The Academic Medical Center’s Perspective on the Physician Scientist

As part of the mini-symposium entitled The Challenge of Maintaining our Physician-Scientist Workforce, Dr. Volturo discusses balancing the needs of the clinical enterprise and optimizing hospital finances with the needs of the physician scientist workforce

Platelet Inhibitors in Non-ST-Segment Elevation Acute Coronary Syndromes and Percutaneous Coronary Intervention: Glycoprotein IIb/IIIa Inhibitors, Clopidogrel, or Both?

The role of glycoprotein (Gp) IIb/IIIa receptor antagonists remains controversial and these agents are infrequently utilized during non-ST-segment elevation acute coronary syndromes (NSTE-ACS) despite American Heart Association/American College of Cardiology guidelines. Despite recommendations, the NRMI-4 (National Registry of Myocardial Infarction 4) and CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines?) registries observed that only 25%–32% of eligible patients received early Gp IIb/IIIa therapy, despite a 6.3% absolute mortality reduction in NRMI-4 and a 2% absolute mortality reduction in CRUSADE. A pooled analysis of Gp IIb/IIIa data from these registries suggest a major reduction in mortality (Odds Ratio = 0.43, 95% Confidence Index 0.25–0.74, p = 0.002) with early Gp IIb/IIIa therapy, yet clinicians fail to utilize this option in NSTE-ACS. The evidence-based approach to NSTE-ACS involves aspirin, clopidogrel, low-molecular weight heparins, or unfractionated heparin in concert with Gp IIb/IIIa receptor antagonists, however, newer percutaneous coronary intervention (PCI)-based trials challenge current recommendations. Novel strategies emerging in NSTE-ACS include omitting Gp IIb/IIIa inhibitors altogether or using Gp IIb/IIIa inhibitors with higher doses of clopidogrel in selected patients. The ISAR-REACT (Intracoronary stenting and antithrombotic regimen–Rapid early action for coronary treatment) and ISAR-SWEET (ISAR–Is abciximab a superior way to eliminate elevated thrombotic risk in diabetics) trials question the value of abciximab when 600 mg of clopidogrel concurrently administered during PCI. The CLEAR-PLATELETS (Clopidogrel loading with eptifibatide to arrest the reactivity of platelets) and PEACE (Platelet activity extinction in non-Q-wave MI with ASA, clopidogrel, and eptifibatide) trials suggest more durable platelet inhibition when Gp IIb/IIIa inhibitors are used with higher doses clopidogrel. The ISAR-COOL (ISAR: Cooling off strategy) trial found no difference in ischemic outcomes when Gp IIb/IIIa inhibitors were excluded and ARMYDA-2 (Antiplatelet therapy for reduction of myocardial damage during angioplasty) suggested higher doses of clopidogrel are more appropriate during PCI when Gp IIb/IIIa inhibitors are not utilized. This constellation of new trials forces reconsideration of current recommendations in regards to patient risk stratification, choice of antithrombotic therapy, doses, and timing. These new data will impact emerging guidelines and updates are currently in progress

Prevalence and antimicrobial susceptibilities of bacteria isolated from blood cultures of hospitalized patients in the United States in 2002

BACKGROUND: Bloodstream infections are associated with significant patient morbidity and mortality. Antimicrobial susceptibility patterns should guide the choice of empiric antimicrobial regimens for patients with bacteremia. METHODS: From January to December of 2002, 82,569 bacterial blood culture isolates were reported to The Surveillance Network (TSN) Database-USA by 268 laboratories. Susceptibility to relevant antibiotic compounds was analyzed using National Committee for Clinical Laboratory Standards guidelines. RESULTS: Coagulase-negative staphylococci (42.0%), Staphylococcus aureus (16.5%), Enterococcus faecalis (8.3%), Escherichia coli (7.2%), Klebsiella pneumoniae (3.6%), and Enterococcus faecium (3.5%) were the most frequently isolated bacteria from blood cultures, collectively accounting for >80% of isolates. In vitro susceptibility to expanded-spectrum β-lactams such as ceftriaxone were high for oxacillin-susceptible coagulase-negative staphylococci (98.7%), oxacillin-susceptible S. aureus (99.8%), E. coli (97.3%), K. pneumoniae (93.3%), and Streptococcus pneumoniae (97.2%). Susceptibilities to fluoroquinolones were variable for K. pneumoniae (90.3–91.4%), E. coli (86.0–86.7%), oxacillin-susceptible S. aureus (84.0–89.4%), oxacillin-susceptible coagulase-negative staphylococci (72.7–82.7%), E. faecalis (52.1%), and E. faecium (11.3%). Combinations of antimicrobials are often prescribed as empiric therapy for bacteremia. Susceptibilities of all blood culture isolates to one or both agents in combinations of ceftriaxone, ceftazdime, cefepime, piperacillin-tazobactam or ciprofloxacin plus gentamicin were consistent (range, 74.8–76.3%) but lower than similar β-lactam or ciprofloxacin combinations with vancomycin (range, 93.5–96.6%). CONCLUSION: Ongoing surveillance for antimicrobial susceptibility remains essential, and will enhance efforts to identify resistance and attempt to limit its spread

An exploration of the role of religion/spirituality in the promotion of physicians\u27 wellbeing in Emergency Medicine

BACKGROUND: Burnout is highly prevalent among Emergency Medicine (EM) physicians and has significant impact on quality of care and workforce retention. The objective of this study was to determine whether higher religion/spirituality (R/S) is associated with a lower prevalence of burnout among EM physicians (primary outcome). A history of malpractice lawsuits and maladaptive behaviors were the secondary outcomes. METHODS: This was a cross-sectional, survey-based study conducted among a random sample of physicians from the Massachusetts College of Emergency Physicians mailing list. Burnout was measured using a validated 2-item version of the Maslach Burnout Inventory. Maladaptive behaviors (smoking, drinking, and substance use) and medical malpractice were self-reported. R/S measures included organized religiosity, religious affiliation, private R/S practice, self-rated spirituality, religious rest, and religious commitment. Logistic regression was used to model study outcomes as a function of R/S predictors. RESULTS: Of 422 EM physicians who received the invitation to participate, 138 completed the survey (32.7%). The prevalence of burnout was 27%. No significant associations were observed between burnout and R/S indicators. Maladaptive behaviors (adjusted OR = 0.42, CI: 0.19 to 0.96; p = 0.039) and history of medical malpractice (adjusted OR = 0.32; CI: 0.11 to 0.93; p = 0.037) were less likely among physicians reporting to be more involved in organized religious activity and to observe a day of rest for religious reasons, respectively. CONCLUSION: This study provides preliminary evidence for a possible protective association of certain dimensions of R/S on maladaptive behaviors and medical malpractice among EM physicians

Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process

BACKGROUND: Emergency Department (ED) care has been reported to be prone to patient safety incidents (PSIs). Improving our understanding of PSIs is essential to prevent them. A standardized, peer review process was implemented to identify and analyze ED PSIs. The primary objective of this investigation was to characterize ED PSIs identified by the peer review process. A secondary objective was to characterize PSIs that led to patient harm. In addition, we sought to provide a detailed description of the peer review process for others to consider as they conduct their own quality improvement initiatives. METHODS: An observational study was conducted in a large, urban, tertiary-care ED. Over a two-year period, all ED incident reports were investigated via a standardized, peer review process. PSIs were identified and analyzed for contributing factors including systems failures and practitioner-based errors. The classification system for factors contributing to PSIs was developed based on systems previously reported in the emergency medicine literature as well as the investigators\u27 experience in quality improvement and peer review. All cases in which a PSI was discovered were further adjudicated to determine if patient harm resulted. RESULTS: In 24 months, 469 cases were investigated, identifying 152 PSIs. In total, 188 systems failures and 96 practitioner-based errors were found to have contributed to the PSIs. In twelve cases, patient harm was determined to have resulted from PSIs. Systems failures were identified in eleven of the twelve cases in which a PSI resulted in patient harm. CONCLUSION: Systems failures were almost twice as likely as practitioner-based errors to contribute to PSIs, and systems failures were present in the majority of cases resulting in patient harm. To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction

Rationale and Methods of the Study Protocol: Streptococcus pneumoniae Serotypes in Adults 18 Years and Older with Radiographically-Confirmed Community-Acquired Pneumonia (CAP)

This study was an active, prospective surveillance study of adults 18 years and older hospitalized with community-acquired pneumonia (CAP) due to Streptococcus pneumoniae conducted at 21 hospitals in ten cities across the United States. This report describes the surveillance methodology applied between October 7, 2013 and September 30, 2016, including the identification and description of surveillance areas and populations at-risk for CAP hospitalization for estimation of incidence rates for selected study sites

Pneumococcal epidemiology among us adults hospitalized for community-acquired pneumonia

BACKGROUND: Few studies have measured the burden of adult pneumococcal disease after the introduction of 13-valent pneumococcal conjugate vaccine (PCV13) into the US infant vaccination schedule. Further, most data regarding pneumococcal serotypes are derived from invasive pneumococcal disease (IPD), which represents only a fraction of all adult pneumococcal disease burden. Understanding which pneumococcal serotypes cause pneumonia in adults is critical for informing current immunization policy. The objective of this study was to measure the proportion of radiographically-confirmed (CXR+) community-acquired pneumonia (CAP) caused by PCV13 serotypes in hospitalized US adults. METHODS: This observational, prospective surveillance study recruited hospitalized adults aged \u3e /=18years from 21 acute care hospitals across 10 geographically-dispersed cities in the United States between October 2013 and September 2016. Clinical and demographic data were collected during hospitalization. Vital status was ascertained 30days after enrollment. Pneumococcal serotypes were detected via culture from the respiratory tract and normally-sterile sites (including blood and pleural fluid). Additionally, a novel, Luminex-based serotype-specific urinary antigen detection (UAD) assay was used to detect serotypes included in PCV13. RESULTS: Of 15,572 enrolled participants, 12,055 eligible patients with CXR+CAP were included in the final analysis population. Mean age was 64.1years and 52.7% were aged \u3e /=65years. Common comorbidities included chronic obstructive pulmonary disease (43.0%) and diabetes mellitus (28.6%). PCV13 serotypes were detected in 552/12,055 (4.6%) of all patients and 265/6347 (4.2%) of those aged \u3e /=65years. Among patients aged 18-64years PCV13 serotypes were detected in 3.8-5.3% of patients depending on their risk status. CONCLUSIONS: After implementation of a pneumococcal conjugate vaccination program in US children, and despite the herd protection observed in US adults, a persistent burden of PCV13-type CAP remains in this population

Leggere il mondo urbano alla luce delle pratiche di mediazione di vicinato. Il caso italiano in prospettiva comparata

Il lavoro di ricerca dottorale ha indagato a livello teorico ed empirico un oggetto di studio poco esplorato nell\u2019ambito della ricerca sociologica, ossia la mediazione in ambito urbano, pi\uf9 nello specifico nei contesti abitativi, sia pubblici che privati, ossia il quartiere e l\u2019abitazione. La scelta di studiare la mediazione a partire dalla sua implementazione nei contesti abitativi \ue8 motivata da alcune riflessioni derivanti sia dall\u2019ambito del dibattito teorico che dai risultati di alcune ricerche empiriche. Tali riflessioni, riguardanti i principali mutamenti sociali nei contesti urbani, sottolineano - tra le altre cose \u2013 aspetti caratterizzanti la societ\ue0 contemporanea, ossia l\u2019indebolimento del legame sociale e di forme tradizionali di appartenenza. Tali dinamiche sono particolarmente evidenti nel caso dei rapporti di vicinato in cui tendenzialmente ad una prossimit\ue0 di tipo spaziale \u2013 essere \u2018vicini\u2019 di casa o di quartiere \u2013 \ue8 tutt\u2019altro che scontato associare anche una prossimit\ue0 di tipo sociale. A partire da questa apparente contraddizione, si \ue8 sviluppata una riflessione in grado di cogliere gli aspetti teorici riguardanti il rapporto tra processi di urbanizzazione e forme di socialit\ue0, sia grazie alla ricognizione delle letteratura in merito, sia grazie alle riflessioni emergenti dalla ricerca sul capo. Se questo \ue8 il contesto generale di impostazione dell\u2019ambito della ricerca, a livello empirico si \ue8 cercato di osservare tali fenomeni a partire proprio dalle pratiche di mediazione. Pi\uf9 specificamente la ricerca dottorale ha inteso comprendere: 1) Come nascono i progetti di mediazione di vicinato, in particolare quali sono le condizioni di contesto che favoriscono la nascita e l\u2019implementazione dei progetti di mediazione di vicinato e chi sono gli attori coinvolti in questa fase (ad. Es. enti locali, Terzo settore); 2) Come funziona la mediazione nelle pratiche concrete e nelle strategie adottate dai mediatori; 3) Gli elementi di successo e le criticit\ue0 riscontrabili nelle pratiche di mediazione di vicinato. Per raggiungere tali finalit\ue0 la ricerca empirica si \ue8 basata su metodi prevalentemente qualitativi, in linea con gli obiettivi della ricerca e la prospettiva teorica adottata. Per quanto riguarda gli strumenti e le tecniche di ricerca, si \ue8 condotta un\u2019analisi documentale approfondita dei progetti e delle iniziative che hanno come oggetto la mediazione di vicinato; sono state somministrate 40 interviste semi-strutturate ai mediatori che operano presso i centri di mediazione di vicinato e, laddove possibile, sono state effettuate osservazioni partecipanti delle attivit\ue0 di mediazione. Per quanto riguarda la scelta del campione, sono state individuate le realt\ue0 pi\uf9 significative che in Italia si occupano di mediazione di vicinato. Sono state cos\uec rintracciate circa 15 realt\ue0 di mediazione di vicinato, concentrate soprattutto nell\u2019area centro-settentrionale del Paese. All\u2019interno di ciascuna struttura di mediazione sono stati poi intervistati i mediatori che ivi operano. In realt\ue0, essi rappresentano i testimoni privilegiati sia delle pratiche di mediazione, sia delle dinamiche sociali nei contesti urbani. Sin dalle prime interviste si \ue8 rivelata con chiarezza l\u2019importanza del modello francese, ed in particolare lionese, di mediazione per i mediatori italiani. Per tale ragione si \ue8 ritenuto necessario recarsi a Lione presso l\u2019Association de M\ue9diation Lyonnaise (Am\ue9ly) per effettuare le medesime interviste condotte in Italia con i mediatori lionesi. In tale contesto si \ue8 venuti a conoscenza di un\u2019ulteriore esperienza di mediazione nella citt\ue0 di Lione, ossia l\u2019esperienza dell\u2019Association Lyonnaise pour la Tranquillit\ue9 et la M\ue9diation (ALTM), che, per il fatto di ispirarsi ad un approccio molto diverso alla mediazione rispetto all\u2019associazione Am\ue9ly, ha costituito un elemento interessante per effettuare un ulteriore approfondimento empirico, intervistando cos\uec anche i mediatori che lavorano presso l\u2019ALTM. I dati raccolti sono stati analizzati facendo costantemente dialogare gli aspetti teorici e quelli empirici al fine di ricostruire un panorama dettagliato degli approcci e delle pratiche di mediazione, nonch\ue9 fornire una lettura accurata delle dinamiche sociali in gioco nei contesti abitativi. I risultati emergenti dalla ricerca, oltre a chiarire quali siano le concezioni che soggiacciono alle pratiche di mediazione in Italia in comparazione con l\u2019esperienza lionese, mettono in luce alcuni aspetti originali e, per certi versi, inaspettati. Di particolare interesse \ue8 la concezione della mediazione come spazio di ascolto e riconoscimento, piuttosto che mera tecnica di gestione dei conflitti.The research mainly carried out in Italy is focused on mediation, its theoretical orientations and practices. In Italy the culture of mediation is not well-rooted in the social and institutional fabric. However, during the last decade mediation has known a significant development in several areas of social life, such as family and school, urban space and workplace, civil and penal controversies. The outbreak of the phenomenon has not been followed by systematic studies which could help to comprehend the state of art of Italian mediation. Therefore, the main goal is to close the gap between practice and theory. We draw up an overview of mediation in Italy by analysing representations, different processes and practices of implementation, policies of mediation promoted by local authorities. In order to reach this aim, we decided to interview Italian mediators who work in the area of 'social' mediation, which seem to be one of the least clear because of the confusion concerning its purposes and contexts of implementation. Participant observation and documental analyses also have been done in order to deepen the comprehension of the phenomenon. During the fieldwork we discovered the influence of the 'French model' on the Italian mediation. For this reason we decided to empirically investigate an experience very often quoted by Italian mediators, namely the Amely Association and the ALTM Association in Lyon, France

Lotta alla povertà minorile. Il ruolo delle politiche di supporto all’infanzia

L’articolo analizza il fenomeno della povertà minorile nella sua multidimensionalità, presentando dati sulla situazione italiana in prospettiva comparata europea. L'approccio analitico adottato concepisce la povertà minorile come una forma estrema di disuguaglianza e riflette sul ruolo delle politiche per sociali in ambito minorile nel contrasto alle disuguaglianze

Cultura, stili di vita e orientamenti partecipativi dei giovani. Un approfondimento sul territorio forlivese

Il rapporto presenta i risultati di un'indagine sulla partecipazione giovanile nell'ambito delle pratiche artistiche. La prospettiva analitica adottata si richiama alla cornice del welfare culturale come possibile 'spazio' di conciliazione tra sfera sociale e culturale