Rates of Adverse Events in Hospitalized Patients After Summer-Time Resident Changeover in the United States: Is There a July Effect?

OBJECTIVES: This study aimed to determine whether patients in teaching hospitals are at higher risk of suffering from an adverse event during the summer trainee changeover period. METHODS: We performed a retrospective analysis of data from the Medicare Patient Safety Monitoring System, a medical-record abstraction-based database in the United States. Hospital admissions from 2010 to 2017 for acute myocardial infarction, heart failure, pneumonia, or a major surgical procedure were studied. Admissions were divided into nonsurgical (acute myocardial infarction, heart failure, or pneumonia) and surgical. Adverse event rates in July/August were compared with the rest of the year. Hospitals were stratified into major teaching, minor teaching, or nonteaching. Results were adjusted for patient demographics, comorbidities, and hospital characteristics. Outcomes were the adjusted odds of having at least 1 adverse event in July/August versus the rest of the year. RESULTS: We included 185,652 hospital admissions. The adjusted odds ratios (ORs) of suffering from at least one adverse event in a major teaching hospital in July/August was 0.83 (95% confidence interval [CI], 0.69-0.98) for nonsurgical patients and 1.09 (95% CI, 0.84-1.40) for surgical patients. In minor teaching hospitals, the adjusted ORs were 0.96 (95% CI, 0.88-1.04) for nonsurgical patients and 0.99 (95% CI, 0.87-1.12) for surgical patients. In nonteaching hospitals, the adjusted ORs were 0.98 (95% CI, 0.91-1.06) for nonsurgical patients and 1.10 (95% CI, 0.96-1.24) for surgical patients. CONCLUSIONS: Patients admitted to teaching hospitals in July/August are not at increased risk of adverse events. These findings should reassure patients and medical educators that patients are not excessively endangered by admission to the hospital during these months.

Prevalence and Determinants of Atrial Fibrillation-Associated In-Hospital Ischemic Stroke in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

Atrial fibrillation (AF) is an established risk factor ischemic stroke (IS) and is commonly encountered in patient hospitalized with acute myocardial infarction (AMI). Uncommonly, IS can occur as a complication resulting from percutaneous coronary intervention (PCI). There is limited real world data regarding AF-associated in-hospital IS (IH-IS) in patients admitted with AMI undergoing PCI. We queried the National Inpatient Sample database from January 2010 to December 2014 to identify patients admitted with AMI who underwent PCI. In this cohort, we determined the prevalence of AF associated IH-IS and compared risk factors for IH-IS between patients with AF and without AF using multivariable logistic regression models. IH-IS was present in 0.46% (n = 5,938) of the patients with AMI undergoing PCI (n = 1,282,829). Prevalence of IH-IS in patients with AF was higher compared with patients without AF (1.05% vs 0.4%; adjusted odds ratio: 1.634, 95% confidence interval: 1.527 to 1.748, p <0.001). Regardless of AF status, prevalence and risk of IH-IS was higher in females and increased with advancing age. There was significant overlap among risk-factors associated with increased risk of IH-IS in AF and non-AF cohorts, except for obesity in AF patients (adjusted odds ratio: 1.268, 95% confidence interval: 1.023 to 1.572, p = 0.03) in contrast to renal disease, malignancy, and peripheral vascular disease in non-AF patients. In conclusion, IH-IS is a rare complication affecting patients undergoing PCI for AMI and is more likely to occur in AF patients, females, and older adults, with heterogeneity among risk factors in patients with and without AF.

Left Atrial Myxoma Presenting as Lateral Medullary (Wallenberg's) Syndrome.

Myxomas are benign, primary tumors of the heart. Atrial myxomas can present with a variety of clinical features including dyspnea, orthopnea, pulmonary edema, and pulmonary or systemic emboli. Constitutional symptoms such as fever and weight loss may also be present. We report the case of a young female presenting with headache, facial numbness, and vertigo, who was found to have a posterolateral medullary stroke secondary to a large left atrial cardiac myxoma.

Internal Medicine Residents' Perspectives on Receiving Feedback in Milestone Format.

BACKGROUND: In contrast to historical feedback, which was vague or provided residents' numerical scores without clear meaning, milestone-based feedback is focused on specific knowledge, skills, and behaviors that define developmental trajectory. It was anticipated that residents would welcome the more specific and actionable feedback provided by the milestone framework, but this has not been studied. OBJECTIVE: We assessed internal medicine (IM) residents' perceptions of receiving feedback in the milestone framework, particularly assessing perception of the utility of milestone-based feedback compared to non-milestone-based feedback. METHODS: We surveyed a total of 510 IM residents from 7 institutions. Survey questions assessed resident perception of milestone feedback in identifying strengths, weaknesses, and trajectory of professional development. Postgraduate years 2 and 3 (PGY-2 and PGY-3) residents were asked to compare milestones with prior methods of feedback. RESULTS: Of 510 residents, 356 (69.8%) responded. Slightly less than half of the residents found milestone-based feedback "extremely useful" or "very useful" in identifying strengths (44%), weaknesses (43%), specific areas for improvement (45%), and appropriate education progress (48%). Few residents found such feedback "not very useful" or "not at all useful" in these domains. A total of 51% of PGY-2 and PGY-3 residents agreed that receiving milestone-based feedback was more helpful than previous forms of feedback. CONCLUSIONS: IM residents are aware of the concepts of milestones, and half of the residents surveyed found milestone feedback more helpful than previous forms of feedback. More work needs to be done to understand how milestone-based feedback could be delivered more effectively to enhance resident development.

Clerkship sharing on inpatient internal medicine rotations: an emerging clerkship model.

BACKGROUND: "Clerkship sharing" is the coexistence of students from 2 or more medical schools rotating on the same specialty at a single clerkship site. PURPOSE: Clerkship sharing was characterized by answering three related questions regarding the prevalence of clerkship sharing on internal medicine inpatient rotations, stakeholders views of the advantages and disadvantages of clerkship sharing, and the ways that clerkship sharing affects medical student outcomes at an institution. METHODS: In 2001, the Clerkship Directors in Internal Medicine (CDIM) surveyed its members; 1 section addressed clerkship sharing on inpatient rotations. In addition, the authors surveyed a convenience sample of teachers and learners at 41% of schools with clerkship sharing. Finally, using a 10-year database from one institution, we searched for differences in clerkship outcomes among students who rotated at clerkship sites with or without clerkship sharing. RESULTS: The overall clerkship director (CD) survey response rate was 78% (96/123); 22 of 96 (23%) of CDs reported having clerkship sharing on inpatient rotations. Advantages reported included a greater diversity of clinical exposure for students (77%) and a fostering of collegial relationships (73%). We also collected 79 teacher and 77 medical student surveys from 9 (41%) medical schools identified as having clerkship sharing. The majority of these teachers and learners believed that sharing improves teaching and the overall rotation quality. All surveyed groups were concerned that clerkship sharing affected the clarity of clerkship goals, objectives, and grading. However, clerkship outcomes from 1 institution demonstrated no effect of clerkship sharing on faculty ratings of students or student examination performance. CONCLUSIONS: Clerkship sharing appears to be an emerging clerkship model, and, although it may have inherent advantages that benefit student education, CDs should address challenges such as common goals and expectations for students and teachers.

Internal medicine training in the inpatient setting. A review of published educational interventions.

PURPOSE: Although the inpatient setting has served as the predominant educational site of internal medicine training programs, many changes and factors are currently affecting education in this setting. As a result, many educational organizations are calling for reforms in inpatient training. This report reviews the available literature on specific internal medicine inpatient educational interventions and proposes recommendations for improving internal medicine training in this setting. METHOD: We searched Medline for articles published between 1966 and August 2004 which focused on internal medicine training interventions in the inpatient setting; bibliographies of Medline-identified articles, as well as articles suggested by experts in the field provided additional citations. We then reviewed, classified, and abstracted only articles where an assessment of learner outcomes was included. RESULTS: Thirteen studies of inpatient internal medicine educational interventions were found that included an outcome assessment. All were single institution studies. The majority of these studies was of poor methodological quality and focused on specific content areas of internal medicine. None assessed the effectiveness or impact of internal medicine core inpatient experiences or curriculum. CONCLUSION: This review identifies significant gaps in our understanding of what constitutes effective inpatient education. The paucity of high quality research in the internal medicine inpatient setting highlights the urgent need to formally define and study what constitutes an effective "core" inpatient curriculum.

Progressive multifocal leukoencephalopathy in a patient with chronic myelogenous leukemia.

A 42-year-old man with chronic myelogenous leukemia presented to the hospital with hip pain. After undergoing surgical repair for a hip fracture, he developed aphasia, facial droop and fever. He was initially diagnosed with a stroke. A lumbar puncture excluded common infections, and an ELISA test for HIV was negative. Serial MRI scans revealed a progressive demyelinating pattern. Polymerase chain reaction performed on cerebrospinal fluid was positive for the JC virus (JC are the initials of the first person diagnosed with this virus). The patient was treated with cidofovir but died before a full course could be administered. JC virus is present in most adult hosts but is only harmful in immuno-compromised hosts. The active form of the disease is known as progressive multifocal leukoencephalopathy. This is the first reported case of a patient developing progressive multifocal leukoencephalopathy. with chronic myelogenous leukemia as the only underlying condition.