Grady Health System

Chief nurse executives (CNEs) face unprecedented moral and ethical challenges navigating tensions between professional obligations, organizational demands, and personal values. This article distinguishes morality, individual conscience, and values from ethics, formal codes and professional standards, and examines how misalignment between these domains generates moral distress. Without intervention, accumulated distress produces moral residue, triggering a crescendo effect that may culminate in moral injury and professional departure. The article addresses organizational culture evaluation, economic consequences of ethical compromise, and the critical need for explicit institutional support of the CNE. Evidence-based resources, including the Rushton Moral Resilience Scale, ANA Code of Ethics, and Beauchamp-Childress "principlist framework" are identified to provide practical guidance for sustaining integrity.

Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.

This study examined the benefit of belimumab as standard treatment in patients with systemic lupus erythematosus (SLE) treated without versus with immunosuppressants (IS) prior to belimumab initiation. This retrospective cohort study (GSK Study 217537) used healthcare claims from the US Komodo Health Database from January 2015 to October 2023. Eligible adults had ≥ 1 inpatient or ≥ 2 outpatient SLE diagnosis codes, ≥ 1 belimumab claim (January 2017-October 2023; index date) and 24months continuous data pre-index. Two cohorts were defined: those with ≥ 1 claim for non-IS SLE treatment (antimalarials, oral glucocorticoids [OGC] or biologics; non-IS cohort) or ≥ 1 claim for incident IS (IS cohort) within 12months pre-index. Cohort comparability was assessed across the 12months before non-IS/IS treatment, applying inverse probability of treatment weighting (IPTW) to adjust for confounding. Outcomes included OGC use, SLE flare rates and healthcare resource utilisation, compared using Cox, Poisson regression and logit models, respectively. Overall, 2190 and 2533 patients were included in IPTW-adjusted non-IS and IS cohorts, respectively. The non-IS cohort had a median (95% confidence interval [CI]) time to OGC discontinuation of 9.8 (8.2, 12.2) months versus 11.7 (10.5, 13.4) for the IS cohort, and a 30% higher likelihood of OGC discontinuation (hazard ratio [95%CI] 1.30 [1.11, 1.52]). The likelihood of OGC dose reduction and discontinuation or dose reduction alone was similar between cohorts. The non-IS versus IS cohort had a lower incidence rate ratio (IRR [95%CI]) of total (0.94 [0.92, 0.96]) and moderate (0.77 [0.74, 0.80]) SLE flares, with similar odds of SLE-related inpatient stays (odds ratio [95%CI] 1.12 [0.94, 1.34]) and emergency visits (1.02 [0.82, 1.27]). In this large, retrospective, real-word study using IPTW adjustment, initiating belimumab without prior IS use was associated with OGC-sparing benefits and reduced incidence and severity of SLE flares.

Abstract Ketosis-prone diabetes mellitus (KPD) is a subtype of type 2 diabetes, which presents much like type 1 diabetes, with dramatic hyperglycemia and ketoacidosis. Although KPD patients are initially insulin-dependent, after a few months of insulin treatment, roughly 70% undergo near-normoglycemia remission and can maintain blood glucose without insulin, as in early type 2 diabetes or prediabetes. Here, we propose that these phenomena can be explained by the existence of a fast, reversible glucotoxicity process, which may exist in all people but be more pronounced in those susceptible to KPD. We develop a simple mathematical model of the pathogenesis of KPD, which incorporates this assumption, and show that it reproduces the phenomenology of KPD, including variations in the ability for patients to achieve and sustain remission. These results suggest that a variation of our model may be able to quantitatively describe variations in the course of remission among individuals with KPD.

ObjectiveTo evaluate the effectiveness and benefit-harm balance of various statins for the primary prevention of cardiovascular disease in people with HIV.DesignTarget trial and modelling study.SettingNorth American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), 1995 to 2019. NA-ACCORD integrates individual level data from >20 HIV cohorts across the US and Canada from people with HIV who have successfully linked into care.Participants157 699 people with HIV enrolled in one of the cohorts of NA-ACCORD. 54 165 eligible individuals, aged 40-75 years, were enrolled in the target trial.Main outcome measuresThe primary outcomes for the target trial were the 10 year effects of statins on cardiovascular disease events (fatal and non-fatal myocardial infarction, hospital admission for unstable angina, coronary or arterial revascularisation, fatal and non-fatal stroke, or transient ischaemic attack) and harm outcomes (type 2 diabetes, mild cognitive impairment, rhabdomyolysis, and myopathy). The secondary outcome was the 10 year risk threshold where the reduction in cardiovascular disease outweighed the increased risk of harm outcomes, showing an overall net benefit of statins.ResultsParticipants who first started receiving treatment with statins (statin initiators) had a 21% reduction in cardiovascular disease events (hazard ratio 0.79, 95% confidence interval (CI) 0.72 to 0.87) and a 26% reduction in the combined risk of stroke and myocardial infarction (0.74, 0.56 to 0.98), but a 12% increase in the risk of type 2 diabetes (1.12, 1.01 to 1.25) compared with participants who developed the indication but did not take statins (non-initiators). The effects on cognitive impairment (hazard ratio 1.13, 95% CI 0.82 to 1.56), myopathy (1.10, 0.76 to 1.61), and rhabdomyolysis (1.09, 0.68 to 1.75) were not statistically significant. On average, the benefit of statins exceeded harms for individuals with a 10 year baseline risk of cardiovascular disease of ≥13.8%. Subgroup specific thresholds included men (14.2%), women (11.1%), ages 40-64 years (13.8%) versus 65-75 years (15.1%), and CD4 count >200 cells/mm³ (13.6%) versus <200 cells/mm³ (15.3%). Varying weights for cardiovascular disease yielded thresholds ranging from 11.6% to 54.0%, whereas weights for harm outcomes resulted in thresholds ranging from 5.0% to >30.0%.ConclusionsIn this study, statins benefitted individuals with HIV with a moderate or high risk of cardiovascular disease, but the threshold for net benefit varied by patient subgroup and preference, implying the need to customise statin treatment to individual risks, preferences, and treatment goals. Given the limitations of observational data, further controlled studies are needed to evaluate the efficacy and safety of statins in people with HIV receiving modern antiretroviral therapy.

Introduction: Warfarin management remains essential for a variety of anticoagulated patients and is impacted by dietary vitamin K intake, potentially leading to variation in international normalized ratio (INR), and increased bleeding or thrombosis. Food insecurity (FI) may limit consistent access to vitamin K foods, and thus INR control. This cross-sectional cohort study aims to characterize the correlation of FI and time in therapeutic range (TTR).

People with HIV (PWH) who use cocaine are less likely to achieve virologic suppression (<200 copies/mL) because of poor engagement in care. We tested the efficacy of an integrated substance use treatment and outpatient HIV care intervention on improving viral suppression in nonsuppressed PWH who use cocaine. Project RETAIN recruited 360 cocaine-using PWH who were not virologically suppressed in Miami, FL, and Atlanta, GA. Patients were randomized to treatment as usual (TAU) or the intervention, which included patient navigation and substance use treatment with motivational enhancement therapy and cognitive-behavioral therapy. The primary outcome assessed viral suppression at 6- and 12-month follow-up. There was no difference in viral suppression by group (TAU = 17.1%, intervention = 15.6%, P = .897). The intervention group had significantly more participation in substance use treatment (87.0%) than TAU (7.2%, P < .001). There were significant decreases in stimulant use in both groups, but oxycodone use decreased more in the intervention group. Severe psychological distress (32% of the baseline sample) declined differentially at 6 months (TAU = 24.5%, intervention = 16.1%, P = .0492). Only a minority of PWH who used cocaine became virally suppressed over the 12-month study, with no effect of the integrated intervention. Patients in the intervention did have reduced psychological distress postintervention. Despite more substance use treatment in the intervention, both groups declined equally in substance use. Interventions that improve retention in care and viral suppression are needed for this vulnerable population, including those that address their other complex medical and psychosocial needs. NCT01614106.

Residency programs face increasing expectations to grow competency in system-based practice and quality improvement (QI) among trainees. Organizations like the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education have included QI knowledge in their recertification and accreditation requirements. We describe our experiences over a decade of sustaining a longitudinal experiential QI curriculum at a large Internal Medicine residency program. Each resident participated in interactive seminars as well as a faculty-mentored, team-based QI project. Each project was formally evaluated at an end-of-year poster presentation. One hundred thirty-six projects were completed between 2007 and 2016. A presurvey of 51 PGY-1 residents (59%) and a postsurvey of 50 PGY-2 and PGY-3 residents (46%) demonstrated increased comfort leading a QI project and improved knowledge of QI principles. We continue a modified version of the curriculum to accommodate the residency program's restructured ambulatory teaching experiences and the impacts of the COVID-19 pandemic. Implementing a performance improvement curriculum based in a resident continuity clinic is feasible and affords several advantages. In applying QI methodologies, residents learn how to measure adherence with current evidence-based medicine guidelines and develop interventions to maintain positive momentum within the reality of busy clinical practice.