Use of the Consultation Letter Rating Scale among Geriatric Medicine Postgraduate Trainees.

OBJECTIVES: The implementation of competency-based evaluations increases the emphasis on in-training assessment. The Consultation Letter Rating Scale (CLRS), published by the Royal College of Physicians and Surgeons of Canada, is a tool that assesses written-communication competencies. This multisite project evaluated the tool's validity, reliability, feasibility, and acceptability for use in postgraduate geriatric medicine training. METHODS: Geriatric medicine trainees provided consultation letters from the 2017-2018 academic year. Geriatricians reviewed a standardized module and completed the tool for all the deidentified letters. The reviewers recorded the time used to complete the tool for each letter and completed a survey on content validity. Trainees completed a survey on the tool's usefulness. Responses were reviewed independently by two authors for thematic content. The unweighted and the weighted κ were used to measure interrater reliability. RESULTS: A total of 10 of 11 (91%) eligible trainees each provided five letters that were reviewed independently by six geriatricians, leading to a total of 300 assessments. A very small portion (4% [N = 12]) of assessments was incomplete. An average of 4.82 minutes (standard deviation = 3.17) was used to complete the tool. There was high interrater agreement for overall scores, with a multiple-rater weighted κ of 83% (95% confidence interval = 76%-89%). The interrater agreement was lower for the individual components. Both raters and trainees found the comments more useful than the numerical ratings. CONCLUSIONS: Our results support the use of the CLRS for facilitating feedback on the quality of consult letters to improve written-communication competencies among geriatric medicine trainees. J Am Geriatr Soc 67:2157-2160, 2019.

A Challenging Diagnosis of IgG4-Related Disease When Understanding Limitations of Laboratory Testing Was Pivotal.

A 76-year-old man was incidentally found on a CT scan to have lymphadenopathy and bilateral kidney enlargement suggestive of infiltrative renal disease. He was largely asymptomatic but had bilateral salivary and lacrimal gland enlargement. A grossly elevated serum IgG (>70 g/L) with concomitant suppression of other immunoglobulins, a small IgG restriction, and a parotid biopsy revealing lymphoplasmacytic infiltrate with slight kappa light chain excess all suggested a lymphoproliferative disorder (LPD). The diagnostic workup was further confounded by a normal serum IgG4 concentration. Moreover, bone marrow and renal biopsies did not reveal evidence of LPD. Discussion with the laboratory not only clarified that the markedly increased total IgG could not be accounted for by the small IgG restriction, but also identified a discrepancy in the IgG4 measurement. Repeat analysis of a follow-up sample revealed an elevated IgG4 of 5.94 (reference interval: 0.039-0.864) g/L, which prompted a repeat parotid biopsy that showed predominant IgG4+ lymphocytic infiltrates. Despite the deluding presentations, a final diagnosis of IgG4-related disease (IgG4-RD) was made based on elevated serum IgG4 concentrations and histopathological findings. This case highlights the importance of recognizing limitations of laboratory testing and the benefit of close communications among clinical subspecialties and the laboratory.

Validation of a Food Frequency Questionnaire for Bone Nutrients in Pregnant Women.

PURPOSE: The aim was to validate a food frequency questionnaire (FFQ) against a 3-day food record (3DFR) for pregnant women with a focus on nutrients important for bone health from food and supplements. METHODS: The FFQ and 3DFR were administered to pregnant women (n = 42) aged 18-45 years in their third trimester of pregnancy in Hamilton, Ontario. Nutrient analysis of intakes was conducted using an FFQ calculator and Nutritionist-Pro software. The average daily serving consumption of Milk and alternatives group and Vegetable subgroup from Canada's Food Guide were also compared. RESULTS: There was a high positive correlation between methods for total dietary vitamin D (r = 0.83). Low positive associations were observed for total protein (r = 0.37), calcium (r = 0.36), vitamin K (r = 0.41), and servings of Milk and alternatives (r = 0.36). A cross-classification analysis using participants' intake quartiles revealed no major misclassifications. Bland-Altman analysis showed that the FFQ mildly underestimated the intake for protein, whereas it grossly overestimated the intake of vitamin K, and daily servings of Milk and alternatives and Vegetable. CONCLUSIONS: This FFQ can serve as a useful tool in clinical and research settings to assess key bone nutrients from foods and supplement sources in pregnant women.

Pre-Clerkship Observerships to Increase Early Exposure to Geriatric Medicine.

BACKGROUND AND PURPOSE: To foster interest in geriatric care, the Queen's Geriatrics Interest Group (QGIG) collaborated with the Division of Geriatric Medicine to arrange a Geriatrics Pre-Clerkship Observership Program. METHODS: Forty-two pre-clerkship medical students participated in the program between October 2013 and May 2014. Participants were paired with a resident and/or attending physician for a four-hour weekend observership on an inpatient geriatric rehabilitation unit. The program was assessed using: (1) internally developed Likert scales assessing student's experiences and interest in geriatric medicine before and after the observership; (2) University of California Los Angeles-Geriatric Attitudes Scale (UCLA-GAS); and (3) narrative feedback. RESULTS: All participants found the process of setting up the observership easy. Some 72.7% described the observership experience as leading to positive changes in their attitude toward geriatric medicine and 54.5% felt that it stimulated their interest in the specialty. No statistically significant change in UCLA-GAS scores was detected (mean score pre- versus post-observership: 3.5 ± 0.5 versus 3.7 ± 0.4; p=.35). All participants agreed that the program should continue, and 90% stated that they would participate again. CONCLUSIONS: The observership program was positively received by students. Structured pre-clerkship observerships may be a feasible method for increasing exposure to geriatric medicine.