An observational pre-post study of re-structuring Medicine inpatient teaching service: Improved continuity of care within constraint of 2011 duty hours.

BACKGROUND: Implementation of more stringent regulations on duty hours and supervision by the Accreditation Council for Graduate Medical Education in July 2011 makes it challenging to design inpatient Medicine teaching service that complies with the duty hour restrictions while optimizing continuity of patient care. OBJECTIVE: To prospectively compare two inpatient Medicine teaching service structures with respect to residents' impression of continuity of patient care (primary outcome), time available for teaching, resident satisfaction and length-of-stay (secondary endpoints). DESIGN: Observational pre-post study. METHODS: Surveys were conducted both before and after Conventional Medicine teaching service was changed to a novel model (MegaTeam). SETTINGS: Academic General Medicine inpatient teaching service. RESULTS: Surveys before and after MegaTeam implementation were completed by 68.5% and 72.2% of internal medicine residents, respectively. Comparing conventional with MegaTeam, the % of residents who agreed or strongly agreed that the (i) ability to care for majority of patients from admission to discharge increased from 29.7% to 86.6% (p<0.01); (ii) the concern that number of handoffs was too many decreased from 91.9% to 18.2% (p<0.01); (iii) ability to provide appropriate supervision to interns increased from 38.1% to 70.7% (p<0.01); (iv) overall resident satisfaction with inpatient Medicine teaching service increased from 24.7% to 56.4% (p<0.01); and (v) length-of-stay on inpatient Medicine service decreased from 5.3±6.2 to 4.9±6.8 days (p<0.03). CONCLUSIONS: According to our residents, the MegaTeam structure promotes continuity of patient care, decreases number of handoffs, provides adequate supervision and teaching of interns and medical students, increases resident overall satisfaction and decreases length-of-stay.

Evaluating the role of single-photon emission computed tomography in the assessment of neurotologic complaints.

We conducted a retrospective study to reexamine the value of single-photon emission computed tomography (SPECT) in the evaluation of patients with neurotologic complaints, and to assess the intra- and inter-radiologist variability of SPECT readings. Our study population was made up of 63 patients--23 men and 40 women, aged 34 to 91 years (mean: 59)--who had presented to a tertiary care otolaryngology practice and university hospital for evaluation of head trauma, sensorineural hearing loss, tinnitus, and/or vertigo. All patients had undergone brain scanning with SPECT during their evaluation, and almost all had also undergone magnetic resonance imaging (MRI) and standard computed tomography (CT). We compared the findings of all three imaging modalities in terms of their ability to detect neurotologic abnormalities. We found that detection rates were very similar among the three modalities; abnormalities were found in 24% of SPECT scans, 26% of MRIs, and 23% of CTs. Nevertheless, we did find that among 60 patients who underwent all three types of imaging, 13 (22%) exhibited areas of cerebral hypoperfusion on SPECT while their MRIs and CTs were read as either normal or nonspecific. In all, 18 of these 60 patients (30%) exhibited normal or nonspecific findings on all three types of imaging. In addition, when SPECT scans were read by the same radiologist at different times, different results were reported for 17 of the 63 scans (27%). Likewise, when SPECT scans were read by different radiologists, different results were reported for 21 of 63 scans (33%). We conclude that SPECT may be a valuable complementary diagnostic modality for making a comprehensive neurotologic evaluation and that it may detect abnormalities in some patients whose other imaging is read as normal. However, we did not find that SPECT was the most sensitive of the three modalities in neurotologic evaluation, as we had previously found in a preliminary study that the senior author (R.T.S.) published in 1996. In addition, with respect to our radiologists, both their intra- and inter-reader reliability was low, and we recommend additional study on this matter.

The predictors of postoperative laryngeal nerve paresis in patients undergoing thyroid surgery: a pilot study.

OBJECTIVES: The objective of this study was to evaluate the factors predictive of postoperative laryngeal nerve paresis (LNP) in patients undergoing thyroid surgery. We also assess the implications of preoperative LNP on postoperative vocal fold status. STUDY DESIGN: Case series with retrospective chart review. METHODS: Charts of 17 patients who underwent thyroid surgery and had pre- and postoperative laryngeal electromyography (LEMG) were reviewed. LEMGs were ordered routinely in all patients undergoing thyroid surgery, not just in those with clinical findings suggestive of paresis. We collected data relating to pre- and postoperative laryngeal and thyroid evaluations and the details of the surgical procedure. We analyzed the prevalence of preoperative LNP and relationship of thyroid diagnoses, size of thyroid mass, and type of surgery performed with respect to the outcome of the LNP. RESULTS: All the 17 patients had a mild to moderate degree of unilateral or bilateral LNP preoperatively. However, only seven (41.2%) had vocal symptoms. After surgery, only five of these seven patients had voice complaints, and there were no patients with voice complaints among the group that had been asymptomatic preoperatively. Thyroid diagnoses included 11 cases of benign disease (64.7%) in which LNP improved in two, worsened in four, and remained the same in five; and six cases of malignant disease (35.3%) in which LNP improved in none, worsened in two, and remained the same in four. Predictors of worsening postoperative LNP on LEMG included the diagnosis of goiter (P=0.0005) and size of mass greater than 5cm (0.032). CONCLUSIONS: This study supports the notion that there is an intrinsic relationship between benign thyroid diseases and LNP that is probably related to local effects of the disease on the laryngeal nerves. All patients with the postoperative diagnosis of goiter worsened, and all patients with the postoperative diagnosis of adenoma showed no change on postoperative electromyography (EMG). Similarly, all patients with the diagnosis of thyroiditis alone improved, and there were no cases of improvement outside this group. Of the six cases of malignancy, four exhibited no change on EMG and only two worsened. The only reliable predictors of worsening paresis postoperatively are mass size greater than 5cm and diagnosis of goiter.

The prevalence of undiagnosed thyroid disease in patients with symptomatic vocal fold paresis.

OBJECTIVE: Vocal fold paresis has a multifactorial etiology and is idiopathic in many individuals. The incidence of thyroid-related neuropathy in the larynx has not been previously described. The purpose of this study was to evaluate the prevalence of previously undiagnosed thyroid disease in patients with laryngeal neuropathy and to compare this prevalence with that in a cohort of patients with a neurotologic neuropathy. STUDY DESIGN AND SETTING: Case series with chart review; tertiary care, otolaryngology practice. SUBJECTS AND METHODS: Charts of 308 consecutive patients with dysphonia and vocal fold paresis and 333 consecutive patients with sensorineural hearing loss, who presented for evaluation during a 3-year period, were reviewed. RESULTS: One hundred forty-six of 308 (47.4%) patients with vocal fold paresis were diagnosed with concurrent thyroid disease, whereas 55 of 333 (16.5%) patients with sensorineural hearing loss were diagnosed with concurrent thyroid disease (P<0.001, Pearson chi-square = 92.896; degrees of freedom = 5). Thyroid diagnoses among those with vocal fold paresis included benign growths (29.9%), thyroiditis (7.8%), hyperthyroidism (4.5%), hypothyroidism (3.6%), and thyroid malignancy (1.6%). CONCLUSIONS: Thyroid abnormalities are more prevalent in patients with dysphonia and vocal fold paresis than in patients with symptomatic sensorineural hearing loss, suggesting a greater association between previously undiagnosed thyroid abnormalities and laryngeal neuropathy than that between neurotologic neuropathy and thyroid disease.