A novel virtual course to teach medical students high-value decision-making.

BACKGROUND: Although a clinician's ability to employ high-value decision-making is influenced by training, many undergraduate medical education programmes lack a formal curriculum in high-value, cost-conscious care. We present a curriculum developed through a cross-institutional collaboration that was used to teach students at two institutions about this topic and can serve as a framework for other institutions to develop similar curricula. APPROACH: The faculty from the University of Virginia and the Johns Hopkins University School of Medicine created a 2-week-long online course to teach medical students the fundamentals of high-value care. The course consisted of learning modules, clinical cases, textbook studies, journal clubs and a competitive 'Shark Tank' final project where students proposed a realistic intervention to promote high-value clinical care. EVALUATION: Over two-thirds of students rated the course's quality as excellent or very good. Most found the online modules (92%), assigned textbook readings (89%) and 'Shark Tank' competition (83%) useful. To evaluate the student's ability to apply the concepts learned during the course in clinical contexts, we developed a scoring rubric based on the New World Kirkpatrick Model to evaluate students' proposals. Groups chosen as finalists (as determined by faculty judges) were more likely to be fourth-year students (56%), achieved higher overall scores (p = 0.03), better incorporated cost impact at several levels (patient, hospital and national) (p = 0.001) and discussed both positive and negative impacts on patient safety (p = 0.04). IMPLICATIONS: This course provides a framework for medical schools to use in their teaching of high-value care. Cross-institutional collaboration and online content overcame local barriers such as contextual factors and lack of faculty expertise, allowed for greater flexibility, and enabled focused curricular time to be spent on a capstone project competition. Prior clinical experience amongst medical students may be an enabling factor in promoting application of learning related to high-value care.

Faculty Development in Academic Hospital Medicine: a Scoping Review.

This scoping review sought to identify and describe the state of academic faculty development programs in hospital medicine and other specialties. We reviewed faculty development content, structure, metrics of success including facilitators, barriers, and sustainability to create a framework and inform hospital medicine leadership and faculty development initiatives. We completed a systematic search of peer-reviewed literature and searched Ovid MEDLINE ALL (1946 to June 17, 2021) and Embase (via Elsevier, 1947 to June 17, 2021). Twenty-two studies were included in the final review, with wide heterogeneity in program design, program description, outcomes, and study design. Program design included a combination of didactics, workshops, and community or networking events; half of the studies included mentorship or coaching for faculty. Thirteen studies included program description and institutional experience without reported outcomes while eight studies included quantitative analysis and mixed methods results. Barriers to program success included limited time and support for faculty attendance, conflicting clinical commitments, and lack of mentor availability. Facilitators included allotted funding and time for faculty participation, formal mentoring and coaching opportunities, and a structured curriculum with focused skill development supporting faculty priorities. We identified heterogeneous historical studies addressing faculty development across highly variable program design, intervention, faculty targeted, and outcomes assessed. Common themes emerged, including the need for program structure and support, aligning areas of skill development with faculty values, and longitudinal mentoring/coaching. Programs require dedicated program leadership, support for faculty time and participation, curricula focused on skills development, and mentoring and sponsorship.

Clinical course of COVID-19 in a liver transplant recipient on hemodialysis and response to tocilizumab therapy: A case report.

The novel coronavirus disease 2019 (COVID-19) is a highly infectious and rapidly spreading disease. There are limited published data on the epidemiology and outcomes of COVID-19 infection among organ transplant recipients. After initial flulike symptoms, progression to an inflammatory phase may occur, characterized by cytokine release rapidly leading to respiratory and multiorgan failure. We report the clinical course and management of a liver transplant recipient on hemodialysis, who presented with COVID-19 pneumonia, and despite completing a 5-day course of hydroxychloroquine, later developed marked inflammatory manifestations with rapid improvement after administration of off-label, single-dose tocilizumab. We also highlight the role of lung ultrasonography in early diagnosis of the inflammatory phase of COVID-19. Future investigation of the effects of immunomodulators among transplant recipients with COVID-19 infection will be important.

Hodgkin lymphoma presenting as alcohol-induced back pain.

A 32-year-old Chinese man without significant medical history presented with a 2-month history of worsening lumbosacral back pain radiating to the groin and left lower extremity. He also described a shooting pain in the sciatic nerve distribution that began with and was exacerbated by alcohol consumption, a rare but known symptom of Hodgkin lymphoma (HL). On exam, an anterior chest wall mass was noted. Radiographic evaluation of an anterior mediastinal mass showed osseous erosion into the manubrium. MRI of the lumbar spine showed diffuse osseous disease of the lower thoracic and lumbar spine with extension into the right sacroiliac joint and S2 neural foramen without vertebral body collapse or stenosis. Tissue biopsy revealed nodular sclerosis HL, stage IVB IPS2. The patient was primary refractory to ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) therapy. Salvage ICE (ifosfamide, carboplatin, etoposide) chemotherapy was used and then followed by non-myeloablative haploidentical bone marrow transplant was performed on 5 March 2019.

Single-Center Experience in Pre-transplant Hepatitis C Virus (HCV) Treatment Among Living Donor Liver Transplant Candidates: Bridging the Direct-Acting Antivirals (DAA).

BACKGROUND Treatment with DAAs before deceased donor liver transplantation has been shown to be an effective strategy to prevent post-transplant HCV recurrence, with a 95% cure-rate among individuals who achieve undetectable HCV VL for ≥30 days pre- transplant. This strategy has not been evaluated in LDLT. MATERIAL AND METHODS We evaluated outcomes in LDLT recipients treated with DAAs pre-transplant and bridged with 4 weeks of post-transplant SOF. All cases of LDLT at Johns Hopkins (1/1/2014-3/1/15) were retrospectively reviewed. RESULTS There were 4 HCV+ LDLT cases treated with DAAs pre- and post-transplant. Pre-transplant DAA regimens included SOF plus SIM in 2 cases of HCC and SOF plus RBV in 2 cases of ESLD. All patients achieved negative VL by week 7 of treatment and all patients had at least 30 days of HCV RNA negativity at the time of LDLT. Patient 4 had a delay in LDLT due to uncontrolled pulmonary hypertension, and experienced viral breakthrough because of treatment interruption. Due to concerns for SOF resistance, a salvage regimen of LDV-SOF and SIM was used. Post-LDLT patients 1-3 received 4 weeks of SOF monotherapy and patient 4 received 14 weeks of LDV-SOF. Three patients achieved SVR12. One died from non-HCV related complications at 4 months post-LDLT. CONCLUSIONS Our preliminary experience suggests that bridging DAAs pre- and post-LDLT is an effective strategy to prevent HCV recurrence. With delays in transplant and prolonged use of SOF/RBV, there is a risk of viral breakthrough, but a salvage strategy of triple DAA therapy can be effective.

Serum sickness-like reaction after the treatment of cellulitis with amoxicillin/clavulanate.

Serum sickness-like reaction is a rare disease presentation. We describe a case of a man aged 58 years who presented with acute-onset polyarthralgia, intense pruritus of hands and feet, fever to 39.5°C and leucocytosis to 17.2×103/mm3 5 days after completing a 10-day course of amoxicillin/clavulanate for the treatment of finger cellulitis. With history, symptoms, physical examination findings and reported cases in the literature of serum sickness-like reactions to amoxicillin, a clinical diagnosis of serum sickness-like reaction was made. The patient was treated with non-steroidal anti-inflammatories with improvement in symptoms by the time of discharge.

Ammonia Level and Mortality in Acute Liver Failure: A Single-Center Experience.

BACKGROUND Acute liver failure (ALF) is an emergent condition that requires intensive care and manifests in particular by significant elevation in serum ammonia level. Patients with ALF with concomitant renal failure experience a further rise in ammonia levels due to decreased kidney excretion. The aim of this study was to evaluate the relationship between elevated ammonia levels and mortality and to characterize the subgroup of ALF patients who develop acute kidney injury (AKI) and require renal replacement therapy. MATERIAL AND METHODS This was a retrospective study of 36 consecutive patients admitted to Johns Hopkins Hospital's intensive care units from December 2008 to May 2013 who presented with grade III and IV hepatic encephalopathy (HE). Patients who developed AKI and required hemodialysis (HD) were compared to those without AKI. Patients with chronic kidney disease were excluded. RESULTS Sixteen patients developed AKI and underwent HD (HD group). Median ammonia levels in the HD and non-HD groups were not significantly different (p=0.95). In the HD group, 4 patients underwent liver transplantation (LT) and 3 of them survived the hospitalization. Among the 12 HD patients who did not receive LT, 6 (50%) survived. Out of 20 non-HD patients, 3 were transplanted, all of whom survived the hospitalization. Among the 17 non-HD patients who did not receive LT, 14 (82%) survived. Admission ammonia level (>120 µmol/L) was associated with higher mortality rate (OR=7.188 [95% CI 1.3326-38.952], p=0.026) in all patients. CONCLUSIONS Admission ammonia level is predictive of mortality in ALF patients with grade 3-4 HE.

Telephone calls to patients after discharge from the hospital: an important part of transitions of care.

BACKGROUND: Teaching interns patient-centered communication skills, including making structured telephone calls to patients following discharge, may improve transitions of care. OBJECTIVE: To explore associations between a patient-centered care (PCC) curriculum and patients' perspectives of the quality of transitional care. METHODS: We implemented a novel PCC curriculum on one of four inpatient general medicine resident teaching teams in which interns make post-discharge telephone calls to patients, contact outpatient providers, perform medication adherence reviews, and engage in patient-centered discharge planning. Between July and November of 2011, we conducted telephone surveys of patients from all four teaching teams within 30 days of discharge. In addition to asking if patients received a call from their hospital physician (intern), we administered the 3-Item Care Transitions Measure (CTM-3), which assesses patients' perceptions of preparedness for the transition from hospital to home (possible score range 0-100). RESULTS: The CTM-3 scores (mean±SD) of PCC team patients and standard team patients were not significantly different (82.4±17.3 vs. 79.6±17.6, p=0.53). However, regardless of team assignment, patients who reported receiving a post-discharge telephone call had significantly higher CTM-3 scores than those who did not (84.7±16.0 vs. 78.2±17.4, p=0.03). Interns exposed to the PCC curriculum called their patients after discharge more often than interns never exposed (OR=2.78, 95% CI [1.25, 6.18], p=0.013). CONCLUSIONS: The post-discharge telephone call, one element of PCC, was associated with higher CTM-3 scores--which, in turn, have been shown to lessen patients' risk of emergency department visits within 30 days of discharge.