Exploring Models of Exposure to Primary Care Careers in Training: a Narrative Review.

Multiple models of clinical exposure to primary care exist within undergraduate medical education (UME) and graduate medical education (GME). In this narrative review, we explore the evidence behind these different models of exposure, their alignment with positive promoters of primary care careers, and the pros and cons of each. Without positive exposure to primary care during training, sustaining the future primary care work force becomes increasingly challenging. Here, we explore multiple models of clinical exposure in UME, including longitudinal integrated clerkships, primary care tracks, and primary care clerkships. Within GME, we will review the impact of primary care tracks, Area Health Education Centers, block scheduling models, and continuity clinic scheduling models. The goal of this narrative review is to allow educators to think broadly and intentionally about the array of models to develop positive primary care experiences and perceptions in training, ultimately sustaining the primary care workforce.

Utilizing Television Clips for Graduate Medical Education Anti-racist Curricula: An Acceptability Study.

Introduction Racism is a pervasive social problem that influences medicine, highlighting the need for interventions. One promising educational technique, referred to as edutainment, utilizes clips from television shows as an instructive strategy. The objective of this study was to examine the acceptability of edutainment around anti-racist curricula for residents. Methods We conducted a survey of underrepresented in medicine (URM) medical faculty to inform content for subsequent focus groups with medicine, psychiatry, and pediatrics residents. For the survey, URM faculty were randomly assigned to view four of eight clips and responded to close- and open-ended items. Focus group participants viewed selected clips and provided feedback. All study procedures occurred in 2020-2021. We calculated descriptive statistics for close-ended survey items and employed thematic analysis for open-ended items and focus group transcripts. Results Twelve URM faculty completed the survey. Feedback was uniformly positive so we included all eight clips in the resident focus groups. For each of the three participating specialties, we conducted two focus groups (2-11 participants each, total n=25) with participants viewing four of the eight clips. Analysis of focus group transcripts found that participants were receptive to the edutainment approach. Feedback as to the realism and acceptability of certain clips differed by specialty. Triangulation of survey and focus group results found differences in the acceptability of specific clips between residents and faculty. Conclusion Edutainment with medical television shows may be a promising avenue for anti-racist curricular content for residents. The educational methods described here are being incorporated into a multi-pronged, hospital system wide graduate medical education anti-racist curriculum.

New ACGME Clinician Educator Milestones as a Roadmap for Faculty Development: a Position Paper from the Society of General Internal Medicine Education Committee.

Traditionally, clinician educators are tasked with the responsibility of training future physician workforce. However, there is limited identification of skills required to fulfill this responsibility and a lack of consensus on effective faculty development for career growth as a clinician educator. The newly released Accreditation Council of Graduate Medical Education (ACGME) Clinician Educator (CE) Milestones framework outlines important skills for clinician educators and provides the opportunity to create robust faculty development. In this paper, members of the Society of General Internal Medicine Education Committee discuss the importance of these CE Milestones, outline the novel themes highlighted in the project, and provide recommendations for proper application on both the individual and institutional levels to optimize faculty development. The paper discusses strategies for how to apply the CE Milestones as a tool to create a culture of professional growth and self-directed learning. Using a reflective approach, CE faculty and mentors can identify areas of proficiency and opportunities for growth, thereby creating individualized professional development plans for career success. Institutions should use aggregate CE Milestones data as a needs assessment of their faculty "population" to create targeted faculty development. Most importantly, institutions should not use CE Milestones for high-stakes assessments but rather encourage reflection by CE faculty and create subsequent robust faculty development programs. The ACGME CE Milestones present an exciting opportunity and lay an important foundation for future CE faculty development.

Case Series of Stillbirths Due to Syphilis in Edmonton, Alberta, Canada.

BACKGROUND: Data on the incidence and characteristics of stillbirths attributed to congenital syphilis were collected. METHODS: We extracted data on stillbirths in the Edmonton Zone on January 1, 2015, through June 30, 2021, born to persons diagnosed with infectious syphilis (primary, secondary, early latent, or early neurosyphilis) during pregnancy or at the time of delivery. RESULTS: Of 314 infants documented to be exposed to infectious syphilis during gestation, 16 (5.1%) were stillborn. Three of the 16 females with stillbirths were diagnosed with syphilis during pregnancy but not treated, 12 were diagnosed only at the time of stillbirth (1 of whom was treated early in pregnancy and presumably reinfected), and 1 had a stillbirth in the week after one dose of benzathine penicillin G. CONCLUSIONS: Stillbirths due to congenital syphilis were all due to failure to treat syphilis in pregnancy. Innovative strategies to prevent syphilis in the community and to reach those experiencing barriers to care are urgently required to not miss opportunities to diagnose and treat syphilis as early as possible during pregnancy.

The use of Special-Order products in England between 2012 and 2020: An insight into the need for Point-of-Care manufacturing.

Point-of-care manufacturing such as 3D printing has recently received significant attention from regulatory bodies and the pharmaceutical industry. However, little information is available on the quantity of the most prescribed patient-specific items, their dosage form, and why they were required to be dispensed. In England, 'Specials' are unlicensed medicines formulated to meet the requirements of a specific prescription, prescribed if no suitable licensed alternative exists. This work aims to quantify and examine trends in the prescribing of 'Specials' in England during 2012-2020, using the NHS Business Services Authority (NHSBSA) database. Quarterly prescription data from NHSBSA for the top 500 'Specials' by quantity from 2012 to 2020 were compiled yearly. The changes in net ingredient cost, the number of items, British National Formulary (BNF) drug category, dosage form, and a potential reason for requiring a 'Special' were identified. In addition, the cost-per-unit was calculated for each category. The total spending on 'Specials' decreased by 62 % from £109.2 M in 2012 to £41.4 M in 2020, primarily due to a 55.1 % reduction in the number of 'Specials' items issued. The most frequently prescribed dosage form type of 'Special' was oral dosage forms (59.6 % of all items in 2020) particularly oral liquids. The most common reason for prescribing a 'Special' was an inappropriate dosage form (74 % of all 'Specials' in 2020). The total number of items dropped over the 8 years as commonly prescribed 'Specials' such as melatonin and cholecalciferol became licensed. In conclusion, the total spending on 'Specials' dropped from 2012 to 2020 primarily due to a reduction in the number of 'Specials' items issued and pricing changes in the Drug tariff. Based on the current demand for 'special order' products, these findings are instrumental for formulation scientists to identify 'Special' formulations to design the next generation of extemporaneous medicine to be produced at the point of care.

Evaluation of an Internal Medicine Transition to Residency Course.

OBJECTIVES: We sought to evaluate the effectiveness of a novel Internal Medicine (IM) transition to residency (TTR) curriculum. METHODS: We performed a paired pre-/postsurvey evaluation of graduating fourth-year medical students' perceived preparedness and medical knowledge after participating in a recently developed IM TTR course. RESULTS: The response rate was 51% (24 of 47). There was a significant improvement in 15 of 17 perceived preparedness items and significant improvement in the medical students' performance on the 8-question medical knowledge test. CONCLUSIONS: The IM TTR curriculum improved medical students' medical knowledge and perceived preparedness for internship on a variety of high-yield clinical topics. The curriculum may be appealing to other institutions that are developing or revamping TTR courses.

Using Fictional Medical Television Programs to Teach Interprofessional Communication to Graduating Fourth-Year Medical Students.

OBJECTIVES: Effective interprofessional (IP) communication is crucial to high-quality patient care, but significant obstacles remain regarding implementing IP communication curricula for undergraduate medical students. As such, as part of a bootcamp required for University of Pittsburgh graduating medical students in 2021, we developed and evaluated a workshop using clips from medical television shows (eg, ER) to teach IP communication skills. METHODS: The workshop was hosted on Zoom videoconferencing software and evaluated using pre- and postcurricular surveys that included adapted Communication Skills Attitude Scale (CSAS) and Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) instruments. The postcurricular survey also included two open-ended items. We used Wilcoxon signed-rank tests to compare pre- and postcurricular CSAS and SPICE-R scores and used thematic analysis for qualitative data. RESULTS: Approximately 94% (n = 105) of assigned students attended the workshop. Comparison of pre- and postcurricular means for all CSAS and SPICE-R items indicated improvements in attitudes toward communication training and IP communication, with statistically significant (P < 0.05) changes for 4 of 10 (40%) CSAS items and 8 of 10 (80%) SPICE-R items. Thematic analysis of open-ended items suggests that the workshop is acceptable to students and may be efficacious at improving both their IP communication skills and skills related to addressing equity and bias. CONCLUSIONS: Results suggest that using clips from fictional medical television programs may be a valuable approach to teaching graduating medical students IP communication skills. Future research could examine whether improved attitudes are sustained over time and the influence of the workshop on clinical IP communication behavior.

The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

The Safe Discharge Checklist: A Standardized Discharge Planning Curriculum for Medicine Trainees.

OBJECTIVES: Hospital discharge is a challenging time for residents, requiring the completion of many tasks to ensure safe transitions for patients. Despite recognition of the importance of hospital discharge planning, formal curricula are lacking. We sought to improve medicine residents' comfort and skills with discharge planning and enhance the quality of care by introducing a standardized approach to discharge on the medicine wards. METHODS: The intervention included a didactic, a bedside rounds component, and a discharge checklist. Interns were surveyed at the end of rotations to measure confidence, attitudes, and frequency of completing discharge planning tasks. Results were compared with a control group of experienced interns from the previous academic year. Clinical outcomes included hospital readmission and emergency department return rates and patient satisfaction scores in discharge-related domains. RESULTS: Study interns reported similar confidence to control group interns with discharge planning and endorsed completing four of five discharge tasks more frequently than control interns. There were no differences in clinical outcomes. CONCLUSIONS: We did not identify changes in clinical outcomes, although this finding likely reflects the multifactorial nature of hospital readmissions. Interns exposed to the curriculum early in the academic year had a higher reported frequency of completing key discharge tasks and similar confidence around discharge, when compared with end-of-the-year interns. These improvements suggest that the curriculum led to a change in culture surrounding discharge planning and perhaps accelerated learning of skills associated with discharge best practices.

Avoiding Death by Meeting: An Interactive Workshop for Academic Faculty Highlighting Strategies to Facilitate Effective Team Meetings.

Introduction: Effective meetings are a key marker of team function and are critical for task management. While important, the skill set for running an effective meeting is poorly understood. Methods: We developed an interactive curriculum that provided physician leaders in academic medicine with generalizable knowledge and skills to effectively plan and lead various types of team meetings, leverage engagement, and troubleshoot challenging personalities. This workshop (either 60 or 90 minutes) included a video-based demonstration, interactive and facilitated small- and large-group discussion, and a brief didactic to teach best practices in leading meetings. Participants included academic physicians across a spectrum of rank, specialty, and leadership experience. Knowledge, attitudes, and anticipated behavior changes were evaluated using postsurveys including 5-point Likert-type scale questions (1 = poor, 5 = outstanding) and free-text responses. Results: Fifty-seven participants rated the workshop highly with regard to content (M = 4.8), audiovisual materials (M = 4.7), and overall (M = 4.8). Most participants (82%) indicated a plan to change future design or utilization of an agenda as a result of this workshop. Feedback highlighted the need to incorporate practice opportunities in future iterations of the workshop. Discussion: Our results demonstrated that this standalone, interactive workshop focused on skills to effectively lead team meetings was well received and improved knowledge and attitudes of participants across a spectrum of rank, specialty, and leadership experience. The curriculum was time-efficient, widely generalizable, and can be easily adapted for use within academic medical centers to improve meeting effectiveness.

A Survey of Internal Medicine Interns Regarding the Most Useful Topics to Include in an Internal Medicine Track of a "Get Ready for Residency Boot Camp" Course.

In the last decade, boot camp residency preparatory courses for fourth-year medical students have become increasingly popular in medical schools across the USA; however, the curricular content of these courses varies widely. The authors surveyed internal medicine interns at a large academic medical center regarding clinical and non-clinical topics that would be useful for an internal medicine residency preparatory curriculum. The response rate was 79% (64/81). A rational approach to antibiotics (42%) and electrolyte management (41%) were the most frequent clinical topics and cross-cover (69%) was the most frequent non-clinical topic selected by interns.

Effect of Lewis Acids on the Structure and Reactivity of a Mononuclear Hydroxomanganese(III) Complex.

The addition of Sc(OTf)3 and Al(OTf)3 to the mononuclear MnIII-hydroxo complex [MnIII(OH)(dpaq)]+ (1) gives rise to new intermediates with spectroscopic properties and chemical reactivity distinct from those of [MnIII(OH)(dpaq)]+. The electronic absorption spectra of [MnIII(OH)(dpaq)]+ in the presence of Sc(OTf)3 (1-ScIII) and Al(OTf)3 (1-AlIII) show modest perturbations in electronic transition energies, consistent with moderate changes in the MnIII geometry. A comparison of 1H NMR data for 1 and 1-ScIII confirm this conclusion, as the 1H NMR spectrum of 1-ScIII shows the same number of hyperfine-shifted peaks as the 1H NMR spectrum of 1. These 1H NMR spectra, and that of 1-AlIII, share a similar chemical-shift pattern, providing firm evidence that these Lewis acids do not cause gross distortions to the structure of 1. Mn K-edge X-ray absorption data for 1-ScIII provide evidence of elongation of the axial Mn-OH and Mn-N(amide) bonds relative to those of 1. In contrast to these modest spectroscopic perturbations, 1-ScIII and 1-AlIII show greatly enhanced reactivity toward hydrocarbons. While 1 is unreactive toward 9,10-dihydroanthracene (DHA), 1-ScIII and 1-AlIII react rapidly with DHA (k2 = 0.16(1) and 0.25(2) M-1 s-1 at 50 °C, respectively). The 1-ScIII species is capable of attacking the much stronger C-H bond of ethylbenzene. The basis for these perturbations to the spectroscopic properties and reactivity of 1 in the presence of these Lewis acids was elucidated by comparing properties of 1-ScIII and 1-AlIII with the recently reported MnIII-aqua complex [MnIII(OH2)(dpaq)]2+ ( J. Am. Chem. Soc. 2018, 140, 12695-12699). Because 1-ScIII and 1-AlIII show 1H NMR spectra essentially identical to that of [MnIII(OH2)(dpaq)]2+, the primary effect of these Lewis acids on 1 is protonation of the hydroxo ligand caused by an increase in the Brønsted acidity of the solution.

The impact of residents sitting at the bedside on patient satisfaction during team rounds.

OBJECTIVES: Patient satisfaction ratings are a priority for academic medical centers. Sitting during patient encounters has been recommended as a "best practice."1 A prior study showed that hospitalists had higher-rated communication skills when sitting compared to standing at the bedside during rounds.2 It is unclear whether the same is true of resident-led team rounds. METHODS: We performed a cluster-randomized crossover trial assigning 18 internal medicine residents to sit or stand at the bedside during rounds. RESULTS: A total of 347 patients were surveyed to assess physician communication skills. Standing residents received higher ratings than sitting residents on 2 of 5 survey items and rounding duration did not differ. These results differ from prior work that suggests sitting is superior to standing2-6. CONCLUSION: We suspect that one rounding member sitting, while all others stand, is not enough to impact patients' perceptions. These results suggest that initiatives to optimize patient satisfaction on resident-staffed units should be focused elsewhere. PRACTICE IMPLICATIONS: Patients do not have better impressions of physician communication skills when one team member is sitting and the rest are standing.

Hospital Medicine Update: High-Impact Literature from March 2018 to April 2019.

To assist busy hospital medicine clinicians, we summarized 10 impactful articles from last year. The authors reviewed articles published between March 2018-April 2019 for the Hospital Medicine Updates at the Society of Hospital Medicine and the Society of General Internal Medicine Annual Meetings. The authors voted to select 10 of 30 presented articles based on quality and clinical impact for this summary. The key findings include: (1) Vancomycin or fidaxomicin are the first-line treatment for initial Clostridioides difficile infection; (2) Unnecessary supplemental oxygen is linked to increased mortality; aim for a target oxygen saturation of 90%-94% in most hospitalized patients; (3) Stigmatizing language in medical records impacts physician trainees' attitudes and pain management practices; (4) Consider ablation for atrial fibrillation in patients with heart failure; (5) Patients with opioid use disorder should be offered buprenorphine or methadone therapy; (6) Apixaban is safe and may be preferable over warfarin in patients with atrial fibrillation and end-stage kidney disease; (7) It is probably safe to discontinue antimethicillin-resistant Staphylococcus aureus (MRSA) coverage in patients with hospital-acquired pneumonia who are improving and have negative cultures; (8) Selected patients with left-sided endocarditis (excluding MRSA) may switch from intravenous (IV) to oral antibiotics if they are clinically stable after 10 days; (9) Oral antibiotics may be equivalent to IV antibiotics in patients with joint and soft tissue infections; (10) A history-electrocardiogram-age-risk factors-troponin (HEART) score ≥4 is a reliable threshold for determining the patients who are at risk for short-term major adverse cardiac events and may warrant further evaluation.

Update in Hospital Medicine: Practical Lessons from Current Literature.

BACKGROUND: Hospital medicine continues to grow in workforce, clinical scope, and academic inquiry. This article provides a summary of recent high-impact publications for busy clinicians who provide care to hospitalized adults. METHODS: Authors reviewed articles that were published between March 2017 and March 2018 for the Update in Hospital Medicine presentations at the 2018 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 29 articles presented were selected for this review based on quality and potential to influence practice. RESULTS: The following key insights were gained: (1) the perioperative continuation of aspirin in patients with previous percutaneous intervention is beneficial; (2) delaying hip fracture surgery beyond a 24-hour window increases complications; (3) oral antibiotics may be effective treatment for select bloodstream infections; (4) pulmonary embolism may not be as common a cause of syncope as previously suggested; (5) balanced intravenous fluids and normal saline are similar with respect to hospital-free days but a difference exists in renal events at 30 days favoring balanced crystalloids; (6) speaker introductions may reveal gender bias in academic medicine; (7) edoxaban is a reasonable choice for the treatment of venous thromboembolism in cancer; (8) high-flow nasal cannula reduces the need for intubation in respiratory failure when compared with usual oxygen therapy and noninvasive positive pressure ventilation; and (9) diagnostic errors in spinal epidural abscess lead to delays and morbidity. CONCLUSIONS: This research provides insight into how we can approach common medical problems in the care of hospitalized adults. The selected works have the potential to change or confirm current practices.

Teaching to Teach: An Effective and Feasible Teaching Curriculum for Internal Medicine Interns.

OBJECTIVES: New competency requirements from the Accreditation Council for Graduate Medical Education have prompted greater emphasis on developing residents' teaching skills. Many residents make their first foray into teaching during internship, making it an important yet underrecognized opportunity to develop basic teaching skills. In addition, in the current graduate medical education climate, residents' tasks are compressed into an even shorter time, which has caused teaching opportunities and expectations to be balanced with the need for efficiency. After performing needs assessment surveys of medicine interns and medical students, we developed an interns-as-teachers curriculum to equip internal medicine interns with skills specific to their unique role as medical student teachers. METHODS: We conducted a workshop focused around four specific skills: role modeling, using teachable moments (ie, teaching on the fly), thinking out loud, and coaching. We evaluated the curriculum by comparing pre- and postcurricular teaching knowledge, attitudes, and self-reported teaching behaviors among 51 interns in the intervention group with 20 interns in the comparison group from the previous year's class. RESULTS: Sixty-one interns participated in the curriculum, and 51 (84%) completed both surveys. Knowledge and several self-reported teaching behaviors improved significantly among the intervention group, but not in the comparison group. CONCLUSIONS: Interns participating in a half-day interns-as-teachers workshop aimed at preparing them to teach medical students in clinical settings achieved significant improvement in teaching knowledge and in several core, self-reported teaching behaviors.

Faculty Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant Pain Improve with Online Training.

OBJECTIVE: Many physicians struggle to communicate with patients with chronic, non-malignant pain (CNMP). Through the use of a Web module, the authors aimed to improve faculty participants' communication skills knowledge and confidence, use of skills in clinical practice, and actual communication skills. SUBJECTS: The module was implemented for faculty development among clinician-educators with university faculty appointments, outpatient clinical practices, and teaching roles. METHODS: Participants completed the Collaborative Opioid Prescribing Education Risk Evaluation and Mitigation Strategy (COPE-REMS®) module, a free Web module designed to improve provider communication around opioid prescribing. Main study outcomes were improvements in CNMP communication knowledge, attitudes, and skills. Skills were assessed by comparing a subset of participants' Observed Structured Clinical Exam (OSCE) performance before and after the curriculum. RESULTS: Sixty-two percent of eligible participants completed the curriculum in 2013. Knowledge-based test scores improved with curriculum completion (75% vs. 90%; P < 0.001). Using a 5-point Likert-type scale, participants reported improved comfort in managing patients with CNMP both immediately post-curriculum and at 6 months (3.6 pre vs. 4.0 post vs. 4.1 at 6 months; P = 0.02), as well as improvements in prescribing opioids (3.3 vs. 3.8 vs. 3.9, P = 0.01) and conducting conversations about discontinuing opioids (2.8 vs. 3.5 vs. 3.9, P < 0.001). Additionally, CNMP-specific communication skills on the OSCE improved after the curriculum (mean 67% vs. 79%, P = 0.03). CONCLUSIONS: Experienced clinician-educators improved their communication knowledge, attitudes, and skills in managing patients with CNMP after implementation of this curriculum. The improvements in attitudes were sustained at six months. A Web-based curriculum such as COPE-REMS® may be useful for other programs seeking improvement in faculty communication with patients who have CNMP.

Knowledge of carbohydrate counting and insulin dose calculations in paediatric patients with type 1 diabetes mellitus.

BACKGROUND: Patients with type 1 diabetes mellitus (T1DM) who are able to adjust their insulin doses according to the carbohydrate content of a meal, as well as their blood glucose, are likely to have improved glycaemic control (Silverstein et al., 2005). With improved glycaemic control, patients have a lower risk of developing long-term microvascular complications associated with T1DM (Diabetes Control and Complications Trial Research Group, 1993). To assess the carbohydrate and insulin knowledge of patients attending our paediatric diabetes clinic at the University Hospital Limerick (UHL), the validated PedCarbQuiz (PCQ) was applied to our clinic population. METHODS: This study was completed by applying a questionnaire called the PedCarbQuiz (PCQ) to children exclusively attending our paediatric diabetes clinic at UHL. Of the clinic's 220 patients, 81 participated in the study. RESULTS: The average total PCQ score (%) was higher in the continuous subcutaneous insulin infusion (CSII) group compared with the multiple daily insulin (MDI) injection user group (79.1 ± 12.1 versus 65.9 ± 6.6 p = 0.005). The CSII group also had a higher average carbohydrate score (%) compared with the MDI group (79.4 ± 12.4 versus 66.3 ± 16.2, p = 0.004). CONCLUSIONS: This study demonstrates that in a representative Irish regional paediatric T1DM clinic, knowledge of carbohydrates and insulin is better among patients treated with CSII compared with MDI. However, knowledge in both groups is poorer than in the original US sample. GENERAL SIGNIFICANCE: This study demonstrates that in a representative Irish regional paediatric T1DM clinic, knowledge of carbohydrates and insulin is poorer than in a US based sample, although this knowledge is better among patients treated with CSII compared with MDI. This highlights the need for improved resources for diabetes and carbohydrate counting education for patients with T1DM.

Anticoagulation duration in heterozygous factor V Leiden: a decision analysis.

BACKGROUND: Current anticoagulation guidelines suggest that optimal anticoagulation duration for unprovoked venous thromboembolism is determined by an individual risk assessment, balancing risks of anticoagulation bleeding with venous thromboembolism recurrence. Among individuals heterozygous for the factor V Leiden mutation, while venous thromboembolism recurrence risk is greater, the risk for bleeding is recognized to be lower, suggesting longer duration anticoagulation could be considered. OBJECTIVE: The objective of this study was to compare standard vs. lifelong anticoagulation in 20-year-old factor V Leiden heterozygotes with unprovoked venous thromboembolism. METHODS: A Markov state-transition model was used, incorporating risks of major, minor, and fatal anticoagulation bleeding, bleeding and thromboembolism morbidity and mortality, and quality of life utilities. Model parameter values favoring lifelong anticoagulation in factor V Leiden heterozygotes were determined in sensitivity analyses. Outcomes were in quality-adjusted life years, discounted at 3% per year. RESULTS: In general population groups with odds ratios for venous thromboembolism recurrence and anticoagulation bleeding of 1.0, a short-term anticoagulation strategy gained 0.09 quality-adjusted life years more than a lifelong anticoagulation strategy. By contrast, in factor V Leiden heterozygotes, lifetime anticoagulation was favored if their relative risk of venous thromboembolism was greater than 1.07 or their relative risk for bleeding was less than 0.91. Results were relatively insensitive to individual variation in other parameter values. CONCLUSION: Lifelong anticoagulation may benefit individuals heterozygous for factor V Leiden and previous idiopathic venous thromboembolism. Studies assessing bleeding risk with anticoagulation in factor V Leiden heterozygotes and the costs of indefinite anticoagulation are needed to determine if lifelong anticoagulation is the optimal strategy.