Sandeep K. Dhillon

Telemetry monitoring guidelines for efficient and safe delivery of cardiac rhythm monitoring to noncritical hospital inpatients.

Telemetry monitoring is a limited resource in most hospitals. Few clinical studies have established firm criteria for inpatient telemetry. At our urban institution, we have developed and incorporated guidelines to identify patients who benefit from cardiac rhythm monitoring. These guidelines serve to minimize inappropriate use of telemetry beds, thereby preventing emergency department overcrowding and ambulance diversion. This improvement in efficiency is achieved without compromising health care.

Interpretation of electrocardiograms by first-year residents: the need for change

BACKGROUND Prior studies have shown that misinterpretation of the electrocardiogram (ECG) can lead to inappropriate diagnoses and clinical decisions. This may be particularly true during the first month of postgraduate training. This study was designed to assess proficiency in ECG interpretation among residents at the start of their internal medicine (IM) residency. METHODS Ten ECGs were selected from IM department teaching files. All were representative of conditions that a starting IM resident should be able to identify. The ECGs had 1 correct primary diagnosis and a short list of secondary findings as determined by 2 cardiologists who reviewed them independently. Fifty-two first-year IM residents were given copies and asked to record their interpretations and an assessment of their certainty in each interpretation. Certainty was scored on a scale of 0 to 4 (0 representing a guess and 4 representing 100% certainty). Two blinded, independent graders scored each interpretation on a scale of 0 to 2 (0 = incorrect, 1 = partially correct, 2 = correct). RESULTS Overall, only half of all ECGs were read correctly. For the most critical diagnoses, the mean scores were as follows: 1.73/2.0 for acute myocardial infarction, 1.5/2.0 for atrial flutter, 1.11/2.0 for ventricular tachycardia, and 0.23/2.0 for complete heart block. The average level of certainty recorded by all participants was low at 18.5 of a maximum of 40. CONCLUSIONS Internal medicine residents at the beginning of their residency training demonstrated low overall proficiency in interpreting ECGs and self-perceived confidence. Nearly all residents felt that their training was insufficient. These findings emphasize the need for improved and more effective training in ECG interpretation for physicians starting residency.

Visualizing the Engram: Learning Stabilizes Odor Representations in the Olfactory Network

The nature of memory is a central issue in neuroscience. How does our representation of the world change with learning and experience? Here we use the transcription of Arc mRNA, which permits probing the neural representations of temporally separated events, to address this in a well characterized odor learning model. Rat pups readily associate odor with maternal care. In pups, the lateralized olfactory networks are independent, permitting separate training and within-subject control. We use multiday training to create an enduring memory of peppermint odor. Training stabilized rewarded, but not nonrewarded, odor representations in both mitral cells and associated granule cells of the olfactory bulb and in the pyramidal cells of the anterior piriform cortex. An enlarged core of stable, likely highly active neurons represent rewarded odor at both stages of the olfactory network. Odor representations in anterior piriform cortex were sparser than typical in adult rat and did not enlarge with learning. This sparser representation of odor is congruent with the maturation of lateral olfactory tract input in rat pups. Cortical representations elsewhere have been shown to be highly variable in electrophysiological experiments, suggesting brains operate normally using dynamic and network-modulated representations. The olfactory cortical representations here are consistent with the generalized associative model of sparse variable cortical representation, as normal responses to repeated odors were highly variable (∼70% of the cells change as indexed by Arc). Learning and memory modified rewarded odor ensembles to increase stability in a core representational component.

The Disconnect Between Novel Oral Anticoagulant Eligibility and Provincial Drug Coverage: An Albertan Anticoagulation Clinic Audit

Canadian practice guidelines for nonvalvular atrial fibrillation (NVAF) recommend that most patients receive a novel oral anticoagulant (NOAC) in preference to warfarin to prevent stroke, but not all patients have insurance that covers NOACs. The gap between optimal therapy and drug coverage is unknown. We retrospectively assessed eligibility for NOACs in patients with NVAF at our single-centre anticoagulation clinic and ascertained whether provincial drug coverage would be in place. Most patients (89%-95%) were eligible, but only 39%-41% qualified for drug coverage. Our findings suggest most Albertans with NVAF might not have drug coverage for optimal medical therapy for stroke prevention.