A Mobile Clinic Care Coordination Program: Enhancing Patient Care with Innovative Roles for Undergraduate Students.

The University of Florida Mobile Outreach Clinic's Care Coordination Program uses trained undergraduate volunteers to provide vital services; these include patient intake, recording vital signs, scribing first drafts of clinic notes, and making follow-up phone calls. The program and its benefits are replicable as demonstrated by our systematic implementation plan.

Preliminary report of a Web-based instrument to assess and teach knowledge and clinical thinking to medical student.

OBJECTIVE: We report the preliminary development of a unique Web-based instrument for assessing and teaching knowledge and developing clinical thinking called the "Sequential Questions and Answers" (SQA) test. Included in this feasibility report are physicians' answers to the Sequential Questions and Answers pre- and posttests and their brief questionnaire replies. METHODS: The authors refined the SQA test case scenario for content, ease of modifications of case scenarios, test uploading and answer retrieval. Eleven geographically distant physicians evaluated the SQA test, taking the pretest and posttest within two weeks. These physicians completed a brief questionnaire about the SQA test. RESULTS: Eleven physicians completed the SQA pre- and posttest; all answers were downloaded for analysis. They reported the ease of website login and navigating within the test module together with many helpful suggestions. Their average posttest score gain was 53% (p=0.012). CONCLUSIONS: We report the successful launch of a unique Web-based instrument referred to as the Sequential Questions and Answers test. This distinctive test combines teaching organization of the clinical narrative into an assessment tool that promotes acquiring medical knowledge and clinical thinking. We successfully demonstrated the feasibility of geographically distant physicians to access the SQA instrument. The physicians' helpful suggestions will be added to future SQA test versions. Medical schools might explore the integration of this multi-language-capable SQA assessment and teaching instrument into their undergraduate medical curriculum.

Content analysis of medical students' seminars: a unique method of analyzing clinical thinking.

BACKGROUND: The study of communication skills of Asian medical students during structured Problem-based Learning (PBL) seminars represented a unique opportunity to assess their critical thinking development. This study reports the first application of the health education technology, content analysis (CA), to a Japanese web-based seminar (webinar). METHODS: The authors assigned twelve randomly selected medical students from two universities and two clinical instructors to two virtual classrooms for four PBL structured tutoring sessions that were audio-video captured for CA. Both of the instructors were US-trained physicians. This analysis consisted of coding the students' verbal comments into seven types, ranging from trivial to advanced knowledge integration comments that served as a proxy for clinical thinking. RESULTS: The most basic level of verbal simple responses accounted for a majority (85%) of the total students' verbal comments. Only 15% of the students' comments represented more advanced types of critical thinking. The male students responded more than the female students; male students attending University 2 responded more than male students from University 1. The total mean students' verbal response time for the four sessions with the male instructor was 6.9%; total mean students' verbal response time for the four sessions with the female instructor was 19% (p < 0.05). CONCLUSIONS: This report is the first to describe the application of CA to a multi-university real time audio and video PBL medical student clinical training webinar in two Japanese medical schools. These results are preliminary, mostly limited by a small sample size (n = 12) and limited time frame (four sessions). CA technology has the potential to improve clinical thinking for medical students. This report may stimulate improvements for implementation.

A rare case of group A streptococcal endocarditis with absence of valvular vegetation.

Group A streptococcal endocarditis has been described in intravenous drug misusers and as a post-varicella infection in children. We report a 64-year-old man with no prior risk factors who presented with a persistent fever, malaise, polyuria and cola-colored urine. On examination peripheral stigmata of endocarditis without a cardiac murmur and asymptomatic pharyngeal exudates were found. Blood and urine analysis revealed renal failure from suspected glomerulonephritis. Blood cultures revealed fully sensitive Group A streptococci. Transthoracic and transesophageal echocardiographies revealed no vegetation. The Modified Duke's Criteria aided in the diagnosis of definite infective endocarditis, despite the absence of valvular vegetation.

Vital sign triage to rule out diabetic ketoacidosis and non-ketotic hyperosmolar syndrome in hyperglycemic patients.

AIMS: To develop a prediction algorithm to rule out diabetic ketoacidosis (DKA) and non-ketotic hyperosmolar syndrome (NKHS) based on vital signs for early triage of patients with diabetes. METHODS: The subjects were consecutive adult diabetic patients with hyperglycemia (blood glucose >or=250mg/dl) who presented at an emergency department. Based on a derivation sample (n=392, 70% of 544 patients at a hospital in Okinawa), recursive partitioning analysis was used to develop a tree-based algorithm. Validation was conducted using the other 30% of the patients in Okinawa (n=152, internal validation) and patients at a hospital in Tokyo (n=95, external validation). RESULTS: Three risk groups for DKA/NKHS were identified: a high-risk group of patients with glucose >400mg/dl or systolic blood pressure <100mmHg; a low risk group of patients with glucose or=100mmHg, pulse

Identifying low-risk patients for bacterial meningitis in adult patients with acute meningitis.

OBJECTIVE: To derive and validate a clinical prediction model with high sensitivity for differentiating aseptic meningitis (AM) patients from bacterial meningitis (BM) patients. METHODS: We developed the model using the derivation cohort in a community rural hospital in Okinawa and assessed its performance using the validation cohort in a metropolitan urban hospital in Tokyo. There were 66 (39.5%) and 5 (17.9%) adult patients with BM among the derivation (n=167) and the validation cohort (n=28), respectively. Recursive partitioning analysis was used to determine the important classification variables and to develop a sensitive model to safely exclude BM. RESULTS: The model produced high- and low-risk groups based on the following: 1) Gram stain, 2) CSF neutrophil percent < or =15%, 3) CSF neutrophil count < or =150 cells/mm(3), and, 4) mental status change. Among the derivation cohort, there were 65 patients with BM in the high-risk group (n=76), while only one patient with BM was noted (sensitivity, 99%) in the low-risk group (n=91). Among the validation cohort, there were 5 patients with BM in the high-risk group (n=7), while no patient was classified with BM (sensitivity, 100%) in the low-risk group (n=21). CONCLUSION: This simple and sensitive model might be useful to safely identify low-risk patients for BM who would not require antibiotic treatment.

Acute care hospital mortality of schizophrenic patients.

BACKGROUND: Although schizophrenic patients have higher mortality than the general nonschizophrenic population, few studies have investigated acute care hospital mortality of schizophrenic patients. METHODS: To assess acute care hospital mortality of schizophrenic patients, we analyzed hospital mortality, the risk factors for hospital mortality, and the causes of death of schizophrenic patients admitted to an acute care hospital in Japan over an 18-year period. RESULTS: We identified 55 deaths among 1108 schizophrenic patients, for a mortality rate of 5.0%. The overall standardized mortality ratio was 1.29 (95% CI, 0.98-1.68) compared with nonschizophrenic hospitalized patients. Significant risk factors for mortality were malignant neoplasm, cardiovascular disease, and admission through the emergency department. The leading causes of death in acute care hospitalizations were suicide (14.5%), malignant lymphoma or leukemia (10.9%), stroke (9.0%), and sepsis (7.3%). CONCLUSIONS: There was a nearly significant trend toward increased mortality of schizophrenic patients receiving acute hospital care compared with that of nonschizophrenic patients. Because suicide was the most frequent cause of death, a focus on suicide prevention is needed in this population.

Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age.

OBJECTIVE: We aimed to develop a clinical prediction rule to distinguish pelvic inflammatory disease (PID) from acute appendicitis in women of childbearing age. METHODS: We reviewed medical records over a 4-year period of female patients of childbearing age who had presented with abdominal pain at an urban emergency department and had either appendicitis (n = 109) or PID (n = 72). A prediction rule was developed by use of recursive partitioning based on significant factors for the discrimination. RESULTS: The significant factors to favor PID over appendicitis were (1) no migration of pain (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.5-11.5), (2) bilateral abdominal tenderness (OR, 16.7; 95% CI, 5.3-50.0), and (3) absence of nausea and vomiting (OR, 8.4; 95% CI, 2.8-24.8). The prediction rule could rule out appendicitis from PID with sensitivity of 99% (95% CI, 94-100%) when classified as a low-risk group by the following factors: (1) no migration of pain, (2) bilateral abdominal tenderness, and (3) no nausea and vomiting. CONCLUSION: We developed a prediction rule for childbearing-aged women presenting with acute abdominal pain to distinguish acute appendicitis from PID based on 3 simple, clinical features: migration of pain, bilateral abdominal tenderness, and nausea and vomiting. Prospective validation is needed in other settings.

The causes of hypercalcemia in Okinawan patients: an international comparison.

OBJECTIVE: Our objective was to determine the causes and relative prevalence of hypercalcemia in patients at a major community hospital in Okinawa, Japan. Additionally, we compared these causes of hypercalcemia with the previously published international data. MATERIALS AND METHODS: We analyzed all patients with hypercalcemia in a community teaching hospital in Okinawa, Japan, from 1999 to 2002 and determined the cause of hypercalcemia in each patient. We also performed a literature review of the original articles describing causes of hypercalcemia in patients from Eastern as well as Western countries. RESULTS: We identified 145 patients with hypercalcemia (median age, 69; range, 22 to 97). Major causes included malignant disorders (n=100; 69%), primary hyperparathyroidism (n=31; 21%), vitamin D-induced (n=4; 3%), and miscellaneous or unknown cause in 11 (8%). Among malignant disorders, adult T cell leukemia was the most frequent (n=35), being followed by lung cancer (n=25). Breast carcinoma was less prevalent (n=4). CONCLUSION: The major causes of hypercalcemia are malignancy and primary hyperparathyroidism in Okinawan Japanese patients. Adult T cell leukemia and lung carcinoma are among the top leading malignancies, while breast carcinoma is less frequent in this patient population. The etiologic prevalence of hypercalcemia in the Eastern population including Okinawans is significantly different from that in the Western population.

Cocoa supplementation for copper deficiency associated with tube feeding nutrition.

OBJECTIVE: Because of an increasing number of case reports of copper deficiency associated with long-term tube feeding nutrition in Japan, we identified patients with copper deficiency associated with long-term tube feeding and described the prevalence, clinical data and cocoa treatment for these patients. MATERIALS AND METHODS: We conducted a retrospective study to identify patients who were referred from long-term care institutions and had copper deficiency associated with tube feeding. We reviewed all serum copper concentration data during a 6-year period. We also compared admission and post-treatment peripheral blood counts. RESULTS: Among 210 consecutive admissions with nutritional tube feeding from long-term care institutions (N=210), we identified 13 (6.2%) patients with copper deficiency (aged 46-91; 12 women). All patients had anemia, while most had neutropenia. The range of serum copper concentrations of these patients was 0.1-2.4 microg/L (normal; 6.8-12.8 microg/L). Their feeding formulas revealed a low copper content (5 to 12 microg per 100 kcal of each formula). Cocoa powder was used as the treatment. With cocoa supplements, the blood leukocyte count and hemoglobin significantly improved in all patients. Median leukocyte counts were 1,800 /mm(3)at admission and 6,300/mm(3) at follow-up (p=0.001). Median hemoglobin were 7.0 g/dl at admission and 10.3 g/dl at follow-up (p=0.001). Two patients developed transient tachycardia as a possible adverse effect of cocoa. CONCLUSION: We identified many cases with copper deficiency associated with tube feeding in Okinawa, Japan. Cocoa supplement appeared to be a safe and effective treatment. Increasing the copper content of Japanese tube feeding formulas should be considered for its prevention.

Intrapleural fibrinolytic agents for empyema and complicated parapneumonic effusions: a meta-analysis.

BACKGROUND: Randomized controlled trials have shown conflicting findings about the role of intrapleural fibrinolytic therapy for the treatment of empyema and complicated parapneumonic effusions in adult patients. OBJECTIVES: To assess the clinical efficacy and summarize the current evidence of intrapleural fibrinolytic use in patients with empyema and complicated parapneumonic effusions in adult patients. METHODS: We performed a meta-analysis of all properly randomized trials comparing intrapleural fibrinolytic agents with placebo in adult patients with empyema and complicated parapneumonic effusions. Outcome of primary interest was the reduction of death and surgical intervention. RESULTS: We included five trials totaling 575 patients. The number of enrolled patients for each trial was small, except for the recent trial by Multicenter Intrapleural Sepsis Trial (MIST1) group. Compared with placebo, intrapleural fibrinolytic therapy was associated with a nonsignificant reduction in death and need for surgery (27.6% of the treatment group vs 32.8% of the control group; random-effects pooled risk ratio, 0.55; 95% confidence interval, 0.28 to 1.07; heterogeneity, p = 0.023). A separate analysis for outcomes on either death or need for surgery also showed nonsignificant results. CONCLUSION: Our meta-analysis does not support the routine use of fibrinolytic therapy for all patients who require chest tube drainage for empyema or complicated parapneumonic effusions. However, there was significant heterogeneity of the treatment effects among the trials. Selected patients might benefit from the treatment.

Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack.

Chemical agents have been used previously in wartime on numerous occasions, from World War I to the Gulf War. In 1994 and 1995, sarin nerve gas was used first in peacetime as a weapon of terrorism in Japan. The Tokyo subway sarin attack was the first large-scale disaster caused by nerve gas. A religious cult released sarin gas into subway commuter trains during morning rush hour. Twelve passengers died and about 5500 people were harmed. Sarin is a highly toxic nerve agent that can be fatal within minutes to hours. It causes the clinical syndrome of cholinergic hyperstimulation by inhibition of the crucial enzyme acetylcholinesterase. Therapy of nerve agent toxicity is divided into three categories, decontamination, respiratory support, and antidotes. All of these therapies may be given simultaneously. This article reviews toxicology and management of this acute chemical emergency. To help minimize the possible catastrophic impact on the public, we make several recommendations based on analysis of the Tokyo subway sarin attack and systematically review the current scientific literature.

The degree of chills for risk of bacteremia in acute febrile illness.

PURPOSE: Patients with acute febrile illness may experience different degrees of chills. To evaluate the different degrees of chills in predicting risk of bacteremia in patients with acute febrile illness, we performed a single-center prospective observational study. METHODS: We enrolled consecutive adult patients with acute febrile illness presenting to our emergency department. We defined mild chills as cold-feeling equivalent such as the need of an outer jacket; moderate chills as the need for a thick blanket; and shaking chills as whole-body shaking even under a thick blanket. We estimated risk ratios of the different degrees of chills for bacteremia using multivariable adjusted Poisson regression. RESULTS: Of a total 526 patients, 40 patients (7.6%) had bacteremia. There were 65 patients (12.4%) with shaking chills, 100 (19%) with moderate chills, and 105 (20%) with mild chills. By comparing patients with no chills, the risk ratios of bacteremia were 12.1 (95% confidence interval [CI] 4.1-36.2) for shaking chills, 4.1 (95% CI 1.6-10.7) for moderate chills, and 1.8 (95% CI 0.9-3.3) for mild chills. Shaking chills showed a specificity of 90.3% (95% CI 89.2-91.5) and positive likelihood ratio of 4.65 (95% CI 2.95-6.86). The absence of chills showed a sensitivity of 87.5% (95% CI 74.4-94.5) and negative likelihood ratio of 0.24 (95% CI 0.11-0.51). CONCLUSION: Evaluation of the degree of chills is important for estimating risk of bacteremia in patients with acute febrile illness. The more severe degree of chills suggests the higher risk of bacteremia.

Serum lipids as protective factors for subarachnoid hemorrhage.

Identification of common serum lipid profiles in patients with subarachnoid hemorrhage (SAH) may allow a better understanding of its pathogenesis. We conducted a hospital-based case-control study in Japan. One hundred and fifty consecutive cases of spontaneous SAH during a 5-year period were examined and their lipid profiles assessed. Age- and gender-matched controls were identified for each case through random hospital sampling. Median serum total cholesterol was 161 mg/dl (range 77-288) in patients with SAH, and 209 mg/dl (134-441) in controls (p < 0.001). Median serum triglycerides were 95 mg/dl (range 28-589) in SAH and 122 mg/dl (31-371) in controls (p < 0.001). A high serum total cholesterol of more than 5.20 mmol/L (200 mg/dl) (odds ratio 0.22 [95% confidence interval 0.12-0.40]) and a high serum triglyceride of more than 1.70 mmol/L (150 mg/dl) (odds ratio 0.29 [95% CI 0.14-0.60]) were independent protective factors for SAH. In conclusion, higher values of both serum cholesterol and triglyceride may be inversely associated with the occurrence of SAH.