Journal Of General Internal Medicine Research Articles

New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders-The Perfect Storm.

New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders-The Perfect Storm.

MON-135 Improving Thyroid Fine Needle Aspiration Education: Implementation of a Formal Clinical Procedure Assessment Tool for Teaching Thyroid FNA to Endocrinology Fellows

Fellows must demonstrate competence in the performance of thyroid biopsy (bx) from the 2019 ACGME Program Requirements for GME in Endocrinology, Diabetes, and Metabolism. During fellowship, trainees are often taught thyroid bx using an unstructured approach, through demonstration followed by supervised performance on patients. Concerns regarding patient safety, lack of readily available faculty & patients, and lack of competency checkpoints limit the utility of such an approach to teaching procedural skills (1). Application of Psychomotor Learning Theory to teaching procedural skills has modified prior philosophy to “learn, see, practice, prove, do, maintain.” (2) Two phases exist: 1) cognitive- conceptualization and visualization of the procedure and 2) psychomotor- acquisition of procedural skills. Formal training has been shown to improve FNA diagnostic accuracy along with fewer surgical procedures for benign lesions.(2) There is no evidence to support any specific recommendations for training fellows on safe and efficient thyroid bx techniques further highlighting the need for a competency based approach.(3) Since the didactic lecture format is not well suited for the acquisition of complex manual operations, in our study, we seek to 1) create, implement, and standardize the thyroid FNA curriculum for Endocrine fellows at our institution by employing global learning objectives and a skill checklist to help guide competency, and 2) assess the impact of this curriculum on knowledge, performance, and comfort. The goal is to prepare fellows for unsupervised practice through clinical procedure assessment tools to guide practical learning in conjunction with didactic lectures. Curriculum could be implemented not only across the nation to other endocrine fellowships but widely across multiple disciplines such as otolarynology, radiology, pathology. To assess the nationwide need for a formal means of teaching and evaluating thyroid US/ FNA skills within fellowship programs, we will be administering a nationwide survey to all Endocrinology Program Directors and recently graduated Endocrinology Fellows.1.Vogelgesang, S. A., Karplus, T. M., Kreiter, C. D. (2002). An instructional program to facilitate teaching joint/soft-tissue injection and aspiration. Journal of general internal medicine, 17(6), 441–445.2. Ljung, B., Drejet, A., Chiampi, N., Jeffrey, J., Goodson, W. H., Chew, K, Miller, T. R. (2001). Diagnostic accuracy of fine-needle aspiration biopsy is determined by physician training in sampling technique. Cancer, 93(4), 263-268. doi:10.1002/cncr.9040.3. Pitman, B., Abele, J., Ali, S. Z., Elsheikh, T. M., Jeffrey, R. B., Scoutt, L. (2008). Techniques for thyroid FNA: A synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagnostic Cytopathology Diagn. Cytopathol., 36(6), 407-424. doi:10.1002/dc.20829.

COVID-19 and Canadian General Internists

In advance of our next issue of the Canadian Journal of General Internal Medicine, we are disseminating work by Dr. Irene Ma and colleagues on use of POCUS for the management of patients with suspected or confirmed COVID-19 illness.

Correction to: Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association.

Correction to: Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association.

Gender gap in research: a bibliometric study of published articles in primary health care and general internal medicine.

Many studies examined gender inequalities in research, but only a few data are available for general biomedical journals. We assessed the prevalence of female first authorship in general biomedical journals and examined its variations across a number of author, article and journal characteristics. This study was nested within a larger project designed to analyze the bibliometric characteristics of scientific articles. We retrieved 767 randomly selected articles published in 2016 in high impact factor journals of primary healthcare (n = 9) and general internal medicine (n = 9). We extracted the following data: author (gender, number of publications and affiliation of the first author), paper (number of authors, number of participants and study design) and journal characteristics (journal discipline and 2015 impact factor). We compared the proportion of articles authored by women and men using univariate and multivariate logistic regressions adjusted for intra-cluster correlations. The female authorship proportion was 48% (63% for primary healthcare and 33% for general internal medicine, P-value < 0.001). In multivariate analysis, women published fewer articles (<5 versus >15 publications: OR 1.6 [95% CI 1.1-2.4]), were more often affiliated with institutions in the Western world (OR 2.2 [95% CI 1.2-3.9]), were more likely to publish qualitative studies (versus systematic reviews or experiments: OR 2.7 [95% CI 1.5-4.8]) and to publish in primary healthcare journals (OR 1.7 [95% CI 1.1-2.7]). The underrepresentation of women in articles published by general internal medicine journals, in articles from the non-Western world and in systematic reviews and trials should be addressed.

Multidisciplinary Teams Knock Down Barriers to Medication Treatment for OUD

Multidisciplinary Teams Knock Down Barriers to Medication Treatment for OUD

A CASE OF EXOGENOUS LIPOID PNEUMONIA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Exogenous lipoid pneumonia (ELP) is a rare form of pneumonia caused by inhalation or aspiration of a fatty substance. In adults, most cases result from the use of oil-based laxatives for the treatment of constipation, followed by the nasal instillation of oily products for chronic rhino pharyngeal diseases. We present a patient who presented with persistent infiltrates and was diagnosed with lipoid pneumonia on lung biopsy. CASE PRESENTATION: A 48 year old female with past medical history of severe gastroesophageal reflux disease and Barrett’s esophagus was referred to the pulmonary clinic for recurrent pneumonia. She had been having gradual exertional dyspnea over two years. She denied chronic cough, wheezing, hemoptysis or overt aspiration. Social history was unremarkable with exception for tobacco abuse. Physical examination revealed oxygen saturation of 93% on room air; symmetrical breath sounds without crackles or wheezing and had normal heart sounds. Investigations including blood chemistries and serologies were unremarkable. Her pulmonary function test revealed normal spirometry with moderate diffusion impairment. Computed tomography revealed ground glass opacities with consolidative changes, with primarily left lung involvement. She was managed as pneumonia with multiple courses of antibiotics but her symptoms persisted. On serial imaging, the ground glass changes remain unchanged. Diagnostic bronchoscopy with biopsy revealed nonspecific chronic inflammatory changes which were assumed to be due to subclinical aspiration. She was treated with anti-acid medications but she continued to have exertional dyspnea. Eventually, she underwent left video assisted thoracoscopic surgery for tissue biopsy and diagnosis was consistent with lipoid pneumonia. She later revealed that she had been using mineral oil laxatives daily over the prior years. She has since stopped the usage of mineral oils. She continues to be mildly symptomatic and has persistent imaging findings. DISCUSSION: ELP is a rare cause of dyspnea and recurrent pneumonia. The typical clinical presentation of this condition includes a chronic cough with or without dyspnea and the presence of diffuse interstitial infiltrates on imaging studies of the chest. However, patients with ELP can present with symptoms ranging from asymptomatic state to severe life threatening respiratory failure. The imaging findings present with varying patterns and distribution and are not diagnostic. As seen in our case, the diagnosis can be delayed because of rather nonspecific clinical features of the disease and lack of a careful history taking for potential chemical irritants. Often, the exposure is identified only retrospectively after the diagnosis is made. CONCLUSIONS: Physicians need to have a high index of suspicion for ELP when managing patients with chronic cough or dyspnea and should elicit a history of mineral oil ingestion. Reference #1: Simmons, A., Rouf, E., & Whittle, J. (2007). Not Your Typical Pneumonia: A Case of Exogenous Lipoid Pneumonia. Journal of General Internal Medicine, 22(11), 1613-1616. https://doi.org/10.1007/s11606-007-0280-7 Reference #2: Marchiori, E., Zanetti, G., Mano, C. M., & Hochhegger, B. (2011). Exogenous lipoid pneumonia. Clinical and radiological manifestations. Respiratory Medicine, 105(5), 659-666. https://doi.org/10.1016/j.rmed.2010.12.001 DISCLOSURES: No relevant relationships by Amirahwaty Abdullah, source=Web Response no disclosure on file for Conrad Schuerch

2982 Gastroenterology Journal Prestige and Impact: Analysis of Journal Rankings

INTRODUCTION: Scientific research is critical to the progression of the field of gastroenterology. Journals are given impact factor ratings annually to determine the utilization and citation of their published articles. The rankings of gastroenterology journals have not been investigated. METHODS: We conducted a retrospective study of gastroenterology journals from 2010 to 2017. Ranking scores from the SCImago Journal Rank (SJR) indicator, a composite score of impact factor, prestige, and closeness of citing articles. The top twenty journals in gastroenterology and hepatology were included and compared to the top ten journals in cardiovascular disease, general internal medicine, and general surgery. RESULTS: The number of gastroenterology journals increased from 134 to 143 in this time period. The top ten journals were Gastroenterology, Gut, Journal of Hepatology, American Journal of Gastroenterology, Alimentary Pharmacology &amp; Therapeutics, Liver Cancer, Natural Clinical Practice Gastroenterology, Clinical Gastroenterology &amp; Hepatology, and Journal Crohn’s and Colitis. Gastroenterology rankings increased from an average of 2.61 to 4.82 (185% increase), compared to a 322% increase and 254% increase in cardiovascular disease and general internal medicine, respectively. The percentage increase per year was significantly lower than similar increase in cardiovascular disease and general internal medicine journals (P &lt; 0.05 for all years). CONCLUSION: Gastroenterology journals lag in citation and prestige compared to other major internal medicine fields. The reasons for this diminished impact should be investigated, and journals should explore mechanisms to disseminate research effectively and improve outreach.

Turning Oral Presentations at the Academy of Consultation-Liaison Psychiatry's Annual Meeting Into Published Articles: A Review and Analysis

Oral presentations at academic conferences typically describe recent or ongoing research projects or provide literature reviews. However, conversion of these presentations into full-length journal articles is not routine. We sought to assess the frequency with which oral presentations at the Academy of Consultation-Liaison Psychiatry's annual meetings from 2012 to 2018 were turned into peer-reviewed publications and review the factors that affected publication of them. Conferencepresentation titles and authors from the 2012-2018 Academy of Consultation-Liaison Psychiatry Annual Meetings were searched using PubMed to find corresponding published reports by the presenters. Data were organized in an Excel spreadsheet, and the time to publication, the journals in which they were published, and general content areas were recorded and analyzed. Of the 287 oral presentations delivered during the study period, 47% were published in a peer-reviewed journal. Articles were published in 72 different journals; the journals that published the most articles were Psychosomatics, General Hospital Psychiatry, Psycho-oncology, Academic Psychiatry, and the Journal of General Internal Medicine. The most common subspecialty topics of the published articles were neuropsychiatry, psycho-oncology, surgery and transplantation, and delirium. The mean time to publication after presentation was 1 year. Knowledge of the rate at which presentations are converted into peer-reviewed publications can be used to enhance the academic success of presenters, and strategies to enhance the rate of publication (e.g., by coaching on scientific writing or by selecting oral presentations with the highest publication potential) can be established.

Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) consensus statement regarding labels and definitions of disease states of gout

ObjectiveThere is a lack of standardisation in the terminology used to describe gout. The aim of this project was to develop a consensus statement describing the recommended nomenclature for disease...

Gender Bias, Discrimination Common in Academic Psychiatry

Gender Bias, Discrimination Common in Academic Psychiatry

Accelerating the Growth of Evidence-Based Care for Women and Men Veterans.

Accelerating the Growth of Evidence-Based Care for Women and Men Veterans.

Pharmacy model for methadone, NAS link to demographics

In “Methadone Matters: What the United States Can Learn from the Global Effort to Treat Opioid Addiction,” senior author Jeffrey H. Sabet, M.D., and colleagues write about the lack of access to methadone treatment, in particular, for opioid use disorder (OUD) in the United States. They look at three pharmacy‐based models that exist in other countries. In their article, published online Feb. 6 in the Journal of General Internal Medicine, they promote the model of patients picking up methadone from pharmacies, as is done in, for example, Canada. The study was funded by the National Institute on Drug Abuse (NIDA) (from the United States) and cited by many as a call to reform the current opioid treatment program (OTP) system in the United States, where patients often prefer buprenorphine simply because they don't have to abide by methadone regulations.

Association between self-reported sleep quality and verbal learning in early stage clinically-stable schizophrenia outpatients

Oral presentations at academic conferences typically describe recent or ongoing research projects or provide literature reviews. However, conversion of these presentations into full-length journal articles is not routine.We sought to assess the frequency with which oral presentations at the Academy of Consultation-Liaison Psychiatry's annual meetings from 2012 to 2018 were turned into peer-reviewed publications and review the factors that affected publication of them.Conference presentation titles and authors from the 2012–2018 Academy of Consultation-Liaison Psychiatry Annual Meetings were searched using PubMed to find corresponding published reports by the presenters. Data were organized in an Excel spreadsheet, and the time to publication, the journals in which they were published, and general content areas were recorded and analyzed.Of the 287 oral presentations delivered during the study period, 47% were published in a peer-reviewed journal. Articles were published in 72 different journals; the journals that published the most articles were Psychosomatics, General Hospital Psychiatry, Psycho-oncology, Academic Psychiatry, and the Journal of General Internal Medicine. The most common subspecialty topics of the published articles were neuropsychiatry, psycho-oncology, surgery and transplantation, and delirium. The mean time to publication after presentation was 1 year.Knowledge of the rate at which presentations are converted into peer-reviewed publications can be used to enhance the academic success of presenters, and strategies to enhance the rate of publication (e.g., by coaching on scientific writing or by selecting oral presentations with the highest publication potential) can be established.

Heterogeneity assessment in gastroenterology systematic reviews: an analysis of current practices.

In systematic reviews and meta-analyses, variation (heterogeneity) in the primary studies is often a concern resulting from factors such as study design, data analysis methods, study quality, settings and interventions and/or patient characteristics. After determining the extent of heterogeneity, authors examine the causes of heterogeneity via sensitivity analysis, subgroup analysis and/or meta-regression analysis. There is no assessment of heterogeneity practices in gastroenterological literature; thus, we present this assessment. We performed a PubMed search to identify systematic reviews published from 2011 to 2016 in the top 10 gastroenterology journals, as well as gastrointestinal topics in general medical journals and the PROSPERO trial registry. The first and second authors independently abstracted data elements, such as levels of inconsistency, sensitivity analysis, subgroup analysis and meta-regression analysis. The search identified 3154 studies; of these, 337 were eligible for inclusion. Included studies consisted of 306 from the gastroenterology literature, 19 studies from PROSPERO and 12 studies from the general internal medicine journals. A significant number of reviews in gastroenterology journals (31.05%, 95/306), internal medicine journals (16.67%, 2/12) and PROSPERO (52.63%, 10/19) conducted a meta-analysis despite having fewer than 10 primary studies. Most of the reviews in gastroenterology journals (81.05%, 248/306), general internal medicine journals (75%, 9/12) and PROSPERO results (73.68%, 14/19) used a combination of methods to assess heterogeneity. There were 20 various definitions of levels of inconsistency (I) throughout all the results. Random effects was the most common model choice in gastroenterology journals reviews (57.84%; 177/306), internal medicine journals (75%, 9/12) and for PROSPERO results (41.11%, 8/19). The majority of reviews did not discuss the impact of heterogeneity on results in the gastroenterology journals (62.09%, 190/306), only one study in the general internal medicine journals and only one study in the PROSPERO results. In gastroenterology journals and other journals printing gastrointestinal topic systematic reviews, most conducted statistical tests for heterogeneity; however, the statistical methods could be more robust and the impact of heterogeneity discussed more often in the article.

The nomenclature of the basic disease elements of gout: A content analysis of contemporary medical journals.

There is currently no standardised nomenclature for the basic disease elements of gout. This study aimed to identify these elements and examine how they are labelled in contemporary medical literature. We analysed articles from the ten highest ranked general rheumatology journals, and five highest ranked general internal medicine journals (by Impact Factor, according to 2015 Thomson-Reuters Journal Citation Reports), published between 1 January 2012 and 31 January 2017. For each journal, articles relevant to gout and hyperuricaemia were identified by the search terms 'gout' and/or 'urate' and/or 'uric acid' using MEDLINE. Basic disease elements were identified and their labels extracted. Labels designated 'unique' used different words or phrases to describe an element. A total of 549 articles were analysed. Eleven basic disease elements and 343 unique labels were identified. Labelling was imprecise for most elements. 'An episode of acute inflammation triggered by the presence of pathogenic crystals' was represented by a total of 162 unique labels; 33.6% of articles referring to this element used at least four unique labels. For articles referencing 'the circulating form of the final enzymatic product generated by xanthine oxidase in purine metabolism in humans', the labels 'uric acid' and 'urate' were used with similar frequency (63.0% and 62.5%, respectively), and both labels were used in 25.9% of articles. Labelling of the basic disease elements of gout is characterised by imprecision, inaccuracy and lack of clarity. Consensus regarding the nomenclature of these elements is required.

Why is trust important for effective healthcare teams?

British Journal of Healthcare ManagementVol. 24, No. 2 DiscussionWhy is trust important for effective healthcare teams?Adam LaylandAdam LaylandSearch for more papers by this authorAdam LaylandPublished Online:10 Feb 2018https://doi.org/10.12968/bjhc.2018.24.2.61AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Abualrub RF, Gharaibeh HF, Bashayreh AEI. The relationships between safety climate, teamwork, and intent to stay at work among Jordanian hospital nurses. Nursing Forum. 2012;47(1):65–75 Crossref, Google ScholarCIPD. Where has all the trust gone? Research Report. [Internet]. 2012. [cited 2017 Nov 21]. Available from: http://www.trustinorganizations.com/Resources/Documents/WhereHasAllTheTrustGone.pdf.pdf Google ScholarCommittee on Standards in Public Life. 7 principles of public life. [Internet]. 1995. [Cited 2017 Nov 21]. Available from: https://www.gov.uk/government/publications/the-7-principles-of-public-life/the-7-principles-of-public-life--2 Google ScholarDepartment of Health and Social Care. The NHS Constitution for England. [Internet]. 2013. [cited 2017 Nov 21]. Available from: https://www.gov.uk/government/publications/the-nhs-constitution-for-england Google ScholarDietz G, Gillespie N, Chao G. Unravelling the complexities of trust and culture. In: Saunders MSkinner DDietz G (eds). Organizational trust: a cultural perspective. Cambridge: Cambridge University Press; 2010:3–41 Crossref, Google ScholarDirks K, Ferrin D. Trust in leadership: meta-analytic findings and implications for research and practice. Journal of Applied Psychology. 2002;87(4):611–28 Crossref, Google ScholarFrancis R. Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009 [Internet]. 2010. [cited 2017 Nov 21]. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/ http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113447.pdf Google ScholarFrancis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry; Executive summary [Internet]. 2013. [Cited 2017 Nov 21]. Available from: http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf Google ScholarHall M et al.. Trust in physicians and medical institutions: what is it, can it be measured and does it matter? Milbank Quarterly. 2001;79(4):613–39 Crossref, Google ScholarHope-Hailey V, Farndale E, Kelliher C. Trust in turbulent times: Organizational change and the consequences for intra-organizational trust. In: Saunders MSkinner DDietz G (eds). Organizational trust: a cultural perspective. Cambridge: Cambridge University Press; 2010:336–57 Crossref, Google ScholarKipnis A, Rhodes KV, Burchill CN, Datner E. The relationship between patients' perceptions of team effectiveness and their care experience in the Emergency Department. Journal of Emergency Medicine. 2013;45(5):731–78 Crossref, Google ScholarMacLeod D, Clarke N. Engaging for Success: enhancing performance through employee engagement. [Internet]. 2012. [cited 2017 Nov 21]. Available from: https://www.2degreesnetwork.com/groups/2degrees-community/resources/macleod-review-engaging-success-enhancing-performance-through-employee-engagement/attachments/8191/ Google ScholarMahon A. Relationships in Healthcare: Trust in Transition? In: Llewellyn SBrookes SMahon (eds). Trust and Confidence in Government and Public Services. 2013 Google ScholarMaguire S, Phillips N. ‘Citibankers’ at Citigroup: a study of the loss of institutional trust after a merger. Journal of Management Studies. 2008;45(2):372–401 Crossref, Google ScholarNHS Leadership Academy. The Healthcare Leadership Model, version 1.0. Leeds: NHS Leadership Academy; 2013 Google ScholarRousseau D, Sitkin S, Burt R. Not so different after all: a cross-discipline view of trust. Academy of Management Review. 1998;23(3):393–404 Crossref, Google ScholarSearle R, Skinner D. New agendas and perspectives. In: Searle RSkinner D (eds). Trust and human resource management. Cheltenham: Edward Elgar; 2011 Crossref, Google ScholarPearson S, Raeke L. Patients' trust in physicians: many theories, few measures and little data. Journal of General Internal Medicine. 2000;15:509–13 Crossref, Google ScholarWest M, Lyubovnikova J. Real teams or pseudo teams? The changing landscape needs a better map. Industrial and Organizational Psychology. 2012;5:25–55 Crossref, Google ScholarWhite K. Trust in Healthcare: Making Progress [Internet]. 2017. [Cited 2018 Jan 15]. Available from: https://www.edelman.com/post/trust-healthcare-making-progress/ Google Scholar FiguresReferencesRelatedDetailsCited byLocus of control: the impact on self-leadership and effectiveness in healthcare teamsStephen Joseph6 August 2021 | British Journal of Healthcare Management, Vol. 27, No. 8The NMC Code and its application to the role of the midwife in antenatal care: a student perspectiveNicole Rajan-Brown, Allison Mitchell9 December 2020 | British Journal of Midwifery, Vol. 28, No. 12 2 February 2018Volume 24Issue 2ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 10 February 2018 Published in print 2 February 2018 Information© MA Healthcare LimitedPDF download

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

A Case of Tenofovir Causing Fanconi Syndrome and Pancreatitis

SESSION TITLE: Critical Care 5 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Fanconi syndrome is known to cause type 2 proximal renal tubular acidosis characterized by inadequate reabsorption in the proximal tubule. As a result there is excessive loss of substances in the urine including amino acids, glucose, phosphate and bicarbonate in the absence of high serum levels. CASE PRESENTATION: A 62-year-old female on Stribid therapy for aquired immunodeficiency syndrome presented to the emergency department with diarrhea, nausea, vomiting and decreased urine output. She was hypotensive and laboratory testing revealed acute renal failure. She also had significant electrolyte and metabolic derangements including hyponatremia, hypokalemia, hyperchloremic non-anion gap metabolic acidosis, low serum uric acid. Urine studies showed high urine protein and glucose levels. The patient was subsequently diagnosed with Fanconi syndrome. Furthermore lipase was also elevated supported by radiologic evidence of acute pancreatitis. DISCUSSION: Acquired causes of Fanconi syndrome include multiple myeloma, renal transplantation, and medications. Tenofovir has been documented as a causative agent in inducing Fanconi syndrome worldwide. In all of these cases the patients had been boosted by lopinavir-ritonavir, a component that is absent from this presentation. Tenofovir is primarily excreted from the renal tubules via MDR-2 (multi drug resistance) protein. Ritonavir inhibits MDR-2, which is what leads to the accumulation of tenofovir in the tubules allowing the drug to damage the tubular cells. Our patient was being treated with elvitegravir (as opposed to ritonavir), which is also a documented, strong MDR reversing agent. It is likely the elvitegravir acted in a similar method to the ritonavir documented in other cases. Unfortunately, in our case, the patient had pancreatitis as well. Although not listed as a side effect, there are multiple reports of pancreatitis with concomitant use of tenofovir and didanosine. It is unclear whether our patient presented with an idiopathic pancreatitis or if there is actually a link between tenofovir treatment alone and pancreatitis. This is the first documented case to our knowledge of tenofovir, without didanosine, causing pancreatitis. CONCLUSIONS: Fanconi syndrome continues to be a rare cause of renal failure and tenofovir has been implicated as a cause when combined with a MDR inhibitor such as ritonavir, and now possibly elvitegravir. This case of pancreatitis and Fanconi syndrome caused by tenofovir may be the first documented, but not the first existant case. More cases must be documented to be sure of this relationship. The risks and benefits must always be weighed when initiating therapies, which have the potential to cause significant harm. Reference #1: Mathew, G., & Knaus, S. J. (2006). Acquired Fanconi’s syndrome associated with tenofovir therapy. Journal of General Internal Medicine, 21(11), 1206-1206. doi:10.1111/j.1525-1497.2006.00518_1.x DISCLOSURE: The following authors have nothing to disclose: Brittany Duchene, Bibi Aneesah Jaumally, Francois Gregoire No Product/Research Disclosure Information

For Super-Utilizers, Integrated Care Offers A New Path.

Many health systems continue to experiment with the best way to care for those patients who end up in the hospital most frequently.