Features, risk factors, and outcomes of older internal medicine patients triggering a medical emergency team call.

BACKGROUND: Information about the epidemiology of older Internal Medicine patients receiving medical emergency team (MET) calls is limited. We assessed the prevalence, characteristics, risk factors, and outcomes of this vulnerable group. METHODS: Internal Medicine patients aged >75 years who were admitted via the Emergency Department to a tertiary hospital between January 2015 to December 2018 and who activated a MET call were compared to patients without MET call activation during the same time period. Outcome measures included management post-MET call, Intensive Care Unit (ICU) admission rates, discharge disposition, length of hospital stays (LOS), and in-patient mortality. RESULTS: There were 10,803 Internal Medical admissions involving 10,423 patients; median age 85 (IQR 81-89) years. Of these, 995 (10%) patients received at least one MET call. MET call patients had greater physiological instability in the Emergency Department and higher median Charlson comorbidity index values (2, IQR 1-3 vs. 1, IQR 0-2; p < .0001) than non-MET call patients. Overall, 10% of MET call patients were admitted to ICU. MET patients had a longer median length of stay (9 [IQR 5-14] vs. 4 days [IQR 2-7]; p < .001) and higher in-hospital mortality (29% vs. 7%; p < .001). However, mortality of MET call patients without treatment limitations was 48/357 (13%). CONCLUSION: One in ten Internal Medicine patients aged >75 years and admitted via ED had a MET call. Physiological instability in ED and comorbidities were key risk factors. Mortality in MET patients approached 30%. These data can help predict at-risk patients for improving goals of care and pre-MET interventions.

Fully online OSCEs: A large cohort case study.

This article was migrated. The article was marked as recommended. Objective Structured Clinical Examinations (OSCEs) are extensively used for clinical assessment in the health professions. However, current social distancing requirements (including on-campus bans) at many universities have made the co-location of participants for large cohort OSCEs impossible. While there is a developing literature on remote OSCEs, particularly in response to the COVID-19 pandemic, this is dominated by approaches dealing with small participant numbers. This paper describes our recent large scale (n = 361 candidates) implementation of a remotely delivered 2 station OSCE. The planning for this OSCE was extensive and involved comprehensive candidate, examiner and simulated patient orientation and training. Our processes were explicitly designed to develop platform familiarity for all participants and included building on remote tutorial experiences and device testing. Our remote OSCE design and logistics made use of using existing enterprise solutions including videoconferencing, survey and collaboration platforms and allowed extra time between candidates in case of technical issues. We describe our process in detail including examiner, simulated patient, and candidate perspectives to provide precise detail, hopefully assisting other institutions to understand and adopt our approach. Although logistically complex, we have demonstrated that it is possible to deliver a remote OSCE assessment involving a large student cohort with a limited number of stations using commonly available enterprise solutions. We recognise it would be ideal to sample more broadly across stations and examiners, yet given the constraints of our current COVID-19 impacted environment, we believe this to be an appropriate compromise for a non-graduating cohort at this time.

Ambiguous medical abbreviation study: challenges and opportunities.

BACKGROUND: Healthcare workers often abbreviate for convenience, but ambiguous abbreviations may cause miscommunication, which jeopardises patient care. Robust large-scale research to quantify abbreviation frequency and ambiguity in medical documents is lacking. AIMS: To calculate the frequency of abbreviations used in discharge summaries, the proportion of these abbreviations that are ambiguous and the potential utility of auto-expansion software. METHODS: We designed a software programme to extract all instances of abbreviations from every General Medical Unit discharge summary from the Royal Melbourne Hospital in 2015. We manually expanded abbreviations using published inventories and clinical experience, logging multiple expansions for any abbreviation if identified. Abbreviations were classified based on well defined criteria as standardised and likely to be well understood, or ambiguous. Outcome measures included the range and frequency of standardised and ambiguous abbreviations, and the feasibility of electronic auto-expansion software based on these measures. RESULTS: Of the 1 551 537 words analysed from 2336 documents, 137 997 (8.9%) were abbreviations with 1741 distinct abbreviations identified. Most abbreviations (88.7%) had a single expansion. The most common abbreviation was PO (per os/orally), followed by BD (bis in die/twice daily) and 68.1% of abbreviations were standardised, largely pertaining to pathology/chemicals. This meant, however, that a large proportion (31.9%) of abbreviations (2.8% of all words) were ambiguous. The most common ambiguous abbreviation was Pt (patient/physiotherapy), followed by LFT (liver function test/lung function test). CONCLUSIONS: Close to one-third of abbreviations used in general medical discharge summaries were ambiguous. Electronic auto-expansion of ambiguous abbreviations is likely to reduce miscommunication and improve patient safety.

Assessing Diagnostic Reasoning Using a Standardized Case-Based Discussion.

BACKGROUND: Development of diagnostic reasoning (DR) is fundamental to medical students' training, but assessing DR is challenging. Several written assessments focus on DR but lack the ability to dynamically assess DR. Oral assessment formats have strengths but have largely lost favour due to concerns about low reliability and lack of standardization. Medical schools and specialist medical colleges value many forms of oral assessment (eg, long case, Objective Structured Clinical Examination [OSCE], viva voce) but are increasingly searching for ways in which to standardize these formats. We sought to develop and trial a Standardized Case-Based Discussion (SCBD), a highly standardized and interactive oral assessment of DR. METHODS: Two initial cohorts of medical students (n = 319 and n = 342) participated in the SCBD as part of their assessments. All students watch a video trigger (based on an authentic clinical case) and discuss their DR with an examiner for 15 minutes. Examiners probe students' DR and assess how students respond to new standardized clinical information. An online examiner training module clearly articulates expected student performance standards. We used student achievement and student and examiner perceptions to gauge the performance of this new assessment form over 2 implementation years. RESULTS: The SCBD was feasible to implement for a large student cohort and was acceptable to students and examiners. Most students and all examiners agreed that the SCBD discussion provided useful information on students' DR. The assessment had acceptable internal consistency, and the associations with other assessment formats were small and positive, suggesting that the SCBD measures a related, yet novel construct. CONCLUSIONS: Rigorous, standardized oral assessments have a place in a programme of assessment in initial medical training because they provide opportunities to explore DR that are limited in other formats. We plan to incorporate an SCBD into our clinical assessments for the first year of clinical training, where teaching and assessing basic DR is emphasized. We will also explore further examiners' understanding of and approach to assessing DR.

Impact of extreme prematurity or extreme low birth weight on young adult health and well-being: the Victorian Infant Collaborative Study (VICS) 1991-1992 Longitudinal Cohort study protocol.

INTRODUCTION: Infants born extremely preterm (EP, <28 weeks' gestation) or with extremely low birth weight (ELBW,<1000 g) in the era when surfactant has been available clinically are at high risk of health and developmental problems in childhood and adolescence. However, how their health and well-being may be affected in adulthood is not well known. This study aims to compare between EP/ELBW and normal birthweight (NBW) controls: (1) physical health, mental health and socioemotional functioning at 25 years of age and (2) trajectories of these outcomes from childhood to adulthood. In addition, this study aims to identify risk factors in pregnancy, infancy, childhood and adolescence for poor physical health and well-being in EP/ELBW young adults. METHODS AND ANALYSIS: The Victorian Infant Collaborative Study (VICS) is a prospective geographical cohort of all EP/ELBW survivors to 18 years of age born in the State of Victoria, Australia, from 1 January 1991 to 31 December 1992 (n=297) and contemporaneous term-born/NBW controls (n=262). Participants were recruited at birth and followed up at 2, 5, 8 and 18 years. This 25-year follow-up includes assessments of physical health (cardiovascular, respiratory and musculoskeletal), mental health and socioemotional functioning. Outcomes will be compared between the birth groups using linear and logistic regression, fitted using generalised estimating equations (GEEs). Trajectories of health outcomes from early childhood will be compared between the birth groups using linear mixed-effects models. Risk factors for adult outcomes will be assessed using linear and logistic regression (fitted using GEEs). ETHICS AND DISSEMINATION: This study was approved by the Human Research Ethics Committees of the Royal Women's Hospital, Mercy Hospital for Women, Monash Medical Centre and the Royal Children's Hospital, Melbourne. Study outcomes will be disseminated through conference presentations, peer-reviewed publications, the internet and social media.

Taking OSCE examiner training on the road: reaching the masses.

BACKGROUND: To ensure the rigour of objective structured clinical examinations (OSCEs) in assessing medical students, medical school educators must educate examiners with a view to standardising examiner assessment behaviour. Delivering OSCE examiner training is a necessary yet challenging part of the OSCE process. A novel approach to implementing training for current and potential OSCE examiners was trialled by delivering large-group education sessions at major teaching hospitals. METHODS: The 'OSCE Roadshow' comprised a short training session delivered in the context of teaching hospital 'Grand Rounds' to current and potential OSCE examiners. The training was developed to educate clinicians about OSCE processes, clarify the examiners' role and required behaviours, and to review marking guides and mark allocation in an effort to standardise OSCE processes and encourage consistency in examiner marking behaviour. A short exercise allowed participants to practise marking a mock OSCE to investigate examiner marking behaviour after the training. RESULTS: OSCE Roadshows at four metropolitan and one rural teaching hospital were well received and well attended by 171 clinicians across six sessions. Unexpectedly, medical students also attended in large numbers (n=220). After training, participants' average scores for the mock OSCE clustered closely around the ideal score of 28 (out of 40), and the average scores did not differ according to the levels of clinical experience. CONCLUSION: The OSCE Roadshow demonstrated the potential of brief familiarisation training in reaching large numbers of current and potential OSCE examiners in a time and cost-effective manner to promote standardisation of OSCE processes.

Neural correlates of cough hypersensitivity in humans: evidence for central sensitisation and dysfunctional inhibitory control.

INTRODUCTION: Chronic non-productive coughing is a major complication of pulmonary disease and can also occur in many individuals without identifiable underlying pathology. The common clinical link in patients with cough is an enhanced sensitivity of the respiratory system to stimuli that subsequently evoke excessive coughing. The aetiology of this 'cough hypersensitivity syndrome' is unclear but believed to involve hypersensitivity of the sensory neural pathways that innervate the airways and lungs. METHODS: In the present study, we used functional brain imaging to compare central neural responses to airway stimulation using inhaled capsaicin in healthy people and patients with cough hypersensitivity. RESULTS: Hypersensitivity in response to inhaled capsaicin coincided with elevated neural activity in the midbrain in a region encompassing the nucleus cuneiformis (left: p<0.001; right: p<0.001) and periaqueductal gray (p=0.008) in comparison to normal sensitivity in controls. The enhanced activity noted in the midbrain is similar to that occurring in patients with chronic pain, thus providing empirical evidence to support the notion that cough and pain share neurobiological similarities. Furthermore, patients with cough hypersensitivity displayed difficulty controlling their cough, which manifested as a failure to suppress cough during capsaicin challenge (ie, reduced cough frequency) in controls compared with patients with cough hypersensitivity (p=0.046). Cough suppression was associated with reduced activity in a forebrain network that included the dorsomedial prefrontal and anterior mid-cingulate cortices. Additionally, cough frequency was correlated with activity in the right inferior frontal gyrus (R(2)=0.6, p<0.001) and right anterior insula (R(2)=0.6, p<0.001), regions previously implicated in voluntary cough suppression. CONCLUSIONS: These findings provide insight into the central neurobiology of cough hypersensitivity and suggest that both central amplification of cough sensory inputs and reduced capacity to suppress cough motor behaviours define patients with problematic cough.

Life-threatening rhabdomyolysis following the interaction of two commonly prescribed medications.

We report an interaction between erythromycin and simvastatin resulting in life-threatening rhabdomyolysis in an elderly patient. Drugs that inhibit CYP3A4 enzyme can cause elevated serum levels of statins which amplifies the risk of statin-induced rhabdomyolysis. Physicians should be aware of potential drug interactions of statins, which are widely used in the community.

Identifying viral infections in vaccinated Chronic Obstructive Pulmonary Disease (COPD) patients using clinical features and inflammatory markers.

BACKGROUND: Known inflammatory markers have limited sensitivity and specificity to differentiate viral respiratory tract infections from other causes of acute exacerbation of COPD (AECOPD). To overcome this, we developed a multi-factorial prediction model combining viral symptoms with inflammatory markers. METHODS: Interleukin-6 (IL-6), serum amyloid A (SAA) and viral symptoms were measured in stable COPD and at AECOPD onset and compared with the viral detection rates on multiplex PCR. The predictive accuracy of each measure was assessed using logistic regression and receiver operating characteristics curve (ROC) analysis. RESULTS: There was a total of 33 viruses detected at the onset of 148 AECOPD, the majority 26 (79%) were picornavirus. Viral symptoms with the highest predictive values were rhinorrhoea [Odds ratio (OR) 4.52; 95% CI 1.99-10.29; P < 0.001] and sore throat (OR 2.64; 95% CI 1.14-6.08; P = 0.022), combined the AUC ROC curve was 0.67. At AECOPD onset patients experienced a 1.6-fold increase in IL-6 (P = 0.008) and 4.5-fold increase in SAA (P < 0.001). The addition of IL-6 to the above model significantly improved diagnostic accuracy compared with symptoms alone (AUC ROC 0.80 (P = 0.012). CONCLUSION: The addition of inflammatory markers increases the specificity of a clinical case definition for viral infection, particularly picornavirus infection.

Endobronchial extension of granulomatous lymphadenitis in an HIV-positive man with immune reconstitution syndrome.

Endobronchial granuloma is a rare manifestation of endobronchial tuberculosis (TB). This case report describes a patient with endobronchial granuloma due to contiguous extension of granulomatous mediastinal lymph node inflammation, occurring following commencement of highly active anti-retroviral therapy in an HIV-positive man. Bronchoscopic findings mirrored CT imaging of endobronchial involvement of sub-carinal lymphadenopathy. Microbiologic studies were negative for acid-fast bacilli, fungal elements and malignancy. Mycobacterial and fungal culture as well as PCR for TB were all negative. Empiric anti-tuberculous therapy was commenced with complete resolution of symptoms. Immune reconstitution syndrome with development of active TB is common in patients commencing highly active retroviral therapy. Lymphadenitis is the commonest manifestation of this, and 20% of patients are culture negative for mycobacteria. Endobronchial granulomata due to TB are rare and no specific endobronchial therapy is required in such disease.

Serum amyloid a is a biomarker of acute exacerbations of chronic obstructive pulmonary disease.

RATIONALE: Much of the total disease burden and cost of chronic obstructive pulmonary disease (COPD) is associated with acute exacerbations of COPD (AECOPD). Serum amyloid A (SAA) is a novel candidate exacerbation biomarker identified by proteomic screening. OBJECTIVES: To assess SAA as a biomarker of AECOPD. METHODS: Biomarkers were assessed (1) cross-sectionally (stable vs. AECOPD; 62 individuals) and (2) longitudinally with repeated measures (baseline vs. AECOPD vs. convalescence; 78 episodes in 37 individuals). Event severity was graded (I, ambulatory; II, hospitalized; III, respiratory failure) based on consensus guidelines. MEASUREMENTS AND MAIN RESULTS: Presumptively newly acquired pathogens were associated with onset of symptomatic AECOPD. In the cross-sectional study, both SAA and C-reactive protein (CRP) were elevated at AECOPD onset compared with stable disease (SAA median, 7.7 vs. 57.6 mg/L; P < 0.01; CRP median, 4.6 vs. 12.5 mg/L; P < 0.01). Receiver operator characteristics analysis was used to generate area-under-curve values for event severity. SAA discriminated level II/III events (SAA, 0.88; 95% confidence interval, 0.80-0.94 vs. CRP, 0.80; 95% confidence interval, 0.70-0.87; P = 0.05). Combining SAA or CRP with major symptoms (Anthonisen criteria, dyspnea) did not further improve the prediction model for severe episodes. IL-6 and procalcitonin were not informative. CONCLUSIONS: SAA is a novel blood biomarker of AECOPD that is more sensitive than CRP alone or in combination with dyspnea. SAA may offer new insights into the pathogenesis of AECOPD.

A community-based, time-matched, case-control study of respiratory viruses and exacerbations of COPD.

Respiratory viruses are associated with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) in hospitalized patients. However, exacerbations are increasingly managed in the community, where the role of viruses is unclear. In community exacerbations, the causal association between viruses and exacerbation maybe confounded by random fluctuations in the prevalence of circulating respiratory viruses. Therefore, to determine whether viral respiratory tract infections are causally associated with community exacerbations, a time-matched case-control study was performed. Ninety-two subjects (mean age 72 yrs), with moderate to severe COPD, (mean FEV(1) 40% predicted), were enrolled. Nasopharyngeal swabs for viral multiplex polymerase chain reaction and atypical pneumonia serology were obtained at exacerbation onset. Control samples were collected in synchrony, from a randomly selected stable patient drawn from the same cohort. In 99 weeks of surveillance, there were 148 exacerbations. Odds of viral isolation were 11 times higher in cases, than their time-matched controls (34 discordant case-control pairs; in 31 pairs only the case had virus and in three pairs only control). Picornavirus (26), influenza A (3), parainfluenza 1,2,3 (2), respiratory syncytial virus (1), and adenovirus (1) were detected in cases while adenovirus (1) and picornavirus (2) were detected in controls. In patients with moderate or severe COPD the presence of a virus in upper airway secretions is strongly associated with the development of COPD exacerbations. These data support the causative role of viruses in triggering COPD exacerbations in the community.

The effects of oxygen therapy in patients presenting to an emergency department with exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: To elucidate oxygen administration practices in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) and compare these practices with those recommended in internationally accepted guidelines. DESIGN: Retrospective audit. PARTICIPANTS AND SETTING: 65 patients admitted to a Melbourne university teaching hospital via the emergency department (ED), identified through medical records by a discharge diagnosis (discharged between 1 June and 30 September 2005) of acute exacerbation of COPD (AECOPD). Those included had respiratory function test results consistent with British Thoracic Society guidelines for the diagnosis of COPD. MAIN OUTCOME MEASURES: Length of stay, need for high dependency unit (HDU) admission, use of non-invasive ventilation (NIV), and use of arterial blood gas (ABG) tests. RESULTS: Our audit showed that 95% of patients defined as retaining carbon dioxide received oxygen at a flow rate greater than 2 L/min. This process began in the ambulance and continued in the ED, often without monitoring of ABG levels. Length of stay was significantly longer (P = 0.029); need for NIV on admission greater (P = 0.0124); and rate of admission to the HDU higher (P = 0.0124) in patients who achieved a partial pressure of arterial oxygen (PaO(2)) >/= 74.5 mmHg compared with those with a PaO(2) < 74.5 mmHg. CONCLUSIONS: The vast majority of patients with AECOPD presenting to our university teaching hospital receive oxygen therapy outside of internationally accepted guidelines, often without monitoring of ABG levels. The use of high-flow oxygen may contribute to an increased length of stay, more frequent admission to HDU and greater use of NIV among patients who achieve a higher PaO(2).

Interstitial lung disease: effects of thin-section CT on clinical decision making.

PURPOSE: To retrospectively quantify the change in the diagnosis and management of suspected interstitial lung disease when thin-section computed tomography (CT) is added to pretest probabilities. MATERIALS AND METHODS: The institutional review board does not require approval or patient informed consent for retrospective study of case records and CT studies. Six pulmonologists reviewed data sheets containing clinical information and results of pulmonary function tests and chest radiographs of 168 consecutive patients (86 women and 82 men; mean age, 59.8 years; age range, 22-86 years) suspected of having interstitial lung disease. Differential diagnoses and responses to specific questions regarding patient care were recorded before and after assimilation of thin-section CT findings. Both unweighted and weighted kappa analyses were used to determine agreement between pulmonologists before and after CT. RESULTS: First-choice diagnosis changed in 520 (51%) of 1008 cases, and agreement on first-choice diagnosis increased from 0.47 to 0.72 after thin-section CT. In addition, confidence in the first-choice diagnosis increased, and there was a reduction in the number of differential diagnoses offered by all pulmonologists (P < .005 and P < .001, respectively). Agreement on diagnostic probabilities for individual disorders increased substantially, particularly for diagnoses of idiopathic pulmonary fibrosis (weighted kappa = 0.58-0.89). With CT findings, pulmonologists changed their pre-CT responses regarding the use of bronchoalveolar lavage, transbronchial biopsy, and thoracoscopic biopsy in 242 (24.0%), 282 (28.0%), and 292 (29.0%) of 1008 cases, respectively. However, agreement for the use of these investigations was low both before and after CT. The request rate for thoracoscopic biopsy in patients in whom idiopathic fibrosis was diagnosed decreased from 48 of 179 (26.8%) to 26 of 233 (11.2%) after CT. CONCLUSION: Thin-section CT resulted in a change in first-choice diagnosis in half the cases. Diagnostic confidence improved, and CT findings increased agreement between pulmonologists on diagnostic probabilities across a range of interstitial lung diseases.

Research Designs for Assessing the USDA's Food Assistance and Nutrition Programs Outcomes, Part 2: Impact Evaluation of Demonstrations.

This is the second part of a 2-part article that summarizes a review of research designs for assessing the impact of the USDA's food assistance and nutrition programs on nutrition and health. The first part focused on the research designs for evaluating ongoing national programs. Here, the random experiment and 3 quasi-experimental designs that can be used to evaluate the impacts of demonstration projects are reviewed.

Evaluating the effects of the Dietary Guidelines for Americans on consumer behavior and health: methodological challenges.

The Dietary Guidelines for Americans is the official nutrition policy statement for the United States. Government involvement in providing information on private behavior, such as food choice, is justified by the high cost of poor diets, as measured in medical expenses and lost productivity. The Guidelines are intended to provide an up-to-date, consistent information base for federal nutrition education and information efforts and food assistance program regulations. Through these policy mechanisms, the Guidelines are assumed to improve dietary behavior, and, ultimately, health. By law, the Dietary Guidelines for Americans must be updated every five years; however, there is no mandate for evaluation. Evaluation could provide useful information to assess the extent to which the Guidelines positively influence health and provide insights into reasons for their successes and limitations. However, evaluation would also present considerable challenges. This paper discusses the critical data and methodological needs for improving evaluation of the Dietary Guidelines for Americans.