Importance-There are concerns about the current quality of undergraduate medical education (UME) and its effect on students' well-being.Objective-This systematic review was designed to identify best practices for UME learning environment interventions that are associated with improved emotional well-being of students.Data Sources-Learning environment interventions were identified by searching the biomedical electronic databases Ovid MEDLINE, EMBASE, the Cochrane Library, and the ERIC database from the database inception dates to October 2016. Studies examined any intervention designed to promote medical students' emotional well-being in the setting of a US academic medical school, with an outcome defined as students' reports of well-being as assessed by surveys, semistructured interviews, or other quantitative methods.Data Extraction and Synthesis-Two investigators independently reviewed abstracts and full-text articles. Data were extracted into tables to summarize results. Study quality was assessed by the Medical Education Research Study Quality Instrument (MERQSI), which has a possible range of 5-18; higher scores indicate higher design and methods quality, and a score of ≥ 14 indicates a high-quality study.Findings-Twenty-eight articles including at least 8224 participants met eligibility criteria. Study designs included single-group cross-sectional or post-test only (n=10), single-group pre-/ post-test (n=2), nonrandomized two-group (n=13), and randomized clinical trial (n=3); 93% were

Objective Prevention of Clostridium difficile infection (CDI) in acute care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. Design We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. Setting We included studies performed in acute care hospitals. Patients or participants We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. Interventions We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. Results Of 3236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% on the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand hygiene practices were not effective for reducing CDI rates. Conclusions Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates.

BACKGROUND: Although specific interventions previously demonstrated benefit in patients with the ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown.RESEARCH QUESTION: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? STUDY DESIGN AND METHODS: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO 2 to FIO 2 ratio of # 150 with positive endexpiratory pressure of $ 5 cm H 2 O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed.RESULTS: A total of 2,466 patients were enrolled. Median baseline PaO 2 to FIO 2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, # 6.5 mL/kg predicted body weight; plateau pressure, peak inspiratory pressure, or both, # 30 mm H 2 O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR.

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A class quality project can teach QI to residents incorporating both didactic and practical methods to maximise the experience and minimise the barriers. We found that this method improved residents experience, knowledge and interest in quality initiatives.

A reciprocal relationship between obesity and obstructive sleep apnea (OSA) likely exists, wherein obesity contributes to OSA, and OSA-related sleep disturbances promote weight gain. It remains unclear whether continuous positive airway pressure (CPAP) affects body composition. We conducted an open-label, parallel-arm, non-randomized, matched before-after study in individuals with OSA who were starting CPAP use (n = 12) and who were not (n = 12) to examine the effects of CPAP on total body composition (via air displacement plethysmography) including fat and fat-free mass. CPAP users (n = 12) were studied at baseline and after 8 weeks of CPAP use, and 12 age- and sex-matched non-CPAP OSA controls were studied at baseline and after an 8 week period. Statistically significant group x time interactions were seen for body weight, fat-free mass, and fat-mass, such that body weight and fat-free mass were increased, and fat mass decreased, at 8-week follow-up in the CPAP group compared to baseline. Body weight and body composition measures were unchanged in the non-CPAP control group. These findings are consistent with prior studies showing CPAP-induced weight gain, and suggest that weight gain observed following CPAP may be driven primarily by increases in fat-free mass. An increase in lean mass (and decrease in fat mass), despite an overall increase in body weight, can be considered a favorable metabolic outcome in response to CPAP use.

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A 48-year-old woman presented to our emergency department with progressive dyspnea, cough with clear sputum, and a 9-kg weight loss. Evaluation at an outside emergency department 6 months previously had revealed a right middle lobe infiltrate on chest radiography (CXR), and she was treated with a 10-day course of levofloxacin for presumed community-acquired pneumonia. Her symptoms continued, and 1 month later, she went to an outside pulmonologist who found bilateral alveolar infiltrates on chest computed tomography (CT).On presentation to our emergency department, the patient reported no orthopnea, fevers, chills, or night sweats. Her medical history was notable for nonischemic dilated cardiomyopathy that was treated with cardiac resynchronization therapy and an automatic implantable cardioverter-defibrillator (AICD), atrial fibrillation, and myelodysplastic syndrome. She had a 10-pack-year smoking history but had quit smoking 1 year previously. Her medications included furosemide, losartan, digoxin, coumadin, amiodarone, and spironolactone. No new medications had been added to her treatment regimen during the past 10 years.On admission, the patient's vital signs were as follows: temperature, 37.0 o C; blood pressure, 101/64 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 94% while the patient breathed room air. She was in no acute distress. Her sclera had a blue-grey discoloration. Cardiac examination revealed a regular rhythm, grade 1/6 systolic murmur heard at the left upper sternal border, no gallops, no jugular venous distention, and no peripheral edema. Pulmonary examination revealed crackles over the right middle lobe but otherwise normal results. Abdominal, musculoskeletal, and neurologic examination findings were unremarkable.Chest radiography showed bilateral dense consolidations that were greater on the right with clear costophrenic angles, an AICD, and cardiomegaly. Chest CT revealed asymmetric bilateral, multilobar alveolar consolidations without pleural effusions or engorgement of the intralobar space, 4-chamber cardiomegaly, and an AICD.Laboratory studies yielded the following results (reference ranges shown parenthetically): hemoglobin, 10.1 g/dL (12.0-15.5 g/dL; previous level, 10.0 g/dL); white blood cell count, 1.6 ϫ 10 9 /L (3.5-10.5 ϫ 10 9 /L); 10% segmented neutrophils; 59% lymphocytes with an absolute neutrophil count of 2.0 ϫ 10 9 /L (0.9-2.9 ϫ 10 9 /L); platelet count, 125 ϫ 10 9 /L (150-450 ϫ 10 9 /L); erythrocyte sedimentation rate, 64 mm/h (Ͻ29 mm/h); international normalized ratio, 1.7 (0.8-1.2); brain naturietic peptide (BNP), 1260 pg/mL (Ͻ71 pg/mL); digoxin, 1.59 ng/mL (0.5-2.0 ng/mL); thyroid stimulating hormone, 0.52 mIU/L (0.3-5.0 mIU/L); and human immunodeficiency virus antibody, negative. The patient was admitted to the hospital for evaluation of new neutropenia, progressive dyspnea, and undiagnosed pulmonary infiltrate.