Neera Ahuja

Eculizumab Induces Sustained Remission in a Patient With Refractory Primary Catastrophic Antiphospholipid Syndrome.

Catastrophic antiphospholipid syndrome (CAPS) is fatal in approximately 44% of patients in whom the diagnosis is made, thus demonstrating the inadequacy of current medical therapy. In this report, we discuss a 47-year-old man with a known history of primary antiphospholipid syndrome, who presented with CAPS after undergoing cholecystectomy and a treatment-refractory early relapse after development of colitis. Given the potential therapeutic efficacy of complement inhibition in antiphospholipid syndrome, the patient was administered eculizumab, a terminal complement inhibitor. Progressive clinical improvement and laboratory improvement were observed upon initiation of eculizumab. He has remained in remission for over 16 months of follow-up while on eculizumab. In conclusion, this case represents successful use of eculizumab for the treatment of primary CAPS.

Surgical Comanagement by Hospitalists Improves Patient Outcomes: A Propensity Score Analysis.

Objective: The aim of the study was to examine the impact of a surgical comanagement (SCM) hospitalist program on patient outcomes at an academic institution. Background: Prior studies may have underestimated the impact of SCM due to methodological shortcomings. Methods: This is a retrospective study utilizing a propensity score-weighted intervention (n = 16,930) and control group (n = 3695). Patients were admitted between January 2009 to July 2012 (pre-SCM) and September 2012 to September 2013 (post-SCM) to Orthopedic or Neurosurgery at our institution. Using propensity score methods, linear regression, and a difference-in-difference approach, we estimated changes in outcomes between pre and post periods, while adjusting for confounding patient characteristics. Results: The SCM intervention was associated with a significant differential decrease in the proportion of patients with at least 1 medical complication [odds ratio (OR) 0.86; 95% confidence interval (CI), 0.74–0.96; P = 0.008), the proportion of patients with length of stay at least 5 days (OR 0.75; 95% CI, 0.67–0.84; P < 0.001), 30-day readmission rate for medical cause (OR 0.67; 95% CI, 0.52–0.81; P < 0.001), and the proportion of patients with at least 2 medical consultants (OR 0.55; 95% CI, 0.49–0.63; P < 0.001). There was no significant change in patient satisfaction (OR 1.08; 95% CI, 0.87–1.33; P = 0.507). We estimated average savings of

The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation?

2642 to

Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost

4303 per patient in the post-SCM group. The overall provider satisfaction with SCM was 88.3%. Conclusions: The SCM intervention reduces medical complications, length of stay, 30-day readmissions, number of consultants, and cost of care.

Gastrointestinal Manifestations of Henoch-Schoenlein Purpura

Purpose The medical student performance evaluation (MSPE), a letter summarizing academic performance, is included in each medical student’s residency application. The extent to which medical schools follow Association of American Medical Colleges (AAMC) recommendations for comparative and transparent data is not known. This study’s purpose was to describe the content, interpretability, and transparency of MSPEs. Method This cross-sectional study examined one randomly selected MSPE from every Liaison Committee on Medical Education–accredited U.S. medical school from which at least one student applied to the Stanford University internal medical residency program during the 2013–2014 application cycle. The authors described the number, distribution, and range of key words and clerkship grades used in the MSPEs and the proportions of schools with missing or incomplete data. Results The sample included MSPEs from 117 (89%) of 131 medical schools. Sixty schools (51%) provided complete information about clerkship grade and key word distributions. Ninety-six (82%) provided comparative data for clerkship grades, and 71 (61%) provided complete key word data. Key words describing overall performance were extremely heterogeneous, with a total of 72 used and great variation in the assignment of the top designation (median: 24% of students; range: 1%–60%). There was also great variation in the proportion of students awarded the top internal medicine clerkship grade (median: 29%; range: 2%–90%). Conclusions The MSPE is a critical component of residency applications, yet data contained within MSPEs are incomplete and variable. Approximately half of U.S. medical schools do not follow AAMC guidelines for MSPEs.

Integrating Mobile Fitness Trackers Into the Practice of Medicine

BACKGROUND Telemetry monitoring is a widely used, labor-intensive, and often-limited resource. Little is known of the effectiveness of methods to guide appropriate use. OBJECTIVE Our intervention for appropriate use included: (1) a hospitalist-led, daily review of bed utilization, (2) hospitalist-driven education module for trainees, (3) quarterly feedback of telemetry usage, and (4) financial incentives. DESIGN/METHODS Hospitalists were encouraged to discuss daily telemetry utilization on rounds. A module on appropriate telemetry usage was taught by hospitalists during the intervention period (January 2013-August 2013) on medicine wards. Pre- and post-evaluations measured changes regarding telemetry use. We compared hospital bed-use data between the baseline period (January 2012-December 2012), intervention period, and extension period (September 2014-March 2015). During the intervention period, hospital bed-use data were sent to the hospitalist group quarterly. Financial incentives were provided after a decrease in hospitalist telemetry utilization. SETTING Stanford Hospital, a 444-bed, academic medical center in Stanford, California. RESULTS Hospitalists saw reductions for both length of stay (LOS) (2.75 vs 2.13 days, P = 0.005) and total cost (22.5% reduction) for telemetry bed utilization in the intervention period. Nonhospitalists telemetry bed utilization remained unchanged. We saw significant improvements in trainee knowledge of the most cost-saving action (P = 0.002) and the least cost-saving action (P = 0.003) in the pre- and post-evaluation analyses. Results were sustained in the hospitalist group, with telemetry LOS of 1.93 days in the extension period. CONCLUSIONS A multipronged, hospitalist-driven intervention to improve appropriate use of telemetry reduces LOS and cost, and increases knowledge of cost-saving actions among trainees.

The Medical Education of Generation Y

A 43-year-old Hispanic male was admitted to the hospital with a 2-week history of epigastric pain, hematochezia, rash, and joint pain in his elbows and knees. The pain was non-radiating, without nausea, vomiting, or exacerbating or alleviating factors. Two weeks prior to the onset of these symptoms he had developed flu-like symptoms that resolved without treatment. His past medical history was significant for hypertension; however, he had no personal or family history of gastrointestinal, hematological, or autoimmune disease. He had been taking hydrochlorothiazide and irbesartan for his hypertension. He did not smoke or drink alcohol. On admission, he was afebrile without any abnormalities in his vital signs or cardiopulmonary examination. Physical examination was notable for palpable petechial and purpuric lesions on his legs, arms, and periumbilical region; epigastric tenderness was elicited upon deep palpation, and his elbows and knees were tender to touch (Fig. 1). Stool occult blood was positive. Laboratory investigations revealed leukocytosis and positive inflammatory markers but without evidence of bacterial, infectious, or autoimmune process. Urine analysis did not reveal hematuria or proteinuria. A skin biopsy was reported as leukocytoclastic vasculitis. Computed tomography, performed at the referring outside hospital, revealed focal thickening of the third and fourth portions of the duodenum and proximal jejunum without signs of intussusception or pancreatic inflammation. An upper endoscopy revealed acute, moderately severe, patchy inflammation, as well as ulcerations and friability of the distal duodenum and jejunum. Duodenal and jejunal biopsies revealed benign small bowel mucosa with acute and chronic inflammation, ulceration and fragments of ulcer bed. Fungal Grocott methenamine silver staining was negative; no granulomas or viral changes were noted. A chest radiograph was normal. Colonoscopy revealed small non-bleeding vasculitic lesions and red erythematous plaques throughout the colon and the terminal ileum (Fig. 2). A small bowel capsule endoscopy, performed to evaluate the extent of gastrointestinal tract involvement, demonstrated scattered areas of erythematous ulcerated mucosa extending from the duodenum to the ileum (Fig. 3). His symptoms began to resolve within 2 days after admission without further treatment. His rash, diarrhea, abdominal pain, and joint pain steadily improved during his hospitalization. At follow-up 2 months later, he remained symptom-free; his urine screen for hematuria remained negative.

Diffuse Alveolar Damage in a Patient Receiving Dronedarone

Mobile fitness trackers are increasingly used by patients as a means to become more involved in their own self-care; however, these devices measure disparate outcomes that may have equivocal relevance to true health status. It is vital for physicians to interpret both the quality and accuracy of the information that these trackers provide, and it is important to delineate which role, if any, these devices may serve in promoting quality patient care in the future. Potential benefits of mobile fitness trackers include the ability to motivate patients toward a healthier lifestyle, to develop a community of like-minded individuals seeking to improve their health, as well as to create an environment of sustainability and accountability for long-term promotion of health maintenance. However, limitations include the fact that mobile fitness trackers are not regulated by the Food and Drug Administration, that the employed metrics are not necessarily the best surrogates for true health status, and that the accuracy of measured endpoints has not yet been proven. As mobile fitness trackers both continue to rise in popularity and become increasingly sophisticated, physicians must be equipped to interpret and use this technology to better serve patients within an ever-changing, more technology-reliant health care system.

R-SCAN: Imaging for Low Back Pain

Medical schools face challenges preparing students to meet evolving health-care needs in society. However, little has changed in the way that education is delivered to aspiring health professionals [1]. The in-class lectures continuing in the majority of classrooms across the country do not acknowledge the unique proclivities of the current crop of medical students. An explanation of this observation is gleaned by understanding the fundamental attributes of the current generation of medical trainees. Educational research in schools outside of medicine demonstrates that students with different learner characteristics will value instructional measures in relation to the way they suit their own habits, ideas, and preferences of learning well [2]. To be effective, teaching styles have to take into account learning styles [3]. Therefore, instructional measures should address learner beliefs to improve the quality of student learning [2]. Our paper responds to the need to examine the impact of social and motivational variables in learning. Specially, we sought to understand the implications of generational differences in medical education, and how medical education can consciously evolve to accommodate the learning styles of current trainees.

A resident-created hospitalist curriculum for internal medicine housestaff.

Dronedarone is an amiodarone-like antiarrhythmic with a modified structure. The addition of a methyl sulfonyl group theoretically reduces the toxicity of amiodarone, specifically, adverse thyroid and pulmonary effects. Although animal studies have implicated dronedarone as a cause of lung injury, to date controlled trials in humans have not demonstrated an association. A 68-year-old woman developed a dry cough and worsening respiratory distress after receiving dronedarone for 6 months. Discontinuation of dronedarone therapy and subsequent steroid therapy led to a dramatic improvement of symptoms. Dronedarone may be associated with interstitial lung disease. We believe that patients receiving dronedarone should have their diffusing capacity of lung for carbon monoxide and lung volumes monitored prior to initiation of therapy and frequently thereafter.