Division Of Internal Medicine Research Articles

The Development and Assessment of a Physician-Specific Antibiotic Usage and Spectrum Feedback Tool

BackgroundMeasuring antimicrobial usage is a hallmark of antimicrobial stewardship programs. Service –level antimicrobial consumption data is easily obtained but offers limited value to individual clinicians. More specific data via spot audit is resource intensive to collect and may not reflect true practice. Additionally, though clinicians may prescribe antimicrobials with differing frequency, there may also be variability in the choice and spectrum of antimicrobials prescribed. We developed an individualized multidimensional tool using available prescribing and dispensing data to enhance peer comparison and feedback on antimicrobial prescribing.MethodsDevelopment was conducted in a 442-bed academic acute care hospital in the division of General Internal Medicine (GIM), in Toronto, Canada. Physician-specific antibiotic consumption data (DDD/100 patient days and DOT/100 patient days) was obtained between February 15th and August 24th, 2016. Summative spectrum of activity was calculated using a metric assigning a value from 0 to 60 to each antimicrobial and obtaining a weighted average of total antimicrobial prescribing by clinician (spectrum scorephysician, modified from Madaras-Kelly et al 2014).ResultsMean antimicrobial consumption was 39.1 ± 13.5 DDD/100 patient-days and 38.5 ± 8.4 DOT/100 patient-days. There was significant variability between the lowest and highest prescribers in both the DDD and DOT (3.3-fold difference DDD/100 patient days, 2.2-fold difference DOT/100 patient days). Mean spectrum score was 23.7 ± 1.8 (approximating Second generation cephalosporins). Variability was also pronounced in this group with the minimum prescriber being 19.5 (equivalent to cefazolin) and maximum being 26.7 (more broad than ceftriaxone). Feedback of this data were given individually to clinicians with other prescribers de-identified. Physicians found the data to be easy to understand and acceptable for further use.ConclusionIndividualized feedback of summative antimicrobial consumption and spectrum provides insight to clinicians. This data can be considered to promote peer comparison and reflection of antimicrobial prescribing. This tool may also be helpful for benchmarking antibiotic usage within and between institutions.Disclosures All authors: No reported disclosures.

Clinical and Etiological Profile of Ascites in the Departmental University Hospital of Porto-Novo

Aim: To determine the frequency, the clinical and etiological aspects of ascites in the Internal Medicine Division of the University Hospital of Porto-Novo. Methods: It was a cross-sectional study with a descriptive focus covering the period from January 16 to August 31, 2015. It covered patients hospitalized for ascites in Internal Medicine Department at the Departmental University Hospital of Porto-Novo during the study period. Data were collected on a survey sheet and entered by Excel and analyzed with SPSS. The Chisquare test was used for statistical analysis and a significance threshold of 5% was retained. Results: Of the 511 hospitalized patients during the study period, 61 (11.9%) had ascites. The mean age was 49.6 ± 13.6 years with extremes of 19 years and 80 years. There was a male predominance with a sex ratio of 2.05. Ascites were often type III (34 patients, 55.7%), or type II (22 patients, 36.1%). The frequent signs were hepatomegaly (65.6%), splenomegaly (45.9%), pelvic limb edema (44.3%), and abdominal collateral venous circulation (39.3%). The macroscopic appearance of the ascites fluid was dominated by citrin yellow (82%), followed by hazy (11.5%). The hematic appearance was found in 6.5% of the cases. Hepatic cirrhosis was the most frequent etiology (34.4%) followed by overall heart failure (21.0%). Hepatocellular carcinoma was found in 16% of cases and nephrotic syndrome in 10% of cases. Conclusion: The etiological diversity of ascites, found in our study, imposes a careful clinical and paraclinical approach.

PP.07.12] ARMC5 MUTATIONS IN PATIENTS WITH PRIMARY ALDOSTERONISM AND BILATERAL ADRENAL LESIONS

Objective: Primary aldosteronism (PA) is the most frequent form of secondary hypertension and bilateral adrenal hyperplasia (BAH) is the most common PA subtype. The molecular mechanisms responsible for the development of BAH are still unknown, but the bilateral involvement of the adrenal glands suggests a potential predisposing genetic defect. Heterozygous germline mutations of armadillo repeat containing 5 (ARMC5) cause hypercortisolism due to sporadic primary bilateral macronodular adrenal hyperplasia and have been also observed in African-American patients affected by PA. We investigated the presence of germline ARMC5 mutations in a cohort of PA patients who had bilateral adrenal alterations detectable at CT-scanning. Design and method: We retrospectively assessed 39 consecutive patients with PA (25 males and 14 females) at the Division of Internal Medicine and Hypertension Unit of the University of Torino between 2010 and 2014. All patients had bilateral alterations of the adrenals at CT-scanning. Results: Thirty-nine PA patients (37 Caucasians and 2 black Africans; 8 unilateral, 27 bilateral and 4 undetermined subtype) with bilateral adrenal lesions were included in the study. The entire coding region of ARMC5 and all intron/exon boundaries were succesfully sequenced in all 39 patients; we identified 11 common variants, 5 rare variants with a minor allele frequency <1% and 2 new variants not previously reported in public databases. We did not detect by in silico analysis any ARMC5 sequence variations that were predicted to alter protein function. Conclusions: To conclude, ARMC5 mutations are not present in a fairly large series of Caucasian patients with PA and bilateral adrenal lesions. Further studies are warranted to definitively clarify the involvement of ARMC5 in the pathogenesis of adrenal nodules and aldosterone excess in PA patients.

Facilitating direct observation in the resident primary care clinic.

Medical EducationVolume 50, Issue 5 p. 587-588 Really Good Stuff Facilitating direct observation in the resident primary care clinic Majken Wingo, Corresponding Author Majken WingoCorrespondence: Majken Wingo, Division of Primary Care Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55902, USA. Tel: 00 1 507 284 0945; E-mail: wingo.majken@mayo.eduSearch for more papers by this authorAndrew Halvorsen, Andrew HalvorsenSearch for more papers by this authorMatthew Thomas, Matthew ThomasSearch for more papers by this authorKris Thomas, Kris ThomasSearch for more papers by this author Majken Wingo, Corresponding Author Majken WingoCorrespondence: Majken Wingo, Division of Primary Care Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55902, USA. Tel: 00 1 507 284 0945; E-mail: wingo.majken@mayo.eduSearch for more papers by this authorAndrew Halvorsen, Andrew HalvorsenSearch for more papers by this authorMatthew Thomas, Matthew ThomasSearch for more papers by this authorKris Thomas, Kris ThomasSearch for more papers by this author First published: 13 April 2016 https://doi.org/10.1111/medu.13019Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume50, Issue5May 2016Pages 587-588 RelatedInformation

A survey on anti-thrombosis treatment plans for elderly patients with non-valvular atrial fibrillation in the different divisions of internal medicine

Objective To identify anti-thrombosis treatment plans for hospitalized elderly patients with non-valvular atrial fibrillation adopted by the different divisions of the internal medicine department. Methods Retrospective data on CHADS2 scores and the frequencies of anti-platelet aggregation and anticoagulation medication in 990 elderly hospitalized patients with non-valvular atrial fibrillation in the different divisions of internal medicine were analyzed. Results Most of the 990 subjects were located in Cardiology (357 cases, 36.1%), Geriatrics (131 cases, 13.2%), the Cadres' Ward (162 cases, 16.4%) and Neurology (138 cases, 13.9%), while a minority stayed in Emergency Medicine (70 cases, 7.0%), Respiratory Medicine (56 cases, 5.7%), Endocrinology (38 cases, 3.8%), Gastroenterology (20 cases, 2.0%) and Nephrology (18 cases, 1.8%). Of the 573 cases with a CHADS2 score of 2 or higher, 58.1% (333/573) received single antiplatelet aggregation therapy, 24.1% (138/573) received dual antiplatelet aggregation therapy and only 14% (80/573) received anticoagulation therapy (warfarin + new oral anticoagulants). The proportion of patients receiving anticoagulation (warfarin) was relatively high in Cardiology (20.1%, 43/214), Geriatrics (17.2%, 10/58) and the Cadres' Ward (13.1%, 11/84). Conclusions The use of anticoagulation therapy in elderly patients with non-valvular atrial fibrillation is generally infrequent and is relatively more commonly used in Cardiology, Geriatrics, and the Cadres' Ward than in other divisions of internal medicine. Key words: Atrial fibrillation; Platelet aggregation inhibitors

Implementation Science Workshop: Engaging Patients in Team-Based Practice Redesign- Critical Reflections on Program Design.

Center for Patient Partnerships, University of Wisconsin, Madison, WI, USA; University of Wisconsin Law School, Madison, WI, USA; University of Wisconsin Medical Foundation, Madison, WI, USA; Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital, Boston, MA, USA.

Bedside echocardiography in internal medicine: which key questions and answers for our decision-making?

The advent of portable equipment in the last years has brought ultrasound technology available at patient bedside, giving the opportunity to non-cardiologists to extend cardiac assessment based on physical examination. Bedside echocardiography is a ‘question-driven’ examination, where simple and often dichotomic answers are searched. It is performed using phased-array probes and bidimensional images are visually evaluated to obtain information regarding cardiac size and function, presence of pericardial effusion, gross valvular diseases. Although this approach can not in any case substitute a standard 2D color-doppler echocardiography, bedside echocardiography has been demonstrated to maintain a good diagnostic accuracy when limited to basic questions, even in the hands of short-trained non cardiologist physicians. At present the bedside ultrasound approach is widely used in different settings and focused echocardiography takes part together with US explorations of lung, abdomen and deep veins in an integrated perspective that perfectly fit with the holistic approach of the internist. In this context we address two typical scenarios encountered in the internal medicine divisions -the patient presenting with dyspnea or non-post-traumatic hypotension- showing the main questions we can ask to bedside echocardiography for a rapid identification of the determinants of symptoms and consequently for a therapeutic choice based on more objective evidences.

Pancreatitis and intragastric balloon insertion

Pancreatitis and intragastric balloon insertion Farhat Said, M.D.*, Salameh Robert, M.D., El Khoury Mansour, M.D. Department of Internal Medicine, Gastroenterology and Hepatology Division, Saint Georges Hospital University Medical Center, Beirut, Lebanon Department of Surgery, General Surgery Division, Saint Georges Hospital University Medical Center, Beirut, Lebanon Received November 17, 2015; accepted December 8, 2015

“ Good Tuberculosis Men”: The Army Medical Department’s Struggle with Tuberculosis by Carol R. Byerly (review)

Reviewed by: “Good Tuberculosis Men”: The Army Medical Department’s Struggle with Tuberculosis by Carol R. Byerly Stephen C. Craig Carol R. Byerly. “Good Tuberculosis Men”: The Army Medical Department’s Struggle with Tuberculosis. Fort Sam Houston, Tex.: Office of the Surgeon General Borden Institute, 2013. xxviii + 340 pp. Ill. (978-0-16-092198-8). Micobacterium tuberculosis is an ancient—and still quite active—nemesis to society and the medical profession at large. Its insidious and aggressive natures have been chronicled by historians, romanticized and deplored in the open literature, and monitored closely by scientists and public health professionals for over a century. In “Good Tuberculosis Men” Carol Byerly offers a fresh and engaging account of an old tale. Framing her story in the U.S. Army and its Medical Department, ca. 1899–1950, Byerly has captured the struggle against tuberculosis in one of the most TB-vulnerable segments of American society during a half century of tremendous politico-military upheaval and medical change. Moreover, in this exhaustively researched and superbly written account she has opened a window not only to an untold chapter in Army Medical Department history, but also to a human drama of dedication to duty and personal sacrifice. After a succinct introduction of the mycobacterium and its characteristics, the reader is transported to Fort Bayard, New Mexico, 1899. The first three chapters chronicle the trials and tribulations experienced and eventual success in establishing this tiny desert outpost as a TB sanitarium. Colonel George E. Bushnell, Medical Corps, the erudite, administratively efficient post commander from 1904 to 1917, recognized the potential benefit of the sanitarium to provide a more detailed understanding of TB, including its diagnosis, therapy, and prognosis. As a TB victim, Bushnell understood that the treatment of TB—that is, the TB lifestyle of seclusion from society in a dry climate, long hours of outdoor exposure, plenty of rest, high protein diet, and attention to respiratory hygiene—required strict discipline tempered by compassion and common sense. The human drama recounted in South Carolina Congressman George S. Legare’s days as a patient at Fort Bayard speaks to Bushnell’s remarkable success as commander and clinician. In chapter 4 Colonel Bushnell is brought to Washington with the advent of World War I to establish and direct the Office of Tuberculosis in the Division of Internal Medicine. Bushnell’s office provided appropriate criteria with which to assess TB in draftees, established TB surveillance in Europe, and defined the resources needed to care for TB patients. By war’s end it would also assist in defining the magnitude of the disease in young Americans. Of 22,000 cases diagnosed during the war, some “18,500 [were] from training camps in the United States” (p. 122). The government was now responsible for the treatment of these veterans, and Fort Bayard was wholly inadequate to the task. Chapters 5, 6, and 7 describe governmental, military, and medical efforts to detect, treat, and control TB in the “modern” albeit pre-antimicrobial inter-war years. These efforts were expensive—made even more so by the Great Depression—and consumed tremendous physical, therapeutic, and human resources. Byerly provides a concise account of the administrative factors and political machinations that finally achieved Fitzsimmons Army Hospital. However, as in the first three chapters, she takes the reader beyond the dry and mundane to the human aspect of the story: the physicians and nurses—who were [End Page 827] exposed to and often contracted TB—their patients, and the frequently brutal pre-streptomycin therapeutics. The last two chapters provide an appropriate denouement to the story and bring the reader into the twenty-first century. The criticality of M. tuberculosis airborne transmission, the fielding of streptomycin and other anti-TB drugs, the subsequent development and spread of drug-resistance, and lack of an efficient immunological remind one that medical victory is often fleeting. Even vaccine-preventable diseases are being ignored today, as evidenced by the measles epidemics in Britain and Continental Europe (2012–13) and in the United States this year. Society must remain eternally vigilant for its health. And last, the narrative of World War II Army Nurse Margaret E. Gaule, in which dedicated service and...

Nursing and clinical course on a burned person complicated by polymicrobial infections

Here we describe the assistential complexity in an Internal Medicine Division via a multidisciplinary approach taking care of a burned woman. She was transferred in our Division after 90 days of hospitalisation in an Intensive Care Unit from an important centre for burned people for the treatment of burns on 35-40% of the body surface area. We analyse the therapeutic strategies and nursing management in a case complicated by polymicrobial infections: Acinetobacter baumanii and Providencia stuartii on burns, Escherichia coli on respiratory system and Clostridium difficile on enteric apparatus.

Physical symptoms in outpatients with psychiatric disorders consulting the general internal medicine division at a Japanese university hospital.

PurposeGeneral practitioners have an important role in diagnosing a variety of patients, including psychiatric patients with complicated symptoms. We evaluated the relationship between physical symptoms and psychiatric disorders in general internal medicine (GIM) outpatients in a Japanese university hospital.Materials and methodsWe coded the symptoms and diagnoses of outpatients from medical documents using the International Classification of Primary Care, second edition (ICPC-2). The participants were new outpatients who consulted the GIM outpatient division at Jichi Medical University Hospital in Tochigi, Japan from January–June, 2012. We reviewed all medical documents and noted symptoms and diagnoses. These were coded using ICPC-2.ResultsA total of 1,194 participants were evaluated, 148 (12.4%) of whom were diagnosed as having psychiatric disorders. The prevalence of depression, anxiety disorder, and somatization was 19.6% (number [n] =29), 14.9% (n=22), and 14.2% (n=21), respectively, among the participants with psychiatric disorders. The presence of several particular symptoms was associated with having a psychiatric disorder as compared with the absence of these symptoms after adjusting for sex, age, and the presence of multiple symptoms (odds ratio [OR] =4.98 [95% confidence interval {CI}: 1.66–14.89] for palpitation; OR =4.36 [95% CI: 2.05–9.39] for dyspnea; OR =3.46 [95% CI: 1.43–8.36] for tiredness; and OR =2.99 [95% CI: 1.75–5.13] for headache).ConclusionNot only the psychiatric symptoms, but also some physical symptoms, were associated with psychiatric disorders in GIM outpatients at our university hospital. These results may be of help to general practitioners in appropriately approaching and managing patients with psychiatric disorders.

The discipline of onco-cardiology.

Future OncologyVol. 11, No. 14 CommentaryThe discipline of onco-cardiologyElie MouhayarElie Mouhayar*Author for correspondence: E-mail Address: emouhayar@mdanderson.org Division of Internal Medicine, Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA 1515 Holcombe Boulevard, Unit 1451, Houston, TX 77030-4009, USASearch for more papers by this authorPublished Online:22 Jul 2015https://doi.org/10.2217/fon.15.71AboutSectionsView ArticleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInReddit View articleKeywords: cancer survivorscardiotoxicityonco-cardiologytargeted therapytyrosine kinase inhibitorsvascular toxicityReferences1 Siegel R, Desantis C, Virgo K et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J. Clin. 62(4), 220–241 (2012).Crossref, Medline, Google Scholar2 Ning Y, Shen Q, Herrick K et al. Cause of death in cancer survivors (abstr). Cancer Res. 72, Abstract LB339 (2012).Google Scholar3 McMullen JR, Boey EJ, Ooi JY, Seymour JF, Keating MJ, Tam CS. Ibrutinib increases the risk of atrial fibrillation, potentially through inhibition of cardiac PI3K-AKT signaling. Blood 124(25), 3829–3830 (2014).Crossref, Medline, CAS, Google Scholar4 Sawyer DB, Zuppinger C, Miller TA, Eppenberger HM, Suter TM. Modulation of anthracycline-induced myofibrillar disarray in rat ventricular myocytes by neuregulin-1beta and anti-ERBB2: potential mechanism for trastuzumab-induced cardiotoxicity. Circulation 105(13), 1551–1554 (2002).Crossref, Medline, CAS, Google Scholar5 Zhang S, Liu X, Bawa-Khalfe T et al. Identification of the molecular basis of doxorubicin-induced cardiotoxicity. Nat. Med. 18(11), 1639–1642 (2012).Crossref, Medline, Google Scholar6 Groarke JD, Cheng S, Moslehi J. Cancer-drug discovery and cardiovascular surveillance. N. Engl. J. Med. 369(19), 1779–1781 (2013).Crossref, Medline, CAS, Google Scholar7 Gao R, Zhang J, Cheng L et al. A Phase II, randomized, double-blind, multicenter, based on standard therapy, placebo-controlled study of the efficacy and safety of recombinant human neuregulin-1 in patients with chronic heart failure. J. Am. Coll. Cardiol. 55(18), 1907–1914 (2010).Crossref, Medline, CAS, Google Scholar8 Oliveira GH, Dupont M, Naftel D et al. Increased need for right ventricular support in patients with chemotherapy-induced cardiomyopathy undergoing mechanical circulatory support: outcomes from the intermacs registry (interagency registry for mechanically assisted circulatory support). J. Am. Coll. Cardiol. 63(3), 240–248 (2014).Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited ByCardio-oncology: a special focus issue from Future OncologyRobin L Jones & Maria Teresa Sandri22 July 2015 | Future Oncology, Vol. 11, No. 14 Vol. 11, No. 14 eToC Sign up Follow us on social media for the latest updates Metrics Downloaded 78 times History Published online 22 July 2015 Published in print July 2015 Information© Future Medicine LtdKeywordscancer survivorscardiotoxicityonco-cardiologytargeted therapytyrosine kinase inhibitorsvascular toxicityFinancial & competing interests disclosureThe author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download

Development and Impact of a Novel Academic Primary Care Compensation Model.

Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits. To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes. Observational study. Forty-seven general internists who practice in affiliated academic and community clinics. Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity. The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %. An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population.

Evaluating the Need for Palliative Care Services at a General Hospital in Israel.

Most hospitals in Israel do not provide palliative care beds and only few general hospitals have palliative consultation services. To date there are no data on the rate of hospitalizations and the need for palliative care in general hospitals in Israel. The objective was to characterize patients in need of palliative treatment during hospitalization in a general hospital in Israel. A retrospective review was performed of a random sample of files of patients admitted to the Internal Medicine Department at the Soroka University Medical Center (SUMC) between May 2007 and April 2008. Patients were defined as in need of palliative care if they had a CARING score ≥13. The data were collected using a structured questionnaire that included sociodemographic data and data on comorbid conditions, main complaints, primary diagnosis, duration of hospitalization, and hospitalization outcome. We reviewed 2795 hospitalizations. Of these, 14.9% were defined as in need of palliative care. Fourteen percent of the patients died during hospitalization and 47% died over the six-month follow-up period. The most common primary diagnosis was malignancy (61%), followed by end-stage pulmonary disease (19%) and Alzheimer's and other causes of dementia (9%). In only 12 hospitalizations (3.5%) was palliative care arranged for patients at discharge. A high percentage of patients hospitalized in internal medicine divisions could benefit from palliative care. The data presented here could aid hospitals in the integration of palliative care services.

Genetic and potential autoimmune triggers of primary aldosteronism.

Hypertension is a major life-threatening disease of high morbidity and mortality, which affects between 10% to 40% of the general population in an age-dependent manner. The pathogenesis of essential hypertension is multifactorial, with various underlying contributory mechanisms. Primary aldosteronism (PA) is the leading cause of secondary hypertension that affects 4.3% of patients in the general hypertensive population and 9.5% of patients referred to hypertension units.1 The 2 predominant causes of the constitutive aldosterone secretion that define PA is either aldosterone-producing adenomas (APA) or bilateral adrenal hyperplasia (BAH, also called idiopathic hyperaldosteronism). Exome sequencing has unraveled the pathogenetic basis of around half of APA, but the underlying cause of the aldosterone excess in BAH remains an enigma. The diagnosis of PA is made by a multistep process, recommended by the Endocrine Society guidelines,2 that ends with the invasive protocol of adrenal venous sampling. Once diagnosed, it is imperative to distinguish the surgically correctable forms (APA) from those that should be treated pharmacologically with mineralocorticoid receptor antagonists (BAH). With the application of wider screening for PA, >70% of cases of aldosterone excess have been defined as caused by BAH, with APA making up most of the remainder. APA and BAH are sporadic forms of PA, but 3 rarer familial forms of PA also exist called familial hyperaldosteronism (FH) types I, II, and III, described in more detail below. Three familial forms of PA with distinct clinical characteristics have been described.3,4 FH type I or glucocorticoid remediable aldosteronism is caused by a hybrid gene resulting from the unequal crossing-over between the adjacent genes CYP11B1 and CYP11B2 .5,6 Only few families (≈50) have been identified worldwide. FH type II seems to be inherited as an autosomal dominant trait. A locus has been mapped on chromosome 7p22 …

CORR Insights(®): Time-driven Activity-based Costing More Accurately Reflects Costs in Arthroplasty Surgery.

R ecent studies [7, 9] have conclusively demonstrated that hospital administrators and physicians in the United States often are flummoxed by a relatively simple question: ‘‘How much will my [insert name of procedure] cost?’’ Any reasonable person should be outraged, perplexed, and infuriated. Call your local Wal-Mart and ask them for the cost of any item. You will get answer within seconds. Go online and you can quickly find the cost of a roll of toilet paper, a new car, or a round-trip bus ticket to Peoria, IL, USA. Yet most of us are unable to provide our own patients with reasonable cost estimates for the tests, procedures, and products we prescribe every day. Akhavan et al. [1] used a rigorous accounting method (Time-driven Activity Based Costing [TDABC]) to examine the cost of TKA and THA procedures. The authors then compared the costs ascertained using TDABC with the traditional accounting method used by virtually all US hospitals. Not surprisingly, the authors found that methods matter. Specifically, the authors found that TDABC methods yielded ‘‘cost’’ estimates for TKA and THA that were approximately 45% lower than traditional accounting methods (USD 10,000 per case). These results have a number of important implications. First, the results provide an explanation for recent research studies that indicated hospitals were unable to provide credible estimates of prices for many of the most routine services that they provide [2, 12]. If hospitals’ internal accounting systems are fundamentally flawed and inaccurate as Akhavan and colleagues suggest, it is no wonder that hospitals are unable to provide accurate pricing data to consumers [5]. We cannot excuse our healthcare system for dysfunctional accounting systems and its inability to know costs and provide prices, but this does at least provide an explanation for the problem at hand. Second, the results have implications for hospital leadership when This CORR Insights is a commentary on the article ‘‘Time-drive Activity-based Costing More Accurately Reflects Costs in Arthroplasty Surgery’’ by Akhavan and colleagues available at: DOI: 10.1007/ s11999-015-4214-0. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999-0154214-0. PC is supported by a K24 award from NIAMS (AR062133). This work is also funded in-part by R01 AG033035 from NIA at the NIH. P. Cram MD, MBA (&) Division of General Internal Medicine, Toronto General Hospital, 200 Elizabeth Street, Eaton 14th Floor, Toronto, ON M5G 2C4, Canada e-mail: peter.cram@uhn.ca CORR Insights Published online: 27 May 2015 The Association of Bone and Joint Surgeons1 2015

The Effect of Practitioner Education on Fertility Preservation Awareness, Perception, and Clinical Practice [27

BACKGROUND: Given the risks of premature ovarian failure when using radiation and chemotherapeutics in women of reproductive age, clinicians caring for these patients should discuss fertility preservation with them and refer appropriate patients to specialists. However, this happens infrequently, partially as a result of lack of fertility preservation knowledge. METHODS: This is a dual-institution, prospective survey-based study assessing if an educational lecture can increase likelihood of fertility preservation consideration, discussion, and referral. Surveys were validated by the reproductive endocrinology division at an academic center, and lectures were given to the internal medicine, pediatric, rheumatology, and breast oncology divisions. A total of 70 prelecture and postlecture surveys were completed; all were analyzed. RESULTS: A total of 83.4% of clinician respondents reported that their patients rarely initiate fertility preservation discussion. Postlecture, clinicians' likelihood to consider fertility preservation increased from 22.8% to 59.7% (P<.01), likelihood to initiate discussion increased from 6.7% to 46.0% (P<.01), and likelihood to refer increased from 3.4% to 40.3% (P<.05). At baseline, respondents were most familiar with in vitro fertilization (IVF) (60.6%) with zero respondents reporting familiarity with radical trachelectomy. Afterward familiarity with all methods increased (IVF 93.9%, oocyte cryopreservation 84.8%, tissue cryopreservation 80.3%, gonadotropin-releasing hormone analogs 78.8%, radical trachelectomy 68.2%). CONCLUSION: It is extremely important for clinicians to initiate fertility preservation discussion, because patients are unlikely to initiate it themselves. A lecture is an effective means of imparting fertility preservation knowledge to clinicians. This simple strategy increased the likelihood that clinicians will consider and discuss fertility preservation with appropriate patients and increased the likelihood they will refer appropriate patients to fertility specialists.

Tu1533 Esophageal Posterior and Right Wall Are the Most Common Localizations of Barrett's Esophagus

trials most enrolled patients underwent systematic, four-quadrant, sampling to characterize patients’ baseline histologic grade prior to therapy. Because of the availability of these level-specific pathological readings, the proximal-to-distal spatial distribution of dysplasia could be characterized for most patients. We performed logistic regression with auto-regressive generalized estimating equations (GEE) to assess patterns of dysplasia, both stratified by trial and pooled, using location measurements statistically standardized to the extent of BE. In this schema, dysplasia at the top of the BE segment was assigned a value of 1, dysplasia at the bottom of the BE segment was assigned as 0, and dysplasia in the middle of the segment was assigned 0.5. Results: Of 140 patients randomized in the SURF trial, 114 had adequately detailed information regarding location of dysplasia, and were included in the analytic subset. Of 127 patients randomized in the AIM-Dysplasia trial, 55 had adequately detailed reports of baseline endoscopy. In both the AIM-Dysplasia trial (OR Z 7.98, 95% CL: [3.13, 20.4]) and the SURF trial (1.97, 95% CL: [1.02, 3.83]) dysplasia was more common at the top of the Barrett’s segment than at the bottom. In the pooled analysis, for every quarter of the segment more proximal, there was an absolute increase in risk of dysplasia of 0.07 [0.03, 0.10].Thus, on average, dysplasia was approximately 21% more common in the proximal-most quartile of BE length compared to the distal-most. The pooled, mean, standardized location of dysplasia was 0.63 [0.59, 0.67]. Discussion: In baseline biopsies from two multicenter, randomized, controlled trials the yield for dysplasia was highest in the proximal area of the Barrett’s segment. Surveillance sampling strategies over-sampling the most proximal areas of the BE segment would thus be expected to have increased yield of dysplasia compared to current standard of care, randomly distributed biopsies. Figure 1. Classification and Statistical Standardization of Biopsy Locations; Biopsy Location is defined as the Length B Divided by the Length A. Figure 2. Estimated prevalence of dysplasia among proximal to distal sampling levels pooled between the AIM-dysplasia and SURF trials. www.giejournal.org Vol Tu1533 Esophageal Posterior and Right Wall Are the Most Common Localizations of Barrett’s Esophagus Stefano Bibbo, Gianluca Ianiro*, Lucio Petruzziello, Cristiano Spada, Alberto Larghi, Maria Elena Riccioni, Antonio Gasbarrini, Guido Costamagna, Giovanni Cammarota Internal Medicine and Gastroenterology Division, “A. Gemelli” University Hospital, Rome, Italy; Digestive Endoscopy Unit, “A. Gemelli” University Hospital, Rome, Italy Background and Aim: Barrett’s esophagus (BE) prevalence is higher in patient with GERD with a rate of 10%, and an associated cancer risk of 0,5%/year. So, careful endoscopic surveillance assumes a paramount importance. Only few literature data on the preferred esophageal location of BE are available to date. The aim of this study is to identify the preferred area where BE can develop within esophageal circumference. Material and Methods: We retrospectively analyzed patients with BE who underwent upper endoscopy between January 2010 and March 2014 at our Endoscopy Center. We included only patients with short BE. In the case of multiple BE tongues, each lesion was considered individually. The circumferential localization of the lesions was determined according to the numbers of a clock face. Results: In the study period, 204 subjects were newly diagnosed of BE or had an endoscopic follow-up of BE. 24 patients with circumferential lesions were excluded. Among the 180 remaining patients, multiple BE lesions were diagnosed in 110 of them, for a total amount of 332 areas of BE. Our analysis of data showed a clear prevalence of BE in the position near 3 o’clock and 6 o’clock of the endoscopic image. The area between 5 and 7 o’clock (posterior wall) was the most affected (38.25% of the lesions). Other localizations were the arc between 2 and 4 o’clock (right wall) with 27.71%, the arc 11 to 1 o’clock 23.80% (anterior wall) and the arc 8 to 10 o’clock 10.24% (left wall). For each of the four walls, difference between observed and expected (dividing equally the number of lesions for the number of quadrants) lesions was statistically significant (P!0.0001 for each wall). Lesions were preferrably located in the right (1 to 6 o’clock) than in the left (7 to 12 o’clock) quadrant (207 versus 125 two-tailed P valueZ 0.01). Conclusions: We found, in a large cohort of Italian patients, an uneven localization of BE in the distal esophagus, with an higher prevalence on the posterior-right wall. Anatomical and environmental factors could explain this finding. The circumferential asymmetry of LES pressure (in particular, a lower pressure on the right quadrant) and the preference of supine position during sleep are two situations that may promote the reflux of gastric fluids preferably in the right and posterior wall of the distal esophagus. A more accurate observation of such areas during endoscopic surveillance is advisable in GERD patients.

Su1597 Predictive Factors for Percutaneous Drainage Placement in Patients Developing Bilomas From Bile Leaks

Su1596 A Suggested Method for Preventing Post Palliative SEMS Cholecystitis in Selective Patients With Courvoisier’s Gallbladder, a Preliminary Study Tariq A. Hammad*, Yaseen Alastal, Muhammad Ali Khan, Usman Ahmad, Muhammad Z. Bawany, Osama Alaradi, Ali Nawras Internal Medicine Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH Background: Cholecystitis is a potential complication for self-expandable Metallic stents (SEMS) that occurs in about 2-12% of patients. Objective: This study suggests a method to minimize the risk of post palliative SEMS cholecystitis in very high risk group of patients. This method has been adapted at our institution after having few incidences on post SEMS cholecystitis requiring interventional treatment.Design: Single arm study and single center design.Setting: University tertiary medical center. Patients: Five consecutive patients with obstructive jaundice and Courvoisier’s gallbladder (GB) secondary to suspected malignant pancreatic-biliary tumor.Intervention: Endoscopic ultrasound guided decompression of the Courvoisier GB by fine needle aspiration. Patients underwent a single session of EUS-FNA for diagnosis and staging of the tumors, and ERCP for possible palliative SEMS. Once the patients were assigned to palliative SEMS based on the clinical, radiographic and cytopathologic findings (table 1); the need for GB decompression was carefully assessed based on several factors (Diagram). Patients with Courvoisier GB whom CD’s were not visualized during the ERCP underwent this procedure. Results: All patients had the procedure without complications. None of the patients developed any clinical symptoms or signs of post SEMS cholecystitis. Conclusion: Endosonographic guided Courvoisier GB decompression post simultaneous palliative SEMS placement and diagnostic EUS -FNA is a suggestive method for preventing cholecystitis. Larger studies are required to validate these results. Patients’ Characteristics.

The challenge of integrating professionalism and mentoring in a program for medicine residents: a pilot study using critical incident reports

Introduction and description of the problem Residents deal with high levels of stress during their training. They face routinely emotional charged situations and not always have the resources and support to cope with present demands – difficult patients, sleep deprivation, fatigue, not enough time to social and familial engagement and high competitiveness, among other distressful situations. Studies performed worldwide report high levels of depression, anxiety, burnout and other psychological problems during this phase. Mentoring programs are described as a good tool to address those issues, but its feasibility and usefulness amongst residents are not easily achieved. Objective Aiming at developing a Mentoring Program for the residents of the Division of General Internal Medicine and Semiology - Department of Internal Medicine of the School of Medicine – University of Sao Paulo, we developed an exploratory study to get a better understanding on the challenges and difficulties our residents face during their training. Our purpose is to define goals to be met and then chose teaching and assessment methods to be implemented considering available faculty and resources. Methodology We evaluated the description and reports regarding a previous Mentoring program implemented at the institution 10 years ago and closed sub sequentially. We collected 96 critical incident reports from the residents presently involved in the program (80%), describing situations experienced by them as emotionally charged. Analysis The critical incidents reports were analyzed by 2 researchers (T.K; C.A.L) and 6 categories were defined as recurrent and typical. Those 6 categories were discussed between the coordination group and were all found to be connected to professionalism issues. Results A Mentoring program was designed and is being pilot tested during the last 5 months, including support groups and Professionalism content in the form of video-lectures. Those issues are being gradually included in all forms of assessment during Residency. This process will continue for another 6 months in order to define the final program to be implemented in the long term. Alignment between objectives, methods and assessment is our main objective for this pilot phase of design. Conclusions Professionalism is well defined and recognized as a basic competence but not always systematically taught during graduation. Professionalism assessment is still a challenge but its relevance is clear in international discussions. Mentoring Programs seem to be an appropriate setting for those issues to be reflected upon. Its efficacy needs to be evaluated longitudinally, as well as the influence that a Mentoring Program has being and levels of Professionalism.