How Would You Prevent Subsequent Strokes in This Patient? Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Stroke is a major cause of morbidity, mortality, and disability. The American Heart Association/American Stroke Association recently published updated guidelines on secondary stroke prevention. In these rounds, 2 vascular neurologists use the case of Mr. S, a 75-year-old man with a history of 2 strokes, to discuss and debate questions in the guideline concerning intensity of atrial fibrillation monitoring in embolic stroke of undetermined source, diagnosis and management of moderate symptomatic carotid stenosis, and therapeutic strategies for recurrent embolic stroke of undetermined source in the setting of guideline-concordant therapy.

How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.

How Would You Resuscitate This Patient With Septic Shock? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Sepsis is a potentially life-threatening systemic dysregulatory response to infection, and septic shock occurs when sepsis leads to systemic vasodilation and subsequent tissue hypoperfusion. The Surviving Sepsis Campaign published updated guidelines in 2021 on the management of sepsis and septic shock. Here, in the context of a patient with septic shock, 2 critical care specialists discuss and debate conditional guideline recommendations on using lactate to guide resuscitation, the use of balanced crystalloids versus normal saline, and the use of corticosteroids.

Lessons learned for surveillance system strengthening through capacity building and partnership engagement in post-Ebola Guinea, 2015-2019.

The 2014-2016 Ebola outbreak in Guinea revealed systematic weaknesses in the existing disease surveillance system, which contributed to delayed detection, underreporting of cases, widespread transmission in Guinea and cross-border transmission to neighboring Sierra Leone and Liberia, leading to the largest Ebola epidemic ever recorded. Efforts to understand the epidemic's scale and distribution were hindered by problems with data completeness, accuracy, and reliability. In 2017, recognizing the importance and usefulness of surveillance data in making evidence-based decisions for the control of epidemic-prone diseases, the Guinean Ministry of Health (MoH) included surveillance strengthening as a priority activity in their post-Ebola transition plan and requested the support of partners to attain its objectives. The U.S. Centers for Disease Control and Prevention (US CDC) and four of its implementing partners-International Medical Corps, the International Organization for Migration, RTI International, and the World Health Organization-worked in collaboration with the Government of Guinea to strengthen the country's surveillance capacity, in alignment with the Global Health Security Agenda and International Health Regulations 2005 objectives for surveillance and reporting. This paper describes the main surveillance activities supported by US CDC and its partners between 2015 and 2019 and provides information on the strategies used and the impact of activities. It also discusses lessons learned for building sustainable capacity and infrastructure for disease surveillance and reporting in similar resource-limited settings.

How Would You Treat This Patient With Pulmonary Embolism? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Pulmonary embolism can be acutely life-threatening and is associated with long-term consequences such as recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. In 2020, the American Society of Hematology published updated guidelines on the management of patients with venous thromboembolism. Here, a hematologist and a cardiology and vascular medicine specialist discuss these guidelines in the context of the care of a patient with pulmonary embolism. They discuss advanced therapies such as catheter-directed thrombolysis in the short-term management of patients with intermediate-risk disease, recurrence risk stratification at presentation, and ideal antithrombotic regimens for patients whose pulmonary embolism was associated with a transient minor risk factor.

When and How Would You Screen This Patient for Cervical Cancer? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Successful screening programs based on cervical cytology have dramatically reduced the incidence of cervical cancer in the United States. Human papillomavirus immunization is poised to reduce it further as an increasing percentage of vaccinated women reach adulthood. A recent guideline from the American Cancer Society advises that cervical cancer screening begin at age 25 and that high-risk human papillomavirus testing is the preferred screening test. The U.S. Preventive Services Task Force recommends screening begin at age 21 and that cytology remain incorporated into screening. Here, 2 experts debate how to apply these guidelines to Ms. L, a 22-year-old woman who has never undergone cervical cancer screening.

Effect of an Immersive Primary Care Training Program on Educational and Clinical Outcomes in an Internal Medicine Residency Training Program: Meeting the Training Needs of a Modern-Day Physician Workforce.

BACKGROUND: Residents planning careers in primary care have unique training needs that are not addressed in traditional internal medicine training programs, where there is a focus on inpatient training. There are no evidence-based approaches for primary care training. OBJECTIVES: Design and test the effect of a novel immersive primary care training program on educational and clinical outcomes. DESIGN: Nested intervention study. SETTING, PARTICIPANTS: Twelve primary care residents, 86 of their categorical peers, and an 11-year historical cohort of 69 primary care trainees in a large urban internal medicine residency training program. INTERVENTIONS: Two 6-month blocks of primary care immersion alternating with two 6-month blocks of standard residency training during the second and third post-graduate years. MAIN MEASURES: Total amount of ambulatory and inpatient training time, subjective and objective educational outcomes, clinical performance on cancer screening, and chronic disease management outcomes. KEY RESULTS: Participants in the intervention increased ambulatory training in both general medicine and specialty medicine and still met all ACGME training requirements. Residents reported improved subjective educational outcomes on a variety of chronic disease management topics and ambulatory care skills. They reported higher satisfaction with the amount of ambulatory training (4.3/5 vs. 3.6/5, p=0.008), attended more ambulatory clinics (242 vs. 154, p<0.001), and carried larger, more complicated panels (173 vs. 90 patients, p<0.001). They also performed better on diabetes management (86% vs. 76% control, p<0.001). Alumni who completed the intervention reported higher primary care career preparation (79% response rate) than those who did not (85% response rate) among an 11-year cohort of primary care alumni (4/5 vs. 3/5, p<0.001). CONCLUSIONS: A primary care training program that provides clinical immersion in the ambulatory setting improved educational outcomes for trainees and clinical outcomes for their patients. Providing more training in the ambulatory environment should be a priority in graduate medical education.

How Would You Treat This Patient Hospitalized With Community-Acquired Pneumonia? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Community-acquired pneumonia is a major cause of morbidity and mortality in the United States, leading to 1.5 million hospitalizations and at least 200 000 deaths annually. The 2019 American Thoracic Society/Infectious Diseases Society of America clinical practice guideline on diagnosis and treatment of adults with community-acquired pneumonia provides an evidence-based overview of this common illness. Here, 2 experts, a general internist who served as the co-primary author of the guidelines and a pulmonary and critical care physician, debate the management of a patient hospitalized with community-acquired pneumonia. They discuss disease severity stratification methods, whether to use adjunctive corticosteroids, and when to prescribe empirical treatment for multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.

Transcatheter Aortic Valve Replacement Versus Surgical Aortic Valve Replacement: How Would You Manage This Patient With Severe Aortic Stenosis? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Aortic stenosis (AS) is common, especially among the elderly. Left untreated, severe symptomatic AS is typically fatal. Surgical aortic valve replacement (SAVR) was the standard of care until transcatheter aortic valve replacement (TAVR) was shown to have lower mortality rates in patients at the highest surgical risk and was recommended for this group in the 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines. In the 2017 AHA/ACC focused update, evidence of benefit and noninferiority extended the use of TAVR to intermediate-risk patients. More recent studies suggest potential benefit to low-risk patients, although no published guidelines yet recommend the use of TAVR for this population. An advantage of SAVR is a 30-year experience with valve durability, but SAVR may have higher rates of perioperative death and a slower return of quality of life. Although TAVR has less than 10-year experience with valve durability, it has lower or noninferior primary end points, such as mortality and stroke, and fewer periprocedural complications among anatomically permissive patients. Here, a cardiologist and a cardiothoracic surgeon debate the risks and benefits of TAVR versus SAVR for a patient with severe symptomatic AS who is at low risk for surgical death.

Implementation of DHIS2 for Disease Surveillance in Guinea: 2015-2020.

A robust epidemic-prone disease surveillance system is a critical component of public health infrastructure and supports compliance with the International Health Regulations (IHR). One digital health platform that has been implemented in numerous low- and middle-income countries is the District Health Information System Version 2 (DHIS2). In 2015, in the wake of the Ebola epidemic, the Ministry of Health in Guinea established a strategic plan to strengthen its surveillance system, including adoption of DHIS2 as a health information system that could also capture surveillance data. In 2017, the DHIS2 platform for disease surveillance was piloted in two regions, with the aim of ensuring the timely availability of quality surveillance data for better prevention, detection, and response to epidemic-prone diseases. The success of the pilot prompted the national roll-out of DHIS2 for weekly aggregate disease surveillance starting in January 2018. In 2019, the country started to also use the DHIS2 Tracker to capture individual cases of epidemic-prone diseases. As of February 2020, for aggregate data, the national average timeliness of reporting was 72.2%, and average completeness 98.5%; however, the proportion of individual case reports filed was overall low and varied widely between diseases. While substantial progress has been made in implementation of DHIS2 in Guinea for use in surveillance of epidemic-prone diseases, much remains to be done to ensure long-term sustainability of the system. This paper describes the implementation and outcomes of DHIS2 as a digital health platform for disease surveillance in Guinea between 2015 and early 2020, highlighting lessons learned and recommendations related to the processes of planning and adoption, pilot testing in two regions, and scale up to national level.

Should This Patient Be Screened for Pancreatic Cancer? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Because pancreatic cancer is typically advanced at the time of diagnosis, it has a very low 5-year survival rate and may become the second leading cause of cancer death in the United States. A screening program to find early-stage pancreatic cancer is needed but has been challenging to develop because of the lack of an effective screening test. In 2019, the U.S. Preventive Services Task Force performed an evidence review and updated its guidance, confirming its 2004 "D" recommendation against routine screening for average-risk patients. Here, 2 experts review the updated guideline and recent evidence and discuss whether a patient with a family history of pancreatic cancer should undergo screening.

Leveraging Partnerships to Maximize Global Health Security Improvements in Guinea, 2015-2019.

In response to the 2014-2016 West Africa Ebola virus disease (EVD) outbreak, a US congressional appropriation provided funds to the US Centers for Disease Control and Prevention (CDC) to support global health security capacity building in 17 partner countries, including Guinea. The 2014 funding enabled CDC to provide more than 300 deployments of personnel to Guinea during the Ebola response, establish a country office, and fund 11 implementing partners through cooperative agreements to support global health security engagement efforts in 4 core technical areas: workforce development, surveillance systems, laboratory systems, and emergency management. This article reflects on almost 4 years of collaboration between CDC and its implementing partners in Guinea during the Ebola outbreak response and the recovery period. We highlight examples of collaborative synergies between cooperative agreement partners and local Guinean partners and discuss the impact of these collaborations in strengthening the above 4 core capacities. Finally, we identify the key elements of the successful collaborations, including communication and information sharing as a core cooperative agreement activity, a flexible funding mechanism, and willingness to adapt to local needs. We hope these observations can serve as guidance for future endeavors seeking to establish strong and effective partnerships between government and nongovernment organizations providing technical and operational assistance.

Caring for the Transgender Patient: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

The term transgender refers to persons whose gender identity is different from that recorded at birth. Similar to other marginalized populations, transgender patients commonly experience discrimination in the health care setting, and they may not have access to medical professionals who can provide competent care. In addition to primary medical and preventive health care, transgender patients need access to gender-affirming interventions, including hormone therapy and surgeries. In 2017, the Endocrine Society updated its clinical practice guideline for the care of transgender persons on the basis of the best available evidence from systematic reviews and individual studies. Among its general requirements for adolescents and recommendations for adults were the following: Involvement of a mental health professional who is knowledgeable about the diagnostic criteria for gender dysphoria and criteria for gender-affirming treatment, has training and experience in assessing psychopathology, and is willing to participate in ongoing care. Hormone therapy should be offered to transgender adult patients, with levels maintained within the normal range for gender identity and treatment appropriately monitored. Clinicians involved in the care of transgender adult patients should be knowledgeable about diagnostic criteria for gender dysphoria/gender incongruence, the use of medical and surgical gender-affirming interventions, and appropriate monitoring for reproductive organ cancer risk. Here, 2 clinicians with expertise in this area debate whether psychological evaluation is warranted in a transgender patient requesting gender-affirming hormones or surgery, the potential risks and benefits of estrogen therapy, and the role of the primary care practitioner in the care of transgender persons.

Medical Scribes, Provider and Patient Experience, and Patient Throughput: a Trial in an Academic General Internal Medicine Practice.

BACKGROUND: Medical scribes have been proposed as a solution to the problems of excessive documentation, work-life balance, and burnout facing general internists. However, their acceptability to patients and effects on provider experience have not been tested in a real-world model of effectiveness. OBJECTIVE: To measure the effect of medical scribes on patient satisfaction, provider satisfaction, and provider productivity. DESIGN: Quasi-experimental difference-in-differences longitudinal design. PARTICIPANTS: Four attending physicians who worked with scribes, 9 control physicians who did not, and their patients in a large, hospital-affiliated academic general internal medicine practice. MAIN MEASURES: Provider experience and patient experience using 5-point Likert scale surveys from the AMA Steps Forward Team Documentation Module, and visits and wRVUs per hour during 4 weeks before and 12 weeks after initiation of a practice model that included use of scribes and a shortened visit template. KEY RESULTS: Participating providers worked a total of 664 clinic sessions and returned 547 (82%) surveys. Average provider experience scores did not differ between providers working with scribes and control providers working without (4.01 vs. 3.40 respectively; p time-by-group interaction = 0.26). Providers with scribes were more likely to agree that work for the encounter would be completed during the visit then controls (3.58 vs. 2.48 respectively; p interaction = 0.04). A total of 6202 visits occurred during the study period. Average patient experience scores did not differ between the experimental and control groups (4.73 vs. 4.75 respectively; p interaction = 0.90). Compared with the control providers, providers with scribes completed more visits per hour (2.29 vs. 1.91; p interaction < 0.001) and generated more wRVUs per hour (3.42 vs. 3.27; p interaction < 0.001). CONCLUSIONS: In this test of a modified practice model, scribes supported greater patient throughput and improved provider perceptions of documentation burden with no decrement in high patient satisfaction.

How Would You Manage This Patient With Nonalcoholic Fatty Liver Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Nonalcoholic fatty liver disease (NAFLD), a common diagnosis in the United States and other developed countries, has been increasing in prevalence. The American Association for the Study of Liver Diseases recently published updated practice guidelines for diagnosing and managing NAFLD, including the following recommendations: Routine screening for NAFLD in high-risk groups is not advised because of uncertainties surrounding test and treatment options, along with a lack of knowledge about cost-effectiveness and long-term benefits. Noninvasive studies, including biomarkers from laboratory tests and liver stiffness measured through elastography, are clinically useful tools for identifying advanced fibrosis in patients with NAFLD. Liver biopsy should be considered in patients with NAFLD who are at increased risk for nonalcoholic steatohepatitis (NASH) or advanced fibrosis. Weight loss of at least 3% to 5% generally reduces NASH, but greater weight loss (7% to 10%) is needed to improve most histopathologic features, including fibrosis. Pharmacologic therapies (such as pioglitazone and vitamin E) should be considered only in patients with biopsy-proven NASH. Patients with NAFLD should not consume heavy amounts of alcohol, although insufficient data exist to provide advice about other levels of alcohol use. Here, 2 clinicians with expertise in this area debate whether to screen for NAFLD in primary care, how to monitor patients with NAFLD, and what interventions should be used to manage this condition.

Would You Refer This Patient With Cancer to a Palliative Care Specialist?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

In 2016, the American Society of Clinical Oncology published a guideline recommending that all patients with advanced cancer be referred to palliative care providers. This recommendation was based on a series of trials showing that palliative care, when added to standard oncology treatment, improves outcomes, including quality of life. Here, 2 oncologists, 1 of whom is also a palliative care specialist, debate the guideline and discuss how best to care for a 71-year-old woman with metastatic neuroendocrine carcinoma who has a short life expectancy but feels well and has no symptoms related to her cancer or chemotherapy.

Effect of a Flipped Classroom on Knowledge Acquisition and Retention in an Internal Medicine Residency Program.

BACKGROUND: The flipped classroom is a teaching approach with strong evidence for effectiveness in undergraduate medical education. Objective data for its implementation in graduate medical education are limited. OBJECTIVE: We assessed the efficacy of the flipped classroom compared with standard approaches on knowledge acquisition and retention in residency education. METHODS: During academic year 2016-2017, 63 medical interns in a large academic internal medical residency program on their ambulatory block were randomized to a flipped classroom or standard classroom during a 6-hour cardiovascular prevention curriculum. The primary outcome was performance on a 51-question knowledge test at preintervention, immediate postintervention, and 3- to 6-month postintervention (delayed postintervention). Secondary outcomes included satisfaction with the instructional method and preparation time for the flipped classroom versus standard approach. We also examined feasibility and barriers to the flipped classroom experience. RESULTS: All 63 interns (100%) responded during the preintervention period, 59 of 63 (94%) responded during the postintervention period, and 36 of 63 (57%) responded during the delayed postintervention. The flipped classroom approach significantly improved knowledge acquisition immediately after the curriculum compared with the standard approach (knowledge test scores 77% versus 65%, P < .0001). This effect was sustained several months later (70% versus 62%, P = .0007). Participants were equally satisfied with the flipped classroom and standard classroom. CONCLUSIONS: A flipped classroom showed greater effectiveness in knowledge gain compared with a standard approach in an ambulatory residency environment.