Summary Background : Practitioners routinely misuse acid suppression medications on general medical floors and inappropriately continue the drug at discharge. Aims : To: (i) retrospectively study the appropriateness of acid suppression use on the general medical floors; (ii) characterize the patient population discharged on unnecessary acid suppression and (iii) evaluate whether patients discharged on unnecessary acid suppression continue the medicine long term. Methods : Retrospective chart review of general medical patients admitted to an in‐patient teaching service over 6 consecutive months. Results : About 60% of patients lacked an indication for initiation of acid suppression and 34% of these patients were discharged on the medicine. The only independent predictor of continuation of acid suppression at discharge was longer length of stay. Multivariate analysis did not identify a characteristic distinguishing those patients discharged inappropriately on acid suppression. At 3 and 6 months of follow‐up, 80% and 50% of patients, respectively, remained on acid suppression therapy without an appropriate indication. Conclusions : Our data verifies that practitioners routinely start general medical in‐patients on acid suppression without an appropriate indication. Many of these prescriptions are continued at discharge for no apparent reason, leading to their long‐term misuse.
Background and objectives: Many patients with chronic kidney disease (CKD) are seen by primary care physicians who may not be aware of indications or benefits of timely nephrologist referral. Late referral to a nephrologist may lead to suboptimal pre-end stage renal disease care and greater mortality. It is not known whether current postgraduate training adequately prepares a future internist in this aspect of CKD management. Design, setting, participants, and measurements: The authors performed an online questionnaire survey of internal medicine residents in the United States to determine their perceptions of indications for nephrology referral in CKD management. Results: Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution of 166 PGY 1,187 PGY 2 and 126 PGY 3. Few residents chose nephrology referral for proteinuria (45%), uncontrolled hypertension (64%), or hyperkalemia (26%). Twenty-eight percent of the residents considered consulting a nephrologist for anemia of CKD, whereas 45% would do so for bone disorder of CKD. Most of the residents would involve a nephrologist at glomerular filtration rate (GFR) <30 ml/min/1.73 m2 (90%) and for rapid decline in GFR (79%). Many residents would refer a patient for dialysis setup at GFR 15 to 30 ml/min/1.73 m2 (59%); however, 18% would do so at GFR <15 ml/min/1.73 m2. Presence of CKD clinic experience or an in-house nephrology fellowship program did not considerably change these perceptions. Conclusions: Results show that internal medicine residents have widely differing perceptions of indications for nephrology referral. Educational efforts during residency training to raise awareness and benefits of early referral may improve CKD management by facilitating better collaboration between internist and nephrologist.
ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Kinoshita H, Zhang J, Ponthisarn A, et al. Clinical practice guidelines in the diagnosis and management of acute pancreatitis. Medical Studies/Studia Medyczne. 2019;35(4):304-311. doi:10.5114/ms.2019.91248. APA Kinoshita, H., Zhang, J., Ponthisarn, A., Sharma, M. K., Binh, N. Q., & Siam, A. L. et al. (2019). Clinical practice guidelines in the diagnosis and management of acute pancreatitis. Medical Studies/Studia Medyczne, 35(4), 304-311. https://doi.org/10.5114/ms.2019.91248 Chicago Kinoshita, Hiroyuki, Jianhua Zhang, Aroon Ponthisarn, Manoj K Sharma, Nguyen Q Binh, Alex L Siam, and Chandika Samaranayake et al. 2019. "Clinical practice guidelines in the diagnosis and management of acute pancreatitis". Medical Studies/Studia Medyczne 35 (4): 304-311. doi:10.5114/ms.2019.91248. Harvard Kinoshita, H., Zhang, J., Ponthisarn, A., Sharma, M., Binh, N., Siam, A., Samaranayake, C., Darnindro, A., and Barnes, M. (2019). Clinical practice guidelines in the diagnosis and management of acute pancreatitis. Medical Studies/Studia Medyczne, 35(4), pp.304-311. https://doi.org/10.5114/ms.2019.91248 MLA Kinoshita, Hiroyuki et al. "Clinical practice guidelines in the diagnosis and management of acute pancreatitis." Medical Studies/Studia Medyczne, vol. 35, no. 4, 2019, pp. 304-311. doi:10.5114/ms.2019.91248. Vancouver Kinoshita H, Zhang J, Ponthisarn A, Sharma M, Binh N, Siam A et al. Clinical practice guidelines in the diagnosis and management of acute pancreatitis. Medical Studies/Studia Medyczne. 2019;35(4):304-311. doi:10.5114/ms.2019.91248.
88 Background: This study compares outcomes between different types of loco-regional treatment modalities used in patients with triple negative breast cancers. Methods: 299 patients with triple negative breast cancer diagnosed between April 2004 and August 2011 at a single institution and who were treated with radiation therapy were included in an IRB-approved retrospective review. Electronic charts were reviewed for demographic and pathologic data as well as outcome data including locoregional and distant recurrence. The median follow up period was 3 years. 200 (70%) patients underwent lumpectomy with whole breast irradiation (WBI). 68 (22.7%) patients received mastectomy and radiation while 31(10.4%) patients were treated with lumpectomy with accelerated partial breast irradiation (APBI). Results: Forty-nine patients (16.4%) experienced recurrence (10 local; 6 contralateral; 3 regional; 36 distant). There was a significant (p<0.0001) difference in the proportion of patients that experienced a recurrence in each treatment group: 34% (n=23) in mastectomy with radiation group; 12% (n=23) in lumpectomy with WBI group; 10% (n=3) in lumpectomy with APBI group. On univariate analysis, tumor size, tumor stage, nodal stage, overall stage, total number of positive nodes, total number of nodes removed, and whether or not the patients had an axillary lymph node dissection were significantly associated with recurrence (p<0.05). When these predictor variables, including treatment type, were examined using a stepwise cox proportional hazards regression model for recurrence, the only variables that remained significant were tumor stage (p= 0.0003) and the number of positive nodes (p= 0.0008). Survival curves were significantly different (p = 0.016) between the lumpectomy with WBI group and the mastectomy with radiation group. Over all follow-up times, the probability of survival was smallest for the mastectomy with radiation group. Conclusions: The recurrence pattern for triple negative breast cancers treated with radiation therapy was primarily distant for all treatment modalities. In our patient population, tumor stage and number of positive lymph nodes predicted for recurrence while radiotherapy technique did not.
Introduction: There have been several concerns about the quality of documentation in electronic health records (EHRs) when compared to paper charts. This study compares the accuracy of physical examination findings documentation between the two in initial progress notes. Methodology: Initial progress notes from patients with 5 specific diagnoses with invariable physical findings admitted to Beaumont Hospital, Royal Oak, between August 2011 and July 2013 were randomly selected for this study. A total of 500 progress notes were retrospectively reviewed. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm. The primary endpoints were accuracy, inaccuracy, and omission of information. Secondary endpoints were time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training. Results: The rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts (24.4% vs 4.4%). However, expected physical examination findings were more likely to be omitted in the paper notes compared to EHRs (41.2% vs 17.6%). Resident physicians had a smaller number of inaccuracies (5.3% vs 17.3%) and omissions (16.8% vs 33.9%) compared to attending physicians. Conclusions: During the initial phase of implementation of an EHR, inaccuracies were more common in progress notes in the EHR compared to the paper charts. Residents had a lower rate of inaccuracies and omissions compared to attending physicians. Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation.
