Internal medicine rounding practices and the Accreditation Council for Graduate Medical Education core competencies.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) has established the requirement for residency programs to assess trainees' competencies in 6 core domains (patient care, medical knowledge, practice-based learning, interpersonal skills, professionalism, and systems-based practice). As attending rounds serve as a primary means for educating trainees at academic medical centers, our study aimed to identify current rounding practices and attending physician perceived capacity of different rounding models to promote teaching within the ACGME core competencies. METHODS: We disseminated a 24-question survey electronically using educational and hospital medicine leadership mailing lists. We assessed attending physician demographics and the frequency with which they used various rounding models, as defined by the location of the discussion of the patient and care plan: bedside rounds (BR), hallway rounds (HR), and card-flipping rounds (CFR). Using the ACGME framework, we assessed the perceived educational value of each model. RESULTS: We received 153 completed surveys from attending physicians representing 34 institutions. HR was used most frequently for both new and established patients (61% and 43%), followed by CFR for established patients (36%) and BR for new patients (22%). Most attending physicians indicated that BR and HR were superior to CFR in promoting the following ACGME competencies: patient care, systems-based practice, professionalism, and interpersonal skills. CONCLUSIONS: HR is the most commonly employed rounding model. BR and HR are perceived to be valuable for teaching patient care, systems-based practice, professionalism, and interpersonal skills. CFR remains prevalent despite its perceived inferiority in promoting teaching across most of the ACGME core competencies.

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Hospitals now have the responsibility to implement strategies to prevent adverse outcomes after discharge. This systematic review addressed the effectiveness of hospital-initiated care transition strategies aimed at preventing clinical adverse events (AEs), emergency department (ED) visits, and readmissions after discharge in general medical patients. MEDLINE, CINAHL, EMBASE, and Cochrane Database of Clinical Trials (January 1990 to September 2012) were searched, and 47 controlled studies of fair methodological quality were identified. Forty-six studies reported readmission rates, 26 reported ED visit rates, and 9 reported AE rates. A "bridging" strategy (incorporating both predischarge and postdischarge interventions) with a dedicated transition provider reduced readmission or ED visit rates in 10 studies, but the overall strength of evidence for this strategy was low. Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. Most studies did not report intervention context, implementation, or cost. The strategies hospitals should implement to improve patient safety at hospital discharge remain unclear.

Assessing bleeding risk in patients taking anticoagulants.

Anticoagulant medications are commonly used for the prevention and treatment of thromboembolism. Although highly effective, they are also associated with significant bleeding risks. Numerous individual clinical factors have been linked to an increased risk of hemorrhage, including older age, anemia, and renal disease. To help quantify hemorrhage risk for individual patients, a number of clinical risk prediction tools have been developed. These risk prediction tools differ in how they were derived and how they identify and weight individual risk factors. At present, their ability to effective predict anticoagulant-associated hemorrhage remains modest. Use of risk prediction tools to estimate bleeding in clinical practice is most influential when applied to patients at the lower spectrum of thromboembolic risk, when the risk of hemorrhage will more strongly affect clinical decisions about anticoagulation. Using risk tools may also help counsel and inform patients about their potential risk for hemorrhage while on anticoagulants, and can identify patients who might benefit from more careful management of anticoagulation.

"Can we just stop and talk?" patients value verbal communication about discharge care plans.

BACKGROUND: Studies show that hospitalized patients often do not understand their postdischarge care plan. There are few studies about patients' preferences regarding the content of discharge care plans. OBJECTIVE: To identify what patients view as essential elements of a post-hospitalization plan. DESIGN: Anonymous written survey distributed on the second day of admission to internal medicine wards. SETTING: An academic tertiary care hospital and an academic county hospital in Seattle, Washington. PATIENTS: Two hundred English-speaking adult inpatients ≥ 18 years or their proxies. RESULTS: The majority of patients (64.5%) surveyed wanted verbal discharge instructions, with only 10.5% requesting written instructions (P < 0.0001). One hundred percent of patients valued the following discharge instructions as essential: "when you need to follow-up with [primary care provider] PCP," "warning signs to call PCP," and "medicines to continue post-hospitalization." One hundred percent of patients wanted "a lot of information about my condition" and "test results," but only 39% wanted "a lot of information about my medications" (P < 0.0001). When asked to choose the most important piece of discharge instruction related to their disease, 67.5% of patients chose "lifestyle changes." One hundred percent of patients thought that personal communication between the inpatient provider and the outpatient primary care provider was "extremely important" or "essential." CONCLUSION: Patients uniformly placed high value on: 1) verbal communication about discharge care plans; 2) information about lifestyle changes for improved health; and 3) personal communication between inpatient and outpatient providers.

The forest for the trees: tuberculosis control efforts in west Kalimantan.

Alam Sehat Lestari (ASRI), an Indonesian-American, non-profit organization located on the border of Gunung Palung National Park in west Kalimantan on the island of Borneo, is linking the delivery of health care to the conservation of natural resources. The clinic's experience shows that an unconventional 'forests-for-health care' incentive programme can provide a powerful way to break the cycle that links poverty, poor health and environmental destruction around the park. However, the challenges of preventing, diagnosing and treating tuberculosis in this setting remain considerable and success will still depend upon a multilateral collaborative approach.

The Harvard trauma questionnaire: adapting a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Iraqi refugees.

BACKGROUND: Mental health assessments in post-conflict zones have relied heavily on Western psychiatric scales. Yet, a strict dependence on the paradigms of Western psychiatry risks inappropriately prioritizing syndromes, such as PTSD, which, however important, are eclipsed by local concerns. MATERIAL AND DISCUSSION: In Dearborn, Michigan, home to the largest population of Iraqi refugees in the United States, 60 Iraqi refugee life stories were collected in order to adapt the Harvard Trauma Questionnaire (HTQ) to the Iraqi context. CONCLUSION: The methodology described proved to be a useful approach to developing a trauma measure that is culturally grounded in a multi-dimensional model of mental health.

GABA(B) receptor activation in the ventral tegmental area inhibits the acquisition and expression of opiate-induced motor sensitization.

Opiate-induced motor sensitization refers to the progressive and enduring motor response that develops after intermittent drug administration, and results from neuroadaptive changes in ventral tegmental area (VTA) and nucleus accumbens (NAc) neurons. Repeated activation of mu-opioid receptors localized on gamma-aminobutyric acid (GABA) neurons in the VTA enhances dopaminergic cell activity and stimulates dopamine release in the nucleus accumbens. We hypothesize that GABA(B) receptor agonist treatment in the VTA blocks morphine-induced motor stimulation, motor sensitization, and accumbal Fos immunoreactivity by inhibiting the activation of dopaminergic neurons. First, C57BL/6 mice were coadministered a single subcutaneous injection of morphine with intra-VTA baclofen, a GABA(B) receptor agonist. Baclofen produced a dose-dependent inhibition of opiate-induced motor stimulation that was attenuated by 2-hydroxysaclofen, a GABA(B) receptor antagonist. Next, morphine was administered on days 1, 3, 5, and 9 and mice demonstrated sensitization to its motor stimulant effects and concomitant induction of Fos immunoreactivity in the NAc shell (NAcS) but not NAc core. Intra-VTA baclofen administered during morphine pretreatment blocked the acquisition of morphine-induced motor sensitization and Fos activation in the NAcS. Intra-VTA baclofen administered only on day 9 blocked the expression of morphine-induced motor sensitization and Fos activation in the NAcS. A linear relationship was found between morphine-induced motor activity and accumbal Fos in single- and repeated-dose treatment groups. In conclusion, GABA(B) receptor stimulation in the VTA blocked opiate-induced motor stimulation and motor sensitization by inhibiting the activation of NAcS neurons. GABA(B) receptor agonists may be useful pharmacological treatments in altering the behavioral effects of opiates.

Baclofen inhibits opiate-induced conditioned place preference and associated induction of Fos in cortical and limbic regions.

In C57BL/6 mice, pretreatment with GABA(B) receptor agonist baclofen blocked the rewarding effects of morphine as measured by acquisition of conditioned place preference. Fos immunoreactivity, a neuronal activity marker, was induced in opiate conditioned mice in several forebrain regions including the nucleus accumbens core and shell, anterior cingulate cortex, and prelimbic cortex. Baclofen pretreatment blocked the induction of Fos in opiate conditioned subjects. These result suggest that GABA(B) receptor transmission has a role in reversing morphine-induced activation of motivational circuitry and conditioned reward.

Cellular localization, oligomerization, and membrane association of the hereditary spastic paraplegia 3A (SPG3A) protein atlastin.

Hereditary spastic paraplegias comprise a group of clinically heterogeneous syndromes characterized by lower extremity spasticity and weakness, with distal axonal degeneration in the long ascending and descending tracts of the spinal cord. The early onset hereditary spastic paraplegia SPG3A is caused by mutations in the atlastin/human guanylate-binding protein-3 gene (renamed here atlastin-1), which codes for a 64-kDa member of the dynamin/Mx/guanylate-binding protein superfamily of large GTPases. The atlastin-1 protein is localized predominantly in brain, where it is enriched in pyramidal neurons in the cerebral cortex and hippocampus. In cultured cortical neurons, atlastin-1 co-localized most prominently with markers of the Golgi apparatus, and immunogold electron microscopy revealed a predominant localization of atlastin-1 to the cis-Golgi. Yeast two-hybrid analyses and co-immunoprecipitation studies demonstrated that atlastin-1 can self-associate, and gel-exclusion chromatography and chemical cross-linking studies indicated that atlastin-1 exists as an oligomer in vivo, most likely a tetramer. Membrane fractionation and protease protection assays revealed that atlastin-1 is an integral membrane protein with two predicted transmembrane domains; both the N-terminal GTP-binding and C-terminal domains are exposed to the cytoplasm. Together, these findings indicate that the SPG3A protein atlastin-1 is a multimeric integral membrane GTPase that may be involved in Golgi membrane dynamics or vesicle trafficking.