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Background and Objectives: As clinicians increasingly rely on telemedicine, medical students will need to learn how to appropriately use telemedicine in patient care. A formal approach to curriculum development is needed to identify gaps and needs in early medical student performance. Methods: In October 2020, 120 second-year medical students completed a telemedicine visit with a standardized patient with chronic essential hypertension. Students were assessed across five domains (history-gathering, communication, vitals, physical exam, and assessment/management). An anonymous, voluntary survey was distributed to assess self-efficacy in telemedicine skills. Results: Students perform well in history-gathering and communication (98% of student scored 4 or 5 out of 5 on history, 100% of students received a 7 or 8 out of 8 on communication). Students perform poorly in obtaining vital signs (23% scored 3 or 4 out of 4) and assessment/management (14% scored 3 or 4 out of 4). Students received their lowest scores in physical examination (2% score 4 or 5 out of 5). The number of telemedicine visits completed with patients prior to the standardized patient exercise had no impact on student performance during the exercise. Student response rate on the postexercise survey was 88%. Self-efficacy was lowest in physical examination telemedicine skills compared to other domains. Conclusions: Findings suggest that early medical students are able to gather history and communicate over telemedicine, but perform poorly on telemedicine physical examination skills. More robust curriculum development addressing telemedicine physical examinations skills is needed early in medical training.

Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.

Phenomenon: Because of its importance in residency selection, the United States Medical Licensing Examination Step 1 occupies a critical position in medical education, stimulating national debate about appropriate score use, equitable selection criteria, and the goals of undergraduate medical education. Yet, student perspectives on these issues and their implications for engagement with health systems science-related curricular content are relatively underexplored. Approach: We conducted an online survey of medical students at 19 American allopathic medical schools from March-July, 2019. Survey items were designed to elicit student opinions on the Step 1 examination and the impact of the examination on their engagement with new, non-test curricular content related to health systems science. Findings: A total of 2856 students participated in the survey, representing 23.5% of those invited. While 87% of students agreed that doing well on the Step 1 exam was their top priority, 56% disagreed that studying for Step 1 had a positive impact on engagement in the medical school curriculum. Eighty-two percent of students disagreed that Step 1 scores should be the top item residency programs use to offer interviews. When asked whether Step 1 results should be reported pass/fail with no numeric score, 55% of students agreed, while 33% disagreed. The majority of medical students agreed that health systems science topics were important but disagreed that studying for Step 1 helped learn this content. Students reported being more motivated to study a topic if it was on the exam, part of a course grade, prioritized by residency program directors, or if it would make them a better physician in the future. Insights: These results confirm the primacy of the United States Medical Licensing Examination Step 1 exam in preclinical medical education and demonstrate the need to balance the objectives of medical licensure and residency selection with the goals of the broader medical profession. The survey responses suggest several potential solutions to increase student engagement in health systems science curricula which may be especially important after Step 1 examination results are reported as pass/fail.

Aims and objectives Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource with limited success. Clinical-effectiveness studies have thus far not included care settings in which resident-physicians are the primary caregivers. Methods We implemented two interventions on general internal medicine units of an academic hospital. The first intervention, or nurse-discontinuation protocol, allowed nurses to trigger the discontinuation of telemetry once the appropriate duration had passed according to practice standards. The second intervention, or physician-discontinuation protocol, instituted a best-practice advisory that notified the resident-physician via the electronic medical record when the appropriate telemetry duration for each patient had elapsed and suggested termination of telemetry. Data collection spanned 8 months following the implementation of the nurse-discontinuation protocol and 12 months following the physician-discontinuation protocol. Results During the control period, the average time spent on telemetry was 86.29 hours/patient/month. During the nurse-discontinuation protocol, patients spent, on average, 70.86 hours/patient/month on telemetry. During the physician-discontinuation protocol, patients spent, on average, 81.6 hours/patient/month on telemetry. During the nurse-discontinuation protocol, there was no significant change in the likelihood that a patient was placed on telemetry throughout their admission when compared with the control period. During the physician-discontinuation protocol, there was a significant decrease of 56.1% in the likelihood that a patient would be put on telemetry when compared with the control time period. Conclusions These findings expand our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers. Furthermore, these findings represent an important addition to the telemetry and patient monitoring literature by demonstrating the impact that nurse-managed protocols can have on telemetry use and by highlighting effective strategies to improve telemetry use by physicians in training.

Purpose To report on the implementation of a telephone medicine curriculum as part of the core clerkship in pediatrics for students at Johns Hopkins University School of Medicine and evaluate the curriculum's effect on student performance on a telephone medicine case as part of a required objective structured clinical exam (OSCE). Method Using a prospective cohort design with a convenience sample of third-year medical students during the 2016-2017 and 2017-2018 academic years, the authors compared the OSCE scores of students assigned to the curriculum to both historical and concurrent control groups of students who had not received the curriculum. Additionally, the authors compared the costs of the recommended testing by students in each group using the 2018 Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule. Results Students assigned to the telephone medicine curriculum (students in the intervention group) had a significantly higher mean overall score on the simulated OSCE telephone medicine case compared to the students in the control groups who did not receive the curriculum (the mean score for students in the intervention group was 7.38 vs 6.92 for students in the control groups, P = .02). Additionally, the intervention group had statistically significantly lower costs for their recommended testing compared to the control groups (the median value for tests ordered by students in the intervention group was $27.91 vs $51.23 for students in the control groups, P = .03). CONCLUSIONS;: Implementing a dedicated telephone medicine curriculum for medical students improves their overall performance and delivery of high-value care via telephone medicine as part of an OSCE. Medical educators should pursue ongoing research into effective methods for teaching medical students and residents how to navigate digital encounters.

With more than 3 million people diagnosed and more than 200,000 deaths worldwide at the time this article was written, coronavirus disease of 2019 (COVID-19) poses an unprecedented challenge to the public and to our healthcare system.1 The United States has surpassed every other country in the total number of COVID-19 cases. Hospitals in hotspots are operating beyond capacity, while others prepare for a predicted surge of patients suffering from COVID-19. Now more than ever, clinicians need to prioritize limited time and resources wisely in this rapidly changing environment. Our most precious limited resource, healthcare workers (HCWs), bravely care for patients while trying to avoid acquiring the infection. With each test and treatment, clinicians must carefully consider harms and benefits, including exposing themselves and other HCWs to SARS-CoV-2, the virus causing this disease.

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.

We aimed to determine whether it was feasible to assess medical students as they completed a virtual sub-internship. Six students (out of 31 who completed an in-person sub-internship) participated in a 2-week virtual sub-internship, caring for patients remotely. Residents and attendings assessed those 6 students in 15 domains using the same assessment measures from the in-person sub-internship. Raters marked “unable to assess” in 75/390 responses (19%) for the virtual sub-internship versus 88/3,405 (2.6%) for the in-person sub-internship (P=0.01), most frequently for the virtual sub-internship in the domains of the physical examination (21, 81%), rapport with patients (18, 69%), and compassion (11, 42%). Students received complete assessments in most areas. Scores were higher for the in-person than the virtual sub-internship (4.67 vs. 4.45, P

Introduction Telephone triage requires a unique skillset that is not universally taught in medical school. This curriculum was developed to introduce third- and fourth-year medical students participating in their pediatrics core clerkship to the benefits, challenges, and mechanics of telephone triage. Methods After completing a presession textbook reading and listening to a brief lecture, students participated in two telephone role-play scenarios with parents. The exercise required students to recognize the differences in acuity level of patients and provide appropriate guidance, management, and disposition instructions. Following the session, students completed a telephone note. Students evaluated this curriculum at the completion of the clerkship. Results The majority of the 74 students who completed the 5-point Likert scale evaluation felt that the curriculum met its stated objectives (a score of 4 or 5 given by 82%), increased their knowledge (73%), engaged them (86%), and was of high quality (82%). Students specifically commented that the experience was useful, interactive, and applicable to their clerkship experience and future career. The most common area of constructive feedback was not understanding the purpose of a telephone note. Discussion This easily implemented curriculum provided a foundational experience in the nuances of triaging and managing pediatric patients via the telephone. This serves as an important framework to prepare students for more complex telemedicine technology.

Purpose: The clinical skills needed to practice high-value care (HVC) are core to all medical disciplines. Medical students form practice habits early, and HVC instruction is essential to this formation. The purpose of this study was to describe the state of HVC instruction and assessment in internal medicine clerkships and identify needs for additional curricula. Method: In 2014, the Clerkship Directors in Internal Medicine conducted its annual survey of 121 U.S. and Canadian medical schools. The authors evaluated a subset of questions from that survey asking clerkship directors about the perceived importance of HVC instruction, type and amount of formal instruction and assessment, achievement of student competence, prioritization of topics, and barriers to curriculum implementation. Descriptive statistics were used to summarize responses, and chi-square tests were used to examine associations between response categories. Results: The overall response rate was 77.7% (94/121). The majority (85; 91.4%) agreed that medical schools have a responsibility to teach about HVC across all phases of the curriculum. Of respondents, 31 (32.9%) reported their curricula as having some formal instruction on HVC, and 66 (70.2%) felt the amount was inadequate. Highest-priority topics for inclusion included overuse of diagnostic tests and treatments, defining value and its application to clinical reasoning, and balancing benefit and harm. Only 11 (17.8%) assessed students’ competence in HVC. Conclusions: Internal medicine clerkship directors reported that HVC is insufficiently taught and assessed in medical school, despite relevance to practice. Developing generalizable curricular materials, faculty development, and dedicated curricular time may enhance HVC education.

Purpose The aim of this project was to reduce abdominal ultrasound examinations in patients who had undergone abdominal CT within 72 hours previously. Methods A best practice advisory (BPA) was created in the electronic medical record to advise against the use of abdominal ultrasound in adult inpatients and emergency department patients who had undergone abdominal CT within the preceding 72 hours. Acceptable acknowledgment reasons to proceed with the order were made available if providers chose to override. Frequency of BPA firing and subsequent ordering behavior were evaluated 6 months after integration of the BPA into the electronic medical record. Chart review was conducted for 100 patients whose orders were placed through an override of the alert to determine if the ultrasound study added value and for all patients whose ultrasound studies were canceled to confirm that patient care was not compromised by omitting the ultrasound study. Results In the first 6 months, a total of 614 inpatient and emergency department abdominal ultrasound orders triggered the BPA. A total of 16% of orders (n = 96) were canceled by the provider after the BPA, reflecting 518 overrides. The majority of retained orders were to evaluate the gallbladder (44% [227 of 518]). Chart review confirmed utility for gallbladder imaging and that the canceled ultrasound examinations would not have contributed value to patients’ care. Conclusions A recently performed abdominal CT scan may obviate the need for inpatient and emergency department abdominal ultrasound, particularly in the setting of hospital-acquired acute kidney injury. A BPA resulted in only 16% of orders’ being canceled, whereas chart review revealed a much larger opportunity to avoid duplicative imaging.

Background Most medical schools teach a high-value care (HVC) curriculum during the clinical years. Currently, there lacks any research demonstrating the effectiveness of the HVC curriculum taught to students in their first year of medical school. Methods A total of 118 of 466 first-year medical students at Johns Hopkins School of Medicine between 2013 and 2017 enrolled on an HVC course that provided the initial framework necessary to practice cost-conscious clinical medicine. The curriculum was evaluated by comparing the performance of students who completed the course with the performance of students without training, through a standardised patient encounter on musculoskeletal back pain and how to approach a patient's request for imaging. Chi-square testing was used to assess the impact of the course on performance in a standardised patient encounter. Results Students enrolled on the HVC course were more likely, compared with their counterparts, to assure patients that back pain was a simple strain (48 versus 31%), and were less likely to ask for preceptor help on how to proceed with management (11 versus 29%) [χ2 (4, n = 466) = 14.28, p = 0.007]. There were no differences between students enrolled on the HVC course who had not yet received training compared with students taking another elective [χ2 (4, n = 385) = 8.73, p = 0.07]. Discussion This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice in a simulated clinical setting. This is the first study to assess the effectiveness of an HVC curriculum for first-year medical students, and it demonstrates promise that they can acquire some skill sets necessary for cost-effective practice.

Computerized clinical decision support (CCDS) significantly reduced Clostridioides difficile testing at 3 hospitals; from 12.6 to 9.5, from 10.1 to 6.4, and from 14.0 to 9.6 average weekly tests per 1000 inpatient days. There were no related adverse events. Senior providers were more likely than interns or residents to follow CCDS.

Cross-sectional analysis.Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients.Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts.For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated100 times/year had significantly lower costs than those who operated200 times/year (Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons.

Clinical decision support (CDS) embedded within the electronic health record (EHR) is a potential antibiotic stewardship strategy for hospitalized patients. Reduction in urine testing and treating asymptomatic bacteriuria (ASB) is an important strategy to promote antibiotic stewardship. We created an intervention focused on reducing urine testing for asymptomatic patients at a large tertiary care center. The objective of this study was to design an intervention to reduce unnecessary urinalysis and urine culture (UC) orders as well as the treatment of ASB. We performed a quasiexperimental study among adult inpatients at a single academic institution. We implemented a bundled intervention, including information broadcast in newsletters, hospital-wide screensavers, and passive CDS messages in the EHR. We investigated the impact of this strategy on urinalysis, UC orders, and on the treatment of ASB by using an interrupted time series analysis. Our intervention led to reduced UC order as well as reduced antibiotic orders in response to urinalysis orders and UC results. This easily implementable bundle may play an important role as an antibiotic stewardship strategy.

Treatment of asymptomatic bacteriuria (ASB) frequently lacks appropriate indication, yet remains prevalent across settings. Numerous guidelines, professional societies, and campaigns such as Choosing Wisely advocate against this low-value practice. Efforts aimed at reducing unnecessary treatment of ASB demonstrate improved costs, and avoidable harm without increased risk of adverse events. We propose an evidence-based implementation guide to aid practitioners in reducing inappropriate treatment of ASB.

Payers, providers, and patients increasingly recognize the importance of quality and safety in health care. Academic Departments of Medicine can advance quality and safety given the large populations they serve and the broad spectrum of diseases they treat. However, there are only few detailed examples of how quality and safety can be organized. This article describes a practical model at The Johns Hopkins Hospital Department of Medicine and details its structure and operation within a large academic health system. It is based on a fractal model that integrates multiple smaller units similar in structure (composition of faculty/staff), process (use of similar tools), and approach (using a common framework to address issues). This organization stresses local, multidisciplinary leadership, facilitates horizontal connections for peer learning, and maintains vertical connections for broader accountability.

Background Medical schools are creating high-value care (HVC) curricula in undergraduate medical education; however, there are few studies identifying what are the most pressing low-value care (LVC) practices, as observed by students. This study is a multicentre, targeted needs assessment comparing medical student perceptions of LVC at four institutions, after completion of their internal medicine clerkship, to identify areas of focus for future HVC curriculum development. Methods A total of 307 medical students at four institutions participated in a voluntary survey and identified instances of LVC during the internal medicine clerkship. Responses were organised into seven LVC categories and analysed using chi-square testing to determine response variation by institution. Results The four most common themes identified by all institutions were testing for low prevalence disease processes (44%), excessive daily labwork (44%), errors in clinical judgement (26%) and testing that would not change management (21%). Responses did not vary by institution, with the exception that one school identified fewer instances of ordering excessive labwork compared with the other institutions (28 versus 46-54%; p = 0.05). There are few studies identifying what are the most pressing low-value care practices DISCUSSION: This is the first multi-institutional targeted needs assessment to demonstrate similarities in perceptions of LVC by medical students. Despite differences in geographic location and private and public affiliations, the top four categories remained consistent. These findings can provide a framework for educational objectives that address these issues in an HVC curriculum. Response variation, as seen with institution 2, offers opportunities for schools to personalise their HVC curriculum.

BACKGROUND Rising and burdensome health care costs have driven interest in the practice of high-value care (HVC) and have inspired calls for increased HVC training across all levels of medical education, including among undergraduate medical students. CONTEXT Classroom-based HVC curricula targeted to medical students have not been previously described in the medical literature. INNOVATION We developed and evaluated a workshop comprising a lecture, a small-group exercise and a group discussion to instruct medical students on interpreting cost-effectiveness analyses (CEA), applying CEA to patient care and discussing the cost of care with patients. From January 2014 to September 2015 the workshop was administered to five cohorts, 120 students in total, in the internal medicine clerkships at two US medical schools. Pre- and post-intervention confidence in various domains was assessed with a Likert-type scale ranging from 1 to 4. The overall response rate was 87.9 per cent. The proportion of students reporting high confidence scores (3 or 4) rose significantly (p

Background The near-universal prevalence of electronic health records (EHRs) has made the utilization of clinical decision support systems (CDSS) an integral strategy for improving the value of laboratory ordering. Few studies have examined the effectiveness of nonintrusive CDSS on inpatient laboratory utilization in large academic centres. Methods Red blood cell folate, hepatitis C virus viral loads and genotypes, and type and screens were selected for study. We incorporated the appropriate indications for these labs into text that accompanied the laboratory orders in our hospital's EHR. Providers could proceed with the order without additional clicks. An interrupted time-series analysis was performed, and the primary outcome was the rate of tests ordered on all inpatient medicine floors. Results The rate of folate tests ordered per monthly admissions showed no significant level change at the time of the intervention with only a slight decrease in rate of 0.0109 (P = .07). There was a 43% decrease in the rate of hepatitis C virus tests per monthly admissions immediately after the intervention with a decrease of 0.0135 tests per monthly admissions (P = .02). The rate of type and screens orders per patient days each month had a significant downward trend by 0.114 before the intervention (P = .04) but no significant level change at the time of the intervention or significant change in rate after the intervention. Discussion Our study suggests that nonintrusive CDSS should be evaluated for individual laboratory tests to ensure only effective alerts continue to be used so as to avoid increasing EHR fatigue.

Frontline clinicians are often faced with the task of rapidly sifting through a high volume of information from a variety of electronic sources. Managing this information deluge can be overwhelming, yet paramount to the delivery of highvalue healthcare. Thus, today’s clinicians must become the ‘e-Doctors’, who can best leverage mobile technology to overcome the informational challenges at point-of-care. In this review, we provide a framework for clinicians to manage electronic information, and go through a day in the life of an e-Doctor to understand how clinicians may use mobile health apps to accomplish different tasks and enhance the care and learning.

In-hospital continuous electrocardiographic monitoring, commonly referred to as telemetry, has allowed for rapid recognition of life-threatening conditions, including complex arrhythmias and myocardial ischemia. However, inappropriate use can lead to unnecessary downstream testing from "false alarms," which in turn affects clinician efficiency and increases health care costs without benefiting patients. For these reasons, the Society of Hospital Medicine's Choosing Wisely campaign recommended use of a protocol-driven discontinuation of telemetry. The American Heart Association (AHA) developed a set of Practice Standards for the appropriate use of telemetry monitoring in 2004, which they updated in 2017. Unfortunately, the AHA Practice Standards have not been widely adopted-with as many as 43% of monitored patients lacking a recommended indication for monitoring. Thus, we created an overview discussing the safety and efficacy of incorporating the AHA Practice Standards and a review of studies highlighting their successful incorporation within patient care workflow. We conclude by outlining an "implementation blueprint" for health system professionals and administrators seeking to change their institution's culture of telemetry use. As the health care landscape continues to shift, enacting high-value initiatives that improve patient safety and efficiency of care will be critical.

Gliomas are primary brain tumors with a complex biology characterized by antigenic and genomic heterogeneity and a propensity for invasion into normal brain tissue. High grade glioma cells possess a voltage-independent, amiloride-inhibitable, inward Na+ current. This current does not exist in normal astrocytes or low grade tumor cells. Inhibition of this conductance decreases glioma growth and cell migration making it a potential therapeutic target. Our previous results have shown that the acid-sensing ion channels (ASICs), members of the epithelial Na+ channel (ENaC)/degenerin (DEG) family of ion channels are part of this current pathway. We hypothesized that one member of the ENaC/DEG family, ASIC2, is retained intracellularly and that it is the lack of functional expression of ASIC2 at the cell surface that results in hyperactivity of this conductance in high grade gliomas. In this study we show that the chemical chaperone, glycerol, and the transcriptional regulator, sodium 4-phenylbutyrate, inhibit the constitutively activated inward current and reduce cell growth and migration in glioblastoma multiforme. The results suggest that these compounds induce the movement of ASIC2 to the plasma membrane, and once there, the basally active inward current characteristic of glioma cells is abolished by inherent negative regulatory mechanisms. This in turn compromises the ability of the glioma cell to migrate and proliferate. These results support the hypothesis that the conductance pathway in high grade glioma cells is comprised of ENaC/DEG subunits and that abolishing this channel activity promotes a reversion of a high grade glioma cell to a phenotype resembling that of normal astrocytes.

Routine daily laboratory testing of hospitalized patients reflects a wasteful clinical practice that threatens the value of health care. Choosing Wisely initiatives from numerous professional societies have identified repetitive laboratory testing in the face of clinical stability as low value care. Although laboratory expenditure often represents less than 5% of most hospital budgets, the impact is far-reaching given that laboratory tests influence nearly 60% to 70% of all medical decisions. Excessive phlebotomy can lead to hospital-acquired anemia, increased costs, and unnecessary downstream testing and procedures. Efforts to reduce the frequency of laboratory orders can improve patient satisfaction and reduce cost without negatively affecting patient outcomes. To date, numerous interventions have been deployed across multiple institutions without a standardized approach. Health care professionals and administrative leaders should carefully strategize and optimize efforts to reduce daily laboratory testing. This review presents an evidence-based implementation blueprint to guide teams aimed at improving appropriate routine laboratory testing among hospitalized patients.

Background Ensuring appropriate C. diff nucleic acid amplification testing is increasingly important. We implemented electronic medical record (EMR) hard stop alerts across our health-system to reduce inappropriate tests. We review the impact on testing rates and outcome of those where testing was not pursed. Methods C. diff order in a patient with previous test (14 or 7 days for positive or negative), or receipt of laxative in past 48 hours triggered an EMR alert; test could only proceed with micro lab approved test code. The initiative was rolled out at an academic (October 2016) and two community hospitals (December 2016, January 2017). Statistical control charts (SPC) tracked changes in number of tests over time. Wilcoxon rank-sum tests were used to examine pre-post changes. Forward stepwise logistic regression models was used to explore factors associated pursuit of testing post EMR alert. Clinical outcomes of patients at the academic hospital whose testing attempt triggered an alert and testing was not pursued were reviewed. Results For the 3 hospitals, mean weekly C. diff testing rate pre and post-intervention was 146 (SD 12.5) and 119 (SD 12.9), P

We examined the effect of the trace element selenium on human glioma cell lines: T98G, U373MG, and U87MG, in addition to dermal fibroblast cells. Cultures were incubated with sodium selenite, and the following parameters were studied: cell growth, mitochondrial function, and ultrastructure. Cell growth was assayed by counting the number of viable cells after treatment with selenium. Mitochondrial function was analyzed using the MTT (tetrazolium salt reduction) assay. Apoptosis was determined by evaluating nuclear chromatin condensation by electron microscopy. The results indicated that selenium had a significant inhibitory effect on the growth of the tumor cells but had little effect upon dermal fibroblasts which had been passaged numerous times. Selenium also induced mitochondrial damage as shown by MTT assay in two brain tumor cell lines and in minimally passaged fibroblasts, but it had little effect upon the high-passage fibroblasts. Ultrastructurally, mitochondria had electron-dense inclusions resulting from selenium treatment. High rates of apoptosis were induced by selenium in the tumor cell lines and in the minimally passaged fibroblasts, whereas the fibroblasts with a high number of passages had some resistance to selenium treatment. This study correlates the adverse effects of selenium on mitochondrial function, inhibition of cell growth, and apoptosis and shows that selenium similarly affects three different brain tumor cell lines and minimally passaged fibroblasts. Further, the results with fibroblasts show that some types of cells after repeated passages can develop resistance to selenium damage.

Perioperative cardiac events can be a major consequence of surgery. The American College of Cardiology Foundation/American Heart Association has set out guidelines to aid physicians in identifying patients at the highest risk for these events. The guidelines do recommend for some patients to undergo non-invasive cardiac stress testing for further risk stratification, but their sensitivity and specificity for predicting cardiac events is not optimal. With more data emerging of the superior performance of computed coronary tomography angiography (CCTA) compared to non-invasive stress testing, CCTA could be more useful in risk stratification for these patients.

A 67-year-old man presented to the emergency department with chronic weakness, fatigue and failure to thrive. On physical examination, he was found to have multifocal exophytic cutaneous masses in the pubic and scrotal regions. We obtained a shave biopsy, and subsequent histopathology demonstrated non-native tissue consistent with metastasis from a primary adenocarcinoma. We report this novel case of anogenital cutaneous metastases of colorectal adenocarcinoma.

Human innate immunity to non-pathogenic species of African trypanosomes is provided by human high density lipoprotein (HDL) particles. Here we show that native human HDLs containing haptoglobin-related protein (Hpr), apolipoprotein L-I (apoL-I) and apolipoprotein A-I (apoA-I) are the principle antimicrobial molecules providing protection from trypanosome infection. Other HDL subclasses containing either apoA-I and apoL-I or apoA-I and Hpr have reduced trypanolytic activity, whereas HDL subclasses lacking apoL-I and Hpr are non-toxic to trypanosomes. Highly purified, lipid-free Hpr and apoL-I were both toxic to Trypanosoma brucei brucei but with specific activities at least 500-fold less than those of native HDLs, suggesting that association of these apolipoproteins within the HDL particle was necessary for optimal cytotoxicity. These studies show that HDLs can serve as platforms for the assembly of multiple synergistic proteins and that these assemblies may play a critical role in the evolution of primate-specific innate immunity to trypanosome infection.