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Background: Rotating internal medicine (IM) residents do not feel adequately prepared to approach patients with neurologic issues. The purpose of this project was to conduct a needs assessment to determine the optimal components and delivery of a neurology curriculum for internal medicine residents. Methods: We utilized a mixed-methods design and recruited participants through a combination of purposive and convenience sampling. We conducted interviews with IM residents (n=12) and focus groups with neurology residents (n=7) and neurology staff (n=8). IM residents completed entry- and post-call surveys while on a neurology rotation. Results: Themes according to Kern’s framework for curriculum development: 1. Problem: Discomfort and perception of under-preparedness amongst IM trainees 2. Needs Assessment: What the learners (stakeholders) think they need to know vs. what their teachers want them to know vs external requirements (Royal College) 3. Goals/objectives: What content is relevant for clinical requirements vs assessments? 4. Methods and setting: Didactic vs bedside vs virtual 5. Implementation of the curriculum 6. Evaluation and feedback Conclusions: Our findings illustrate a possible mismatch between internal medicine residents’ needs and neurologist teachers’ expectations in teaching neurology. Addressing learners’ needs could enhance neurology knowledge and sense of preparedness when encountering patients with neurologic issues.
To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain.
We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details – number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either “chronic pain” or “not chronic pain” related.
We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain.
Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.
The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs.
Before-and-after intervention study.
Consecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital.
The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists’ prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle.
Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment.
A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.
I advance a novel interpretation of Kant’s argument that our original representation of space must be intuitive, according to which the intuitive status of spatial representation is secured by its infinitary structure. I defend a conception of intuitive representation as what must be given to the mind in order to be thought at all. Discursive representation, as modelled on the specific division of a highest genus into species, cannot account for infinite complexity. Because we represent space as infinitely complex, the spatial manifold cannot be generated discursively and must therefore be given to the mind, i.e. represented in intuition.
A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially ‘applied neuroscience’. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.
Malignant mesothelioma is a rare, highly aggressive cancer arising from mesothelial cells that line the pleural cavities. Approximately 80% of mesothelioma cases can be directly attributed to asbestos exposure. Additional suspected causes or co-carcinogens include other mineral fibres, simian virus 40 (SV40) and radiation. A mesothelioma epidemic in Turkey has demonstrated a probable genetic predisposition to mineral fibre carcinogenesis and studies of human tissues and animal models of mesothelioma have demonstrated genetic and epigenetic events that contribute to the multistep process of mineral fibre carcinogenesis. Several growth factors and their receptors have a significant role in the oncogenesis, progression and resistance to therapy of mesothelioma. Epidermal growth factor (EGF), hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF) and insulin-like growth factor (IGF) have been shown as targets for therapy based on promising preclinical data. However, clinical trials of tyrosine kinase inhibitors in mesothelioma have been disappointing. Bcl-XL is an important antiapoptotic member of the Bcl-2 family and is overexpressed in several solid tumours, including mesothelioma. Reduction of Bcl-XL expression in mesothelioma induces apoptosis and engenders sensitisation to cytotoxic chemotherapeutic agents. Pharmacological inhibitors of antiapoptotic Bcl-2 family members continue to undergo refinement and have shown promise in mesothelioma.
Disaster preparedness is an area of major concern for the medical community that has been reinforced by recent world events. The emergency healthcare system must respond to all types of disasters, whether the incidents occur in urban or rural settings. Although the barriers and challenges are different in the rural setting, common areas of preparedness must be explored.
This study sought to answer several questions, including: (1) What are rural emergency medical services (EMS) organizations training for, compared to what they actually have seen during the last two years?; (2) What scale and types of events do they believe they are prepared to cope with?; and (3) What do they feel are priority areas for training and preparedness?
Data were gathered through a multi-region survey of 1,801 EMS organizations in the US to describe EMS response experiences during specific incidents as well as the frequency with which these events occur. Respondents were asked a number of questions about local priorities.
A total of 768 completed surveys were returned (43%). Over the past few years, training for commonly occurring types of crises and emergencies has declined in favor of terrorism preparedness. Many rural EMS organizations reported that events with 10 or fewer victims would overload them. Low priority was placed on interacting with other non-EMS disaster response agencies, and high priority was placed on basic staff training and retention.
Maintaining viable, rural, emergency response capabilities and developing a community-wide response to natural or man-made events is crucial to mitigate long-term effects of disasters on a local healthcare system. The assessment of preparedness activities accomplished in this study will help to identify common themes to better prioritize preparedness activities and maximize the response capabilities of an EMS organization.
A long-term research program at the Maya center of Chac (II) is
providing extraordinary new information regarding architecture,
mortuary populations, and foreign presence at the Puuc hills during the
Early Classic period (a.d. 300–600). The finding of
numerous early substructures at monumental and residential contexts,
unusual mortuary practices, and various artifacts showing central
Mexican inspiration and/or origin has led to the serious
realization that the center of Chac did not develop in cultural
isolation. It is becoming increasingly evident that Teotihuacan played
a significant role, either directly or via one of its surrogates, in
the rise of urban centers in the Puuc region. This paper explores the
evidence of foreign influences and contacts at Chac and discusses the
larger implications for the early political economy of the Puuc hills
region and the region's relationship to greater Mesoamerica.