Getting SET for Student Success: Foundations for a Student Education Team.

BACKGROUND: Family medicine clinical education poses logistic issues that we sought to address with the Student Education Team model. METHODS: The model combined team-based, patient-centered care with student experiences in a sustainable precepting model. Four learners successfully underwent precepting simultaneously. Schedulers booked patients in the team schedule, and the patients knew they would see a student and a faculty team member. RESULTS: The Student Education Team model increased the learner to preceptor ratio compared to traditional precepting models. Use of the team increased the number of learners completing rotations. The team schedule nearly eliminated patients refusing student involvement and enhanced throughput because patients saw the most readily available staff. DISCUSSION: The team offered clinicians and learners a model for incorporating learning into clinicians' schedules.

Case of fatal eastern equine encephalitis.

Eastern Equine Encephalitis (EEE) is a rare and very serious arbovirus that is transmitted to humans through the bite of infected mosquitoes. When symptomatic, patients with this condition are typically seriously ill and the fatality rate is high. We present a fatal case of EEE that exhibited classic symptoms and findings. Included are high quality MRI images that show the classic radiographic findings of this infection. In addition to confirmatory laboratory findings, the case report includes pathologic specimens from brain tissue obtained at autopsy. Perhaps due to climate change and human encroachment on mosquito habitat, there is a westward spread of EEE in the United States.

Effect of a Statewide Controlled-Substance Monitoring Requirement on the Opioid Prescribing Practice for Treatment of Acute Pain.

BACKGROUND: The US government affirmed the opioid epidemic as a public health emergency in late 2017. Prior to that, as part of the Heroin, Opiate, Prevention, and Education (HOPE) Agenda, the state of Wisconsin enacted 2015 Wisconsin Act 266. This law, which went into effect April 1, 2017, requires prescribers to review data from the state's enhanced Prescription Drug Monitoring Program (ePDMP) before issuing an opioid prescription, in order to reduce inappropriate prescriptions and, ultimately, decrease opioid overuse. OBJECTIVE: To evaluate the effect of 2015 Wisconsin Act 266 on opioid prescriptions for acute pain in Mayo Clinic Health System sites in northwest Wisconsin. PATIENTS AND METHODS: This retrospective review included all eligible patients who were discharged from emergency or urgent care departments in the Mayo Clinic Health System at northwest Wisconsin sites during the study period. The quantity of opioids prescribed (measured in morphine milligram equivalents per patient encounter) and the total number of opioid prescriptions were compared for the periods May and June 2016 (prior to implementation of Act 266) versus May and June 2017 (post-implementation of Act 266). RESULTS: A 33% reduction occurred in the median opioid quantity prescribed per patient encounter in the post-implementation period vs the pre-implementation period (P <0.001). In addition, a 13% relative reduction occurred in the percentage of patient encounters that involved an opioid prescription (P <0.001). No difference was observed in opioid prescription agents between time periods, except for an increase in morphine prescriptions (P <0.001. CONCLUSION: The HOPE Agenda, specifically 2015 Wisconsin Act 266, appears to have had a positive effect on decreased opioid prescriptions for acute pain at Mayo Clinic Health System sites in northwest Wisconsin.

A Unique Pattern on Memory Testing in Dementia Screening Predicts Obstructive Sleep Apnea.

OBJECTIVES: The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is used to screen for dementia in many Wisconsin Alzheimer Institute memory care clinics. After observing a pattern of lower scores for immediate memory than for delayed memory (immediate memory < delayed memory) that seemed to predict obstructive sleep apnea in patients seen in our memory care clinic, we aimed to confirm the validity of this finding. METHODS: We retrospectively identified all patients seen in our memory care clinic from December 2011 through December 2014 who completed the RBANS. The frequency of obstructive sleep apnea was determined among those with the pattern of interest (immediate memory < delayed memory). RESULTS: Among 191 patients who met the inclusion criteria, 81 (42%) displayed the immediate memory < delayed memory pattern. Of these, 54 patients had been or were subsequently tested for obstructive sleep apnea; 35 (65%) were positive. In the positive group, the mean age was 74 years; 60% were women. CONCLUSIONS: Obstructive sleep apnea is a known risk factor for cognitive dysfunction. It is a potentially treatable cause of memory loss that can be clinically silent. This study shows that a unique pattern (immediate memory < delayed memory) on the RBANS commonly used at memory care clinics can identify a group of patients who can be evaluated and treated for this common and remediable condition.

Identification and treatment of bronchoconstriction induced by a vagus nerve stimulator employed for management of seizure disorder.

We evaluated a 63-year-old woman who developed dyspnea with a sensation of chest tightness that was temporally associated with discharges from a vagus nerve stimulator that had been implanted for the control of intractable seizures. Spirometry demonstrated the development of significant airflow obstruction associated with the firing of the stimulator. Adjustment of the stimulator settings resolved the discharge-associated bronchoconstrictive phenomenon. These findings highlight an important association between vagus nerve stimulators and dyspnea that should be considered in the differential diagnosis of patients with these devices who present with dyspnea and/or chest tightness. The relative importance of vagal stimulation to bronchoconstriction is suggested by the findings.