Point-of-care ultrasound may expedite diagnosis and revascularization of occult occlusive myocardial infarction.

BACKGROUND: Electrocardiographically occult occlusive myocardial infarction (OOMI), defined as coronary artery occlusion requiring revascularization without ST-segment elevation on electrocardiogram (ECG), is associated with delayed diagnosis resulting in higher morbidity. Left ventricular (LV) wall motion abnormalities (WMA) appreciated on echocardiography can expedite OOMI diagnosis. We sought to determine whether point-of-care ultrasound (PoCUS) demonstrating WMA expedites revascularization time when performed on emergency department patients being evaluated for OOMI. METHODS: This was a single-site retrospective cohort study over a 38-month period. All admitted adult ED patients ≥35 years of age evaluated by the emergency physician with PoCUS for LV function, an ECG, and a standard troponin I biomarker assay were included. Patients with ST-segment elevation myocardial infarction (STEMI), prior LV dysfunction, fever ≥100.4 °F, or hypotension were excluded. A structured chart abstraction was performed for relevant demographic and clinical characteristics. RESULTS: We screened 1561 ED patients who underwent cardiac PoCUS for eligibility: 874 met exclusion criteria, 453 were discharged, and 234 were included in the analysis. Twenty-three patients had coronary interventions, of which 14 had WMA. PoCUS was performed 36 min (IQR -9-68) before troponin resulted (n = 234) and 39 min (IQR -23-96) before the first troponin elevation (n = 85). Twenty of the 23 patients diagnosed with OOMI had elevated troponins prior to catheterization with time from PoCUS to first troponin elevation of 43 min (IQR 9-263). Of these patients, 11 had WMA identified on PoCUS, and the WMA was appreciated 47 min (IQR 26-255) prior to troponin elevation. The time from ED arrival to revascularization was 673 min (IQR 251-2158); 432 min (IQR 209-1300) among patients with WMA (n = 14) compared with 2158 min (IQR 552-3390) for those without WMA (n = 9). CONCLUSION: Cardiac PoCUS may identify OOMI earlier than standard evaluation and may expedite definitive management.

The Impact of a Communication Skills Workshop on Doctors' Behavior Over Time.

PURPOSE: Communication skills education is still relatively new in some non-Western countries. Further, most evaluation research on communication skills education examines only short-term results. In our communication skills program in Qatar, we aimed to: 1) assess the impact of the communication skills course on participant skills application; 2) assess the length of time since course completion associated with participant skills application; and 3) assess participant gender or clinical position associated with participant skills application. METHODS: Seven hundred and thirty-eight physicians completed a seven-module communication skills course. Participants reflected on what they learned in the course and how the course had impacted their behavior through a nine-item online survey that included a four-item Communication Workshop Impact Scale (CWIS), three open questions, and two demographic questions. To assess the effect of time since workshop on outcomes, we stratified the respondents into five groups based on how long ago they had completed the course. RESULTS: Three hundred and thirty-two physicians completed the survey. Participants reported agreement with the items on the CWIS: X=4.45 (range 1-5; SD=0.70). When asked which skill(s) they had been able to implement in their clinical practice, 235 gave a specific response, either a specific communication skill (eg, ask open questions), a higher-order category of skills (eg, questioning skills), or the name of one of the seven modules of the course. Only 28 participants listed the name of a skill or module name that they had not been able to implement. There was no evidence of difference in CWIS score based on time since course completion. There was no gender difference; however, residents had significantly lower CWIS scores than fellows (4.70 vs. 4.29, p<0.05). CONCLUSION: Participants reported agreement with response items about the impact of the course on their skills application. Participant gender did not play a significant role, but residents had lower scores than did fellows. Furthermore, most physicians (92%) were able to name something specific that they had learned from the course and were currently implementing in their practice. Positive outcomes of the course did not seem to diminish over time. Future research should identify whether observable communication behavior matches the self-reported behavior.

Prevalence and Type Distribution of High-Risk Human Papillomavirus (HPV) in Breast Cancer: A Qatar Based Study.

Human papillomavirus (HPV) has been implicated in the etiology of a variety of human cancers. Studies investigating the presence of high-risk (HR) HPV in breast tissue have generated considerable controversy over its role as a potential risk factor for breast cancer (BC). This is the first investigation reporting the prevalence and type distribution of high-risk HPV infection in breast tissue in the population of Qatar. A prospective comparison blind research study herein reconnoitered the presence of twelve HR-HPV types' DNA using multiplex PCR by screening a total of 150 fresh breast tissue specimens. Data obtained shows that HR-HPV types were found in 10% of subjects with breast cancer; of which the presence of HPV was confirmed in 4/33 (12.12%) of invasive carcinomas. These findings, the first reported from the population of Qatar, suggest that the selective presence of HPV in breast tissue is likely to be a related factor in the progression of certain cases of breast cancer.

Impact of Urinalysis on Medical Decision-making and Length of Stay.

Introduction The emergency department (ED) is under pressure to meet length of stay (LOS) metrics for care in the ED. An aspect that we propose affects LOS is the order for urine sample collection and subsequent urinalysis (UA) as both are time consuming steps. This project's primary goals are to determine if ordering a UA increases LOS and how often UA contributes to clinical decision-making and/or disposition decisions in the ED. Secondary objectives were to identify factors that contribute to the ordering of a UA and to decipher if LOS was more impacted in patients who were discharged vs. admitted to the hospital. Methods Retrospective chart review was conducted of patients who presented to our ED in April 2016 during 12 consecutive days. Data were abstracted onto a data collection sheet with the abstractor blinded to study hypotheses. Variables included whether a UA was ordered, times of UA order and result, who ordered the UA (mid-level provider [MLP] vs. physician), whether the UA was cancelled, whether the UA result influenced clinical decision-making (based on the medical decision-making section of the physician chart) or disposition decision, LOS, age, and gender. Descriptive statistics and multivariable regression analysis were used to analyze relationships between the variables collected and their influence on LOS. Results The overall median LOS was 157 minutes, with an interquartile range (IQR) of 81 to 246 minutes. For discharged patients, it was 142 minutes, with an IQR of 46 to 236 minutes. For admitted patients, it was 177 minutes, with an IQR of 118 to 260 minutes. Amongst admitted patients, multivariable regression analysis demonstrated that the following factor was associated with increased LOS: being seen first by the provider-in-triage (PIT) then physician in main ED (p < 0.0001). Amongst discharged patients, multivariable regression analysis demonstrated that the following factors were associated with increased LOS: being seen first by the PIT then physician in main ED (p = 0.0296), being seen by MLP only (p < 0.0001), having a UA ordered (p = 0.0005), being seen on weekend (p = 0.0166), and being an older patient (p = 0.0475). The UA was cancelled in 9% of our patients, and in 60% of cases, these UAs were ordered by the PIT. Patient disposition decision was made prior to UA resulting in 60 cases (25%). The UA was used in clinical decision-making in 118 cases (66%). The following predictor factors were associated via univariate analysis with using a UA for decision-making: being female (p = 0.0050, 95% CI: 0.0068-0.378), being an older patient (p < 0.0001, 95% CI: -0.010 to -0.004), being first seen by the PIT and then a physician (p = 0.0486, 95% CI: 0.0048-0.1555), and discharged patients (p < 0.0001, 95% CI: -0.6749 to -0.4487). Conclusion Our results suggest that having a UA ordered increased ED LOS, especially in patients who are ultimately discharged. In our ED, routine UAs are ordered more often by MLPs than physicians. A routine UA may not impact clinical decision-making up to 33% of the time, nor alter disposition decision one out of four times. Given that 9% have the test eventually cancelled, one should reconsider the utility in ordering routine UAs in ED patients, as they increase LOS and place an additional burden on the patient and the ED personnel.

Improving Screening for Latent Tuberculosis Infection in a Student-run Free Clinic.

Introduction Latent tuberculosis infection (LTBI) screening with targeted treatment has been successful in eradicating tuberculosis (TB) as an endemic infection in the United States. The Centers for Disease Control and Prevention (CDC) recommends screening for high-risk patients. The aim of this study was to increase LTBI screening, detection, and treatment in our student-run free clinic while providing an innovative platform for education in primary care topics. Methods A questionnaire for screening for LTBI was adapted from CDC guidelines. Medical students and providers received education on the screening process and administered questionnaires to patients. We analyzed the rate of performed LTBI screening, the rate of diagnostic testing for patients with positive screening, and the feasibility of implementing a preventive screening initiative. Results Fifty-two patients completed primary care visits. Forty patients were screened for LTBI. Of those screened, 42.5% were positive for the screening. Of those with positive screening, 70.6% were followed up via diagnostic testing, with the rest of them being lost for follow-up due to not attending the clinic for care. Conclusions This educational intervention combined with a screening tool was effective in increasing LTBI screening rates amongst patients in a student-run free clinic.