Arrhythmic Recurrence and Outcomes in Patients Hospitalized With First Episode of Electrical Storm.

Electrical storm (ES) is a life-threatening condition that may lead to recurrent arrhythmias, need for ventricular mechanical support, and death. The study aimed to assess the burden of arrhythmia recurrence and in-hospital outcomes of patients admitted for ES in a large urban hospital. We performed a retrospective analysis of patients admitted with ventricular arrhythmias from January 2018 to June 2021 and identified 61 patients with ES, defined as 3 or more episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours. We reviewed the in-hospital outcomes and compared outcomes between patients who had no recurrence of VT/VF after the first 24 hours (34 [56%]), those with recurrence of 1 or 2 episodes of VT/VF within a 24-hour period (15 [24%]), and patients with 3 or more recurrent VT/VF events consistent with recurrent ES after the first 24 hours (12 [20%]). Patients with recurrent ES had significantly higher in-hospital mortality as compared with those with recurrent VT/VF not meeting criteria for ES or no recurrences of VT/VF (3 [25%] vs 0 [0%] vs 0 [0%]; p = 0.002). Moreover, patients with recurrent ES also had higher rates of the combined end points of ventricular mechanical support and death (7 [58%] vs 1 [6%] vs 1 [3%], p <0.001), invasive mechanical ventilation and death (10 [83%] vs 2 [13%] vs 2 [6%], p <0.001), catheter ablation or death (12 [100%] vs 7 [47%] vs 12 [35%], p <0.001) and heart transplantation and death (3 [25%] vs 2 [13%] vs 0 [0%], p = 0.018). In conclusion, patients admitted with ES have a high risk of in-hospital recurrence, associated with extremely poor outcomes.

Relationship of Physical Examination Technique to Associated Clinical Skills: Results from a Direct Observation Assessment.

BACKGROUND: The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy. METHODS: The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents' self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected. RESULTS: From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback. CONCLUSIONS: Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.

Assessing physical examination skills using direct observation and volunteer patients.

BACKGROUND: Feedback based on direct observation of the physical examination (PE) is associated with enhanced educational outcomes, yet attending physicians do not frequently observe graduate trainees performing the PE. METHODS: We recruited volunteer patients (VPs), each with an abnormality of the cardiovascular, respiratory, or neurological system. Interns examined each VP, then presented a differential diagnosis and management plan to two clinician educators, who, themselves, had independently examined the VPs. The clinician educators assessed interns along five domains and provided post-examination feedback and teaching. We collected data on intern performance, faculty inter-rater reliability, correlation with a simulation-based measure of clinical skill, and resident and VP perceptions of the assessment. RESULTS: A total of 72 PGY-1 interns from a large academic training program participated. Performance on the cardiovascular and respiratory system was superior to performance on the neurologic exam. There was no correlation between results of an online test and directly observed cardiovascular skill. Interns preferred feedback from the direct observation sessions. VPs and faculty also rated the experience highly. Inter-rater reliability was good for the respiratory exam, but poor for the cardiovascular and neurologic exams. CONCLUSIONS: Direct observation of trainees provides evidence about PE skill that cannot be obtained via simulation. Clinician educators' ability to provide reliable PE assessment may depend on the portion of the PE being assessed. Our experience highlights the need for ongoing training of clinician educators in direct observation, standard setting, and assessment protocols. This assessment can inform summative or formative assessments of physical exam skill in graduate medical education.

Repetitive and Self-injurious Behaviors in Children with Cornelia de Lange Syndrome.

Cornelia de Lange syndrome (CdLS) is associated with repetitive and self-injurious behaviors (RBs, SIB). Evaluating children with CdLS, this study: (1) characterizes the spectrum of RBs; (2) characterizes the impact and severity of RBs including SIB; (3) describes how age and adaptive functioning relate to RBs including SIB. Fifty children (5-17 years) with CdLS were assessed with Children's Yale-Brown Obsessive Compulsive Scale Modified for PDD; Aberrant Behavior Checklist (ABC); Vineland Adaptive Behaviors Scales (VABS). All children had ≥ 1 type of RB; 44% had some form of SIB. 64% spent > 1 h/day displaying RBs. Lower VABS adaptive functioning was associated with higher stereotypy and SIB scores (ABC). In children with CdLS, RBs including SIB are common, impactful, and associated with lower adaptive functioning.

Diagnostic Errors and the Bedside Clinical Examination.

Diagnostic errors are common in clinical practice and lead to adverse patient outcomes. Systematic reviews have shown that inadequate history taking and physical examination lead to a plurality, if not a majority, of diagnostic errors. Recent advances in cognitive science have also shown that unconscious biases likely contribute to many diagnostic errors. Research into diagnostic error has been hampered by methodologic inconsistency and a paucity of studies in real-world clinical settings. The best evidence indicates that educational interventions to reduce diagnostic error should give physicians feedback about clinical outcomes and enhance their ability to recognize signs and symptoms of specific diseases at the bedside.

Two Novel Urban Health Primary Care Residency Tracks That Focus On Community-Level Structural Vulnerabilities.

BACKGROUND: Although residency programs are well situated for developing a physician workforce with knowledge, skills, and attitudes that incorporate the strengths and reflect the priorities of community organizations, few curricula explicitly do so. AIM: To develop urban health primary care tracks for internal medicine and combined internal medicine-pediatrics residents. SETTING: Academic hospital, community health center, and community-based organizations. PARTICIPANTS: Internal medicine and combined internal medicine-pediatrics residents. PROGRAM DESCRIPTION: The program integrates community-based experiences with a focus on stakeholder engagement into its curriculum. A significant portion of the training (28 weeks out of 3 years for internal medicine and 34 weeks out of 4 years for medicine-pediatrics) occurs outside the hospital and continuity clinic to support residents' understanding of structural vulnerabilities. PROGRAM EVALUATION: Sixteen internal medicine and 14 medicine-pediatrics residents have graduated from our programs. Fifty-six percent of internal medicine graduates and 79% of medicine-pediatrics graduates are seeking primary care careers, and eight overall (27%) have been placed in community organizations. Seven (23%) hold leadership positions. DISCUSSION: We implemented two novel residency tracks that successfully placed graduates in community-based primary care settings. Integrating primary care training with experiences in community organizations can create primary care leaders and may foster collective efficacy among medical centers and community organizations.

A Randomized Cohort Controlled Trial to Compare Intern Sign-Out Training Interventions.

BACKGROUND: Although previous studies have investigated the efficacy of specific sign-out protocols (such as the illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by reviewer [I-PASS] bundle), the implementation of a bundle can be time consuming and costly. We compared 4 sign-out training pedagogies on sign-out quality. OBJECTIVE: To evaluate training interventions that best enhance multidimensional sign-out quality measured by information exchange, task accountability, and personal responsibility. INTERVENTION: Four general internal medicine firms were randomly assigned into 1 of the following 4 training interventions: didactics (control), I-PASS, policy mandate on task accountability, and Plan-Do-Study-Act (PDSA). SETTING: First-year interns at a large, Mid-Atlantic internal medicine residency program. MEASUREMENTS: Eight trained observers examined 10 days each in the pre- and postintervention periods for each firm using a standardized sign-out checklist. RESULTS: Pre- and postintervention differences showed significant improvements in the transfer of patient information, task accountability, and personal responsibility for the I-PASS, policy mandate, and PDSA groups, respectively, in line with their respective training foci. Compared to the control, I-PASS reported the best improvements in sign-out quality, although there was room to improve in task accountability and responsibility. CONCLUSIONS: Different training emphases improved different dimensions of sign-out quality. A combination of training pedagogies is likely to yield optimal results.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training.

BACKGROUND: Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. METHODS: One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). RESULTS: Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. CONCLUSIONS: A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

Perspectives of Clinicians at Skilled Nursing Facilities on 30-Day Hospital Readmissions: A Qualitative Study.

BACKGROUND: Unplanned 30-day hospital readmissions are an important measure of hospital quality and a focus of national regulations. Skilled nursing facilities (SNFs) play an important role in the readmission process, but few studies have examined the factors that contribute to readmissions from SNFs, leaving hospitalists and other hospital-based clinicians with limited evidence on how to reduce SNF readmissions. OBJECTIVE: To understand the perspectives of clinicians working at SNFs regarding factors contributing to readmissions. DESIGN AND PARTICIPANTS: We prospectively identified consecutive readmissions from SNFs to a single tertiary-care hospital. Index admissions and readmissions were to the hospital's inpatient general medicine service. SNF clinicians who cared for the readmitted patients were identified and interviewed about root causes of the readmissions using a structured interview tool. Transcripts of the interviews were inductively analyzed using grounded theory methodology. RESULTS: RESULTS: We interviewed 28 clinicians at 15 SNFs. The interviews covered 24 patient readmissions. SNF clinicians described a range of procedural, technological, and cultural contributors to unplanned readmissions. Commonly cited causes of readmission included a lack of coordination between emergency departments and SNFs, poorly defined goals of care at the time of hospital discharge, acute illness at the time of hospital discharge, limited information sharing between a SNF and hospital, and SNF process and cultural factors. CONCLUSIONS: SNF clinicians identified a broad range of factors that contribute to readmissions. Addressing these factors may mitigate patients' risk of readmission from SNFs to acute care hospitals.

Case of Ovarian Cancer in a Woman with Undiagnosed Graves' Disease: A Case Report and Review of the Literature.

Epithelial ovarian cancer (OC) is a leading cause of death among females in the United States, due in part to challenges of diagnosis in the early stages of the disease. While efforts are underway to develop a high-quality screening test, it is equally important to consider whether high-risk populations are appropriate to screen. One such population may be females with hyperthyroidism, as epidemiologic studies have shown an association between this condition and OC. In this report, we present a case of a female with OC and Graves' disease to highlight the potential significance of this association.

Autism traits in children and adolescents with Cornelia de Lange syndrome.

Cornelia de Lange syndrome (CdLS) is a cohesinopathy causing delayed growth and limb deficits. Individuals with CdLS have mild to profound intellectual disability and autistic features. This study characterizes the behavioral phenotype of children with CdLS, focusing on autistic features, maladaptive behaviors, and impact of age. Children with CdLS (5-18 years) were administered normed instruments to characterize autism features (Childhood Autism Rating Scale, CARS), maladaptive behaviors (Aberrant Behavior Checklist), and adaptive skills (Vineland Adaptive Behaviors Scales). CdLS features and severity were rated with Diagnostic Criteria for CdLS. Forty-one children with CdLS (23 females, 18 males) were classified as having "no autism" (n = 7; 17.1%), "mild autism" (n = 17; 41.4%), and "severe autism" (n = 17; 41.4%), using CARS scores. Characteristic items were abnormal emotional response, stereotypies, odd object use, rigidity, lack of verbal communication, and low intellectual functioning. Verbal communication deficits and repetitive behaviors were higher compared to sensory, social cognition, and behavior abnormalities (P ≤ 0.0001). Maladaptive behaviors associated with autism traits were stereotypies (P = 0.003), hyperactivity (P = 0.01), and lethargy (P = 0.03). Activities of daily living were significantly affected; socialization adaptive skills were a relative strength. However, with advancing age, both socialization (P < 0.0001) and communication (P = 0.001) domains declined significantly. CdLS is characterized by autistic features, notably excessive repetitive behaviors and expressive language deficits. While other adaptive skills are impacted, socialization adaptive skills are less affected. Advancing age can worsen communication and socialization deficits relative to neurotypical peers.