Evaluating clerkship competency without exams.

BACKGROUND: Using examination scores for grading clerkship threatens students' engagement at a time when clinical immersion is critical for socialising into medicine. Narratives of student performance, composed during training by multiple preceptors across diverse settings, may be used to judge competence instead. Preceptor commentary is not trusted as a basis for grading, but the alignment between performance narratives and examination scores has not yet been investigated. METHODS: Performance data were gathered retrospectively from five cohorts of internal medicine clerkship students at one institution. The correlation between end-of-rotation examination scores and the grading committee's ratings of student competency based on preceptors' comments was examined. Patterns in the performance narratives of high- and low-scoring students were also explored. RESULTS: The grading committee's narrative-based ratings of student competence were correlated with examination scores. The majority of preceptors' comments were positive and professionalism-oriented, although students who scored lowest on exams received fewer comments overall and more recommendations for improvement than their highest-scoring peers. Recommendations for the lowest-scoring students equally emphasised knowledge, clinical skill and professionalism, whereas recommendations to highest-scoring students emphasised knowledge and clinical skill at more than twice the rate of professionalism. DISCUSSION: Clerkship preceptors' narratives of student performance can inform competency judgements that are grounded in actual workplace learning and are related to the independent examination of knowledge and clinical performance. Using performance narratives as the basis for grading may be a viable approach to balancing learning and assessment needs during core clerkship block rotations.

Predictors of 30-day hospital readmission: The direct comparison of number of discharge medications to the HOSPITAL score and LACE index.

Effective hospital readmission risk prediction tools exist, but do not identify actionable items that could be modified to reduce the risk of readmission. Polypharmacy has attracted attention as a potentially modifiable risk factor for readmission, showing promise in a retrospective study. Polypharmacy is a very complex issue, reflecting comorbidities and healthcare resource utilisation patterns. This investigation compares the predictive ability of polypharmacy alone to the validated HOSPITAL score and LACE index readmission risk assessment tools for all adult admissions to an academic hospitalist service at a moderate sized university-affiliated hospital in the American Midwest over a 2-year period. These results indicate that the number of discharge medications alone is not a useful tool in identifying patients at high risk of hospital readmission within 30 days of discharge. Further research is needed to explore the impact of polypharmacy as a risk predictor for hospital readmission.

Vital Sign Abnormalities on Discharge Do Not Predict 30-Day Readmission.

OBJECTIVE: Hospital readmissions are common and expensive. Risk factors for hospital readmission may include vital sign abnormalities (VSA) at the time of discharge. The study aimed to validate VSA at the time of discharge as a useful predictor of hospital readmission within 30 days of discharge. VSA was compared to the validated HOSPITAL score and LACE index readmission risk prediction models. DESIGN: All adult medical patients discharged from internal medicine hospitalist service were studied retrospectively. Variables such as age, gender, diagnoses, vital signs at discharge, 30-day hospital readmission, and components for the HOSPITAL score and LACE index were extracted from the electronic health record for analysis. SETTINGS: A 507-bed university-affiliated tertiary care center. PARTICIPANTS: During the 2-year study period, a cohort of 1,916 discharges for the hospitalist service were evaluated. The final analysis was based on the data from 1,781 hospital discharges that met the inclusion criteria. RESULTS: VSA was found in 13% of the study population. Only one abnormal vital sign was present in a higher proportion readmitted to the hospital within 30 days of discharge. No discharges had three or more unstable vital signs. Receiver operating characteristic (ROC) comparisons of the HOSPITAL score (C statistic of 0.67, P < 0.001), LACE index (C statistic of 0.61, P < 0.001), and VSA (C statistic of 0.52, P = 0.318) indicated that VSA at time of discharge was not a useful predictor of hospital readmission within 30 days of discharge. CONCLUSION: Our study indicated that VSA at the time of discharge is not a useful predictor of 30-day hospital readmission at a university-affiliated teaching hospital. The more complex and validated HOSPITAL score and LACE index were useful predictors of hospital readmission in this patient population.

Nivolumab-Associated Acute Demyelinating Encephalitis: A Case Report and Literature Review.

Nivolumab is a checkpoint inhibiting immunotherapeutic agent prescribed for the treatment of resistant cancers. Many immune-related adverse effects including neurological effects have been described, but central nervous system (CNS) toxicities are rarely reported. We present a 59-year-old Caucasian woman with a history of treatment-resistant, progressive, laryngeal squamous cell carcinoma. She received nivolumab and presented with gradual weakness, confusion, and progressive dyspnea. Magnetic resonance imaging of the head showed multifocal cerebral demyelination, primarily involving the parietal lobe. The diagnosis of acute demyelinating encephalitis was made. She improved dramatically after stopping nivolumab and receiving treatment with high-dose intravenous steroid and immunoglobin therapy. We conclude, from this case and literature review, that immune checkpoint inhibitor treatment requires more investigation to determine if autoimmune encephalitis with demyelination can occur as a severe form of immune-related adverse events. CNS toxicity appears to be reversible with prompt cessation of immunotherapy followed by treatment with high doses of steroid with or without intravenous immunoglobulin therapy.

Impact of oral anticoagulants on 30-day readmission: a study from a single academic centre.

Researchers are extensively searching for modifiable risk factors including high-risk medications such as anticoagulation to avoid rehospitalisation. The influence of oral anticoagulant therapy on hospital readmission is not known. We investigated the impact of warfarin and direct oral anticoagulants (DOACs) on all cause 30-day hospital readmission retrospectively in an academic centre. We study the eligible cohort of 1781 discharges over 2-year period. Data on age, gender, diagnoses, 30-day hospital readmission, discharge medications and variables in the HOSPITAL score (Haemoglobin level at discharge, Oncology at discharge, Sodium level at discharge, Procedure during hospitalisation, Index admission, number of hospital Admissions, Length of stay) and LACE index (Length of stay, Acute/emergent admission, Charlson comorbidity index score, Emergency department visits in previous 6 months), which have higher predictability for readmission were extracted and matched for analysis. Warfarin was the most common anticoagulant prescribed at discharge (273 patients) with a readmission rate of 20% (p<0.01). DOACs were used by 94 patients at discharge with a readmission rate of 4% (p=0.219). Multivariate logistic regression showed an increased risk of readmission with warfarin therapy (OR 1.36, p=0.045). Logistic regression did not show DOACs to be a risk factor for hospital readmission. Our data suggests that warfarin therapy is a risk factor for all-cause 30-day hospital readmission. DOAC therapy is not found to be associated with a higher risk of hospital readmission. Warfarin anticoagulation may be an important target for interventions to reduce hospital readmissions.

H. capsulatum: A Not-So-Benign Cause of Pericarditis.

The common causes of pericarditis and its course are benign in the majority of cases. Thus, further testing is usually not pursued and treatment for a presumptive viral etiology with nonsteroidal agents and steroids has been an accepted strategy. We present a patient with pericarditis who was unresponsive to first-line therapy and was subsequently found to have necrotizing granulomas of the pericardium with extensive adhesions and fungal elements seen on tissue biopsy. Serologic testing confirms active H. capsulatum infection, and he responded well to Itraconazole treatment. In patients with pericarditis who fail standard therapy with NSAIDs and steroids, it is suggested that they undergo thorough evaluation and that histoplasmosis be considered as an etiology, especially in endemic regions.

Reducing 30-Day Rehospitalization Rates Using a Transition of Care Clinic Model in a Single Medical Center.

BACKGROUND: Rehospitalization for medical patients is common. Multiple interventions of varying complexity have been shown to be effective in achieving that goal with variable results in the literature. For medical patients discharged home, no single intervention implemented alone has been shown to have a sustainable effect in preventing rehospitalization. OBJECTIVE: To study the effect of a transition of care clinic model on the 30-day rehospitalization rate in a single medical center. METHODS: Retrospective observational analysis of adult patients discharged home from Memorial Medical Center from September 1, 2014, through December 31, 2014. The primary outcome was to compare hospital readmission rates between patients who followed up with a transition of care (TOC) clinic and those who did not. RESULTS: The study population included 378 patient discharges. A total of 40 patients (10.6%) were readmitted to the hospital within 30 days of discharge. Patients who attended the TOC clinic had a significantly lower 30-day readmission rates (3.8% versus 11.7%). A Cox regression analysis showed that the TOC clinic attendance had a significant negative predication for readmission (HR 0.186, 95% CI 0.038-0.898, P = 0.038). CONCLUSION: Adopting a TOC model after discharging medical patients has reduced the readmission rates in our study.

The HOSPITAL score and LACE index as predictors of 30 day readmission in a retrospective study at a university-affiliated community hospital.

INTRODUCTION: Hospital readmissions are common, expensive, and a key target of the Medicare Value Based Purchasing (VBP) program. Validated risk assessment tools such as the HOSPITAL score and LACE index have been developed to identify patients at high risk of hospital readmission so they can be targeted for interventions aimed at reducing the rate of readmission. This study aims to evaluate the utility of HOSPITAL score and LACE index for predicting hospital readmission within 30 days in a moderate-sized university affiliated hospital in the midwestern United States. MATERIALS AND METHODS: All adult medical patients who underwent one or more ICD-10 defined procedures discharged from the SIU-SOM Hospitalist service from Memorial Medical Center (MMC) from October 15, 2015 to March 16, 2016, were studied retrospectively to determine if the HOSPITAL score and LACE index were a significant predictors of hospital readmission within 30 days. RESULTS: During the study period, 463 discharges were recorded for the hospitalist service. The analysis includes data for the 432 discharges. Patients who died during the hospital stay, were transferred to another hospital, or left against medical advice were excluded. Of these patients, 35 (8%) were readmitted to the same hospital within 30 days. A receiver operating characteristic evaluation of the HOSPITAL score for this patient population shows a C statistic of 0.75 (95% CI [0.67-0.83]), indicating good discrimination for hospital readmission. The Brier score for the HOSPITAL score in this setting was 0.069, indicating good overall performance. The Hosmer-Lemeshow goodness of fit test shows a χ2 value of 3.71 with a p value of 0.59. A receiver operating characteristic evaluation of the LACE index for this patient population shows a C statistic of 0.58 (95% CI [0.48-0.68]), indicating poor discrimination for hospital readmission. The Brier score for the LACE index in this setting was 0.082, indicating good overall performance. The Hosmer-Lemeshow goodness of fit test shows a χ2 value of 4.97 with a p value of 0.66. DISCUSSION: This single center retrospective study indicates that the HOSPITAL score has superior discriminatory ability when compared to the LACE index as a predictor of hospital readmission within 30 days at a medium-sized university-affiliated teaching hospital. CONCLUSIONS: The internationally validated HOSPITAL score may be superior to the LACE index in moderate-sized community hospitals to identify patients at high risk of hospital readmission within 30 days.

A Case of Trigger-Point Injection-Induced Hypokalemic Paralysis.

BACKGROUND Trigger-point injection (TPI) therapy is an effective modality for symptomatic treatment of myofascial pain. Serious adverse effects are rarely observed. In this report, we present the case of a 39-year-old man who experienced severe, transient hypokalemic paralysis in the context of TPI therapy with methylprednisolone, bupivacaine, and epinephrine. He was successfully treated with electrolyte replacement in a closely monitored setting. CASE REPORT A 39-year-old man with no past medical history except for chronic left hip pain from a work-related injury received a TPI with methylprednisolone and bupivacaine. The TPI targeted the left iliopsoas tendon and was administered using ultrasound guidance. There were no immediately perceived complications, but within 12 h he presented with severe hypokalemic paralysis with a serum potassium 1.7 mmol/L. Judicious potassium repletion was initiated. Repeated tests after 6 h consistently showed normal potassium levels of 4.5 mmol/L. CONCLUSIONS Severe hypokalemic paralysis in the context of trigger-point injection is an incredibly rare occurrence and this is the first case report in English literature. A high index of clinical suspicion and a systematic approach are therefore required for prompt diagnosis and management of this obscure iatrogenic entity. Clinicians can enhance patient safety by allowing the primary pathology to guide them.

Disseminated Tuberculosis Presenting as Baker's Cyst Infection.

In the absence of coexisting immunocompromised state and lack of specific symptoms a reactivation of treated mycobacterial tuberculosis (MTB) infection is generally not considered in the differential diagnosis of leg pain. We present a unique case of disseminated tuberculosis presenting as an infected Baker's cyst in a 73-year-old immunocompetent male.

Evaluating YouTube as a Source of Patient Education on the Role of the Hospitalist: A Cross-Sectional Study.

BACKGROUND: Hospital medicine is a relatively new specialty field, dedicated to the delivery of comprehensive medical care to hospitalized patients. YouTube is one of the most frequently used websites, offering access to a gamut of videos from self-produced to professionally made. OBJECTIVE: The aim of our study was to determine the adequacy of YouTube as an effective means to define and depict the role of hospitalists. METHODS: YouTube was searched on November 17, 2014, using the following search words: "hospitalist," "hospitalist definition," "what is the role of a hospitalist," "define hospitalist," and "who is a hospitalist." Videos found only in the first 10 pages of each search were included. Non-English, noneducational, and nonrelevant videos were excluded. A novel 7-point scoring tool was created by the authors based on the definition of a hospitalist adopted by the Society of Hospital Medicine. Three independent reviewers evaluated, scored, and classified the videos into high, intermediate, and low quality based on the average score. RESULTS: A total of 102 videos out of 855 were identified as relevant and included in the analysis. Videos uploaded by academic institutions had the highest mean score. Only 6 videos were classified as high quality, 53 as intermediate quality, and 42 as low quality, with 82.4% (84/102) of the videos scoring an average of 4 or less. CONCLUSIONS: Most videos found in the search of a hospitalist definition are inadequate. Leading medical organizations and academic institutions should consider producing and uploading quality videos to YouTube to help patients and their families better understand the roles and definition of the hospitalist.

Cetuximab-Associated Crescentic Diffuse Proliferative Glomerulonephritis.

Cetuximab-induced nephrotoxicity is very rare, occurring in less than 1% of colorectal cancer patients and not defined in other populations. We report a rare case of crescentic diffuse proliferative glomerulonephritis (GN) that developed in close temporal association with cetuximab treatment. A 65-year-old female recently completed chemotherapy with cetuximab treatment for moderately differentiated oral squamous cell carcinoma. She was admitted with acute renal failure and nephrotic-range proteinuria. Laboratory data showed serum creatinine of 6.6 mg/dl and urinalysis showed proteinuria, moderate hemoglobinuria, hyaline casts (41/LPF), WBC (28/HPF), and RBC (81/HPF). Serologic studies were negative for ANA, anti-GBM, ANCA, hepatitis B, and hepatitis C. Serum C3 and C4 level were normal. Renal biopsy showed crescentic diffuse proliferative GN with focal features of thrombotic microangiopathy. Patient was started on cyclophosphamide and steroids. Her renal function did not improve on day 8 and she was started on hemodialysis. Previous reports suggest that EGFR-targeting medications can possibly trigger or exacerbate an IgA-mediated glomerular process leading to renal failure. This case suggests that cetuximab therapy may have triggered or exacerbated a severe glomerular injury with an unfavorable outcome. Treating physicians should maintain a high degree of caution and monitor renal function in patients on EGFR inhibitors.

A Case Report Describing a Rare Presentation of Simultaneous Occurrence of MPO-ANCA-Associated Vasculitis and Rheumatoid Arthritis.

Background. Renal-limited myeloperoxidase vasculitis with simultaneous rheumatoid arthritis is reported as a rare occurrence. Review of literature suggests that most patients had a diagnosis of rheumatoid arthritis for several years prior to presenting with renal failure from myeloperoxidase vasculitis. Case Presentation. A 58-year-old Caucasian male presented to the hospital experiencing malaise, fevers, decreased oral intake, nausea, and vomiting for one week duration. His past medical history consisted of newly diagnosed but untreated rheumatoid arthritis, hypertension, and non-insulin-dependent diabetes mellitus. He was found to have acute renal failure, proteinuria, and hypoglycemia. Standard therapy, including intravenous fluids, did not improve his acute renal failure. A vasculitis workup resulted in a positive myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA). Renal biopsy revealed crescentic glomerulonephritis (GN) pauci-immune type, suggestive of MPO-ANCA-associated vasculitis (MPO-AAV). Treatment consisted of prednisone, cyclophosphamide, and seven cycles of plasmapheresis, in addition to hemodialysis for uremia. Upon discharge, he received hemodialysis for another week and continued treatment with cyclophosphamide and prednisone. Conclusion. Patients with longstanding rheumatoid arthritis may develop renal failure due to nonsteroidal anti-inflammatory medication use and AA type amyloidosis; however, necrotizing glomerulonephritis with crescent formation has been rarely reported. This stresses the importance of early recognition and swift initiation of treatment.

Hypocalcemia and hyperkalemia during magnesium infusion therapy in a pre-eclamptic patient.

We present a case of prominent hypocalcemia and hyperkalemia attributed to magnesium infusion in a preeclamptic patient. Iatrogenic hypermagnesemia is an underrecognized cause of hypocalcemia and hyperkalemia. Our report illustrates the effects of magnesium therapy on serum calcium and potassium, necessitating close electrolytes monitoring when used.

A fractured inferior vena cava filter strut migrating to the left pulmonary artery.

Inferior vena cava filters are increasingly used in patients with recurrent venous thromboembolism who are contraindicated to anticoagulation. Migration of a broken strut to the pulmonary artery is a very rare complication of these filters. We report the case of an 83-year-old female who experienced this complication with the migratory strut remaining in the same position for years. This case provides evidence that such filters probably have higher rates of complications than what has been thought that remain asymptomatic. The indications and the management of complications of such devices need to be studied further.