Platypnea-Orthodeoxia Syndrome: Presentation of a 90-Year-Old.

Platypnea-orthodeoxia syndrome (POS) is a clinical syndrome of dyspnea and hypoxemia that is exacerbated by sitting upright or standing and resolved with lying flat. Here, we discuss an initial presentation of POS as a result of a previously undiagnosed patent foramen ovale (PFO) in a 90-year-old man. Diagnosis of the PFO was limited by technically difficult transthoracic echocardiograms with inconclusive agitated saline studies. Transesophageal echocardiogram (TEE) with Doppler and agitated saline study was eventually diagnostic, and his symptoms resolved after percutaneous PFO closure. The diagnosis and treatment in this patient were complicated by his age, moderate dementia, and limited decision-making capacity. Although our patient was dependent for virtually all instrumental activities of daily living (iADLs), he and his family reported an excellent quality of life prior to presentation, and we anticipated he would be able to regain this post-procedurally, allowing us to advocate for TEE and subsequent PFO repair. In the geriatric population, special consideration must be taken to discuss the risks and benefits of extensive workup and treatment depending on the effectiveness and invasiveness of both; approaching these cases with this holistic approach can thus help guide their clinical course appropriately.

Training junior doctors to lead rapid responses.

BACKGROUND: Transitions during medical training are a significant source of stress, and junior doctors (residents) primarily learn new skills through on-the-job training. As residents transition from postgraduate year (PGY) 1 to 2, they take on new responsibilities, including the management of clinically unstable patients in rapid response (RR) scenarios. APPROACH: In 2018, the internal medicine training programme at Brigham and Women's Hospital implemented a 'Transitions Retreat' to prepare PGY-1s for Year 2. In an informal survey, residents endorsed feeling underprepared to lead RRs. We designed a simulation-based curriculum to teach these skills. Participants completed a questionnaire pre-simulation and post-simulation exploring their perceived preparedness. Volunteer residents assessed performance on the simulation using skills checklists and led structured debriefing sessions. We audiotaped, transcribed and thematically analysed these sessions. EVALUATION: Forty-eight of 58 (82%) PGY-1s participated. Pre-intervention, 12.5% felt 'well-prepared' or 'very well-prepared' to lead RRs, compared with 33% post-intervention. Through qualitative analysis, we identified four key themes in our post-simulation debriefing conversations: (1) the chaos of RRs, (2) emotional reactions during RRs, (3) challenges and goals of task management and (4) value of interdisciplinary collaboration. IMPLICATIONS: Though the majority of residents indicated that the curriculum enabled their preparedness to lead RRs and allowed them to process complex emotions in a safe space, we do not know how well this experience translates to the clinical setting. Therefore, we aim to collect follow-up data 6 months into the PGY-2 to explore residents' reflections on real-life experiences as well as whether the simulation impacted their preparedness to lead real-life RRs.

A Paging Training Program for a Fourth-Year Internship Readiness Course.

Introduction: New medical interns face a steep learning curve as they must manage complex medical scenarios, many of which they have only seen before in a classroom setting. To ameliorate these challenges, medical schools are increasingly including courses designed to address the transition from student to doctor. One of the biggest challenges for new interns is learning to triage and manage nursing pages, so we designed a mock paging program incorporated within our fourth-year transitions course. Methods: We developed a database of clinical scenarios to occur via telephone between a nurse and a medicine intern. Throughout the 2-week course, these cases were administered to 40 fourth-year medical students by Master's level nursing students and nurse evaluators. The nurses used checklists to evaluate medical student management and communication, and at the end of the phone encounter students received immediate feedback. We used an observational prospective design, using a within subjects method with repeated measures. Results: Data from a total of 216 phone calls were analyzed for 36 students. No statistically significant improvement of checklist scores was observed. Substantial interrater reliability was observed for the four observed cases with a Fleiss-Kappa of .76. Student comments indicated the activity was helpful for preparing them to answer pages. Discussion: Our paging program offered students the chance to simulate being on call, as well as the opportunity to receive immediate feedback. It did not show improvement in checklists across time. Limitations included a small sample size and few common variables across the cases.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

BACKGROUND: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.