Chief resident behaviors that lead to effective morning reports, a multisite qualitative study.

BACKGROUND: Morning report is a fundamental component of internal medicine training and often represents the most significant teaching responsibility of Chief Residents. We sought to define Chief Resident behaviors essential to leading a successful morning report. METHODS: In 2016, we conducted a multi-site qualitative study using key informant interviews of morning report stakeholders. 49 residents, Chief Residents, and faculty from 4 Internal Medicine programs participated. Interviews were analyzed and coded by 3 authors using inductive reasoning and thematic analysis. A preliminary code structure was developed and expanded in an iterative process concurrent with data collection until thematic sufficiency was reached and a final structure was established. This final structure was used to recode all transcripts. RESULTS: We identified four themes of Chief Resident behaviors that lead to a successful morning report: report preparation, delivery skills, pedagogical approaches, and faculty participation. Preparation domains include thoughtful case selection, learning objective development, content editing, and report organization. Delivery domains include effective presentation skills, appropriate utilization of technology, and time management. Pedagogical approach domains include learner facilitation techniques that encourage clinical reasoning while nurturing a safe learning environment, as well as innovative teaching strategies. Moderating the involvement of faculty was identified as the final key to morning report effectiveness. Specific behavior examples are provided. CONCLUSION: Consideration of content preparation, delivery, pedagogical approaches, and moderation of faculty participation are key components to Chief Resident-led morning reports. Results from this study could be used to enhance faculty development for Chief Residents.

Colonic vasculopathy and perforation in the initial presentation of adult dermatomyositis in a patient with improving muscle weakness.

A 63-year-old woman with diabetes presented with 8 weeks of proximal muscle weakness and change in bowel habits. Muscle biopsy confirmed myositis, and serological studies were consistent with dermatomyositis (DM), without evidence of overlapping connective tissue disease or malignancy. On day 12 of prednisone therapy and after receiving one dose of IVIG with improvement in muscle strength, the patient developed abdominal pain and was diagnosed with a gastrointestinal (GI) perforation and peritonitis requiring emergent colectomy. The pathology revealed diffuse mucosal ulceration, prominent lymphoplasmacytic infiltration, venous occlusion and arterial hyperplasia. Although GI manifestations due to GI vasculopathy are rare in adult DM and are often a delayed complication, in this patient, it was one of the initial manifestations of this condition. In addition to being a fatal complication, clinicians should be aware of these complications, as immunosuppression used to control the muscular and cutaneous inflammation may not control the GI vasculopathy.

Prospective chest pain evaluation in the emergency department with use of high-sensitivity C-reactive protein (PROCEED-CRP study).

We evaluated the clinical value of a single measurement of high-sensitivity C-reactive protein (hs- CRP) in patients presenting to the emergency department with chest pain. We screened 408 consecutive patients of whom 292 comprised the final cohort for this study. Hs-CRP measured in the emergency department (ED) in patients presenting with chest pain and admitted for evaluation of acute myocardial infarction was neither sensitive nor specific in predicting acute myocardial infarction, myocardial ischemia on SPECT imaging, need for coronary revascularization, or cardiovascular or all-cause rehospitalization at 30 days. In addition, use of a specific CRP cut off >1 was not associated with an increase in all-cause rehospitalization at 30 days.

Time to recovery after a hemodialysis session: impact of selected variables.

BACKGROUND: Patients maintained on hemodialysis (HD) have an impaired health-related quality of life (HRQOL). One factor that has been suggested to contribute to this impairment is the prolonged recovery time after completing a conventional HD session. The present study was designed to carefully examine the time to recovery (TTR) in patients maintained on three times/week conventional HD and evaluate the clinical and demographic features associated with the TTR. METHODS: Two hundred and sixty-seven patients on conventional three times/week HD were studied during three successive HD treatments. Patients were asked how long it took them to recover from their previous session. Detailed demographic and clinical data as well as data involving the most recent HD session were reviewed. RESULTS: The mean ± SD age was 66.4 ± 15.7 and the mean duration of renal replacement therapy was 40.1 ± 37.6 months. The mean time to recovery was 246 ± 451 min. A multivariate regression analysis including age, gender, number of comorbidities, months on renal replacement therapy, occurrence of hypotension during dialysis, amount of ultrafiltration and duration of dialysis session revealed that none of these covariates was significantly associated with TTR from HD. CONCLUSIONS: The present study is important since it clarifies that the TTR after an HD session is not related to various demographic and clinical factors that one might have expected would impact on this variable.

Peritoneal dialysis in patients 75 years of age and older--a 22-year experience.

The role of peritoneal dialysis (PD) in the treatment of end-stage renal disease in elderly patients remains unclear. In the United States, PD is used only to a limited extent in that population. There are concerns about technique failure, including physical and psychosocial limitations and the risks of peritonitis. Thus, we retrospectively reviewed our 22 years of experience with patients 75 years of age and older who started on PD. Basic demographic data were collected, and mortality, technique failure, and peritonitis rates were determined. Quality of life (QOL) was assessed using the SF-36 questionnaire, a global QOL assessment, and a depression questionnaire. Among the 235 patients identified (mean age: 79 +/- 4 years; 51% white; 49% female; mean time on PD: 15.8 +/- 11.5 months), technique failure rates at 12 months were not significantly different for the patients 75 years of age older compared with the patients less than 75 years of age. Mortality rates were significantly higher in elderly patients. The peritonitis rate in patients 75 years of age and older was 1 episode in 23.6 patient-months compared with 1 episode in 23 patient-months in younger patients. The most common gram-positive organisms isolated were Staphylococcus epidermidis (38%0) and S. aureus (50%); gram-negative organisms accounted for 22%, and yeasts, 5% of peritonitis episodes. Reasons for transfer to hemodialysis included psychosocial problems (42%) and peritonitis (25%). Not surprisingly, physical component scores on the SF-36 were lower in the older than in the younger patients, but mental component scores on the SF-36 were slightly better in older than in younger patients, and global QOL and depression scores were not different between the groups. Our data suggest that PD is a reasonable modality for elderly patients.

Endocarditis complicating central venous catheter bloodstream infections: a unique form of health care associated endocarditis.

BACKGROUND: Endocarditis complicating central venous catheter blood stream infection (CVC-BSI) is a serious complication and is being seen with increasing frequency. METHODS: All patients discharged from our institution with International Classification of Disease (ICD-9) codes of endocarditis and CVC-BSI were identified. The medical records of those meeting our inclusion criteria were reviewed. RESULTS: From October 1, 1998 until December 31, 2006, 24 patients were identified with inpatient mortality of 20.8%. Nine cases were nosocomial and 15 were non-nosocomial. The most common comorbidities were diabetes mellitus (45.8%), chronic kidney disease (58.4%), prior valvular abnormalities (37.5%), and multiple prior hospitalizations (65.2%). There were 13 external lines, 9 tunneled lines, and 2 implantable ports. Responsible microorganisms included Staphylococcus aureus in 54.6%, coagulase-negative staphylococci in 37.5%, Candida species (spp.) in 16.6%, and enterococci in 12.5%. Five cases were polymicrobial. The line tip was within the right atrium (RA) in 37.5%, the superior vena cava (SVC)-RA junction in 20.8%, the SVC in 33.3%, and the pulmonary artery in 4.2% of patients. Sites of endocardial involvement were the aortic valve in 6 patients, mitral valve in 7 patients, tricuspid valve in 6 patients, right atrial wall in 11 patients, and pacemaker wire in 2 patients. Isolated right-sided involvement occurred in 50% of cases, isolated left-sided in 33.4%, and bilateral involvement in 16.6%. Transesophageal echocardiography (TEE) was necessary for diagnosis in 10 cases (41.6%). CONCLUSIONS: Endocarditis complicating CVC-BSI more often involves right-sided structures, with catheter tips in or near the right atrium, frequently requires TEE for diagnosis, and has significant inpatient mortality.

Brain natriuretic peptide and impedance cardiography to assess volume status in peritoneal dialysis patients.

Assessment of volume status in patients with end-stage renal disease has long been a problem. Objective tools for estimating dry weight are necessary. The present study was designed to determine if better assessment of volume status could be achieved by measuring brain natriuretic peptide (BNP) and thoracic fluid content (TFC) by bioimpedance. We prospectively surveyed 51 medically stable peritoneal dialysis (PD) patients during their routine visits to our PD facility. There were no exclusion criteria. Clinical volume status was assessed by the attending nephrologist as hypovolemic, euvolemic, or hypervolemic. Once the clinical assessment was complete, plasma BNP concentration was measured. The TFC was determined by bioimpedance cardiography measured in the supine position. Of 51 patients, 19 (37.3%) were considered hypervolemic, 30 (58.8%) euvolemic, and 3 (5.9%) hypovolemic by clinical assessment. As defined by systolic blood pressure > or = 130 mmHg or diastolic pressure > or = 80 mmHg (or both), 57% were hypertensive. The hypovolemic group was excluded from the statistical analysis because of the small sample size. Logistic regression analysis did not show a significant correlation between clinical assessment of volume and BNP (p = 0.76) or TFC (p = 0.39). Our data demonstrate the limitations of BNP and thoracic impedance in helping with the clinical evaluation of volume status in a cohort of chronic PD patients.