Recommendations for the diagnosis and management of vaccine-induced immune thrombotic thrombocytopenia.

There have recently been safety concerns regarding an increased risk of vaccine-induced immune thrombotic thrombocytopenia (VITT) following administration of SARS-CoV-2 adenoviral vector vaccines. The Southern African Society of Thrombosis and Haemostasis reviewed the emerging literature on this idiosyncratic complication. A draft document was produced and revised by consensus agreement by a panel of professionals from various specialties. The recommendations were adjudicated by independent international experts to avoid local bias. We present concise, practical guidelines for the clinical management of VITT.

The Critical Care Society of Southern Africa guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa.

Letter by Gopalan et al. on article by Singh and Moodley (Singh JA, Moodley K. Critical care triaging in the shadow of COVID-19: Ethics considerations. S Afr Med J 2020;110(5):355-359. https://doi.org/10.7196/SAMJ.2020.v110i5.14778); and response by Singh and Moodley.

Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.

In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.

Skills actively performed during a family medicine community-based preceptorship.

BACKGROUND: This study assessed the clinical learning experiences provided to third-year medical students during a 2-week, required, community-based family medicine preceptorship. METHODS: After completing the preceptorship, students classified their level of performance on 80 clinical activities. During 3 academic years, 486 third-year students completed the preceptorship. RESULTS: Delivery of well-child care was the only prevention skill in which a high percentage of students (more than 67%) received experience; students received moderate experience (34%-67% of students) with another seven prevention skills. Students received a high level of active experience with four clinical problems--upper respiratory tract infection, acute otitis media, sinusitis, and strep throat--and a moderate level of active experience on another 17 clinical problems. There were no procedural skills on which students received a high level of experience, but students received a moderate level of experience with 10 procedural skills. CONCLUSIONS: This brief family medicine preceptorship provided a clinical setting in which students actively engaged in several facets of ambulatory primary care. For accountability, programs need to more clearly articulate what exposure is to be gained in each clinical rotation, strive to enhance active practice, and document levels of student performance.

Usage analysis of a primary care medical resource on the Internet.

Physicians and patients need convenient access to quality medical information. This study's goal was to place a medical resource on the World-Wide Web (WWW), allow access to it through a simple to use interface, and analyze the usage of such a resource. The Family Practice Handbook (TFPH) was digitized and placed onto the WWW. Usage data was obtained from June 1995-June 1996. 118,804 individuals accessed TFPH viewing 409,711 pages of information. A broad spectrum of topics was accessed. TFPH proved to be an extremely popular resource, servicing the broad information needs of an international audience. These preliminary findings suggest the future promise of Internet medical resources.

Analysis of questions asked by family doctors regarding patient care.

OBJECTIVES: To characterise the information needs of family doctors by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. DESIGN: Observational study in which investigators visited doctors for two half days and collected their questions. Taxonomies were developed to characterise the clinical topic and generic type of information sought for each question. SETTING: Eastern Iowa. PARTICIPANTS: Random sample of 103 family doctors. MAIN OUTCOME MEASURES: Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; information resources used. RESULTS: Participants asked a total of 1101 questions. Questions about drug prescribing, obstetrics and gynaecology, and adult infectious disease were most common and comprised 36% of all questions. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were "What is the cause of symptom X?" "What is the dose of drug X?" and "How should I manage disease or finding X?" Answers to most questions (702, 64%) were not immediately pursued, but, of those pursued, most (318, 80%) were answered. Doctors spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search. CONCLUSIONS: Family doctors in this study did not pursue answers to most of their questions. Questions about patient care can be organised into a limited number of generic types, which could help guide the efforts of knowledge base developers.

A diagnostic strategy for myocardial infarction.

In attempting to make the diagnosis of myocardial infarction, the family physician has available an increasing array of enzyme and nuclear imaging techniques to add to the clinical and electrocardiographic findings. In this review several of the new diagnostic tests are described, and their role is discussed both in supplementing and replacing older diagnostic tests. A general strategy for employing both old and new tests is proposed, with a goal of achieving both increased diagnostic accuracy and reduced charges for laboratory tests.

Global occupational health issues: Working in partnership to prevent illness and injury.

1. Occupational health problems in developing countries are more widespread and serious because they occur against a background of endemic risk factors for ill health. 2. In general, developing countries have less adequately developed occupational health personnel and programs and less adequately developed and enforced laws and regulations than developed countries. 3. Awareness of the importance of occupational health among workers, management, government officials, and the public is increasing with developing countries. 4. Occupational health professionals in developed countries can contribute in many ways to improving occupational health in developing countries.

The medical school without walls: who will be the faculty?

To involve community physicians as medical school faculty, a survey was completed to establish the needs of 64 community physicians participating in a third-year family medicine clerkship. We received 48 responses that indicated issues of practice regulation, training office staff, and local continuing medical education were highest priority needs. The 27 respondents in rural areas placed more emphasis on issues of referral/consultation, recruiting of physician associates, and faculty development. As a result of the survey, The University of Texas Medical Branch at Galveston has implemented a comprehensive strategy to address the stated needs, with special emphasis on a rural health initiative. This strategy includes a special program for faculty to provide rural practice coverage technical assistance for practice management, a rural communications network, faculty development, and provider recruitment. The goal of this strategy is to continue developing the "medical school without walls."

[Left atrial appendage as a source of stroke: to close (and how), or not to close (and why)]. / La orejuela izquierda como fuente de accidentes cerebrovasculares: cerrar (y cómo), o no cerrar (y por qué).

The left atrial appendage is considered the main source of emboli in strokes in patients with atrial fibrillation. Oral anticoagulant therapy significantly reduces the risk of cerebral embolic events compared to aspirin, but it is associated with bleeding complications, and is not always used. Closure of the left atrial appendage reduces the rate of thromboembolic events, and it is currently recommended in patients with atrial fibrillation submitted to mitral valve surgery. However, the formation of emboli in these patients may be due to other causes, as the role of the atrial appendage could be less important than is assumed. Moreover, not all patients are candidates for oral anticoagulation, and not all are kept in a proper therapeutic range, which could justify the formation of atrial thrombi. There are several methods for performing the closure of the appendage: direct suture in concomitant mitral surgery, epicardial exclusion by stapling or clips, or endovascular occlusion by percutaneous application. However, the results seem inconclusive with regards to their effectiveness for complete occlusion of the appendage, safety, and efficacy in preventing cerebral embolic events. To add to the confusion, some authors reveal no clear benefit in suture closure, and even describe an increased risk of thromboembolism. We present a review of left atrial appendage closure for the prevention of strokes, as well as the different procedures described above.

Venous thromboembolism--prophylactic and therapeutic practice guideline.

BACKGROUND: Pharmacological prophylactic anticoagulation in many countries, including South Africa, is under-prescribed, which unfortunately results in unacceptable morbidity and mortality in a substantial number of patients. METHOD: The Southern African Society of Thrombosis and Haemostasis reviewed the available literature as well as guidelines from other societies. Specialties represented on the committees included anaesthetics, cardiology, clinical haematology, critical care, gynaecology, haematopathology, internal medicine, neurology, orthopaedic surgery, pulmonology and vascular surgery. A draft document was produced, which was revised by consensus agreement. To avoid local bias, the guidelines were adjudicated by recognised independent international external experts. RESULTS AND CONCLUSION. A concise, practical guideline for thrombo-prophylaxis and treatment in medical and surgical patients has been produced for South African conditions. These guidelines will hopefully lead to improved anticoagulation practice in this country, which we believe will directly benefit patient outcomes.

Degree of preparedness of the individual preventive health system during the Gulf War.

We learned the following lessons concerning the role of public health nurses in the Gulf War: Coherence and clarity in the organization of the network is essential. A solution is needed for childcare for nurses while at work. Home aides should be mobilized to aid in evacuation.

A study of bereavement in general practice.

Forty six bereaved relatives were assessed by a general practitioner four to eight weeks after the bereavement. In 36 (78.3 per cent) the immediate reaction to bereavement was one of numbness or stupefaction; in seven (15.2 per cent) emotional relief occurred; and in three cases (6.5 per cent) there was no obvious immediate reaction. The numbness reaction was limited in duration to a week or less in 31 of the 36 instances.At four to eight weeks after bereavement 29 (63.0 per cent) of the subjects continued to experience difficulty in coming to terms with their loss. Twenty subjects reported guilt feelings and a similar number expressed aggressive reactions. The bereaved subjects tended to increase their consumption of cigarettes and alcohol, while their appetite and weight tended to be reduced. Thirty six (78.3 per cent) of the subjects reported physical symptoms, notably headache, dizziness, generalised aches, and abdominal complaints.THE MOST PROMINENT PSYCHOLOGICAL FEATURES OF BEREAVEMENT WERE FOUND TO BE: preoccupation with thoughts of the deceased, idealisation of the lost person, depressive mood, and loneliness.The findings are discussed and reference made to the role of the family doctor in the management of bereavement reactions.

Special report. Working in a camp for Cambodian refugees.

PIP: A physician records, in this article, his experiences as a physician in the Cambodian refugee camp Khao-I-Dang in Thailand. The background to these camps is briefly presented and Dr. Levy also records some personal observations about certain individuals with whom he became acquainted. While the health facilities were not what one could expect to find in the U.S., the health personnel got on quite well. 80-100 patients were seen each day with a median age/patient of 15. Infectious diseases were seen in 3/4 of the individuals examined. The effects of kwashiorkor and chronic undernutrition were seen as were the effects of various vitamin deficiencies. However, malnutrition among children, which was 15% at the end of 1979, had been reduced to 1% by February 1980. The most dramatic result of the camp's existence was the sharp decline in the death rate. Measures of preventive medicine practiced proved quite beneficial. Public health epidemiologic activities consisted of surveillance, investigation of disease outbreaks, and control measures. Family planning, especially with injectable contraceptives, was another public health measure. The greatest impact of all, however, was in the educational activities of Cambodian health personnel. There was an ongoing in-service training for Cambodian physicians, translators, and helpers, a 3-month nursing program, and a course in communicable disease control for 60 Cambodian public health workers.^ieng

Smoking policies and smoking cessation programs of large employers in Massachusetts.

To assess the current extent of programs and policies to facilitate smoking cessation among employees, we queried 128 large employers in Massachusetts in mid-1978. Eighty-four (66 per cent) responded. Fifty-four (64 per cent) of the respondents had designated jobs or work areas in which smoking was prohibited usually because of potential danger to products or equipment. Seven (8 per cent) of the employers provided counseling, and 10 (12 percent) provided smoking cessation programs for those employees who desired to quit smoking. There is a clear need for the development and evaluation of workplace policies and programs aimed at reducing smoking.