Time and Note Characteristic Effects of an Electronic Health Record Template for Internal Medicine Resident Notes.

Background Inpatient internal medicine (IM) residents spend most of their time on indirect patient care activities such as clinical documentation. Objective We developed optimized electronic health record (EHR) templates for IM resident admission and progress notes, with the objective to reduce note-writing time, shorten note length, and decrease the percentage of progress note text that was copy-forwarded from prior notes. Methods In 2022, a multidisciplinary team created, over an 8-month period, optimized EHR templates for IM resident admission and progress notes. A retrospective analysis was performed to assess differences in resident time spent writing notes, note length in characters, and percentage of progress note text that was copy-forwarded. All 94 residents in the IM residency program had the opportunity to use the novel templates. Results Following implementation of the novel templates, residents spent on average 3.6 minutes less per progress note compared to pre-intervention (P=.008; 95% CI of the difference: 1.1-6.0 minutes). Notes in the post-intervention period were shorter for admission notes (mean reduction of 1041 characters; P<.001; 95% CI of the difference: 448-1634 characters) and progress notes (mean reduction of 764 characters; P<.001; 95% CI of the difference: 103-1426 characters). Progress notes also saw an average 22% decrease of copy-forwarded text (P<.001, 95% CI of the difference: 18.7%-25.4%). Conclusions The optimized note templates led to a reduction in resident progress note-writing time, shortened note length, and a lower percentage of copy-forwarded text.

Case Series of End-Stage Liver Disease Patients with Severe Coccidioidomycosis.

Liver disease causes relative compromise of the host immune system through multiple overlapping mechanisms and is an established risk factor for invasive fungal diseases including candidiasis and cryptococcosis. This immunologic derangement also leads to rapid progression of disease with resultant increases in morbidity and mortality. We describe severe coccidioidomycosis cases in the setting of liver dysfunction. Collaborative multi-center epidemiologic studies should be performed to determine the incidence of severe coccidioidomycosis in patients with concurrent liver disease.

Cancer.

Malignancy is the second leading cause of death in the United States, following heart disease. In most cancers, early detection is one of the most important factors in determining prognosis. As clinicians it is therefore important to be aware of potential clues of underlying malignancy on physical examination. Given the wide range of malignancies, and the heterogeneous nature of their presentations, this article is by no means exhaustive. Instead, it discusses in depth some of the more frequently encountered physical examination findings that may suggest malignancy. Specifically, it covers lymphadenopathy, cutaneous findings related to various cancers, and malignancy related thrombosis.

Traumatic Brain Injury and Firearm Use and Risk of Progressive Supranuclear Palsy Among Veterans.

Background: Progressive supranuclear palsy (PSP) is a tauopathy that has a multifactorial etiology. Numerous studies that have investigated lead exposure and traumatic brain injury (TBI) as risk factors for other tauopathies, such as Alzheimer's disease, but not for PSP. Objective: We sought to investigate the role of firearm usage, as a possible indicator of lead exposure, and TBI as risk factors for PSP in a population of military veterans. Methods: We included participants from a larger case-control study who reported previous military service. Our sample included 67 PSP cases and 68 controls. Participants were administered a questionnaire to characterize firearm use in the military and occurrence of TBI. Results: Cases were significantly less educated than controls. In unadjusted analyses, the proportion of PSP cases (80.6%) and controls (64.7%) who reported use of firearms as part of their military job was positively associated with PSP, odds ratio (OR) 2.2 (95% CI: 1-5.0). There were no significant case-control differences in mean service duration. There was only a weak association with history of TBI, OR 1.6 (95% CI: 0.8-3.4). In multivariate models, firearm usage (OR 3.7, 95% CI: 1.5, 9.8) remained significantly associated with PSP. Conclusions: Our findings show a positive association between firearm usage and PSP and an inverse association between education and PSP. The former suggests a possible etiologic role of lead. Further studies are needed to confirm the potential etiologic effects of metals on PSP. The study was registered in clinicaltrials.gov. ClinicalTrials.gov Identifier: NCT00431301.

Description of Mexican Cleft Surgeons' Experience With Foreign Surgical Volunteer Missions in Mexico.

BACKGROUND AND PURPOSE: Mexican cleft surgeons provide multidisciplinary comprehensive cleft lip and palate care to children in Mexico. Many Mexican cleft surgeons have extensive experience with foreign, visiting surgeons. The purpose of this study was to characterize Mexican cleft surgeons' domestic and volunteer practice and to learn more about Mexican cleft surgeons' experience with visiting surgeons. METHODS: A cross-sectional validated e-mail survey tool was sent to Mexican cleft surgeons through 2 Mexican plastic surgery societies and the Asociación Mexicana de Labio y Paladar Hendido y Anomalías Craneofaciales, the national cleft palate society that includes plastic and maxillofacial surgeons who specialize in cleft surgery. We utilized validated survey methodology, including neutral fact-based questions and repeated e-mails to survey nonresponders to maximize validity of statistical data; response rate was 30.6% (n = 81). RESULTS: Mexican cleft surgeons performed, on average, 37.7 primary palate repairs per year with an overall complication rate of 2.5%; 34.6% (n = 28) of respondents had direct experience with patients operated on by visiting surgeons; 53.6% of these respondents performed corrective surgery because of complications from visiting surgeons. Respondents rated 48% of the functional outcomes of visiting surgeons as "acceptable," whereas 43% rated aesthetic outcomes of visiting surgeons as "poor"; 73.3% of respondents were never paid for the corrective surgeries they performed. Thirty-three percent of Mexican cleft surgeons believe that there is a role for educational collaboration with visiting surgeons. CONCLUSIONS: Mexican cleft surgeons have a high volume of primary cleft palate repairs in their domestic practice with good outcomes. Visiting surgeons may play an important role in Mexican cleft care through educational collaborations that complement the strengths of Mexican cleft surgeons.

Predictors, Quality Markers, and Economics of Volunteering Internationally: Results from a Comprehensive Survey of American Society of Plastic Surgeons Members.

BACKGROUND: Plastic surgeons have a long history of international volunteer work. To date, there have been no outcome-based studies among surgeons who volunteer internationally. The purpose of this study was to describe predictors of volunteering, clinical quality markers, and economics of international volunteering among American plastic surgeons. METHODS: A cross-sectional validated e-mail survey tool was sent to all board-certified plastic surgeons by the American Society of Plastic Surgeons. The survey response rate was 15 percent (745 total individuals), of which 283 respondents traveled within the past 5 years. Analysis was performed in R. Stepwise multivariate logistic regression was performed to determine the predictors of death/complication. RESULTS: Respondents reported high use of medical records, follow-up care, and host affiliation. Fewer than half of all respondents reported use of international safety surgery guidelines, and the majority of respondents reported volunteering abroad outside of their scope of practice. The majority of children younger than 5 years were not cared for by a pediatric anesthesiologist. The majority of participants reported personally spending more than $1000 on their last trip and performing surgery estimated to be worth on average $28,000 each. CONCLUSIONS: International surgical volunteer trips attempt to ease the global burden of surgical disease. The authors' study reports variation in quality of care provided on these trips. Most significantly, the majority of children younger than 5 years were not cared for by a pediatric anesthesiologist, and many plastic surgeons operated outside of their scope of practice.

The Role of Stress as a Risk Factor for Progressive Supranuclear Palsy.

BACKGROUND: PSP, like Alzheimer's disease (AD), is a tauopathy. The etiopathogenesis of PSP is not well known and the role of stress has not yet been examined. Recent studies have shown that stress increases the risk for developing AD. This study investigates the role of stress as a risk factor for PSP. OBJECTIVE: B To examine the association between the development of progressive supranuclear palsy (PSP) and self-reported life stressors. METHODS: 76 patients diagnosed with PSP according to the NINDS-SPSP criteria and 68 age-matched unrelated controls were administered a life stressor questionnaire. Stress was quantified as total number of events, number of life changing events, and number of events characterized by self-rated severity. Conditional odds ratio (OR) was calculated for each measure, with participants in the highest quartile of each measure being defined as high-exposure in relation to all other participants. RESULTS: There were no significant differences between the reported number of total events or life-changing events in cases and controls. However, we found 24.4% of cases (N = 11) and 9.1% of controls (N = 5) had a higher exposure to high severity events, yielding an OR of 3.2 (p = 0.04). CONCLUSIONS: We found that cases have over a three times greater odds of high exposure to high-severity events than controls prior to the clinical development of PSP, while there were no differences in overall number of reported events. Our findings suggest that high exposure to highly stressful events may be associated with the development of PSP.