More than Means to an End: Assessing Surgical Provider Familiarity with Palliative Care.

BACKGROUND: As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative care research. Historic surgical dogma viewed mortality and comfort-focused care as a failure of the providers' endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until it became evident a patient could not survive or was actively dying. As the need for surgical palliative care grows, the identification of deficits in surgical providers' understanding of the scope of palliative medicine is necessary to direct further training and development efforts. METHOD: A ten-question survey was emailed to all residents, physician assistants, nurse practitioners, and attending physicians in the general surgery and subspecialty surgical departments within the Einstein Healthcare Network. RESULTS: 30 non-trainees (attending surgeons, nurse practitioners, and physician assistants) and 26 trainees (PGY-1 to PGY-5) completed the survey. Less than half of participants reported training in conversations regarding withdrawal of life-prolonging treatments in the setting of expected poor outcomes, 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news. 54% report being involved in five or more end-of-life discussions in the last year with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions (P = .009). CONCLUSIONS: Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently.

Impact of Repeat Head Computed Tomography on Mild Traumatic Brain Injury Patients With Abbreviated Injury Score 1-2 Injuries.

BACKGROUND: Patients presenting with traumatic intracranial hemorrhage (ICH) routinely undergo repeat head Computed Tomography (CT) scans with the goal of identifying progressing hemorrhage early and providing timely intervention. Glasgow Coma Scale (GCS) score and Abbreviated Injury Score (AIS) are typically used to grade the severity of traumatic brain injury (TBI) and triage subsequent management. However, most patients receive a repeat head CT scan within 6 hours of the initial insult, regardless of these clinical scores. We investigated the yield of a repeat CT scan for mild blunt TBI (GCS 13-15, AIS 1-2). METHODS: This was a single-center retrospective chart review at a level 1 trauma center between 2009 and 2019. Our primary outcome was medical or surgical intervention directly resulted from change in CT head findings. We used multivariate regression to identify predictors of surgical and medical intervention. RESULTS: 234 mild TBI patients met inclusion criteria. 33.7% of all patients had worsening ICH. 7.7% of patients required a surgical intervention, and 27.4% received a medical intervention. Multivariate analysis found that a decline in GCS (OR 8.64), and polytrauma (Injury Severity Score >15; OR 3.32) predicted surgical intervention. Worsening ICH did not predict surgical or medical intervention. Patients requiring medical intervention were more likely to have a decline in GCS (OR 2.53, P = .02) and be older (age >65, OR 2.06, P = .02). CONCLUSION: In the population of blunt traumatic injury, worsening ICH did not predict surgical or medical intervention. Routine repeat imaging for this population is low yield, and clinical exam should guide the decision to reimage.

Development of a Taiwanese computerized database for psychiatric consultation in a general hospital.

OBJECTIVE: The aim of this study was to evaluate the applicability of a modified questionnaire in psychiatric consultation and a new computerized software at one general hospital in Taiwan. METHOD: The Micro-Cares Clinical Information System for Consultation/Liaison Psychiatry (CISCL), an English language-based patient management application, has multiple clinical variables that were translated into Mandarin Chinese. The Mandarin Chinese version of the Micro-Cares Questionnaire (MCMQ) was further modified after extensive testing and clinical use by two staff psychiatrists and eight senior resident doctors. In addition, the structure of the Mandarin Chinese version of the Micro-Cares CISCL Program (MCMP) was created for direct information entry through a specialized Microsoft Access-based support module. RESULTS: The MCMQ has been adapted to regular medical practice. Up to 66% of the consultation cases (618/913 patients) were recorded in 2003. Among those registered, 519 (84%) received psychiatric diagnoses. Eight of the 10 participants evaluated agreed that the MCMQ was clinically applicable. CONCLUSION: MCMQ and MCMP have been routinely applied in the clinical, administrative, research and educational services of our psychiatric consultation.

Psychotropic drug versus psychotropic drug-update.

Psychotropic drugs are not necessarily the drugs of psychiatry. Seventy percent of antidepressants, and 90% of anxiolytics are prescribed by nonpsychiatric physicians. Since psychotropic medications are so frequently employed by nonpsychiatric physicians, e.g., neurologists, primary care physicians, internists, and because large numbers of their patients are concurrently on medical drugs for somatic reasons, the interactions of psychotropic versus medical drugs and psychotropic versus psychotropic drugs as listed below must be understood before primary care physicians or psychiatrists prescribe psychotropic medications, especially to the medically ill. Seventy commonly prescribed psychotropic drugs were examined for their interactions with other psychotropic medications using six reference tools: 1) MEDLINE (PubMed) employing the first generic psychotropic drug name, the second generic psychotropic drug name, and the term "interaction;" 2) Hanston's Drug Interaction Analysis and Management Text (quarterly updated version); 3) Drug Interactions Facts (Facts and Comparisons) (July 2001 quarterly updated version); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; and 6) Food and Drug Administration (MedWatch) (Dear Doctor Letters and new labeling) ( for (1999, 2000, and 2001). The authors recognized that all of the above sources do not necessarily cover the entire information database regarding drug-drug interactions. (Citations regarding children, reports in foreign languages or concerning food, animals, in vitro experiments, analgesics, and naturalistic-herbal or natural products-treatment interactions were excluded).

Consultation-Liaison Psychiatry Literature Database (2003 update). Part I: Consultation - Liaison Literature Database: 2003 update and national lists.

Every day there are 10,000 scientific articles published. Since the Consultation-Liaison ("C-L") psychiatrist may be asked to consult on a patient with any medical illness, e.g., severe acute respiratory syndrome (SARS), malaria, cancer, stroke, amytrophic, lateral sclerosis, and a patient who may be on any medical drug, methods need to be developed to review the recent literature and have an awareness of key and essential current findings. At the same time, teachers need to develop a current listing of seminal papers for trainees and practitioners of this newest cross-over subspecialty of psychiatry-now called Psychosomatic Medicine. Experts selected because of their writings and acknowledged contributions to a specific clinical area or problem hope examined thousands of citations to choose those articles, chapters, books, or letters that they regard as most important to Psychosomatic Medicine. In addition, psychiatric specialists in six countries have provided their national Psychosomatic Medicine (Consultation-Liaison) lists as examples of what they regard as the most important teaching materials journals: Australia, Brazil, Greece, Mexico, Portugal, and Taiwan. It is our belief that a cogent, international, systematic review will provide the greatest success in creating a "regionally appropriate" teaching and consultation literature database with world-wide applicability. We review our current progress on this literature database and software, the technical system and data organization involved, the approach used to populate the literature system, and ongoing development plans to bring this system to the physician via mobile technologies.

Adaptation of a Psychosomatic Medicine Computer Record System for Multi-Language Support: Making Psychiatric Computer Software Regionally Functional in Spanish- Speaking Countries* / La historia clínica sistematizada en medicina psicosomática

Electronic medical record (EMR) systems are becoming a standard for patient care, but are difficult to customize for local, regional, or international use. Particularly in the case of psychosomatic medicine, where diverse sociological, economical, cultural, and political influences may contribute to a patient’s disease state, EMRs have difficulty in being economically implemented. Careful, flexible computer program design, special editing systems to customize graphic user interfaces, and identifying localregional physician experts to assist in translation are keys to making a working application. We discuss the Micro-Cares™ CISCL Clinical Information System and the programming and customization decisions which have gone into adapting it for multi-language support. Discussed are the EMR design, adaptation for multiple hardware platforms (desktop, laptop and tablet computers, and on hand-held PDA systems), multi-tiered data storage, and customizable language manager, and questionnaire designer. Concepts of flexibly “scaling” CISCL to support the single user, or multiple user, or extensive department/ division personnel are discussed. Experience with regional testing and use are described, including modifications to the CISCL program that have been extensively user-guided. Finally, we examine standards of approach to multi-language support that have arisen from adapting CISCL to non-Romance-based languages, e.g., Mandarin. Our current experiences are summarized with description of on-going research efforts.

Los sistemas de registro médico electrónico (RME) se están convirtiendo en el estándar en cuanto al cuidado clínico del paciente se refiere, pero son difíciles de diseñar a medida para uso local, regional o internacional. Ésto es particularmente cierto en el caso de la medicina psicosomática, en la que diversas influencias de tipo sociológico, económico, cultural y político influyen en el estado del paciente, haciendo que los RME sean difíciles de implementar de manera económica. Un programa de computador diseñado de modo cuidadoso y flexible con sistemas de edición para personalizar gráficas, e identificar médicos expertos en el medio local-regional para que asistan en la traducción son las claves para hacer que una aplicación funcione. Presentamos el Micro-Cares™ CISCL Sistema de Información Clínica y discutimos la programación y las decisiones tomadas para adaptar el sistema a un soporte multilingüístico. Se discuten el diseño del RME, su adaptación para múltiples plataformas de hardware (computadores de escritorio, portátiles y tablet y sistemas PDA Palm™), sistemas de almacenamiento multinivel, administrador de idioma personalizado y diseñador de cuestionarios. También se discuten los conceptos de “escalonar” el CISCL de manera flexible para soportar un usuario único o múltiples usuarios, o personal numeroso de un departamento o división. Se presenta una descripción de las pruebas y uso a nivel regional, incluyendo modificaciones en el programa del CISCL que han sido guiados por los usuarios. Para finalizar, examinamos estándares de aproximación en soporte multilingüístico que han surgido al adaptar el CISCL a otros idiomas no basados en las lenguas romance, por ejemplo, el mandarín. Nuestras experiencias actuales se resumen con una descripción de nuestras investigaciones en curso.