Citations

Abstract Purpose This study uses a large national legal database to analyze characteristics of malpractice claims involving U.S. medical students. Method The Westlaw database was searched in September 2023 for malpractice cases involving medical students from January 1, 1900, through September 1, 2023. Each case was independently reviewed by 2 authors, abstracting each variable. Categorical data were summarized as frequency of occurrence (i.e., number and percentage), and continuous data were summarized with means, medians, and ranges. All authors independently reviewed the dataset to identify potential themes and codes. Results There were 65 cases that met the inclusion criteria. Reported patient outcomes were death (19, 29%), pain (25, 38%), and disability (36, 55%). The most common specialties involved were emergency medicine (16, 25%), general surgery (14, 22%), and obstetrics and gynecology (13, 20%). The most common primary alleged errors attributed to students related to medical decision-making (30, 46%), procedural complication (24, 37%), and poor communication (11, 17%). Among 23 (35%) cases reporting year of training, 1 (4%) included a second-year student, 13 (57%) included third-year students, and 9 (39%) included fourth-year students. Of the 65 lawsuits, 28 (43%) resulted in a settlement or verdict against the medical student. The total amount paid in these cases was $78,192,612, with a mean (median) of $3,007,408 ($1,050,000) per case. Of these 28 cases, 14 (50%) cited minimal or no physician supervision. Conclusions Medical malpractice claims involving medical students are rare but commonly relate to medical decision-making, procedural complication, and poor communication, with a lack of supervision being frequently cited. These results can be used to guide students and supervising physicians on how to avoid scenarios that may increase vulnerability to medical malpractice lawsuits.

Abstract There has been an increase in volume as well as an improvement in overall survival (OS) after hematopoietic cell transplantation (HCT) for hematologic disorders. It is unknown if these changes have affected racial/ethnic minorities equally. In this observational study from the Center for International Blood and Marrow Transplant Research of 79 904 autologous (auto) and 65 662 allogeneic (allo) HCTs, we examined the volume and rates of change of autoHCT and alloHCT over time and trends in OS in 4 racial/ethnic groups: non-Hispanic Whites (NHWs), non-Hispanic African Americans (NHAAs), and Hispanics across 5 2-year cohorts from 2009 to 2018. Rates of change were compared using Poisson model. Adjusted and unadjusted Cox proportional hazards models examined trends in mortality in the 4 racial/ethnic groups over 5 study time periods. The rates of increase in volume were significantly higher for Hispanics and NHAAs vs NHW for both autoHCT and alloHCT. Adjusted overall mortality after autoHCT was comparable across all racial/ethnic groups. NHAA adults (hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.04-1.22; P = .004) and pediatric patients (HR 1.62; 95% CI 1.3-2.03; P < .001) had a higher risk of mortality after alloHCT than NHWs. Improvement in OS over time was seen in all 4 groups after both autoHCT and alloHCT. Our study shows the rate of change for the use of autoHCT and alloHCT is higher in NHAAs and Hispanics than in NHWs. Survival after autoHCT and alloHCT improved over time; however, NHAAs have worse OS after alloHCT, which has persisted. Continued efforts are needed to mitigate disparities for patients requiring alloHCT.

Introduction: Somatic mutations accrue in hematopoietic stem cells with age and can lead to selective clonal expansion, a process termed Clonal Hematopoiesis of Indeterminate Potential (CHIP). CHIP has been associated with increased risk of coronary heart disease (CHD) and myocardial infarction (MI). Whether CHIP is a risk factor for incident heart failure is unclear. Methods: The presence of CHIP was assessed in exome sequence data from 200,628 UKB participants using the Genome Analysis Toolkit pipeline and filtering somatic mutations from a pre-specified list within DNMT3A , TET2 , and ASXL1 . CHIP was defined as somatic mutations in these 3 genes with variant allele fraction (VAF) >10%. We ascertained incident heart failure (overall, ischemic, and non-ischemic), death, cardiovascular death, and coronary heart disease (CHD defined as of MI and/or coronary revascularization) as determined by UKB algorithms, self-report, and diagnosis/procedure codes. Cox proportional hazard models adjusted for age, sex, self-reported race/ethnicity, diabetes, hypertension, smoking, and BMI were used to assess whether CHIP was associated with incident adverse events. Results: We identified 3,885 participants with CHIP in DNMT3A , TET2 , and ASXL1 at a VAF of >10%. Over a median follow-up of 9 years, 2,055 participants developed incident heart failure. CHIP was associated with both ischemic and non-ischemic heart failure. We replicated previously reported associations of CHIP with death and incident CHD ( Table ). Conclusions: CHIP was associated with increased risk of both ischemic and non-ischemic heart failure. The association with ischemic subtype is likely mediated by the increased risk of CHD. The basis for the increased hazard of non-ischemic heart failure is unclear but may be due to an inflammatory milieu in CHIP carriers.

Introduction: Studies have demonstrated an association between hyperkalemia and increased mortality in patients with myocardial infarction, but limited data exist regarding hyperkalemia and associated death among unselected cardiac intensive care unit (CICU) patients. Hypothesis: Hyperkalemia is associated with mortality in CICU patients. Methods: Historical cohort of 9,681 CICU patients admitted from January 2007 to December 2015 with serum potassium measured on admission. Hyperkalemia was defined as admission potassium >=5.0 mEq/L, normokalemia as admission potassium 3.5-4.9 mEq/L, and hypokalemia as admission potassium <3.5 mEq/L. Multivariate logistic regression was used to determine predictors of hospital mortality. Post-discharge survival was assessed using Kaplan-Meier analysis and Cox proportional hazards models. Results: Mean age was 67±15 years with 3,629 (36%) females and hospital mortality of 9%. Hyperkalemia occurred in 1,187 (12.3%), and hypokalemia occurred in 719 (7.4%). Compared to normokalemic patients, both hyperkalemic patients (unadjusted OR 2.85, 95% CI 2.40-3.39; P<.001) and hypokalemic patients (unadjusted OR 2.31, 95% CI 1.85-2.88; P<.001) were at increased risk of hospital mortality. After adjustment for illness severity and renal function, only hyperkalemic patients were at increased risk of hospital death (adjusted OR 1.35, 95% CI 1.07-1.69; p = 0.01), while hypokalemic patients were not (P = NS). Among hospital survivors, hyperkalemic patients had lower post-discharge survival by Kaplan-Meier analysis (P <0.001), while hypokalemic patients had similar survival compared to normokalemic patients (p = NS). After adjustment for illness severity and renal function, hospital survivors with hyperkalemia were at increased risk for post-discharge mortality compared with normokalemic patients (adjusted HR 1.16, 95% CI 1.05-1.28; p=.003). Conclusions: Hyperkalemia on CICU admission is associated with higher hospital and post-discharge mortality, independent of renal function and illness severity. This emphasizes the importance of potassium abnormalities as a risk predictor in patients admitted to the CICU.

Background: Impact of right ventricular (RV) overload on left ventricular (LV) performance has been demonstrated in Ebstein’s anomaly (EA). We have shown that LV radial strain (RS) in 83 EA patients was significantly less than in controls. We subsequently sought to evaluate LV strain after EA surgery. Methods: Systolic strain, strain rate (SR) and early diastolic strain rate (SRe) were retrospectively performed, using velocity vector imaging, in 24 repaired EA patients (age 35 ±12 years; 67% women) with LV ejection fraction >50%, preoperatively (median 5 days [1-145 days]) and postoperatively within 5 years at sequential follow-up (6 months-3 years). Repair of EA included tricuspid valve repair, valve replacement and bidirectional cavopulmonary anastomosis. A slope of change postoperatively was estimated for each subject using linear regression. A one-sample t-test of the mean slope=0 assessed average change per year. Results: Mean (standard deviation) and median (range) of preoperative LV RS was 36.5 +/- 11.4% and 36.3% (16.8-59.8) respectively. LV strain analyses are summarized in tables 1 and 2. Conclusions: LV RS improved significantly after EA surgery whereas circumferential strain (CS), SR and radial SR did not. This may reflect the change in RV and subsequently LV geometry after resolution of tricuspid regurgitation with EA surgery. Ongoing evaluation with deformational imaging may help to characterize if these changes are compensatory or maladaptive and may determine optimal timing for surgery. In the subgroup with the lowest RS, significant improvement postoperatively was not seen. This may suggest that surgery was performed too late to allow favorable remodeling.

Background: The first pediatric appropriate use criteria (PAUC) were recently published for initial outpatient transthoracic echocardiography (TTE). We sought to determine the effect of release of the PAUC on the appropriateness of TTE ordering patterns of pediatric cardiologists. Methods: Data were prospectively collected from patients having initial outpatient TTE ordered prior to (Phase I, 6 mo) and 3 months after release (Phase II, 4 mo) of PAUC. Site-investigators determined the indication of the study and assigned appropriateness rating based on the PAUC document [Appropriate (A), May Be Appropriate (M), or Rarely Appropriate (R)] or "Unclassifiable" (U). Results: A total of 4562 TTEs (2655 Phase I, 1907 Phase II) were ordered by 103 physicians at 6 sites. Overall comparison of appropriateness rating for Phase I and II showed no change in the rate for A or M, but a decline in the rate of R and increase in U. Similar results were noted when comparisons were made for physicians that ordered at least 20 TTEs during each phase (N = 30/103, 29%), Table 1. There was no change in any appropriateness rating at 3 sites, a decline in R at 2, an increase in A at 1, and an increase in U at 2 sites. Overall and site-specific comparisons of rate of R TTEs are shown in Fig 1. Conclusions: The release of PAUC document had only a small impact on physician ordering behavior for initial TTEs, including a small decrease in R. Overall, these data suggest that more focused interventions are required to fully implement guideline recommendations and improve the appropriate use of pediatric TTE. This information should be helpful in designing educational interventions to reduce the rate of TTEs ordered for R indications.