A retrospective analysis of the use of electronic consultation in general internal medicine.

BACKGROUND: General internists in Canada are subspecialty providers in the inpatient and outpatient settings. Electronic consultations (eConsult) allow primary care providers (PCPs) to virtually consult specialists to address clinical questions. There is a paucity of literature examining the utility and benefits of eConsults by general internists. AIMS: To determine how an eConsult service is used to access general internists. METHODS: A retrospective cross-sectional analysis of internal medicine cases was completed between 1 January 2016 and 31 December 2019 via the ChamplainBASE eConsult service. Two authors derived and validated a general internal medicine (GIM)-specific taxonomy using the validated: (i) Taxonomy of Generic Clinical Questions; and (ii) Internal Classification for Primary Care. Two hundred seventy-six cases were coded following taxonomy validation. ChamplainBASE utilisation summary and closeout survey data were also analysed. RESULTS: eConsults were responded to in a median of 3.1 days and took 15 min to complete. The eConsult's helpfulness and educational value were rated as 4 to 5/5 and often provided advice for a new or additional course of action. In-person referral was avoided in 40% of cases. The majority of eConsults consisted of a single question (88%) related to diagnostic clarification. The median remuneration per eConsult was $50. CONCLUSIONS: The majority of eConsults to general internists sought diagnostic clarification and confirmed the view of general internists as expert diagnosticians. eConsults cost less than an in-person consultation and were viewed favourably by PCPs. Further research can consider the eConsult provider experience and whether eConsults should become a required part of GIM ambulatory practice.

Using the Electronic Medical Record to Identify Patients at High Risk for Frequent Emergency Department Visits and High System Costs.

BACKGROUND: A small proportion of patients account for a high proportion of healthcare use. Accurate preemptive identification may facilitate tailored intervention. We sought to determine whether machine learning techniques using text from a family practice electronic medical record can be used to predict future high emergency department use and total costs by patients who are not yet high emergency department users or high cost to the healthcare system. METHODS: Text from fields of the cumulative patient profile within an electronic medical record of 43,111 patients was indexed. Separate training and validation cohorts were created. After processing, 11,905 words were used to fit a logistic regression model. The primary outcomes of interest in the 12 months after prediction were 3 or more emergency department visits and being in the top 5% in healthcare expenditures. Outcomes were assessed through linkage to administrative databases housed at the Institute for Clinical Evaluative Sciences. RESULTS: In the model to predict frequent emergency department visits, after excluding patients who were high emergency department users in the previous year, the area under the receiver operating characteristic curve was 0.71. By using the same methodology, the model to predict the top 5% in total system costs had an area under the receiver operating characteristic curve of 0.76. CONCLUSIONS: Machine learning techniques can be applied to analyze free text contained in electronic medical records. This dataset is more predictive of patients who will generate future high costs than future emergency department visits. It remains to be seen whether these predictions can be used to reduce costs by early interventions in this cohort of patients.

The first report of a previously undescribed EBV-negative NK-cell lymphoma of the GI tract presenting as chronic diarrhoea with eosinophilia.

A 74-year-old man presented with a 2-month history of watery diarrhoea. His complete blood count showed lymphopaenia and marked eosinophilia. Investigations for common infectious causes including Clostridium difficile toxin, stool culture, ova and parasites were negative. Endoscopy revealed extensive colitis and a CT of the abdomen identified numerous large abdominal lymph nodes suspicious for lymphoma. Multiple tissue samples were obtained; colon, mesenteric lymph node and bone marrow biopsy, as well as pleural fluid from a rapidly developing effusion, confirmed the presence of metastatic lymphoma with an immunophenotype most consistent with an aggressive variant of Epstein-Barr virus (EBV)-negative natural killer (NK)-cell lymphoma. The patient's clinical condition rapidly deteriorated and he died shortly following diagnosis. To the best of our knowledge, this is the first case report of a primary gastrointestinal EBV-negative NK-cell lymphoma, and its clinical presentation highlights the importance of a broad differential in the management of chronic diarrhoea.

Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial.

IMPORTANCE: Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated. OBJECTIVE: To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital. DESIGN, SETTING, AND PATIENTS: High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014. INTERVENTIONS: Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year. RESULTS: There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups. CONCLUSIONS AND RELEVANCE: In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01108172.

Nabilone therapy for cannabis withdrawal presenting as protracted nausea and vomiting.

Cannabis is one of the most commonly used recreational drugs worldwide. Psychoactive properties of the principal compound, δ-9-tetrahydrocannabinol include euphoria, a sense of relaxation and increased appetite. Chronic cannabis use has been associated with the development of a withdrawal syndrome on abrupt discontinuation. Withdrawal symptoms typically begin within 24 h of abstinence and manifest as irritability, nervousness, sleep disturbances and decreased appetite. There is growing evidence that supports the use of plant-derived and synthetic cannabinoids for the treatment of cannabis withdrawal. In this case report, we present 20-year-old woman who developed protracted nausea and vomiting secondary to cannabis withdrawal and was successfully treated with nabilone. Nausea and vomiting is not listed in the Diagnostic and Statistical Manual-5 diagnostic criteria for cannabis withdrawal syndrome and is an uncommon symptom presentation.

Lateral medullary syndrome: a diagnostic approach illustrated through case presentation and literature review.

Patients with lateral medullary syndrome classically present with crossed hemisensory disturbance, ipsilateral Horner syndrome, and cerebellar signs, all of which are attributable to infarction of the lateral medulla. However, variability in the presentation of this syndrome is the rule, as illustrated in this case presentation and literature review. We propose an approach to diagnosis and management of the lateral medullary syndrome and illustrate the need to integrate clinical information with an understanding of brainstem anatomy with the goal of determining which patients require urgent neuroimaging and acute stroke therapies. The importance of recognition of this condition in the emergency department is underscored by the association between lateral medullary infarction and vertebral artery dissection. With optimal therapy, the prognosis for recovery from lateral medullary syndrome is good.

Morning report blog: a web-based tool to enhance case-based learning.

BACKGROUND: Morning report is an interactive case-based teaching session common to internal medicine training programs across North America. DESCRIPTION: We report here on a morning report web log ("blog"), created and updated after morning report sessions by the Chief Medical Resident with pertinent clinical topics, links to journal articles, and medical images. Trainees on their internal medicine rotation were e-mailed a web link with each posting. The aim was to enhance learning on clinical topics discussed at morning report by reinforcing topics and promoting further reading. EVALUATION: The educational impact of the blog was evaluated using detailed web metrics and surveys of attendees. The intended audience spent on average more than 5 min reading the blog and viewed more than 3 pages per visit. Almost half of attendees accessed the blog after completing their internal medicine rotation. The blog was also accessed by a global audience. Trainees rated the blogs a useful learning tool and cited it to be among the top 3 educational resources accessed during their rotation. CONCLUSIONS: In summary, a morning report blog was perceived by learners to be an effective complement to case-based teaching sessions. The combination of novel web metrics and survey data allowed for a multifaceted evaluation of the educational impact of the blog.

Design and implementation of a low-cost multimodal procedure cart for an internal medicine ward.

INTRODUCTION: General internists perform a large number and variety of procedures in the ward and emergency department settings. Initiatives are needed to facilitate learning and increase efficiency of procedural skill acquisition by trainees. In this article, we describe our experience developing and implementing a low-cost multimodal procedure cart in an academic health sciences center. We also provide pilot data on perceived usefulness by trainees. METHODS: We performed a needs-assessment survey of residents, which indicated that the inconsistent location of materials and time needed to gather them were frustrating. Furthermore, residents reported that having easily accessible educational materials would improve their experience performing procedures. Based on this information, a portable cart was designed and implemented that had all materials required for common ward procedures, as well as multimodal educational materials, including evidence-based checklists, a hard-copy procedure manual, and a portable computer for viewing videos and logging procedures. The cart was equipped for the most commonly performed bedside procedures. After 2 months, we electronically surveyed residents on their experience with the intervention. Measures included self-reported frequency of use, satisfaction, perceived improvement in efficiency, and perceived improvement in patient safety. RESULTS: Residents perceived that the cart increased efficiency. The ready availability of educational materials was also noted as an advantage. Despite its perceived usefulness, trainees did not use the cart as frequently as anticipated. The cart continues to be in use > 1 year later, with modifications made based on feedback. CONCLUSIONS: In this article, we outline suggestions for successful implementation of a similar initiative based on our experience. We describe how a procedure cart can be inexpensively designed and instituted to facilitate more efficient performance of medical procedures and enhance education. Such an intervention may be beneficial in an academic as well as a community setting.

Instruction using a high-fidelity cardiopulmonary simulator improves examination skills and resource allocation in family medicine trainees.

INTRODUCTION: High-fidelity cardiopulmonary simulators have proven promising in various areas of medical education but have yet to be studied in Family Medicine training. METHODS: A 2-hour curriculum, combining didactic and simulator exposure, and addressing common valvular pathologies, was offered to post-graduate year 1 and 2 Family Medicine residents. Residents' abilities to describe and diagnose four simulated murmurs were assessed before the teaching sessions and 2 to 4 weeks after. Confidence in physical examination skills, as well as the use of echocardiography, was also measured. RESULTS: Twenty residents participated. Mean composite murmur description scores improved in 95% of residents (P < 0.001), as did mean diagnostic accuracy (from 43.8% to 85.0%; P < 0.001). For pathologic murmurs, the number of echocardiograms recommended did not change, whereas for the nonpathologic murmur, 16 residents who recommended echocardiography presession no longer did postsession (P < 0.001). Mean confidence significantly increased (P < 0.001). The mean satisfaction score for the session was 4.9/5, and all residents recommended that the session be repeated in future years. CONCLUSION: A didactic and simulator-based session is very well received by Family Medicine residents. It significantly improves description and diagnosis of murmurs and reduces unnecessary echocardiogram use without affecting appropriate use.

Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: a systematic review.

OBJECTIVES: The need for better understanding of end-of-life care has never been greater. Debate about recent U.S. healthcare system reforms has highlighted that end-of-life decision-making is contentious. Providing compassionate end-of-life care that is appropriate and in accordance with patient wishes is an essential component of critical care. Because discord can undermine optimal end-of-life care, knowledge of factors that influence decision-making is important. We performed a systematic review to determine which factors are known to influence end-of-life decision-making among patients and healthcare providers. DATA SOURCES, SELECTION, AND ABSTRACTION: We conducted a structured search of Ovid Medline for interventional and observational research articles incorporating critical care and end-of-life decision-making terms. DATA SYNTHESIS: Of 6259 publications, 102 were relevant to our review question. Patient factors predicting less intensive end-of-life care include increasing age, comorbidity, and limited functional status; these factors appear to be influential for both clinicians and patients. Patient and clinician race, ethnicity, and nationality also appear to influence the technological intensity of end-of-life care. In general, white patients and those in North America and Northern Europe may be less likely to desire intensive end-of-life care than others. Physicians of similar geo-ethnic origin to patients appear less likely to prescribe such therapy. Physicians with more clinical experience and those routinely working in the intensive care unit are less likely than other physicians to recommend technologically intense care for critically ill patients at the end-of-life. CONCLUSIONS: Patients and clinicians may approach end-of-life discussions with different expectations and preferences, influenced by religion, race, culture, and geography. Appreciation of those factors associated with more and less technologically intense care may raise awareness, aid communication, and guide clinicians in end-of-life discussions.

Sex and critical illness.

PURPOSE OF REVIEW: The article reviews and speculates on potential mechanisms underlying sex-related differences in admission patterns, care delivery and outcome of critical illness. RECENT FINDINGS: Evidence from many countries suggests men are more commonly admitted to intensive care units than are women, and may be more likely to receive aggressive life support. These differences may be confounded by differences in incidence of conditions leading to critical illness, such as acute lung injury and sepsis, both more common among men, or to differences in provision of medical or surgical care that require intensive care unit. There may be different decision-making by patients or decision makers that is dependent upon age and sex of the patient and relation to the surrogate. It is unclear whether differences exist in clinical outcomes; if they do, the magnitude may be greatest among older patients. We describe potential biologic rationales and review animal models. Finally, we explore sex-based differences in the inclusion of men and women in clinical research that underlie our understanding of critical illness. SUMMARY: Sex differences in incidence of critical illness and provision of care exist but it is unclear whether they relate to differences in risk factors, or differences in decision-making among patients, surrogates or healthcare professionals.

Oncoming tides in the Age(ing) of Aquarius.

The demographic shift in the age of most industrialized countries' populations is profoundly impacting all areas of healthcare, perhaps nowhere more so than critical care. As the proportion of elderly patients increases, so to will our consideration for admission of elderly patients to the intensive care unit (ICU). Whether explicitly acknowledged or not, intensivists routinely debate (both inwardly and outwardly) the benefit, utility, and patient-focused dignity of admitting very elderly patients to the ICU. Despite the apparent increase in demand for, and provision of critical care services to, the elderly, there are few data on the outcomes from these admissions, and how one might predict which elderly patients are most likely to derive benefit from the invasive and resource-intensive services provided in modern ICUs.

The effect of income on anaphylaxis preparation and management plans in Toronto primary schools.

BACKGROUND: Outcomes of serious allergic reactions are worse at school than at home. Prompt administration of epinephrine is the first-line treatment for anaphylactic reactions, and the EpiPen device is not subsidized by Ontario public health insurance. This study examines the relationship between the proportion of low-income households in Toronto neighbourhoods and the adequacy of anaphylaxis management plans in primary schools. METHODS: A survey was administered to principals of primary schools. It addressed the areas of: prevalence of food allergy, the presence of EpiPen at school and staff training in its use, and exposure prevention policy. The results were correlated to 2001 Canadian Census data for percentage of low-income households in each school's area. RESULTS: Children with reported severe food allergy attending schools in areas with greater than 20% low-income households were less likely to have medication at school than those in neighbourhoods with less than 20% (relative risk 2.2, 95% confidence interval 1.1-4.4). Other aspects of the anaphylaxis action plan, including staff EpiPen training and parental provision of information to the school, showed no significant correlation to income. Overall, about 50% of schools have their entire teaching staff trained to administer the EpiPen. INTERPRETATION: The lack of medication at school for anaphylaxis is a limiting factor in optimal anaphylaxis management in the school setting. Government support in the purchase of EpiPen in low-income households may be indicated.

Reversible assembly of helical filaments by de novo designed minimalist peptides.

We have designed a series of 15 short, helical de novo peptides consisting of lysine, isoleucine, and alanine. We have termed this the KIA series. These peptides differ only in their hydrophobic interface, and thus their self-association is largely a consequence of hydrophobic interactions. One of these peptides, KIA13, forms insoluble helical fibers at specific NaCl concentrations. We have used CD spectroscopy, turbidity assays, and in situ tapping mode atomic force microscopy to characterize the reversible assembly pathway for this peptide. It is unfolded at low NaCl concentration, and forms helical, soluble fibers resembling a coiled-coil conformation at intermediate NaCl concentrations, and rope-like insoluble fibers at high NaCl concentrations. Reducing the NaCl concentration completely reverses this process. Another peptide from the KIA series specifically inhibits the formation of the insoluble KIA13 fibers, and reverses the process to some extent. This work sheds light onto protein fibrillogenesis and offers intriguing possibilities for the use of these types of peptides in drug delivery and biomaterials applications.