Successful Implementation of a Shared Medical Appointment Model for Hepatitis C Treatment at a Community Health Center.

Highly efficacious direct acting antiviral (DAA) therapy for treatment of Hepatitis C Virus (HCV) infection is largely inaccessible to communities facing a shortage of available specialist providers. Though less demanding than previous interferon regimens, DAA therapy requires patients to adhere to 8-12 weeks of daily treatment, which can be challenging for some patient populations. Duffy Health Center, located on Cape Cod, Massachusetts, provides integrated medical, mental health and case management services to people who are homeless or at risk for homelessness. The goal of this manuscript is to evaluate the outcomes of treatment of HCV infection with a shared medical appointment (SMA) model. The primary outcome was sustained virologic response (SVR-12), or HCV RNA ≤ 15 IU/mL at 12 weeks post-treatment. There were 102 patients recruited, with a total of 104 treatments administered. Over three-fourths of patients who attended one SMA visit (78 of 102) continued in SMA for the duration of treatment. Of these patients opting for SMA, 99% (77 of 78) completed the full treatment course, and 91% (71 of 78) of SMA patients achieved SVR-12. DAA therapy provided by non-specialist providers using the SMA model yielded comparable response rates to those achieved by specialist providers, and has the potential to substantially increase access to HCV treatment for patient populations within high-risk communities.

Pediatric Hospitalists' Performance and Perceptions of Script Concordance Testing for Self-Assessment.

OBJECTIVES: The cognitive expertise of Pediatric Hospitalists (PH) lies not in standard knowledge but in making decisions under conditions of uncertainty. To maintain expertise, PH should engage in deliberate practice via self-assessments that promote higher-level cognitive processes necessary to address problems with missing or ambiguous information. Higher levels of cognition are purported with Script Concordance Test (SCT) questions compared to Multiple Choice Questions (MCQ). To determine if PH use higher levels of cognition when answering SCT versus MCQ questions and to analyze participants' perceptions of the utility of using SCT self-assessment for deliberate practice in addressing clinical problems encountered in daily practice. METHODS: This is a mixed methods study comparing the cognitive level expressed according to Bloom's Taxonomy by PH answering MCQ versus SCT questions using a "think aloud" (TA) exercise, followed by qualitative analysis of interviews conducted afterward. RESULTS: A significantly greater percentage of comments were coded as higher cognitive processes (apply, analyze, evaluate, and create) for SCT versus MCQ (74% vs 19%) compared with lower order (remember, understand); chi-square P < .00001. Analysis of interviews revealed 6 themes. CONCLUSION: SCT questions elicited higher level cognition essential to clinical reasoning compared to MCQ questions. PH-indicated MCQ questions measure standard knowledge, while SCT questions better measure decision-making under conditions of uncertainty. PH-perceived SCT could be useful for deliberate practice in Pediatric Hospital Medicine decision-making if they could compare their rationale in answering questions with that of experts.

Predicting breast cancer risk: implications of a "weak" family history.

Published guidelines adopted in many countries recommend that women whose family history of breast cancer places them at a risk>or=1.7 times that of the age-matched general population, should be considered for inclusion in special surveillance programmes. However validation of risk assessment models has been called for as a matter of urgency. The databases of the four Scottish Familial Breast Cancer clinics and the Scottish Cancer Registry have been searched to identify breast cancers occurring among 1,125 women aged 40-56, with family histories placing them below the "moderate" level of genetic risk. The observed incidence over 6 years was compared with age-specific data for the Scottish population. Our findings confirm that when there are two affected relatives (one first degree) the relative risk (RR) exceeds 1.7 regardless of their ages at diagnosis. When only one (first degree) relative was affected at any age from 40 to 55, the RR does not reach 1.7 if that relative was a mother but exceeds it if the relative was a sister. The probable explanation is that sisters are more likely than mother/daughter pairs to share homozygosity for a risk allele. Surveillance programmes might therefore accommodate sisters of women affected before age 55. Evidence that "low penetrance" alleles contributing to breast cancer risk may be recessive should be taken into account in strategies for identifying them.

Long-term attendance at follow-up of women assessed as being at increased risk of developing breast cancer in south-east Scotland.

BACKGROUND: Women with a family history of breast cancer increasingly seek genetic advice and screening. In the present study we investigated referral rates and factors associated with long-term attendance for screening in Scotland. METHODS: We investigated referral rates to the genetic service over a 21-month period and long-term attendance for screening amongst the 226 women at increased risk of developing breast cancer. RESULTS: The overall annual referral rate was 0.31 per 1,000 patients on general practitioners' lists. Some 98% of women for whom it was appropriate attended at least one screening appointment and 88% were continuing to attend appointments for surveillance up to 5 years later. Attendance was significantly lower among more socially deprived patients (p < 0.01). CONCLUSIONS: These results suggest that as increasing numbers of women with a positive family history seek risk assessment and screening, current facilities may be inadequate.

Personal Digital Assistant-Based Self-Work Sampling Study of Pediatric Interns Quantifies Workday and Educational Value.

OBJECTIVE: Optimizing clinical proficiency and education of residents has become more important with restricted residency duty hours. Our objective was to investigate how interns spend their time on inpatient rotations and the perceived educational value of workday activities. METHODS: We performed a descriptive self-work sampling study using a personal digital assistant (PDA) to randomly query interns on inpatient rotations in real time regarding their activity and the perceived educational value of that activity on a 4-point Likert scale. RESULTS: A total of 31 interns participated on 88 workdays over a 5-month period, generating 2082 samples from which the average workday was modeled. Time spent using the electronic health record (EHR) accounted for 33% of intern time, communicating with the health care team 23%, educational activities 17%, and time with patients and families 12%. Time with patients and families was perceived to be the most educational part of clinical service. Time spent using the EHR was perceived as the least educational. Interns perceived clinical service as excellent or good 37% of the time, while planned educational activities were perceived as excellent or good 81% of the time. CONCLUSIONS: Interns spend the majority of their time using the EHR and communicating with the health care team. Interns perceive time spent in planned educational activities has more educational value than time spent in clinical service. The distribution of daily activities is discordant with the perceived educational value of those activities.

Control of vancomycin-resistant enterococci in the neonatal intensive care unit.

BACKGROUND AND OBJECTIVE: Multidrug-resistant organisms (MDROs), such as vancomycin-resistant enterococci (VRE), cause serious infections, especially among high-risk patients in NICUs. When VRE was introduced and transmitted in our NICU despite recommended infection control practices, we instituted active surveillance cultures to determine their efficacy in detecting and controlling spread of VRE among high-risk infants. METHODS: Active surveillance cultures, other infection control measures, and a mandatory in-service education module on preventing MDRO transmission were implemented. Cultures were performed on NICU admission and then weekly during their stay. Molecular DNA fingerprinting of VRE isolates facilitated targeting efforts to eliminate clonal spread of VRE. Repetitive sequence PCR (rep-PCR)-based DNA fingerprinting was used to compare isolates recovered from patients with VRE infection or colonization. Environmental VRE cultures were performed around VRE-colonized or -infected patients. DNA fingerprints were prepared from the products of rep-PCR amplification and analyzed using software to determine strain genetic relatedness. RESULTS: Active surveillance cultures identified 65 patients with VRE colonization or infection among 1,820 admitted to the NICU. Rep-PCR performed on 60 VRE isolates identified 3 clusters. Cluster 1 included isolates from 21 patients and 4 isolates from the environment of the index patient. Clusters 2 and 3 included isolates from 23 and 3 patients, respectively. Similarity coefficients among the members of each cluster were 95% or greater. CONCLUSIONS: Control of transmission of multi-clonal VRE strains was achieved. Active surveillance cultures, together with implementation of other infection control measures, combined with rep-PCR DNA fingerprinting were instrumental in controlling VRE transmission in our NICU.

The development of a psychoeducational intervention for women living with an increased risk of breast cancer.

Research has shown a widespread need for written information on topics related to familial risk of breast cancer amongst women who have been living with an increased risk of the disease for several years. This article describes the development of a psychoeducational intervention designed to meet the needs of these women. Following a review of the literature and existing information resources, a multidisciplinary group developed a written information pack consisting of scientific and psychosocial (self-help) information with the aim of improving knowledge and reducing cancer worry. The information pack has been evaluated by seven independent health professionals and piloted on eight women at increased risk of breast cancer. Aspects of readability and presentation have been considered. The results of a randomised controlled trial of the intervention, which will inform the current provision of clinical services for these women, will be reported elsewhere.

A time-motion study of inpatient rounds using a family-centered rounds model.

OBJECTIVE: Family-centered rounds (FCR) have become increasingly prevalent in pediatric hospital settings. The objective of our study was to describe time use and discrete events during pediatric inpatient rounds by using a FCR model. METHODS: We conducted a prospective observational study at Children's National Medical Center between September 2010 and February 2011. Investigators directly observed rounds on hospitalist and neurology services. Events were timed, and key features were recorded by using a Microsoft Access-based program. Associations with increased time spent during rounds were determined by using regression analyses. RESULTS: One hundred fifty-nine rounding encounters were observed. Rounds lasted 7.9 minutes on average per patient. An average of 1.3 minutes was spent between patients during rounds. Eighty-six (54%) encounters occurred outside the patient's room, 3% of the time because of the family's request. Infectious isolation was associated with rounds occurring outside the room (P<.0001). Participation of the parent, location of rounds inside or outside the patient's room, most teaching behaviors, and interruptions were not significantly associated with increased time spent during rounds. Teaching physical examination techniques by allowing multiple trainees to examine the patient was associated with increased rounding time (P= .02). CONCLUSIONS: The majority of rounds occurred outside the patient's room, yet rarely at the parent's request. Patients on infectious isolation were more likely to have rounds occur outside the patient's room. Neither parental participation nor most teaching behaviors were associated with increased time spent on rounds. These findings will enrich the evidence base needed to establish FCR best practices.

Pediatrics Residents' Perspectives on Family-Centered Rounds: A Qualitative Study at 2 Children's Hospitals.

BACKGROUND: Many academic hospitals have incorporated family-centered rounds, yet little is known about pediatrics residents' perspectives on the educational impact of these rounds. OBJECTIVE: To identify pediatrics residents' knowledge, attitudes, and beliefs about family-centered rounds, including perceived benefits and barriers. METHODS: We conducted focus groups of residents exposed to family-centered rounds at 2 university-affiliated, freestanding children's hospitals. Focus group data were analyzed using grounded theory. RESULTS: A total of 24 residents participated in 4 focus groups. Residents reported that family-centered rounds enhance education by increasing patient encounters and improving physical exam skills, direct observation, real-time feedback, and attending role modeling; improve parent satisfaction, interpersonal and communication skills, and safety; and reduce length of stay. Physical constraints (large teams and small rooms), lack of uniform approaches to family-centered rounds, variable attending teaching styles, and specific conditions (child abuse, patients on isolation) were cited barriers. CONCLUSIONS: Pediatrics residents report that well-conducted family-centered rounds improve their education and the quality of patient care, including parent satisfaction, communication with families, and patients' length of stay. Standardizing family-centered rounds and reducing attending variability in teaching style might further enhance residents' educational experiences.

Effectiveness of a clinical pathway for the emergency treatment of patients with inborn errors of metabolism.

OBJECTIVE: The goal was to measure the effectiveness of a clinical pathway for the emergency department care of patients with inborn errors of metabolism. METHODS: Two years after the implementation of a multidisciplinary clinical pathway for patients with inborn errors of metabolism in our urban, academic, pediatric emergency department, we compared measures of timeliness and effectiveness for patients treated before the pathway with the same measures for patients treated after implementation of the pathway. Measures of timeliness included time to room, time to doctor, time to glucose infusion, and total emergency department length of stay. Measures of clinical effectiveness included the proportion of patients receiving adequate glucose infusions, proportion of patients admitted, inpatient length of stay, and proportion of patients requiring PICU admission. RESULTS: A total of 214 emergency department visits for patients with inborn errors of metabolism were analyzed, 90 before and 124 after initiation of the pathway. All measures of timeliness of care except total emergency department length of stay demonstrated significant improvement in comparisons of values before and after initiation of the pathway. Measures of clinical effectiveness also demonstrated significant improvements after initiation of the pathway. There was improvement in the proportion of patients who received adequate glucose infusions, with a decrease in the proportion of patients who required admission to the PICU. Emergency department length of stay, inpatient length of stay, and the proportion of patients admitted to the hospital were not affected. CONCLUSIONS: Most measures of timeliness and 2 measures of effectiveness showed improvement after implementation of an emergency department pathway for patients with inborn errors of metabolism. Therefore, a clinical pathway can improve the emergency care of patients with inborn errors of metabolism.

Análisis del patrón óseo trabecular de mandíbulas maceradas en radiografías panorámicas digitales / Analysis of the trabecular bone pattern of dry human mandibles in digital panoramic radiographies

Nuestro propósito fue estudiar la sensibilidad de la metodología de esqueletonizacion en las alteraciones del patrón óseo trabecular, en radiografías panorámicas digitales. Con el fin de poder utilizar esta metodología a futuro para el análisis y la observación de los cambios de densidad ósea en la estructura trabecular, en pacientes con osteoporosis y sanos. El material examinado consistió en cinco mandíbulas adultas, maceradas. Los 4 sitios de interés de cada mandíbula fueron escogidos en cuerpo mandibular, debajo de los alvéolos dentarios: Sitio 1. Oral y anterior al foramen mentoniano derecho. Sitio 2. Oral y posterior al foramen mentoniano derecho. Sitio 3. Oral y anterior al foramen mentoniano izquierdo. Sitio 4. Oral y posterior al foramen mentoniano izquierdo. Se realizó la toma de radiografías panorámicas digitales. Posterior a la primera toma radiográfica, se recortaron las áreas delimitadas removiendo las tablas vestibulares, Se fracturó intencionalmente el trabeculado óseo y luego se reubicaron las tablas vestibulares y se realizó una segunda toma radiográfica, con el uso de un soporte confeccionado para el posicionamiento de las mandíbulas, manteniendo las líneas guía fijas,para cada especimen: Plano mediano, Línea canina y Plano de Frankfurt. Los sitios de interés fueron trabajados en software, siguiendo el método empleado por Watanabe (2003), las imágenes resultantes, que muestran los esqueletos de las trabéculas óseas fueron analizadas utilizando las siguientes herramientas: Histograma, Análisis de partículas, Dimensión fractal, Cantidad de Uniones o encuentro triple de trabéculas y Porcentaje de trabéculas por área. En el análisis estadístico según los datos obtenidos de las diferentes regiones, antes y después de la remoción/inserción, no se encontró una diferencia estadísticamente significativa. Las trabéculas vistas en la radiografía panorámica son formadas principalmente por inserciones en las corticales. El método de retirar la tabla óse...