A High-Value Care Curriculum Using Individual and Group Structured Reflection.

OBJECTIVE: One-third of all healthcare dollars are wasted, primarily in the form of clinician-ordered unnecessary diagnostic tests and treatments. Medical education has likely played a central role in the creation and perpetuation of this problem. We aimed to create a curriculum for medical students to promote their contribution to high-value care conversations in the clinical environment. METHODS: At a large university medical center between March 2017 and February 2018, we implemented a 3-phase curriculum combining multimodal educational initiatives with individual and group reflection for third-year medical students during their 12-week long Internal Medicine clerkship rotation. Students were asked to identify examples of clinical decision making that lacked attention to high-value care, propose solutions to the identified situation, and pinpoint barriers to the implementation of effective solutions using a structured reflection framework and then participate in a debrief debate with fellow students. To assess the curriculum, reflective narratives were coded by frequency and codes were compared with one another and with relevant high-value care literature to identify patterns and themes. RESULTS: In total, 151 medical students participated in phase 1 and 119 in phase 3. For phase 2, 126 reflective narratives (94.7% participation rate) comprised 226 problems, 280 solutions, and 179 barriers. CONCLUSIONS: When provided appropriate resources, medical students are able to identify relevant examples of low-value care, downstream solutions, and barriers to implementation through a structured reflection curriculum comprising written narratives and in-person debate.

Potentially inappropriate medicines for older adults with intellectual disability: Clinical implications from a medication audit.

OBJECTIVE: To investigate medications that have the potential to be inappropriately prescribed for people with intellectual disability (ID) and to explore possible issues surrounding the potential harm that can result from the use of groups of medicines for people with ID who are ageing and living longer. METHODS: An audit of medical case records of 350 patients under the care of an organisation in New Zealand was undertaken to examine existing medication profiles. RESULTS: Of the 350 patients, 95% were prescribed at least five or more medicines, with 7% of patients have 10 or more medicines. Increasing prescriptions are evident for those 56 years old and above. CONCLUSION: Medicines that may have been appropriate for people with intellectual disability when they were younger may have the potential to cause harm when they age. It is therefore important that monitoring and evaluation of medications for ageing individuals with intellectual disability are regularly undertaken.

Elevated Hair Mercury Levels Are Associated With Neurodevelopmental Deficits in Children Living Near Artisanal and Small-Scale Gold Mining in Peru.

Children living near artisanal and small-scale gold mining (ASGM) are at risk of exposure to mercury, a neurotoxicant. It is not certain whether such exposures are harming development, as they occur in underresourced contexts entwined with other stressors, such as malnutrition and enteric infection. This study sought to investigate the association between hair-mercury levels and visual-motor, cognitive, and physical development among children living near ASGM in the Peruvian Amazon. Total hair-mercury levels were measured in 164 children ages 5-12 living in Madre de Dios, Peru. Primary outcomes included Visual-Motor Integration assessed via the Beery-VMI Developmental Test, General Cognitive Ability assessed via the Batería-III Woodcock-Munoz (Spanish-language Woodcock-Johnson Tests of Cognitive Abilities), and Physical Health assessed via anthropometry/hemoglobin counts. Mean (SD) hair-mercury level was 2.06 (2.43) µg/g. Fifty-four children (32.9%) had hair-mercury levels above the World Health Organization reference level of 2.0 µg/g. After controlling for sex, child age, maternal education, and family socioeconomic status, each one unit increase in log hair-mercury level was associated with a 1.01 unit decrease in Visual-Motor Integration (95%CI: -2.06, 0.05, p = 0.061), a 2.59 unit decrease in General Cognitive Ability (95%CI: -4.52, -0.66, p = 0.012), and a 2.43 unit decrease in Physical Health (95%CI: -5.34, 0.49, p = 0.096). After adjustment for covariates, children with hair-mercury levels exceeding the World Health Organization reference level scored 4.68 IQ points lower in Cognitive Ability than their peers. Mercury exposures related to ASGM may be harming child development in the Peruvian Amazon. Children in this region may benefit from intervention to reach their full developmental potential.

Case Report: Mucosal Leishmaniasis Presenting with Nasal Septum Perforation after Almost Thirty Years.

Mucosal leishmaniasis (ML) is associated with progressive tissue destruction and granuloma formation, often after a considerable period of latency from an initial cutaneous infection. We report a case of recurrent epistaxis of 3 years duration and nasopharyngeal obstruction in a woman with treated cutaneous leishmaniasis nearly 30 years before and with no further exposure to Leishmania. Computed tomography revealed nasal septal perforation and histopathology demonstrated chronic inflammation. Microscopy was negative for amastigotes, but molecular testing of nasal mucosa biopsy detected Leishmania (Viannia) braziliensis. The patient underwent 28 days of treatment with IV sodium stibogluconate and her symptoms improved significantly. Sixteen months after treatment, she continues to have episodic epistaxis and detectable parasite load in her nasal lesion. Although ML is known to take years to decades to develop, there are few reported cases in the literature of such a long latency period. This report highlights the importance of considering ML in the differential diagnosis of chronic epistaxis in countries where leishmaniasis is endemic or in immigrants from these countries, even when presentation occurs decades after leaving an endemic region.

Therapeutic options for bleeding oesophageal varices: cyanoacrylate and balloon-occluded retrograde obliteration (BRTO).

A 56-year-old male with cirrhosis presented with acute bleeding from cardiofundal gastroesophageal varices (GOV) and was treated with endoscopic cyanoacrylate glue. Glue therapy achieved stabilisation of the patient in the emergent setting. Three months later, the patient suffered rebleeding. At that time, he underwent retreatment with balloon-occluded retrograde obliteration (BRTO), with no recurrence at a follow-up of 14 months.Available treatments for bleeding GOV include methods to (a) directly obstruct the varices (endoscopic variceal ligation , sclerotherapy and cyanoacrylate glue, BRTO) or to (b) decrease portal pressure (surgical portacaval shunts; transportal intrahepatic portosystemic shunt). No precise guidelines are available regarding when to use which modality, and few centres have experience with all of them. This case report illustrates a setting in which both options of cyanoacrylate glue therapy and BRTO were used for acute gastric variceal bleeding.

Premature Bioprosthetic Aortic Valve Degeneration Associated with Allergy to Galactose-Alpha-1,3-Galactose.

We present the cases of two patients with bioprosthetic aortic valves who developed an allergy to alpha-gal. Each had premature degeneration of their bioprosthesis and demonstrated rapidly increasing transvalvular gradients after development of their allergy. Each underwent successful replacement with a mechanical aortic valve within 1-2 years of symptom onset. doi: 10.1111/jocs.12764 (J Card Surg 2016;31:446-448).

The hitchhiker's guide to global health blogging.

Social media use in modern medicine is fraught with ethical dilemmas and risks of unprofessional behavior. This essay surveys the existing literature on the possibilities and pitfalls of social media use by health-care professionals and concludes that non-engagement with social media is not an option. A mindful approach, not vague guidelines or long checklists, will foster a generation of physicians comfortable using online platforms for education and reflection. The use of social media during global health experiences abroad has been largely ignored in the literature and presents special challenges. With a view to starting a reflective dialogue on this subject, this essay identifies some ethically nebulous aspects of global health blogging. The discussion focuses on physician and student blogging, but these principles should apply to other online platforms as well and should prove valuable for health-care professionals who are engaged in developing guidelines, educating medical students and resident physicians, or in sharing their experiences and insights on the internet.