Primary palliative care education in emergency medicine residency: A mixed-methods analysis of a yearlong, multimodal intervention.

Background: Emergency medicine (EM) physicians frequently care for seriously ill patients at the end of life. Palliative care initiated in the emergency department (ED) can improve symptom management and quality of life, align treatments with patient preferences, and reduce length of hospitalization. We evaluated an educational intervention with digital tools for palliative care discussions in an urban EM residency using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. Methods: Our intervention, conducted from July 2020 to August 2021, included education on palliative care techniques, digital tools, and incentives for participation. We tracked goals of care conversations and palliative care consults using electronic medical record data, conducted pre- and posttraining surveys, and used semistructured interviews to assess resident perspectives on palliative care conversations in the ED. Outcomes included number of goals of care conversations recorded by EM residents, consults to palliative care from the ED, and resident perspectives on palliative care in EM. Results: The results were as follows: reach-45 residents participated in the intervention; effectiveness-89 goals of care conversations were documented by 23 ED residents, and palliative care consults increased from approximately four to 10 monthly; adoption-over half the residents who participated in the intervention documented goals of care discussions using an electronic dotphrase; implementation-by the completion of the intervention, residents reported increased comfort with goals of care conversations, saw palliative care as part of their responsibility as EM physicians, and effectively documented goals of care discussions; and maintenance-at 2-month follow up, palliative care consults from the ED remained at approximately 10 monthly, and digital tools to prompt and track palliative care discussions remained in use. Conclusions: An integrated palliative care training for EM residents with technological assists was successful in facilitating goals of care discussions and increasing palliative care consults from the ED.

Body Mass Index and Leptin Are Related to Cognitive Performance Over 10 Years in Women With and Without HIV Infection.

CONTEXT: It is not yet understood whether people living with HIV infection have an increased risk of Alzheimers Disease and Related Dementias due to enhanced survivorship with highly effective antiretroviral therapies and/or increasing adiposity with aging. OBJECTIVE: This work aimed to determine whether body mass index (BMI) and leptin were longitudinally associated over 10 years with neuropsychological performance (NP) among middle-aged women with HIV (WWH) vs without HIV. METHODS: Women's Interagency HIV Study (WIHS) participants (301 WWH, 113 women without HIV from Brooklyn, New York City, and Chicago had baseline and 10-year BMI and fasting plasma leptin levels using commercial enzyme-linked immunosorbent assay (ng/mL); and demographically adjusted NP T scores (attention/working memory, executive function [EF], processing speed, memory, learning, verbal fluency, motor function, global) at 10-year follow-up. Multivariable linear regression analyses, stratified by HIV serostatus, examined associations between BMI, leptin, and NP. RESULTS: Over 10 years, women (baseline age 39.8 ±â€…9.2 years, 73% Black, 73% WWH) transitioned from average overweight (29.1 ±â€…7.9) to obese (30.5 ±â€…7.9) BMI. Leptin increased 11.4 ±â€…26.4 ng/mL (P < .001). Higher baseline BMI and leptin predicted poorer 10-year EF among all women (BMI ß = -6.97, 95% CI (-11.5 to -2.45) P = .003; leptin ß = -1.90, 95% CI (-3.03 to -0.76), P = .001); higher baseline BMI predicted better memory performance (ß = 6.35, 95% CI (1.96-10.7), P = .005). Greater 10-year leptin increase predicted poorer EF (P = .004), speed (P = .03), and verbal (P = .02) and global (P = 0.005) performance among all women, and WWH. Greater 10-year BMI increase predicted slower processing speed (P = .043) among all women; and among WWH, poorer EF (P = .01) and global (P = .04) performance. CONCLUSION: In middle-aged WIHS participants, 10-year increases in BMI and leptin were associated with poorer performance across multiple NP domains among all women and WWH. Trajectories of adiposity measures over time may provide insight into the role of adipose tissue in brain health with aging.

Assessment of Cardiovascular Disease Risk and Therapeutic Patterns among Urban Black Rheumatoid Arthritis Patients.

Rheumatoid arthritis (RA) patients have nearly twice the risk of cardiovascular disease (CVD) compared to the general population. We aimed to assess, in a predominantly Black population, the prevalence of traditional and RA-specific CVD risk factors and therapeutic patterns. Utilizing ICD codes, we identified 503 RA patients ≥18 years old who were seen from 2010 to 2017. Of them, 88.5% were Black, 87.9% were women and 29.4% were smokers. CVD risk factors (obesity, diabetes, hypertension, dyslipidemia) were higher than in previously reported White RA cohorts. Eighty-seven percent of the patients had at least one traditional CVD risk factor, 37% had three or more traditional CVD risk factors and 58% had RA-specific risk factors (seropositive RA, >10 years of disease, joint erosions, elevated inflammatory markers, extra-articular disease, body mass index (BMI) < 20). CV outcomes (coronary artery disease/myocardial infarction, heart failure, atrial fibrillation and stroke) were comparable to published reports. Higher steroid use, which increases CVD risk, and lesser utilization of biologics (decrease CV risk) were also observed. Our Black RA cohort had higher rates of traditional CVD risk factors, in addition to chronic inflammation from aggressive RA, which places our patients at a higher risk for CVD outcomes, calling for revised risk stratification strategies and effective interventions to address comorbidities in this vulnerable population.