Extensively drug-resistant tuberculosis in a young child after travel to India.

Extensively drug-resistant (XDR) tuberculosis is becoming increasingly prevalent worldwide, but little is known about XDR tuberculosis in young children. In this Grand Round we describe a 2-year-old child from the USA who developed pneumonia after a 3 month visit to India. Symptoms resolved with empirical first-line tuberculosis treatment; however, a XDR strain of Mycobacterium tuberculosis grew in culture. In the absence of clinical or microbiological markers, low-radiation exposure pulmonary CT imaging was used to monitor treatment response, and guide an individualised drug regimen. Management was complicated by delays in diagnosis, uncertainties about drug selection, and a scarcity of child-friendly formulations. Treatment has been successful so far, and the child is in remission. This report of XDR tuberculosis in a young child in the USA highlights the risks of acquiring drug-resistant tuberculosis overseas, and the unique challenges in management of tuberculosis in this susceptible population.

Physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients.

OBJECTIVES: To develop a physician-pharmacist collaborative practice for opioid-dependent patients designed to increase access to treatment, optimize patient care, reduce cost, minimize physician burden, and prevent diversion. SETTING: Suburban health department. PRACTICE DESCRIPTION: Physician-pharmacist buprenorphine/naloxone maintenance practice. PRACTICE INNOVATION: Traditionally, health department buprenorphine/naloxone patients have been referred to community physicians at considerable cost with varying outcomes. In this pilot project, patients were managed using a drug therapy management model. Intake assessments and follow-up appointments were conducted by the pharmacist. The pharmacist debriefed with the physician and documented each interaction, allowing for efficient assessment completion. The physician appended notes, when applicable, and cosigned each patient's record. The pharmacist prevented diversion by gathering data from outside providers, pharmacies, and laboratories. RESULTS: This health department program improved care by producing structure and expanding treatment options. A total of 12 patients completed full intakes with 135 follow-up appointments equating to an estimated savings of $22,000. The program demonstrated a 91% attendance rate, 100% 6-month retention rate, and 73% 12-month retention rate. Overall, 127 (98%) urine toxicology screens were positive for buprenorphine and 114 (88%) were positive for buprenorphine and negative for opioids. CONCLUSION: Physician and pharmacist collaboration optimized care of buprenorphine-maintained patients. Data from this pilot were used to develop a permanent physician-pharmacist program and to obtain approval for the first state-approved opioid use disorder drug therapy management protocol.

Effect of Beta-blocker therapy on rehospitalization rates in women versus men with heart failure and preserved ejection fraction.

Beta blockers are empirically used in many patients with heart failure (HF) and preserved ejection fraction (HFpEF) because they allow more time for diastolic filling and because they improve outcomes in patients with systolic HF. However, recent data suggest that impaired chronotropic and vasodilator responses to exercise, which can worsen with beta blockade, may play a key role in the pathophysiology of HFpEF. We prospectively examined the association between beta-blocker therapy after hospitalization for decompensated HF and HF rehospitalization at 6 months in 66 consecutive patients with HFpEF (71 +/- 13 years old, 68% women, 42% Black). Subjects were stratified based on receiving (BB+; 15 men, 28 women) or not receiving (BB-) beta-blockers at hospital discharge. In men, HF rehospitalization occurred less frequently in the BB+ than in the BB- group, albeit nonsignificantly (20% vs 50%, p = 0.29). In women, HF rehospitalization occurred more frequently in the BB+ than in the BB- group (75% vs 18%, p <0.001). In univariate analyses, discharge beta-blocker was associated with HF rehospitalization in women (odds ratio [OR] 14.00, 95% confidence interval [CI] 3.09 to 63.51, p = 0.001), but not in men (OR 0.25, 95% CI 0.03 to 1.92, p = 0.18). In a forward logistic regression model that offered all univariate predictors of HF rehospitalization, discharge beta blocker remained an independent predictor of HF rehospitalization in women (OR 11.06, 95% CI 1.98 to 61.67, p = 0.006). In conclusion, this small observational study suggests that beta-blocker therapy may be associated with a higher risk of HF rehospitalization in women with HFpEF. The risks and benefits of beta-blocker therapy in patients with HFpEF should be evaluated in randomized, controlled trials.

Physician-teacher characteristics associated with learner-centered teaching skills.

BACKGROUND: Academic institutions do not have a way to identify physician-teachers who are proficient in learner-centered teaching. AIM: To identify physician characteristics associated with being highly learner-centered. METHODS: A cohort of 363 physicians was surveyed. Measured items included personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activities. A learner-centeredness scale was developed using factor analysis. Logistic regression models were used to determine which characteristics were independently associated with scoring highly on the learner-centeredness scale. RESULTS: Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Six variables combined to form the learner-centeredness scale and the Cronbach Alpha of the scale was 0.73. The eight characteristics independently associated with high learner-centered scores for physician teachers were (i) proficiency in giving lectures or presentations (OR ;= ;5.1, 95% CI: 1.3-19.6), (ii) frequently helping learners identify resources to meet their own needs (OR ;= ;3.7, 95% CI: 1.3-10.3), (iii) proficiency in eliciting feedback from learners (OR ;= ;3.7, 95% CI: 1.7-8.5), (iv) frequently attempting to detect and discuss emotional responses of the learners (OR ;= ;2.9, 95% CI: 1.2-6.9), (v) frequently reflecting on the validity of feedback from the learners (OR ;= ;2.8, 95% CI: 1.1-7.4), (vi) frequently identifying available resources to meet the teacher's learning needs (OR ;= ;2.8, 95% CI: 1.1-7.2), (vii) having given an oral presentation related to education at a national/regional meeting (OR ;= ;2.6, 95% CI: 1.1-6.0), and (viii) frequently letting learners know how different situations affect the teacher (OR ;= ;2.5, 95% CI: 1.1-5.5). CONCLUSIONS: The clinical competence and professional growth of medical learners can be most effectively facilitated by learner-centered educational methods. It may now be possible to identify medical educators who are more learner-centered in their teaching.

Physician characteristics associated with proficiency in feedback skills.

BACKGROUND: Providing and eliciting high-quality feedback is valuable in medical education. Medical learners' attainment of clinical competence and professional growth can be facilitated by reliable feedback. This study's primary objective was to identify characteristics that are associated with physician teachers' proficiency with feedback. METHODS: A cohort of 363 physicians, who were either past participants of the Johns Hopkins Faculty Development Program or members of a comparison group, were surveyed by mail in July 2002. Survey questions focused on personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activity. The feedback scale, a composite feedback variable, was developed using factor analysis. Logistic regression models were then used to determine which faculty characteristics were independently associated with scoring highly on a dichotomized version of the feedback scale. RESULTS: Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Factor analysis revealed that the 7 questions from the survey addressing feedback clustered together to form the "feedback scale" (Cronbach's alpha: 0.76). Six items, representing discrete faculty responses to survey questions, were independently associated with high feedback scores: (i) frequently attempting to detect and discuss the emotional responses of learners (odds ratio [OR]=4.6, 95% confidence interval [CI] 2.2 to 9.6), (ii) proficiency in handling conflict (OR=3.7, 95% CI 1.5 to 9.3), (iii) frequently asking learners what they desire from the teaching interaction (OR=3.5, 95% CI 1.7 to 7.2), (iv) having written down or reviewed professional goals in the prior year (OR=3.2, 95% CI 1.6 to 6.4), (v) frequently working with learners to establish mutually agreed upon goals, objectives, and ground rules (OR=2.2, 95% CI 1.1 to 4.7), and (vi) frequently letting learners figure things out themselves, even if they struggle (OR=2.1, 95% CI 1.1 to 3.9). CONCLUSIONS: Beyond providing training in specific feedback skills, programs that want to improve feedback performance among their faculty may wish to promote the teaching behaviors and proficiencies that are associated with high feedback scores identified in this study.