Effect on Diabetes Control in a Resident Clinic Following the Integration of a Clinic Pharmacist.

The impact of a pharmacist has been evaluated within the primary care setting but not within a resident-managed internal medicine clinic. This retrospective study found that the integration of a clinical pharmacist within a resident clinic improved the mean HbA1c of a high-risk patient group by 3% in 3 months and 2.6% in 6 months. None of the residents surveyed reported that the presence of a clinical pharmacist hindered their learning experience. The study also found the residents perceived the clinical pharmacist to be helpful with co-management of diabetes. This data supports the addition of a clinical pharmacist into a resident clinic and continues to support the benefits in the primary care setting.

Case of Ischemic Hepatitis in the Setting of HFpEF Exacerbated by Persistent Atrial Fibrillation.

Congestive hepatopathy in the setting of chronic heart failure is predominantly cholestatic. Severe hepatocellular injury can be seen in cardiogenic shock, usually in an acute setting with severe reduction in ejection fraction and with significant hypotension. Hepatic ischemia with preserved ejection fraction in the setting of atrial fibrillation has not been widely recognized, although mild elevations of liver enzymes have been seen in such patients in the chronic state. We present a patient with preserved ejection fraction, rapid atrial fibrillation with hypotension who had ischemic hepatitis, with aspartate aminotransferase and alanine aminotransferase over one thousand.

Quality improvement in hepatitis C screening and treatment in a primary care resident clinic.

Quality improvement projects are an important part of education for residents and outcome-based projects, and data are required by ACGME. Our resident clinic conducted a quality improvement project regarding screening and treatment for hepatitis C. We improved our screening rate per CDC guidelines and found a prevalence of 1.9% in our clinic population, higher than the national prevalence. We, as internal medicine specialists, have also successfully treated several patients with Tenncare (the equivalent of Medicaid) and uninsured through improvement in our case identification, follow-up and use of specialty pharmacies and standardized order sets.

Quality improvement for HIV screening in a primary care resident clinic.

Primary care physicians are responsible for the initiation of the preventive health screening tests and examinations for their patients. Resident physicians may be uncomfortable obtaining a sexual history from their patient. A performance improvement project was carried out in the resident clinic to see if we could improve HIV screening of our patients. With a cohesive effort between the faculty preceptors and residents, we were able to improve screening rates for HIV and improve some aspects, but not all, of sexual history taking for our population of patients. We identified two patients who screened positive for a rate of 1.4%. ABBREVIATIONS: CDC.

Recognizing Wellens' syndrome, a warning sign of critical proximal LAD artery stenosis and impending anterior myocardial infarction.

Wellens' syndrome, also known as LAD coronary T-wave syndrome or the 'widow maker', is a pre-infarction syndrome with non-classical ischemic ECG changes and unremarkable cardiac biomarkers. This syndrome continues to be a 'can't miss' for the clinician as delay in urgent angiography and intervention can result in anterior myocardial infarction, left ventricular dysfunction, arrhythmias, and death. We describe a case followed by a discussion of identification criteria and clinical implications.

An interventional pilot study on obesity among low-income patients using a computer-based weight management module.

Primary care physicians infrequently address lifestyle modification with their obese patients, among whom those of lower economic means are disproportionately represented. To enhance patients' access to education on lifestyle modification, a clinic-based computer kiosk was installed at our residency clinic for the purpose of healthy lifestyle education. While posttest scores improved and were maintained after completion of lifestyle modification education, body mass index (BMI) was essentially unaffected. Computer-based education without intensive counseling on lifestyle modification appears ineffective in reducing BMI amongst obese patients of lower economic means. Accountable care organization-sponsored health coaching may represent a potential means by which intensive counseling is accomplished among such patients.

Exploring the utility of ultra-brief delirium assessments in a nonintensive care geriatric population: the GEM study.

OBJECTIVE: To determine how an ultra-brief structured tool that would require usually less than a minute for delirium assessment compares with a clinical assessment based on Diagnostic and Statistical Manual-IV (DSM-IV) in a geriatric postacute care (PAC) rehabilitation unit. DESIGN: Prospective observational cohort study. SETTING: Postacute geriatric hospital ward of a Veteran's Affairs hospital. PARTICIPANTS: Consecutively admitted patients between 50 and 100 years old for inpatient postacute medical care. MEASUREMENTS: Two teams, blinded to one another's evaluations, performed daily delirium assessments using either the Confusion Assessment Method for the intensive care unit (CAM-ICU) or clinical assessment based on DSM-IV. RESULTS: There were 61 patients enrolled (median 73 years old, range: 52-94), who underwent 521 paired observations. Delirium was detected in 18 patients (29.5%) by one of the two screening methods over the course of the study, most of whom (14 patients, 23%) were delirious on the first day of enrollment. Delirium was identified by the CAM-ICU on 12.6% of the observations and by the clinical assessment on 6% of the observations (κ = 0.25, 95% confidence interval [CI]: 0.09, 0.40). Examination of disagreement between the 2 evaluations revealed that patients with dementia (κ = 0.11, 95% CI: -0.14, 0.27) had 10.7 times higher odds (95% CI: [3.1, 36.8], p value < .001) of having discordance than patients without dementia. CONCLUSIONS: Different delirium assessments may disagree depending on the study population. Dementia patients are especially challenging to evaluate for delirium.