Profile, reasons for hospitalization and nursing diagnoses of refugee-native patients admitted to internal medicine clinic-an evaluation from nursing perspective.

PURPOSE: The study aims to evaluate the hospitalization diagnoses and nursing diagnoses of the refugee and local population hospitalized in internal medicine clinics, which are especially important in the early diagnosis, treatment, and rehabilitation of chronic diseases, and to emphasize their importance in nursing care. METHODS: The study was carried out in a descriptive retrospective design. The files of 3563 patients admitted to the internal medicine clinic of a training and research hospital in Türkiye in 2022 were evaluated. SPSS 26.0 program was used for data analysis. RESULTS: In the study, 95.3% of hospitalizations were native and 4.7% were refugee patients. It was determined that refugee patients admitted to the internal medicine service had a lower mean age compared to the native population (p < 0.05), but there was no difference in the duration of hospitalization (p > 0.05). When the medical diagnoses of hospitalization were examined, it was determined that the highest number of hospitalizations in the native and refugee populations were for bacterial infections in both genders. In nursing diagnoses, it was determined that both populations and genders were diagnosed with infection risk by the medical diagnoses of the patients. CONCLUSION: As a result of the study, it was observed that the duration of hospitalization, reasons for hospitalization, and nursing diagnoses of local and refugee patients were similar. In addition, it was determined that the patients' medical hospitalization diagnoses and nursing diagnoses were compatible.

Differences in provider approach to initiating and titrating guideline directed medical therapy in heart failure with reduced ejection fraction.

BACKGROUND: Despite the strong evidence supporting guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), prescription rates in clinical practice are still lacking. METHODS: A survey containing 20 clinical vignettes of patients with HFrEF was answered by a national sample of 127 cardiologists and 68 internal/family medicine physicians. Each vignette had 4-5 options for adjusting GDMT and the option to make no medication changes. Survey respondents could only select one option. For analysis, responses were dichotomized to the answer of interest. RESULTS: Cardiologists were more likely to make GDMT changes than general medicine physicians (91.8% vs. 82.0%; OR 1.84 [1.07-3.19]; p = 0.020). Cardiologists were more likely to initiate beta-blockers (46.3% vs. 32.0%; OR 2.38 [1.18-4.81], p = 0.016), angiotensin receptor blocker/neprilysin inhibitor (ARNI) (63.8% vs. 48.1%; OR 1.76 [1.01-3.09], p = 0.047), and hydralazine and isosorbide dinitrate (HYD/ISDN) (38.2% vs. 23.7%; OR 2.47 [1.48-4.12], p < 0.001) compared to general medicine physicians. No differences were found in initiating angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARBs), initiating mineralocorticoid receptor antagonist (MRA), sodium-glucose transporter protein 2 (SGLT2) inhibitors, digoxin, or ivabradine. CONCLUSIONS: Our results demonstrate cardiologists were more likely to adjust GDMT than general medicine physicians. Future focus on improving GDMT prescribing should target providers other than cardiologists to improve care in patients with HFrEF.

Comorbidity and multimorbidity in patients with cirrhosis, hospitalised in an internal medicine ward: a monocentric, cross-sectional study.

OBJECTIVES: There are no data regarding the prevalence of comorbidity (ie, additional conditions in reference to an index disease) and multimorbidity (ie, co-occurrence of multiple diseases in which no one holds priority) in patients with liver cirrhosis. We sought to determine the rate and differences between comorbidity and multimorbidity depending on the aetiology of cirrhosis. DESIGN: This is a subanalysis of the San MAtteo Complexity (SMAC) study. We have analysed demographic, clinical characteristics and rate of comorbidity/multimorbidity of patients with liver cirrhosis depending on the aetiology-alcoholic, infectious and non-alcoholic fatty liver disease (NAFLD). A multivariable analysis for factors associated with multimorbidity was fitted. SETTING: Single-centre, cross-sectional study conducted in a tertiary referral, academic, internal medicine ward in northern Italy (November 2017-November 2019). PARTICIPANTS: Data from 1433 patients previously enrolled in the SMAC study were assessed; only those with liver cirrhosis were eventually included. RESULTS: Of the 1433 patients, 172 (median age 79 years, IQR 67-84; 83 females) had liver cirrhosis. Patients with cirrhosis displayed higher median Cumulative Illness Rating Scale (CIRS) comorbidity (4, IQR 3-5; p=0.01) and severity (1.85, IQR 16.-2.0; p<0.001) indexes and lower educational level (103, 59.9%; p=0.003). Patients with alcohol cirrhosis were significantly younger (median 65 years, IQR 56-79) than patients with cirrhosis of other aetiologies (p<0.001) and more commonly males (25, 75.8%). Comorbidity was more prevalent in patients with alcohol cirrhosis (13, 39.4%) and multimorbidity was more prevalent in viral (64, 81.0%) and NAFLD (52, 86.7%) cirrhosis (p=0.015). In a multivariable model for factors associated with multimorbidity, a CIRS comorbidity index >3 (OR 2.81, 95% CI 1.14 to 6.93, p=0.024) and admission related to cirrhosis (OR 0.19, 95% CI 0.07 to 0.54, p=0.002) were the only significant associations. CONCLUSIONS: Comorbidity is more common in alcohol cirrhosis compared with other aetiologies in a hospital, internal medicine setting.

Improving clinical reasoning and communication during handover: An intervention study of the BRIEF-C tool.

BACKGROUND: Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers. DESIGN: A pre-test post-test intervention study. SETTING: Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital. INTERVENTION: The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback. MEASUREMENTS: Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods. RESULTS: A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach's alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen's d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen's d=0.83). CONCLUSION: This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.

A substance use disorder training curriculum for internal medicine residents using resident-empaneled patients.

BACKGROUND: Internal Medicine (IM) residents frequently encounter, but feel unprepared to diagnose and treat, patients with substance use disorders (SUD). This is compounded by negative regard for patients with SUD. Optimal education strategies are needed to empower IM residents to care for patients with SUD. The objective of this study was to evaluate a brief SUD curriculum for IM residents, using resident-empaneled patients as an engaging educational strategy. METHODS: Following a needs assessment, a 2-part SUD curriculum was developed for IM residents at the University of Chicago during the 2018-2019 academic year as part of the ambulatory curriculum. During sessions on Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD), a facilitator covered concepts about screening, diagnosis, and treatment. In session, residents completed structured worksheets applying concepts to one of their primary care patients. A post-session assessment included questions on knowledge, preparedness & attitudes. RESULTS: Resident needs assessment (n = 44/105, 42% response rate) showed 86% characterized instruction received during residency in SUD as none or too little, and residents did not feel prepared to treat SUD. Following the AUD session, all residents (n = 22) felt prepared to diagnose and treat AUD. After the OUD session, all residents (n = 19) felt prepared to diagnose, and 79% (n = 15) felt prepared to treat OUD. Residents planned to screen for SUD more or differently, initiate harm reduction strategies and increase consideration of pharmacotherapy. CONCLUSIONS: A brief curricular intervention for AUD and OUD using resident-empaneled patients can empower residents to integrate SUD diagnosis and management into practice.

Simulated subacromial injection instruction improves accuracy and skill level: a model for musculoskeletal procedural training.

BACKGROUND: Musculoskeletal (MSK) complaints often present initially to primary care physicians; however, physicians may lack appropriate instruction in MSK procedures. Diagnostic and therapeutic injections are useful orthopedic tools, but inaccuracy leads to unnecessary costs and inadequate treatment. The authors hypothesized that trainees afforded the opportunity to practice on a cadaver versus those receiving visual-aided instruction on subacromial injections (SAI) will demonstrate differences in accuracy and technique. METHODS: During Spring of the year 2022, 24 Internal Medicine and Family Medicine residents were randomly divided into control and intervention groups to participate in this interventional randomized cadaveric study. Each group received SAI instruction via lecture and video; the intervention group practiced on cadavers under mentored guidance. Subjects underwent a simulated patient encounter culminating in injection of latex dye into a cadaveric shoulder. Participants were evaluated based on a technique rubric, and accuracy of injections was assessed via cadaver dissection. RESULTS: Twenty-three of twenty-four participants had performed at least one MSK injection in practice, while only 2 (8.3%) of participants had performed more than 10 SAIs. There was no difference in technique between control 18.4 ± 3.65 and intervention 19.2 ± 2.33 (p = 0.54). Dissections revealed 3 (25.0%) of control versus 8 (66.7%) of intervention injections were within the subacromial space. Chi-Square Analysis revealed that the intervention affected the number of injections that were within the subacromial space, in the tissues bordering the subacromial space, and completely outside the subacromial space and bordering tissues (p = 0.03). The intervention group had higher self-confidence in their injection as opposed to controls (p = 0.04). Previous SAI experience did not affect accuracy (p = 0.76). CONCLUSIONS: Although primary care physicians and surgeons develop experience with MSK procedures in practice, this study demonstrates a role for early integrated instruction and simulation to improve accuracy and confidence. The goal of improving accuracy in MSK procedures amongst all primary care physicians may decrease costs and avoid unnecessary referrals, diagnostic tests, and earlier than desired surgical intervention.

[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. / Präoperative Evaluation erwachsener Patientinnen und Patienten vor elektiven, nicht herz-thoraxchirurgischen Eingriffen : Eine gemeinsame Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, der Deutschen Gesellschaft für Chirurgie und der Deutschen Gesellschaft für Innere Medizin.

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.

General internal medicine: acquiring clinical acumen from bedside to front door with opportunities for undergraduate and postgraduate training.

A general physician's training and experience enables them to manage a variety of acute and chronic medical conditions with multi-system pathology, while specialising in one specific area of medicine. In every illness there are other problems outside the specialty, requiring the wider expertise of the generalist as patients have multiple comorbidities and the multitude of disease pathology presenting are quite complex requiring a multi-faceted approach. The horizons of general internal medicine have broadened with a wide landscape of acute illnesses that are now being admitted under general medicine which is the path of least resistance. As we strive relentlessly while working on the ward at the bedside and in acute portals, we ought to remind ourselves of what are the attractions of general internal medicine and lead by example for the undergraduates and postgraduate doctors in training who see us as role models for doing clinical medicine, teaching, training and research.

Erratum: Exploring Communication about Fall Risk and Prevention between Internal Medicine Residents and Geriatric Patients: A Needs Assessment: Erratum.

[This corrects the article DOI: 10.14423/SMJ.0000000000001652.].

The Ottawa resident observation form for nurses (O-RON): evaluation of an assessment tool's psychometric properties in different specialties.

BACKGROUND: Workplace-based assessment (WBA) used in post-graduate medical education relies on physician supervisors' feedback. However, in a training environment where supervisors are unavailable to assess certain aspects of a resident's performance, nurses are well-positioned to do so. The Ottawa Resident Observation Form for Nurses (O-RON) was developed to capture nurses' assessment of trainee performance and results have demonstrated strong evidence for validity in Orthopedic Surgery. However, different clinical settings may impact a tool's performance. This project studied the use of the O-RON in three different specialties at the University of Ottawa. METHODS: O-RON forms were distributed on Internal Medicine, General Surgery, and Obstetrical wards at the University of Ottawa over nine months. Validity evidence related to quantitative data was collected. Exit interviews with nurse managers were performed and content was thematically analyzed. RESULTS: 179 O-RONs were completed on 30 residents. With four forms per resident, the ORON's reliability was 0.82. Global judgement response and frequency of concerns was correlated (r = 0.627, P < 0.001). CONCLUSIONS: Consistent with the original study, the findings demonstrated strong evidence for validity. However, the number of forms collected was less than expected. Exit interviews identified factors impacting form completion, which included clinical workloads and interprofessional dynamics.

Core stories of physicians on a Swiss internal medicine ward during the first COVID-19 wave: a qualitative exploration.

INTRODUCTION: The first COVID-19 wave (2020), W1, will remain extraordinary due to its novelty and the uncertainty on how to handle the pandemic. To understand what physicians went through, we collected narratives of frontline physicians working in a Swiss university hospital during W1. METHODS: Physicians in the Division of Internal Medicine of Lausanne University Hospital (CHUV) were invited to send anonymous narratives to an online platform, between 28 April and 30 June 2020. The analysed material consisted of 13 written texts and one audio record. They were examined by means of a narrative analysis based on a holistic content approach, attempting to identify narrative highlights, referred to as foci, in the texts. RESULTS: Five main foci were identified: danger and threats, acquisition of knowledge and practices, adaptation to a changing context, commitment to the profession, and sense of belonging to the medical staff. In physicians' narratives, danger designated a variety of rather negative feelings and emotions, whereas threats were experienced as being dangerous for others, but also for oneself. The acquisition of knowledge and practices focus referred to the different types of acquisition that took place during W1. The narratives that focused on adaptation reflected how physicians coped with W1 and private or professional upheavals. COVID-19 W1 contributed to revealing a natural commitment (or not) of physicians towards the profession and patients, accompanied by the concern of offering the best possible care to all. Lastly, sense of belonging referred to the team and its reconfiguration during W1. CONCLUSIONS: Our study deepens the understanding of how physicians experienced the pandemic both in their professional and personal settings. It offers insights into how they prepared and reacted to a pandemic. The foci reflect topics that are inherent to a physician's profession, whatever the context. During a pandemic, these foundational elements are particularly challenged. Strikingly, these topics are not studied in medical school, thus raising the general question of how students are prepared for the medical profession.

[Follow-up outpatient clinics for patients with post COVID: a survey to assess and characterize aspects of care]. / Nachsorgeambulanzen für Patient*innen mit Post-COVID: eine Befragung zur Bestandsaufnahme und Charakterisierung von Versorgungsaspekten.

After acute infection with the SARS-CoV-2 virus, up to 10 % of affected individuals suffer from long-term health impairments, also referred to as "Post-COVID". In Germany, specialized outpatient clinics have been established to care for patients with Post-COVID. A structured survey of the care situation is not yet available, but essential for a demand-oriented care. The present study aimed to systematically assess and describe structural and process-related aspects of care, and to perform an inventory and needs analysis of Post-COVID outpatient clinics in Germany.An online survey was developed assessing the structure and organization of the outpatient clinics, service offerings and networking of care from the perspective of the outpatient clinic directors. A total of 95 outpatient clinics were identified, and an invitation to participate in the online survey was sent via e-mail to the directors of the outpatient clinics. Data were collected between February and May 2022. Descriptive data analysis was performed.A total of 28 outpatient clinic managers (29 %) took part in the survey. Participants were between 32 and 66 years old, and 61 % (n = 17) were male. The outpatient clinics were most frequently affiliated with the specialties of pneumology (n = 10; 36 %), internal medicine, psychiatric and psychosomatic medicine, and neurology (n = 8; 29 %, respectively). Among the outpatient clinic directors, 64 % (n = 18) stated that the time spent waiting for an appointment was more than one month. Utilization (n = 25; 89 %), appointment demand (n = 26; 93 %), and the need for more Post-COVID outpatient clinics (n = 20; 71 %) were rated as high by the outpatient clinic directors. Nearly all directors reported networking with in-clinic facilities (n = 27; 96 %), with primary care physicians and with specialists in private practice (n = 21; 75 %, respectively).The main focus of care is pneumology. Internal medicine, psychiatry/psychosomatics and neurology are also equally represented. Our data further suggest a high demand for Post-COVID outpatient clinics and the need to expand this care offer.

R.I.M.E. and reason: multi-station OSCE enhancement to neutralize grade inflation.

To offset grade inflation, many clerkships combine faculty evaluations with objective assessments including the Medical Examiners Subject Examination (NBME-SE) or Objective Structured Clinical Examination (OSCE), however, standardized methods are not established. Following a curriculum transition removing faculty clinical evaluations from summative grading, final clerkship designations of fail (F), pass (P), and pass-with-distinction (PD) were determined by combined NBME-SE and OSCE performance, with overall PD for the clerkship requiring meeting this threshold in both. At the time, 90% of students achieved PD on the Internal Medicine (IM) OSCE resulting in overall clerkship grades primarily determined by the NBME-SE. The clerkship sought to enhance the OSCE to provide a more thorough objective clinical skills assessment, offset grade inflation, and reduce the NBME-SE primary determination of the final clerkship grade. The single-station 43-point OSCE was enhanced to a three-station 75-point OSCE using the Reporter-Interpreter-Manager-Educator (RIME) framework to align patient encounters with targeted assessments of progressive skills and competencies related to the clerkship rotation. Student performances were evaluated pre- and post-OSCE enhancement. Student surveys provided feedback about the clinical realism of the OSCE and the difficulty. Pre-intervention OSCE scores were more tightly clustered (SD = 5.65%) around a high average performance with scores being highly negatively skewed. Post-intervention OSCE scores were more dispersed (SD = 6.88%) around a lower average with scores being far less skewed resulting in an approximately normal distribution. This lowered the total number of students achieving PD on the OSCE and PD in the clerkship, thus reducing the relative weight of the NMBE-SE in the overall clerkship grade. Student response was positive, indicating the examination was fair and reflective of their clinical experiences. Through structured development, OSCE assessment can provide a realistic and objective measurement of clinical performance as part of the summative evaluation of students.

Culture change and lessons learned from ten years in the VA centers of excellence in primary care education.

BACKGROUND: Team-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments. METHODS: A review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home design RESULTS: Each site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration. CONCLUSIONS: Aligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training. TRIAL REGISTRATION: This evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.

Evolution of RANO in Assessing Brain Tumour Outcomes.

Assessing treatment response is extremely important in management of brain tumours. Response assessment in neuro-oncology (RANO) was introduced in 2008 for the purpose of making recommendations for it by addressing and countering the limitations in previously reported response criteriae. Subsequently, multiple RANO working groups have been formed to cater to different tumour types and to update their previous recommendations to counter the limitations in their criteria. Herein we have a summarized list of RANO criteria for adult brain tumours.

Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine.

Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).

[Infectious Diseases - a new specialty for postgraduate training in Germany]. / Infektiologie ­ eine neue Facharztdisziplin in Deutschland.

Medicine in Germany is currently facing major structural and economic challenges. Infectious Diseases, with the recent introduction of a new specialty in "Internal Medicine and Infectious Diseases" and with the existing additional training for almost all specializations, will make an important contribution to overcoming these challenges. Expertise in infectious diseases has to be very broad and requires high interdisciplinarity, which makes infectious diseases an attractive and demanding specialty. The complex fundamentals of infectious diseases must now be quickly conveyed to as many physicians as possible in a short period of time, as part of their specialization or as additional training. Until this is achieved, transitional solutions will be necessary for some time. The adaptation of the current billing and reimbursement system for infectious diseases services and improved intersectoral cooperation are of the utmost importance for the further development of the specialty.