Observational data can be used to answer descriptive, predictive, and causal questions. Analysis of observational data can be challenging and may require complex analytical methods to produce meaningful, unbiased results; for example, when addressing confounding in causal studies. In recent years, there has been a growing appreciation that these different questions should be answered with different analytical approaches. This Methodological Progress Note introduces the key differences between these types of research questions and analytical approaches. In descriptive research, additional variables may be incorporated, for example, via stratification or statistical adjustment, to further characterize the outcome distribution with respect to those variables. In predictor research, the researcher may adjust for established predictors to assess the extent to which the candidate predictor may be a predictor of the outcome, over and above the existing predictors. In prediction modeling, a set of variables is selected based on their collective ability to most accurately predict the outcome within all populations and settings for which the model will be used. In causal research, additional variables are included to account for confounding bias. Examples relating to central venous access device failure are provided.
BACKGROUND:Pediatric encephalitis is associated with significant morbidity. Early recognition of autoimmune encephalitis (AE) is critical for timely immunotherapy and improved outcomes. OBJECTIVES:To externally validate a previously published adult encephalitis prediction model in a pediatric cohort and identify predictors of pediatric AE. METHODS:This retrospective single-center study included children 90 days to 21 years with encephalitis between January 2016 and September 2025. Clinical and laboratory data were extracted using electronic health record. External validation used published coefficients. Discrimination and calibration were assessed using receiver operating characteristic analysis and slope estimation. An exploratory multivariable logistic regression model was constructed. RESULTS:One hundred and twenty-six patients were included (92 autoimmune, 34 infectious). Patients with AE were significantly older (median age 14 vs. 5.5 years, p < .001). Infectious encephalitis was associated with higher serum white blood cell (WBC) (10.8 vs. 8.0 k/µL; p = .033) and cerebrospinal fluid (CSF) WBC (11 vs. 1 cells/µL; p < .001). The model showed acceptable discrimination (area under the receiver operating characteristic curve 0.774; 95% confidence interval [CI] 0.635-0.913) and calibration (slope 1.14; 95% CI 0.45-1.83). In our exploratory model (n = 80), CSF protein ≥30 mg/dL, was associated with lower odds of AE (odds ratio [OR] 0.24; 95% CI 0.07-0.80; p = .021), while increasing age was associated with higher odds (OR 1.13/year; 95% CI 1.01-1.26; p = .031). CONCLUSIONS:Predictors derived from an adult encephalitis model may retain some relevance in pediatrics despite physiologic differences. Specific pediatric predictors of AE included CSF protein <30 and increasing age, highlighting the need for pediatric-specific prediction tools. Multicenter studies are needed to validate models and refine thresholds.
BACKGROUND:Outcome disparities exist among children with asthma, though associations between neighborhood conditions and timing and intensity (i.e., emergency department and readmissions) of recurrent hospital-based reutilization are not well defined. OBJECTIVE:To evaluate associations between Childhood Opportunity Index (COI) and the intensity and timing of hospital-based reutilization for asthma. METHODS:We studied children (2-17 years) from 47 US children's hospitals with an index admission for asthma from 2021 to 2022 using the Pediatric Health Information System database. The exposure was ZIP code-level COI 3.0 quintiles (very low to very high). The primary outcome was reutilization intensity (no reutilization, ≥1 emergency department revisit, 1 hospital readmission, and ≥2 hospital readmissions) across four time windows (30, 90, 180, and 365 days), evaluated using ordinal regression. Secondary analyses evaluated time to any reutilization using adjusted restricted mean survival time. Models were adjusted for patient demographics, complexity, distance-to-hospital, and severity of index admission. RESULTS:We identified 45,520 index admissions. At 90, 180, and 365 days, lower neighborhood opportunity was associated with higher reutilization intensity; differences widened over successive reutilization windows. Adjusted odds ratios for reutilization intensity in the lowest versus highest COI quintiles were 1.52 (1.36-1.70) at 90 days and 1.89 (1.74-2.06) at 365 days. The adjusted mean time to reutilization was 16 days shorter for the lowest versus highest COI quintile. CONCLUSIONS:Lower COI predicted earlier and more intense asthma-related hospital reutilization. The COI could help identify children with asthma who would benefit most from targeted interventions during a hospital-based visit to reduce future reutilization.
Inpatient falls are a common and preventable source of harm among hospitalized patients. At a Veterans Health Affairs medical center, we implemented a mobility-first, multidisciplinary intervention using sequential Plan-Do-Study-Act cycles, including redesigned activity orders to "mobilize unless contraindicated," physical therapist-led education, and interdisciplinary fall huddles with rapid feedback. Over 18 months, total falls decreased by 34%, from 7.6 to 5.0 per 1000 bed-days, and injurious falls decreased by 46%, from 2.4 to 1.3 per 1000 bed-days, with no increase in staff injuries. This low-cost, scalable intervention suggests that standardizing mobility assessment, communication, and execution may reduce inpatient falls.
The safety of iron repletion during acute infections has long been debated. A recent retrospective analysis reported significant and rapid mortality benefits from inpatient iron infusions given to patients with acute infections. This potential paradigm shift in inpatient management of iron deficiency anemia puts into question whether current common practice of withholding iron during infections is not only unnecessary, but actively harming patients. Our analysis utilizing the same database but with adjustments for additional confounders largely identified no difference in mortality in hospitalized patients with iron deficiency anemia who survived at least 7 days after being admitted for an infection, and suggests further studies are needed to truly clarify the safety and role for intravenous iron during acute infections.
BACKGROUND:Point-of-care ultrasonography (POCUS) has expanded rapidly among hospitalists. However, its impact on the use of additional formal investigations and healthcare costs remains unclear. This study aimed to describe the evolution of POCUS use within a university hospital general internal medicine department and assess its association with requests for formal radiological and cardiological investigations. METHODS:We conducted a retrospective observational study including all POCUS exams archived in the hospital's picture archiving system performed by hospital-based internists at the Geneva University Hospitals (Geneva, Switzerland) between January 2020 and December 2025. The association between POCUS use and the number of formal radiological and cardiological investigations requested was assessed through a multivariable linear regression. RESULTS:During the study period, the annual number of POCUS exams increased substantially, with a 402.5% rise between 2020 and 2025. Lung ultrasonography was the most frequently performed exam (44%), followed by focused echocardiography (36%) and abdominal or vascular ultrasonography (20%). The increase in POCUS activity was associated with a parallel reduction in radiological ultrasonography and echocardiography. This result, while significant, was modest. After adjustment for the number of hospitalizations and CT scan requests, POCUS use was independently associated with decreased reliance on radiological ultrasonography (β = -0.10, 95% CI -0.15 to -0.05, p < .001). CONCLUSIONS:The use of POCUS in internal medicine has steadily increased over the past 5 years and appears to provide significant diagnostic value. Its growing adoption may contribute to reduced reliance on additional formal investigations, with potential implications for healthcare cost containment.
Guideline Title: 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. Release Date: February 19, 2026. Prior Version(s): None; de novo guideline. Developer: American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, in collaboration with multiple partner societies including the Society of Hospital Medicine. Target Population: Adults aged 18 years or older with acute pulmonary embolism.
Academic hospitalists supervising residents on inpatient wards face the dual challenge of managing changing patient complexity and learner needs. Resident experience is highly dependent on supervising faculty; however, traditional faculty development often fails to respond to real-time challenges of clinical teaching. To provide just-in-time faculty development, we implemented a weekly educational huddle for hospitalists rotating on resident ward teams using a Community of Practice model. The huddle emphasized peer coaching and discussion of real-time challenges. In this perspective article, we share that our findings showed high participation and self-reported improvements in teaching, feedback, coaching, efficiency, and sense of belonging. This innovation represents a feasible approach to faculty development in hospital medicine.
BACKGROUND:The diagnostic evaluation of infectious diarrhea has evolved with increasing adoption of multiplex gastrointestinal nucleic acid amplification tests and changing diagnostic strategies for Clostridioides difficile. OBJECTIVES:We aimed to assess changes in inpatient pathogen-specific documentation rates and clinical outcomes on a national level. METHODS:We performed a retrospective cross-sectional study using the National Inpatient Sample from 2016 to 2023. Adult hospitalizations with a primary diagnosis of presumed infectious diarrhea were identified using ICD-10 codes. Temporal trends in pathogen-specific documentation were evaluated. Multivariable regression models were used to identify factors associated with pathogen-specific documentation and evaluate associations with clinical outcomes. RESULTS:A total of 1,174,500 hospitalizations for presumed infectious diarrhea were identified, of which 710,335 (60.5%) had a specified pathogen. Pathogen specification rates remained stable from 2016 to 2023 (minimum of 59.6% in 2019 to the maximum of 62.1% in 2023; OR per year 1.00, 95% CI: 1.00-1.01, p = .282). Clostridioides difficile declined over time, accounting for 53.7% of infectious diarrhea hospitalizations in 2016 compared to 41.2% in 2023 (OR per year 0.94, p < .001). In contrast, norovirus and Campylobacter jejuni increased during the study period. Older age and higher comorbidity burden were independently associated with increased pathogen-specific documentation. Pathogen-specific documentation was associated with increased mortality (aOR 3.15, 95% CI: 2.73-3.63). These associations were substantially attenuated after exclusion of Clostridioides difficile. CONCLUSIONS:Pathogen-specific documentation rates among hospitalizations for presumed infectious diarrhea remained stable nationally from 2016 to 2023, although identification of non-Clostridioides difficile infections appeared to increase.
Breastfeeding mothers and children are occasionally hospitalized. Continuing breastfeeding during hospitalization and beyond is important for the health outcomes and well-being of mother and child. Breastfeeding in the hospital is associated with better hospital outcomes for children. However, breastfeeding can be challenging during hospitalization, particularly due to mother-infant separation and unfamiliarity by members of the treatment team with important aspects of breastfeeding. Hospitalization may result in unintended cessation of breastfeeding, which can also cause maternal emotional distress. Hospitals treating women of childbearing age and/or children should have a written policy that minimizes separation and provides knowledgeable breastfeeding/lactation-specific resources and support.
We conducted a multicenter prospective cohort study to identify factors associated with discharge on higher respiratory support in children with tracheostomy hospitalized for bacterial tracheostomy-associated infections (bTRAINs). We included children 0-21 years with tracheostomy hospitalized for bTRAIN at six freestanding children's hospitals between 2020 and 2024. The primary outcome was discharge on higher respiratory support compared to pre-hospital baseline. Generalized linear mixed-effects regression models accounted for patient and hospital clustering. We included 641 children representing 1180 hospitalizations, with a median age of 5 years; 45.9% were female, 35.6% Hispanic, and 20.0% Non-Hispanic Black. 24.7% were discharged on higher respiratory support. In adjusted analyses, discharge on higher respiratory support was associated with increased oxygen requirement, escalation of chronic ventilator settings, acute ventilatory support, and longer length of stay. In our study, discharge on higher respiratory support was driven by illness severity, rather than demographic or home support factors.
Negotiation is a skill essential for leader success yet not often trained in the academic pathway. Ideal negotiation is between at least two parties with overlapping goals where mutual benefit is achieved in a solidified agreement. For long-term success in partnership, integrity, shared value, mutual respect, and clarity should be demonstrated during negotiation, propelling the professional relationship going forward. Negotiation is a skill often addressed in senior leadership development programs. For example, ELAM, Executive Leadership in Academic Medicine, includes negotiation skill development in its discussion-based curriculum. For the purpose of broader distribution of skill development in negotiation, this writing attempts to share strategies for effective negotiation often referred to in such programs and discussions. Some keys to successful negotiation include cultivating a mindset of value and selectivity. Leaders must recognize when a negotiation should be occurring, specify what support is needed to succeed in the proposed endeavor, and consider how to be both strategic and realistic in their asks. For those working with search firms in employment placement, additional considerations are important. Avoiding a transactional approach and instead establishing a relationship based on shared goals, integrity, and professionalism is important. Developing a strategic mindset regarding negotiation will benefit the longevity and trajectory of one's career, and fulfillment of one's mission.
In this article, we discuss two major statistical paradigms: Frequentist and Bayesian. Our objective is to explain the core concepts of each approach, which are often perceived as mathematically complex. Although these paradigms differ in their approaches to problem-solving, each offers distinct strengths. Frequentist methods rely solely on observed data and the concept of repeated experiments, whereas Bayesian methods combine observed data with prior knowledge to inform inference. We argue that modern medical research should incorporate both approaches into its analytical toolbox to ensure that a robust method of data analysis is selected on a case-by-case basis.
Hepatitis B virus is a well-known infectious etiology of acute and chronic liver disease worldwide. Notably, 90% of children infected with hepatitis B in infancy develop chronic infection and subsequent progressive liver disease, including cirrhosis and hepatocellular carcinoma. Significant reduction in perinatal transmission in the United States (US) was seen after implementation of universal infant vaccination 30 years ago, as well as dramatic reductions in HBV incidence across Asia, coinciding with widespread hepatitis B vaccination. However, with ongoing changes to federal vaccine guidance and a steady rise in vaccine hesitancy, a comprehensive understanding of the epidemiology, transmission, screening, and prevention of hepatitis B remains important for pediatric health care providers.
