General Medicine Setting Research Articles

Acute Myocarditis, the Dilemma in the General Practice Setting in the Years of the Coronavirus Pandemic Era: An Italian Experience

Myocarditis is inflammation of the muscle tissue of the heart (myocardium) and unlike most heart disease it tends to affect young people more often. Myocarditis can go almost unnoticed, frequently heals without results, but can sometimes be very serious and life threatening. However, many symptoms are non-specific and difficult to evaluate in the general practice setting. In order to diagnose myocarditis it is necessary to carry out some instrumental tests, too. Very important are the EKG and the dosage of cardiac markers in the blood. The echocardiogram allows you to highlight the valvular and muscle alterations that occur during inflammation and the same thing can be done by myocardial magnetic resonance. For those reasons, myocarditis is difficult to diagnose in the setting of General Practitioner (GP) and therefore it is underdiagnosed or misdiagnosed. The presence of nonspecific symptoms, fatigue and dyspnea, especially in a young person, it can lead the GP to suspect a myocarditis. We present a case of myocarditis in a young person. The patient, without a clinical history of important pathologies, presented asthenic and respiratory symptoms with progressive worsening of the clinical picture. We described the reasons of the diagnostic and therapeutic procedures. The general medicine setting is currently unsuitable for taking care of patients of this type, as the waiting times for the necessary examinations. The evaluation and follow-up are not within the reach of local doctors in Italy or with too long waiting times, so monitoring and optimizing therapies remain difficult outside the hospital.

The cost associated with the development of the antimicrobial stewardship program in the adult general medicine setting in Qatar.

To estimate the economic impact of the developed antimicrobial stewardship program (ASP) versus the preliminary ASP use, in the adults' general medicine settings in Qatar. Patient records were retrospectively reviewed during two periods: preliminary ASP was defined as the 12 months following ASP implementation (i.e. May 2015-April 2016), and developed ASP was defined as the last 12 months of a 5-year ASP implementation in Hamad Medical Corporation (HMC) (i.e. February 2019-January 2020). The economic impact was the overall cost savings in resource use, including operational costs, plus the cost avoidance associated with ASP. A total of 500 patients were included in the study. The operational costs decreased with the developed ASP. Whereas antimicrobial consumption and resource utilisation, and their associated costs, appear to have declined with the developed ASP, with a cost saving of QAR458 (US$125) per 100-patient beds, the avoided cost was negative, by QAR4,807 (US$1,317) per 100-patient beds, adding to a total QAR4,224 (US$1,160) increase in the 100-patient beds cost after ASP development. Despite that the developed ASP attained a total cost saving QAR458 (US$125) per 100-patient beds, the avoided cost was QAR-4,807 (US$-1,317) per 100-patient beds, which exceeded the cost savings achieved.

Study of severe migraine in general medicine

ObjectiveTo evaluate the criteria of severe migraine in a general population consulting a general practitioner (GP) and to evaluate assessment of migraine severity in the migraine patient as well as treating physicians’ knowledge of their patient's migraine and its severity. MethodsWe questioned voluntary headache patients who had an appointment with a GP about the severity of their migraine using recognized scores – HIT-6 and MIDAS – as well as with a specific questionnaire created for the study. We compared the criteria for severe migraine with the patient's description of their symptoms, their HIT-6 score, their MIDAS score, and the GP's opinion, analyzing collected data using means and standard deviations. ResultsWe found that 152 out of 942 headache patients questioned in the general medicine setting met the criteria of “strict migraine”, corresponding to 10.3% prevalence. Seventy-one out of 100 patients (71%) with migraine who filled out in the questionnaire completely had what is characterized as “severe migraine”. Forty-one (57%) of the 71 severe migraine patients presented the strict criteria. Additionally, 21 of the 29 (72%) patients with a non-severe diagnosis agreed that their headache was non-severe. When the HIT-6 score was stratified above 65, correspondence between the questionnaire-derived diagnosis and patient perception of severity was observed in 36 of the 58 (62%) with severe migraine. Finally, participating GPs were aware of their patient's migraine for 60% of patients with migraine. GPs correctly classified the severity of their patient's migraine for 55 (36%) patients. ConclusionGP education and training about migraine remain a public health issue. The diagnosis of severe migraine is necessary for proper patient management. Current criteria for severe migraine are not robust enough; we propose a modification of the criteria.

Treatment of Bowel Syndrome with Constipation: An Experience with The Agonist of Guanylate Cyclase Receptor in Advanced Age Patients

Background Irritable bowel syndrome is a very common condition in the elderly, and it can also be extremely disabling being able to go to undermine the patient's independence. We wanted to conduct a study on the Territory to test a recently approved molecule for treating a variant with constipation-predominant irritable bowel syndrome, testing the treatment in a cohort of elderly subjects and comparing the results with those of other existing therapies. Here we exposed the results of our experience.
 Material and Methods We conducted an open-label study in the general medicine setting, enrolling patients who appeared eligible for drug treatment with the study drug during the medical examination. So we examined 20 elderly patients. Half of the patients were treated with linaclotide 290 mcg, the other 50% with macrogol 27.6 g (25%) and psyllium 2 sachets/day (25%), continuing the treatment up to 12 weeks.
 Results There was a reduction of bloating in 70% of the Linaclotide group and 80% of the macrogol and psyllium group, an improvement/reduction of tenesmus in 100% of patients in the three groups, with a change in the quality of stool occurring with Bristol Stool Scale assessment. 60% of patients failed to complete therapy in 3 months.
 Conclusions Linaclotide is an innovative drug increasingly gaining space in the pharmacopoeia in the possession of doctors for treating intestinal disorders on a functional basis. The limited experience has shown little tolerance of Linaclotide compared to treatments for longer in force, especially in the elderly.

Evaluation and clinical management of drug-drug interactions in hypertensive patients associated co-morbidities: A study in general medicine and ICU ward

This comparative study aims to evaluate and compare the clinical management of drug-drug interactions (DDIs) in hypertensive patients with associated co-morbidities, specifically focusing on the practices in general medicine and ICU ward settings. Hypertensive patients commonly experience co-morbidities that require multiple medications, increasing the risk of DDIs and subsequent adverse events. Understanding the current evaluation and management strategies for DDIs in these patient populations is essential for optimizing patient outcomes. This research investigates the approaches employed in general medicine and ICU wards, including DDI identification, assessment, and intervention methods. By comparing these practices, the study aims to identify potential variations, challenges, and areas for improvement in DDI management across these clinical settings. The findings of this study will contribute to the development of evidence-based guidelines and recommendations for enhancing the clinical management of DDIs in hypertensive patients with co-morbidities, ultimately improving patient safety and therapeutic outcomes.

EE242 The Economic Impact of Antimicrobial Stewardship Program in the Adults’ General Medicine Setting in Qatar

Antimicrobial stewardship programs (ASPs) have shown to minimize the emergence of antimicrobial resistance and healthcare costs associated with an inappropriate use of antimicrobials. This study sought to evaluate the economic benefit of the mature ASP use compared to premature ASP use in the adults’ general medicine settings in Qatar.

The Clinical and Biological Manifestations in Women with Iron Deficiency Without Anemia Compared to Iron Deficiency Anemia in a General Internal Medicine Setting: A Retrospective Cohort Study.

PurposeThe clinical presentation of iron deficiency is not well understood. We aimed to identify the clinical manifestations of iron deficiency without anemia in women.Patients and MethodsWe conducted a retrospective cohort study of women who visited the general internal medicine outpatient department of a university hospital in Japan between 2016 and 2022. Women who were prescribed iron supplements were included in the study. Anemia was defined as hemoglobin levels below 12 g/dl. Iron deficiency was defined as serum ferritin levels < 30.0 μg/l. The primary outcome was the difference in symptoms between patients with iron deficiency with and without anemia. The secondary outcome was the ratio of symptom, hemoglobin, and serum ferritin improvement (levels > 30.0 μg/l after treatment), comparing the measurements at the beginning and after supplementation.ResultsA total of 147 women were included in the final analysis. There were no significant differences in the initial symptoms and the ratio of symptom improvement between the groups. Compared to patients with iron deficiency anemia, patients with iron deficiency without anemia had high initial serum ferritin levels (14.8 vs 7.1 μg/l, p<0.001), and hemoglobin (13.2 vs 9.9 g/dl, p<0.001). Iron supplements significantly improved the serum ferritin level in two groups and the hemoglobin in iron deficiency anemia. After treatment, iron deficiency without anemia still had high serum ferritin levels (37.7 vs 28.2 μg/l, p=0.017) and hemoglobin (13.3 vs 12.3 g/dl, p < 0.001).ConclusionThere were no differences in any of the investigated symptoms and the ratio of the symptom improvement depending on the anemic state in iron deficiency. After iron supplementation, the serum ferritin levels in the iron deficiency without anemia group improved. Hemoglobin and serum ferritin in iron deficiency without anemia were still highly comparable to that of iron deficiency anemia.

Social Work in the Oncology Setting Compared to Social Work in General Medical Settings: An Analysis of Findings From a Multisite Australian Social Work Practice Audit

ABSTRACT Oncology social work provides services to individuals, groups, families, caregivers, and communities. As part of a larger audit of social work activities across 17 Victorian health services, a subanalysis was conducted to investigate social work practice in oncology (n = 49) compared to general medicine settings (n = 55). Social workers in oncology were more likely to address issues of adjustment to the condition, anxiety, and finances. Social workers in general medicine more frequently focused on dementia, elder abuse, and transition of clients to Residential Assisted Care. Oncology social workers conducted higher frequencies of interventions involving advocacy, brief or single session intervention, and counselling compared to general medicine, where discharge planning was significantly more common. Finally, oncology social workers were more likely to have used a narrative or supportive care model compared to the general medicine group. These findings can help better target training and upskilling of social workers for practice in different healthcare settings. IMPLICATIONS Audits of practice assist to describe the complex array of issues addressed by social work both within oncology and the broader healthcare settings. Identifying key interventions and emphases pertaining to oncology provides a focus for future evaluation of the effectiveness of social work practice across key domains within oncology. Better understanding of practice can lay the groundwork for targeted training programs to enhance social worker knowledge and skills in oncology and broader healthcare.

Sharing Clinical Notes and Electronic Health Records With People Affected by Mental Health Conditions: Scoping Review.

BackgroundElectronic health records (EHRs) are increasingly implemented internationally, whereas digital sharing of EHRs with service users (SUs) is a relatively new practice. Studies of patient-accessible EHRs (PAEHRs)—often referred to as open notes—have revealed promising results within general medicine settings. However, studies carried out in mental health care (MHC) settings highlight several ethical and practical challenges that require further exploration.ObjectiveThis scoping review aims to map available evidence on PAEHRs in MHC. We seek to relate findings with research from other health contexts, to compare different stakeholders’ perspectives, expectations, actual experiences with PAEHRs, and identify potential research gaps.MethodsA systematic scoping review was performed using 6 electronic databases. Studies that focused on the digital sharing of clinical notes or EHRs with people affected by mental health conditions up to September 2021 were included. The Mixed Methods Appraisal Tool was used to assess the quality of the studies. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews guided narrative synthesis and reporting of findings.ResultsOf the 1034 papers screened, 31 were included in this review. The studies used mostly qualitative methods or surveys and were predominantly published after 2018 in the United States. PAEHRs were examined in outpatient (n=29) and inpatient settings (n=11), and a third of all research was conducted in Veterans Affairs Mental Health. Narrative synthesis allowed the integration of findings according to the different stakeholders. First, SUs reported mainly positive experiences with PAEHRs, such as increased trust in their clinician, health literacy, and empowerment. Negative experiences were related to inaccurate notes, disrespectful language use, or uncovering of undiscussed diagnoses. Second, for health care professionals, concerns outweigh the benefits of sharing EHRs, including an increased clinical burden owing to more documentation efforts and possible harm triggered by reading the notes. Third, care partners gained a better understanding of their family members’ mental problems and were able to better support them when they had access to their EHR. Finally, policy stakeholders and experts addressed ethical challenges and recommended the development of guidelines and trainings to better prepare both clinicians and SUs on how to write and read notes.ConclusionsPAEHRs in MHC may strengthen user involvement, patients’ autonomy, and shift medical treatment to a coproduced process. Acceptance issues among health care professionals align with the findings from general health settings. However, the corpus of evidence on digital sharing of EHRs with people affected by mental health conditions is limited. Above all, further research is needed to examine the clinical effectiveness, efficiency, and implementation of this sociotechnical intervention.

The Role of General Medicine in the Evaluation of Frailty in the Elderly Population: Definition of a Standardized Instrument for the Correct Framing of Frailty and Comparison with Currently Existing Instruments for Stratification of Clinical Risk

Frailty is a chronic condition that increases the vulnerability to stressogenic factors and prevents the patient from returning to the preceding condition of homeostasis. This increases the risk of negative outcomes and progressively brings the patient toward disability, leading to higher use of healthcare resources. Clinical risk stratification systems can generally be useful for identifying frail patients from the standpoint of a healthcare system, though General Practitioners (GPs) assume a key and irreplaceable role in the definition and correct diagnosis of frailty. This study developed a standardized instrument (called SVaFra) for the definition of frailty in the elderly population in a general medicine setting and compared it with a few clinical risk stratification tools that have already been validated and are in wide use. In addition, the impact of the application of SVaFra on healthcare outcomes was evaluated. A scientific board composed of experienced GPs, biomedical engineers, and other healthcare professionals, involved in the management of patients suffering from frailty, developed a framework in the form of a questionnaire for the evaluation of frailty by creating four principal groupings of the components that characterize it (clinical complexity, disability, family environment, and management complexity). An observational study, involving 98 GPs from four Italian regions who filled out the questionnaire, was then developed. The doctors were asked to provide a judgment for the four frailty components and the overall frailty. Additionally, a cohort of patients was stratified by applying Charlson Comorbidity Index (CCI) and Drug Derived Complexity Index (DDCI) to administrative databases. The utilization of healthcare resources in the year following the administration of the SVaFra framework with this population was compared with a control group with similar clinical or demographic characteristics. A total of 1,305 frail geriatric patients were identified (males 36.0%; mean age 83.1 ±8.52 years). Regarding the four principal areas used by the GPs to formulate a frailty judgment, the clinical categorization “moderate-severe” was most frequently noted (57.0%). The GPs then specified the following most frequent pathologies: arterial hypertension (76.4%), congestive heart failure (31.5%), dementia (30.7%), diabetes (29.9%), cardiac arrhythmia (27.6%), major depression (25.2%), stroke (22.0%), respiratory insufficiency (22.0%), chronic renal insufficiency (12.6%), management complexity (48.3%), disability (43.2%), and family environment (23.8%). For 165 subjects (12.6%), the GPs expressed an overall frailty judgment of “severe” based on management complexity and disability. Record linkage with administrative databases was possible in 102 cases. The presence of a CCI score of &gt;0 was recorded in only 20 (15.3%) patients identified as frail by GPs, while high DDCI scores were recorded for 88 (86.3%) patients. As for the utilization of healthcare resources, a net reduction of healthcare costs, especially those associated with emergency services, was observed for the population characterized as frail by GPs as compared with the control group with similar clinical or demographic characteristics. The SVaFra instrument was simple to apply, with transferability for the individualization and characterization of frail patients in diverse healthcare realities. However, CCI, which was useful for the stratification of clinical risk profiles, classified the majority of patients who were identified as frail by GPs as low risk. On the other hand, high scores were identified by DDCI for the majority of frail patients. The simple focus of GPs on the problem of frailty obtained by the administration of the SVaFra framework led to a reduction of healthcare costs due to emergency room treatments. Thus, the development of adequate diagnostic and therapeutic pathways to be developed about healthcare systems based on the use of SVaFra may result in more careful and accurate management of frail patients in the future.

2019 cardio-vascular risk and socioeconomic classification in central Portugal

Abstract Background The relationship between Cardiovascular Risk (CVR) and the socio-economic family classification (SEC) by the Graffar Index in the Portuguese General and Family Medicine setting is still unknown being an impoirtant Health determinant. SEC interferes with disease perception altering possible health out-comes. Use of specific tools can improve patient’s guidance. So the knowledge of the frequency of estimation of CVR and SEC to understand how they were distributed and related in the Primary Care population of Central Portugal, according to sex, age and place of residence was made using Primary Care generated data. Methods Cross-sectional observational study based on informatics data in anonymity of the population attending all the National Health Service Primary Care Health Units in Central Portugal in December 31, 2019, aged [40–65] years with descriptive and non-parametric analysis at P &amp;lt; 0.05. Results In a Universe of 707 806 CVR was calculated for 27.9%, SEC for 2.5% and both simultaneously for 1.2%. CVR distribution was different by gender (P &amp;lt; 0.001), High/very high risk more prevalent in males. By age group, High/Very high CVR was more prevalent in those over 60 years of age (P &amp;lt; 0.001) and if residing in the southern and more in-land locations presenting a higher risk (P &amp;lt; 0.001). High/very high CVR was more frequent in SEC lower classes (P = 0.047). Conclusions Cardiovascular risk and socioeconomic status were simultaneously registered in 1.2% of the population. Highest Cardiovascular Risk is more frequent in lower SEC classes, males, older and residing in the southern region. Docotr's awareness on these themes mst be increased.

Australian public hospital inpatient satisfaction related to early patient involvement and shared decision-making in discharge planning.

BackgroundSurveys of hospital inpatient satisfaction may help develop actionable plans for quality improvement, and patients have preferred to give feedback during admission at the point of service compared to after discharge. However, patient satisfaction measurement has often been done by questionnaires post‐discharge, and without focussing on an Australian general internal medicine setting.AimsTo understand patients' perceptions of their admission experiences in an Australian public teaching hospital's general internal medicine unit, and to understand the opportunities for quality improvement.MethodsA prospective study of 50 inpatients of a general internal medicine unit at an Australian public teaching hospital was carried out using a patient satisfaction questionnaire given to patients on the day of discharge.ResultsPatients perceived deficits in early communication about discharge destination planning, and provision of written discharge instructions. Responses highlighted the importance of checking with patients to elicit further information that was not previously captured during initial history‐taking, patient‐centred communication to enable informed consent and decision making, use of language readily understandable to laypersons, and checking for patients' understanding of messages as communicated by the treating clinician.ConclusionsIn an Australian general internal medicine service, early involvement and shared decision‐making in discharge planning are valued by patients. Incorporating checking of patients' understanding of diagnoses, management, discharge instructions, and follow‐up plans into ward round routines may benefit patient satisfaction. This study stimulates further research into the use of a proforma to capture and check patients' understanding of discharge diagnoses and plans.

Conducting of Web-Based Workshops for Final Year Medical Students Preparing to Enter the Workforce During the COVID-19 Pandemic.

Medical students were temporarily removed from direct patient contact activities during the COVID-19 pandemic, shortening the duration of ward-based attachment programs. Web-based workshops were organized to equip final year medical students with necessary skills to start work in a general medicine setting. Topics included case-based scenarios reviewing patients with new complaints, medical documentation, and inter-professional communication. They were conducted using an online video conference platform and utilized polling platforms, small group discussions, and the “Chat” function to promote interactivity. Web-based learning enables delivery of useful contents without compromising interactivity and clinical applicability during the COVID-19 pandemic.

Implementation of Antibiotic Time Outs Using Quality Improvement Methodology

Background: Antibiotic time outs (ABTOs), formal reassessments of all new antimicrobial regimens by the care team, can optimize antimicrobial regimens, reducing antimicrobial overuse and potentially improving outcomes. Implementation of ABTOs is a substantial challenge. We used quality improvement methods to implement robust, meaningful, team-driven ABTOs in general medicine ward services. Methods: We identified and engaged stakeholders to serve as champions for the quality improvement initiative. On October 1, 2018, 2 internal medicine teaching services (services A and B), began conducting ABTOs on all patients admitted to their services receiving systemic antimicrobials for at least 36 hours. Eligible patients were usually identified by the team pharmacist. ABTOs were completed within 72 hours of antibiotic initiation and were documented in the electronic medical record (EMR) by providers using a template. The process was modified as necessary in response to feedback from frontline clinicians using plan-do-study-act (PDSA) methods. We subsequently spread the project to 2 additional internal medicine services (services C and D); 2 family medicine teams (services E and F); and 1 general pediatric service (service G). The project is ongoing. We collected data for the following metrics: (1) proportion of ABTO-eligible patients with an ABTO; (2) proportion of ABTOs conducted within the recommended time frame; (3) documented plan changes as a result of ABTO (eg, change IV antibiotics to PO); (4) proportion of documented plan changes actually completed within 24 hours. Results: Within 12 weeks, services A and B were successfully completing time outs in &gt;80% of their patients. This target was consistently reached by services C, D, E, F, and G almost immediately following launch on those services. As of June 29, 2019, &gt;80% of eligible patients across all participating services have had a time out conducted for 16 consecutive weeks. ABTOs have resulted in a change in management in 35% of cases, including IV-to-PO change in 19% of cases and discontinuation in 5%. Overall, 77% of time outs occurred during the 36–72-hour window. Ultimately, 95% of documented plan changes were completed within 24 hours. Conclusions: ABTOs are effective but implementation is challenging. We achieved high compliance with ABTOs without using electronic reminders. Our results suggest that ABTOs were impactful in the non–critical-care general medicine setting. Next steps include (1) development of EMR-based tools to facilitate identifying eligible patients and ABTO documentation; (2) continued spread through our health care system; and (3) analysis of ABTO impact using ABTO-unexposed patients as a control group.Funding: NoneDisclosures: None

Eosinopenia as a diagnostic marker of bloodstream infection in a general internal medicine setting: a cohort study

BackgroundLittle is known about the potential use of the eosinophil count as a predictive marker of bloodstream infection. In this study, we aimed to assess the reliability of eosinopenia as a predictive marker of bloodstream infection.MethodsThis retrospective cohort study was performed in the outpatient department and general internal medicine department of a tertiary university hospital in Japan. A total of 189 adult patients with at least 2 sets of blood cultures obtained during the period January 1–December 31, 2018, were included; those with the use of antibiotic therapy within 2 weeks prior to blood culture, steroid therapy, or a history of haematological cancer were excluded. The diagnostic accuracies of each univariate variable and the multivariable logistic regression models were assessed by calculating the areas under the receiver operating characteristic curves (AUROCs). The primary outcome was a positive blood culture indicating bloodstream infection.ResultsSevere eosinopenia (< 24.4 cells/mm3) alone yielded small but statistically significant overall predictive ability (AUROC: 0.648, 95% confidence interval (CI): 0.547–0.748, P < 0.05), and only moderate sensitivity (68, 95% CI: 46–85%) and specificity (62, 95% CI: 54–69%). The model comprising baseline variables (age, sex), the C-reactive protein level, and neutrophil count yielded an AUROC of 0.729, and further addition of eosinopenia yielded a slight improvement, with an AUROC of 0.758 (P < 0.05) and a statistically significant net reclassification improvement (NRI) (P = 0.003). However, the integrated discrimination index (IDI) (P = 0.284) remained non-significant.ConclusionsSevere eosinopenia can be considered an inexpensive marker of bloodstream infection, although of limited diagnostic accuracy, in a general internal medicine setting.

Vancomycin-resistant enterococci (VRE) screening and isolation in the general medicine ward: a cost-effectiveness analysis

BackgroundVancomycin-resistant enterococci (VRE) are a serious antimicrobial resistant threat in the healthcare setting. We assessed the cost-effectiveness of VRE screening and isolation for patients at high-risk for colonisation on a general medicine ward compared to no VRE screening and isolation from the healthcare payer perspective.MethodsWe developed a microsimulation model using local data and VRE literature, to simulate a 20-bed general medicine ward at a tertiary-care hospital with up to 1000 admissions, approximating 1 year. Primary outcomes were accrued over the patient’s lifetime, discounted at 1.5%, and included expected health outcomes (VRE colonisations, VRE infections, VRE-related bacteremia, and deaths subsequent to VRE infection), quality-adjusted life years (QALYs), healthcare costs, and incremental cost-effectiveness ratio (ICER). Probabilistic sensitivity analysis (PSA) and scenario analyses were conducted to assess parameter uncertainty.ResultsIn our base-case analysis, VRE screening and isolation prevented six healthcare-associated VRE colonisations per 1000 admissions (6/1000), 0.6/1000 VRE-related infections, 0.2/1000 VRE-related bacteremia, and 0.1/1000 deaths subsequent to VRE infection. VRE screening and isolation accrued 0.0142 incremental QALYs at an incremental cost of $112, affording an ICER of $7850 per QALY. VRE screening and isolation practice was more likely to be cost-effective (> 50%) at a cost-effectiveness threshold of $50,000/QALY. Stochasticity (randomness) had a significant impact on the cost-effectiveness.ConclusionVRE screening and isolation can be cost-effective in majority of model simulations at commonly used cost-effectiveness thresholds, and is likely economically attractive in general medicine settings. Our findings strengthen the understanding of VRE prevention strategies and are of importance to hospital program planners and infection prevention and control.

4Q Model: How to Apply Guidelines for COPD in Primary Care

According to Italian General Practitioners (GPs), it is difficult to use guidelines and consensus, because they refer mainly to the disease and they are not close to the variability of real life.To help GPs perform clinical audits and address some management problems, we have devised a new analysis methodology: four-quadrant (4Q) diagnostic analysis.4Q model describes, in a fairly realistic way, the characteristics and clinical issues of patients with chronic obstructive pulmonary disease (COPD) during visits in the General Medicine setting. Using this model, GPs can identify and group patients in four specific areas; depending on the membership, the intervention is defined by the guidelines and the evidence-based medicine.

Initiating a women's health physician–run rehabilitation clinic in the United States

Pelvic dysfunction can lead to persistent impairment and disability when left untreated. While some diagnoses overlap with those seen in a general Physical Medicine and Rehabilitation (PM&R) outpatient setting and Obstetrics/Gynecology (Ob/Gyn), management varies with changes in biomechanics and function in contexts of fecundity, gravidity, post-partum status, post-menopause, history of surgical intervention, or history of sexual trauma. PM&R initiated a collaboration with Ob/Gyn to create a physician-run Women's Health Rehabilitation specialty clinic embedded within an established Ob/Gyn clinic at an academic university hospital in the United States. The clinic focuses on pelvic floor disorders and musculoskeletal issues associated with pregnant or post-partum women. Over 50 referrals were made from Ob/Gyn in the initial months of clinic launch. Diagnoses included low back pain and sacroiliac joint dysfunction related to pregnancy, pelvic floor instability, dyspareunia, post-partum thoracic back pain, and coccydynia. Management included education of biomechanics, referral to Pelvic Floor-specialized Physical Therapy (PFPT), medications, referral to Psychology, and injections. Despite significant enthusiasm from Ob/Gyn and the patients, initial referrals were delayed due misunderstanding regarding difference between PM&R and PT, failure to recall initiation of clinic, and flawed protocol with ancillary staff on scheduling process. Despite infrastructure of a large academic institution in a metropolitan area, there was a paucity of availability of PFPT multiple sites within the academic affiliation or the metropolitan area. Comprehensive Women's Health Rehabilitation lead by physiatrists can address biomechanical issues, treat pain, perform interventional procedures, and coordinate care with PFPT and other professionals to address contributing factors, like mood disturbances and life situations. Our clinic aim is to expand collaborations with increased marketing, face-to-face interaction, and visibility at multidisciplinary events. We expect to increase referral sources and numbers as well as educate more of the medical community about our specialty.

Does clerkship experience influence interest in internal medicine career?

BACKGROUND:The career intention of undergraduate medical students may be influenced by the clerkship experience in the various specialties.AIM:This study was undertaken to assess the medical student's perception of the internal medicine clerkship and determine its influence in the choice of internal medicine as a career.METHODS:The study involved a cross-sectional survey of 2009 and 2010 graduating medical class of Universityof Nigeria using self-administered questionnaires.The clerkship evaluation was assessed using a 3-point Likert scale (1=poor and 3 excellent).RESULTS:The response rate was 70.3% (275/391).Sixty -five (23.6%) rated their medicine clerkship as excellent (mean rating 2.04).Aspects of the clerkship experience that contributed to the overall poor rating include quality of opportunity to participate in direct patient care, ability to manage problems in a general medicine setting, accessibility to consultants and feedback on performance during the postings.Experience in learning basic physical examination skills and overall quality of consultant teaching was considered excellent by 42.3% and 30.8% of the participants respectively. Twenty–six (9.5%) of the participants indicated interest in internal medicine while 96(35%), 43(15.6%) and 34(12.4%) chose surgery, paediatrics and obstetrics and gynecology respectively. Factors that swayed the choice of medicine were personal inclination (57.7%), clerkship experience (30.8%), diligence of faculty (7.7%),and lifestyle (3.8%).CONCLUSION: Clerkship experience may not be the main factor influencing choice of internal medicine. However, a review of clerkship in internal medicine may improve experience and enhance choice of internal medicine as a specialty among medical students.KEY WORDS: clerkship,career choice,internal medicine,medical students,

Bilateral gluteal abscesses and myofibrosis complicating intramuscular pentazocine abuse: A case report

Background : There is paucity of reports on the musculoskeletal complications of pentazocine abuse in Nigeria. The aim was to report a case of bilateral gluteal abscesses and myofibrosis as a consequence of parenteral pentazocine abuse. Case Summary : We report a case of a 39 year old housewife who presented with bilateral gluteal pyomyositis and myofibrosis following intramuscular pentazocine abuse. The patient had received parental pentazocine for pain relief for about 3 weeks seven years ago. She gradually developed dependence on this drug and received increasing doses of this drug by self injection on both buttocks. She subsequently developed bilateral gluteal abscesses and myofibrosis that was treated by surgical drainage, debridement, wound dressing and antibiotics. Conclusion : Pentazocine abuse should be considered a differential diagnosis in cases of multiple gluteal abscesses. Clinicians should be cautious in the use of pentazocine as routine painkillers. Keywords : Pentazocine abuse, gluteal abscesses, Nigeria.