The Effect of Starting a New Residency Program on the Quality of Care Measures at a Community Hospital: A 2-Year Follow-Up.

Background: Introducing graduate medical education to a non-teaching hospital has been a challenging issue due to its perceived possible negative impact on quality and cost of care. Objective: To assess the impact of starting a new Internal Medicine (IM) residency program on the quality of care measures in a Graduate Medical Education (GME) naïve community hospital. Methods: In a retrospective longitudinal study, we compared quality of care parameters (mortality rate, 30-day readmission rate, length of stay, case mix index and severity level) for a hospitalist group ten months before (September 2015-June 2016) and two consecutive years (July 2016-June 2018) after the implementation of an IM residency program at a community hospital. Results: We compared the aggregated data from 1,295 patients before starting the residency program to 2,532 and 3,061 patients, in two consecutive academic years after initiating an IM residency. For the hospitalist group that became the teaching group, the mortality rate decreased significantly from 10 months pre- and the two post-residency periods (2%, 1% and 0.2%, p-value < 0.01), while the mortality rate among non-teaching hospitalist group patients at the same hospital remained unchanged over the same time period (p = 0.70). Length of stay decreased significantly from 10-months pre-residency to 1-year post-residency (6.23 and 5.31, p-value = 0.01). Furthermore, there were no other significant differences between the groups in terms of 30-day readmission rate, complications in care and average cost per case. Conclusions: Starting a new residency program in a non-teaching hospital improves mortality rate without significantly affecting other quality measures.

Comparative analysis of three-dimensional volume rendering and maximum intensity projection for preoperative planning in liver cancer.

Three-dimensional imaging is a useful tool to evaluate liver structure and surrounding vessels for preoperative planning. In this study, we compared two methods of visualizing vascular maps on computed tomography including maximum intensity projection (MIP) and 3D volume rendered (VR) imaging. We compiled important imaging components of pre-surgical planning, and developed criteria for comparison. The imaging techniques were compared based on colorization, volume quantification, rotation, vessel delineation, small vessel clarity, and segmental liver isolation. MIP had more overall limitations due to reduced differentiation of superimposed structures, motion artifact, and interference from calcifications. We determined that because 3D quantitative volume rendered imaging can provide more detail and perspective than MIP imaging, it may be more useful in preoperative planning for patients with liver malignancy. Advanced 3D imaging is a useful tool that can have profound clinical implications on cancer detection and surgical planning.

A Fistula Where? Left Anterior Descending to Pulmonary Artery Fistula.

Fistulas are abnormal passageways between two organs or vessels that usually do not connect. Coronary artery fistulas occur when one of the coronary arteries is connected to either a heart chamber or another blood vessel. This case presents a coronary artery fistula which may or may not be impacting the patient's heart function. A 69-year-old male with multiple comorbidities presents with a chief complaint of shortness of breath. Catheterization reveals an anomalous left anterior descending to pulmonary artery fistula without a step up in oxygen saturation at the level of the pulmonary artery. Surgical management was deferred as this fistula was not deemed to contribute to the patient's declining cardiac function. Operative management versus embolization would be a feasible alternative for patients who are symptomatic secondary to the coronary artery fistula and remains to be controversial in patients who are asymptomatic. Given the possibility of these fistulae eventually causing symptoms it would be practical to close them early on before symptoms arise or before size of the fistulae becomes an issue. Further research should be conducted to understand the management strategies for patients who present with coronary artery fistulas.

Chemotherapy-related complications in the kidneys and collecting system: an imaging perspective.

UNLABELLED: Nephrotoxicity is a common adverse effect of many chemotherapeutic agents. The agents most commonly associated with chemotherapy-associated nephrotoxicity are methotrexate, semustine, streptozocin, mithramycin, and cisplatin. Certain chemotherapeutic agents have adverse effects on the kidneys and urothelium that can be visualized radiographically, including cystic change, interstitial nephritis, papillary necrosis, urothelial changes, haemorrhagic cystitis, acute tubular necrosis, and infarction. This review focuses on imaging features identifying complications of chemotherapy in the kidneys and collecting system and provides didactic cases to alert referring clinicians. TEACHING POINTS: • Nephrotoxicity is a common adverse effect of many chemotherapeutic agents. • Chemotherapies have adverse renal and urothelial effects that can be visualized radiographically. • Crizotinib use can result in the development of complex renal cysts.

Chemotherapy induced liver abnormalities: an imaging perspective.

Treating patients undergoing chemotherapy who display findings of liver toxicity, requires a solid understanding of these medications. It is important for any clinician to have an index of suspicion for liver toxicity and be able to recognize it, even on imaging. Cancer chemotherapy has evolved, and newer medications that target cell biology have a different pattern of liver toxicity and may differ from the more traditional cytotoxic agents. There are several hepatic conditions that can result and keen clinical as well as radiographic recognition are paramount. Conditions such as sinusoidal obstructive syndrome, steatosis, and pseudocirrhosis are more commonly associated with chemotherapy. These conditions can display clinical signs of acute hepatitis, liver cirrhosis, and even liver failure. It is important to anticipate and recognize these adverse reactions and thus appropriate clinical action can be taken. Often times, patients with these liver manifestations can be managed with supportive therapies, and liver toxicity may resolve after discontinuation of chemotherapy.

Portal vein aneurysm presenting with obstructive jaundice.

To the best of our knowledge, a portal vein aneurysm presenting with obstructive jaundice has not been reported in the literature. The preferred treatment for these aneurysms is surgical and a shunting procedure should be considered in cases with portal hypertension to preserve portal vein flow when portal hypertension is present or is secondary to the aneurysm itself. In our case, due to patient's advanced age and co-morbidities, an endoscopic biliary stent was placed which led to successful resolution of symptoms of obstructive jaundice.

Time-motion analysis of health care workers' contact with patients and workers' hand hygiene: open vs closed units.

BACKGROUND: The effects of open (care provided by general medicine teams with a pulmonary intensivist consultant) vs closed (care provided by a dedicated critical care team) intensive care units on health care workers' contact with patients and their hand hygiene is uncertain. OBJECTIVE: To determine if closed intensive care units have fewer visits of patients by health care providers and greater hand-washing compliance among providers than do open units. METHODS: Time-motion analysis was used to observe 2 rooms in a medical intensive care unit at a teaching hospital affiliated with Indiana University School of Medicine, Indianapolis, for 96 hours before and after closure of the unit. The main outcome measures were frequency of health care providers' visits and their hand-washing hygiene compliance rates. RESULTS: Mean number of visits per room per hour by physicians (1.53 in the open unit vs 1.27 in the closed unit; P = .93) and nurses (3.98 in open unit vs 4.14 in closed unit; P = .60) did not differ. No differences were observed in gold-standard hand washing among physicians (0.00% in open unit vs 2.63% in closed unit; P = .11) or nurses (2.50% in open unit vs 3.49% in closed unit; P = .51). However, hand washing decreased significantly in nurses in the closed unit (40.94% in open unit vs 29.84% in closed unit; P = .002). CONCLUSION: Closing the intensive care unit did not decrease the number of contacts between health care providers and patients nor did it increase the providers' compliance with hand hygiene.

Selecting a change and evaluating its impact on the performance of a complex adaptive health care delivery system.

Complexity science suggests that our current health care delivery system acts as a complex adaptive system (CAS). Such systems represent a dynamic and flexible network of individuals who can coevolve with their ever changing environment. The CAS performance fluctuates and its members' interactions continuously change over time in response to the stress generated by its surrounding environment. This paper will review the challenges of intervening and introducing a planned change into a complex adaptive health care delivery system. We explore the role of the "reflective adaptive process" in developing delivery interventions and suggest different evaluation methodologies to study the impact of such interventions on the performance of the entire system. We finally describe the implementation of a new program, the Aging Brain Care Medical Home as a case study of our proposed evaluation process.

The cognitive impact of anticholinergics: a clinical review.

CONTEXT: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes. OBJECTIVE: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults. DATA SOURCES: We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies. STUDY SELECTION: Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles. DATA EXTRACTION: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes. RESULTS: Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia. CONCLUSIONS: Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.