and find? We used a cluster-sample survey to produce a representative sample of births in Rivercess County, Liberia, a part of the country with relatively limited Ebola transmission. Controlling for potential confounders, we compared the odds of facility-based delivery among 686 births in the period before the EVD epidemic with 212 births during the epidemic. We identified a 30% reduction in the odds of facility-based delivery during the EVD epidemic. The odds of facility-based delivery were 41% lower among women who reported a belief that Ebola was or may be transmitted in health facilities, but not significantly lower among women who reported believing that Ebola was not transmitted in health facilities. What do these findings mean? This study provides further evidence that the 2014–2015 West African EVD epidemic caused serious collateral harm to health services. This study also underscores the need to maintain focus on long-term health system reconstruction after the EVD epidemic.

Summary: Background: Tuberculosis (TB) is transmitted in resource-limited facilities where TB infection control (IC) is poorly implemented. Theory-based behavioral models can potentially improve IC practices. Methods: The present study used an anonymous questionnaire to assess healthcare worker (HCW) TB IC information, motivation, and behavioral skills (IMB) and implementation in two resource-limited rural South African hospitals with prevalent drug-resistant TB. Results: Between June and August 2010, 198 surveys were completed. Although the respondents demonstrated information proficiency and positive motivation, 22.8% did not consider TB IC to be worthwhile. Most tasks were rated as easy by survey participants, but responding HCWs highlighted challenges in discrete behavioral skills. The majority of responding HCWs reported that they always wore respirators (54.3%), instructed patients on cough hygiene (63.0%), and ensured natural ventilation (67.4%) in high-risk areas. Most respondents (74.0%) knew their HIV status. Social support items correlated with the implementation of the first three aforementioned practices but not with the respondents’ knowledge of their HIV status. In most cases, motivation and behavioral skills, but not information, were associated with implementation. Conclusion: HCWs in rural South African hospitals with high drug-resistance demonstrated moderate IMB and implementation of TB IC. Improvement efforts should emphasize the development of HCW motivation and behavioral skills as well as social support from colleagues and supervisors. Such interventions should be informed by baseline IMB assessments. In the present study, a trimmed/modified IMB model helped characterize TB IC implementation. Keywords: Infection control, Tuberculosis, MDR/XDR-TB, South Africa, Information–motivation–behavioral skills

A baseline assessment of tuberculosis infection control (TB IC) knowledge, attitude and practice (KAP) was conducted among staff in a resource-limited rural South African hospital where nosocomially transmitted multi- and extensively drug-resistant (M/XDR) TB had been reported. Assessment consisted of anonymous questionnaires and direct observation during July-September 2007, soon after the report of M/XDR-TB. Data were obtained from 57 questionnaires and 10h of direct observation. While knowledge and attitudes were generally supportive of TB IC implementation, 49.1% of staff felt that the hospital did not care about them and/or was not working to prevent staff TB infections, and 42.9% were less willing to continue as a healthcare worker because of staff TB/MDR-TB/XDR-TB deaths. Practices were variable. The recent appointment of an IC officer and implementation of natural ventilation were strengths, but the facility lacked a TB IC policy, the patient TB screening process was inadequate, and 41.5% of respondents were unaware of their personal human immunodeficiency virus (HIV) status. Respondents reported a number of barriers to TB IC implementation such as concerns about the confidentiality of staff health information, the stigma of TB and HIV, inadequate resources, and patient non-compliance. Assessment of staff KAP provided useful data regarding deficits and barriers to TB IC, and helped to focus subsequent IC strategies. Given the critical importance of reducing nosocomial TB transmission, it is recommended that facilities should conduct simplified TB IC assessment, ensure the confidentiality of staff health information, address the stigma of TB/HIV, and implement multi-faceted TB IC facility and behavioural change interventions. Behavioural science methods have the potential to improve TB IC research and implementation.