Search

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major cause of morbidity and mortality of particular relevance for intensivists and hospitalists. Acute VTE is usually managed with parenteral unfractionated heparin or low-molecular-weight heparin, followed by an oral vitamin K antagonist. Data are lacking for optimal treatment of less common occurrences, such as upper extremity DVT, and for approaches such as thrombolysis for PE associated with early signs of hemodynamic compromise or inferior vena cava filters when anticoagulation is contraindicated. Direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are now added to the armamentarium of agents available for acute management of VTE and/or reducing the risk of recurrence. This review outlines an algorithmic approach to acute VTE treatment: from aggressive therapies when anticoagulation may be inadequate, to alternative choices when anticoagulation is contraindicated, to anticoagulant options in the majority of patients in whom anticoagulation is appropriate. Evidence-based guidelines and the most recent DOAC clinical trial data are discussed in the context of the standard of care. Situations and treatment approaches for which data are unavailable or insufficient are identified. VTE therapy in care transitions is discussed, as are choices for secondary prevention.

Many hospitalists incorporate point-of-care ultrasound (POCUS) into their daily practice to answer specific diagnostic questions or to guide performance of invasive bedside procedures. However, standards for hospitalists in POCUS training and assessment are not yet established. Most internal medicine residency training programs, the major pipeline for incoming hospitalists, have only recently begun to incorporate POCUS in their curricula. The purpose of this document is to inform a broad audience on what POCUS is and how hospitalists are using it. This document is intended to provide guidance for the hospitalists who use POCUS and administrators who oversee its use. We discuss POCUS 1) applications, 2) training, 3) assessments, and 4) program management. Practicing hospitalists must continue to collaborate with their local credentialing bodies to outline requirements for POCUS use. Hospitalists should be integrally involved in decision-making processes surrounding POCUS program management.

Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.

Women comprise more than one third of the active physician workforce, an estimated 46% of all physicians-in-training, and more than half of all medical students in the United States. Although progress has been made toward gender diversity in the physician workforce, disparities in compensation exist and inequities have contributed to a disproportionately low number of female physicians achieving academic advancement and serving in leadership positions. Women in medicine face other challenges, including a lack of mentors, discrimination, gender bias, cultural environment of the workplace, imposter syndrome, and the need for better work-life integration. In this position paper, the American College of Physicians summarizes the unique challenges female physicians face over the course of their careers and provides recommendations to improve gender equity and ensure that the full potential of female physicians is realized.

Social determinants of health are nonmedical factors that can affect a person's overall health and health outcomes. Where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy. In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.

Introduction Patients experience numerous transitions, including changes in clinical status, pharmacologic treatment and prophylaxis, and progression through the physical locations of their healthcare setting as they advance through a venous thromboembolism (VTE) clinical experience. This review provides an overview of these transitions and highlights how they can impact clinical care. Methods Major public resources (PubMed, MEDLINE, and Google Scholar) were searched using various combinations of the terms: “venous thromboembolism”, “deep vein thromboses”, “pulmonary embolism”, “transitions in care”, and “hospital protocols” to identify narrative reviews, professional guidelines, or primary manuscripts reporting protocol development strategies and/or clinical data, published in English from 2010 through January 2015. The studies included in this review were selected on the basis of extensive reading of the literature and the author’s clinical expertise. Results VTE treatment and prophylaxis is a dynamic process requiring ongoing patient assessments and adjustments to therapeutic strategies as the patient progresses through various hospital and outpatient settings. Throughout these transitions in care, physicians need to be vigilant of any changes in the patient’s clinical condition which may impact the patient’s risk of VTE, and re-evaluate the intervention(s) employed when such changes occur. A standardized, interdisciplinary VTE clinical pathway developed for medical patients with acute VTE resulted in decreased utilization of hospital resources and healthcare costs, suggesting that further research is warranted in this area. Conclusion The prevention and management of VTE can be optimized by the development and local implementation of standardized evidence-based clinical pathways. Electronic supplementary material The online version of this article (doi:10.1007/s12325-015-0271-8) contains supplementary material, which is available to authorized users.

Objective A number of older adults obtain normal scores on formal cognitive tests, but present clinical concerns that raise suspicion of cognitive decline. Despite not meeting full criteria for Mild Cognitive Impairment (MCI), these PreMCI states confer risk for progression to Alzheimer's disease (AD). This investigation addressed a pressing need to identify cognitive measures that are sensitive to PreMCI and are associated with brain biomarkers of neurodegeneration. Method Participants included 49 older adults with a clinical history suggestive of cognitive decline but normal scores on an array of neuropsychological measures, thus not meeting formal criteria for MCI. The performance of these PreMCI participants were compared to 117 cognitively normal (CN) elders on the LASSI-L, a cognitive stress test that uniquely assesses the failure to recover from proactive semantic interference effects (frPSI). Finally, a subset of these individuals had volumetric analyses based on MRI scans. Results PreMCI participants evidenced greater LASSI- L deficits, particularly with regards to frPSI and delayed recall, relative to the CN group. No differences on MRI measures were observed. Controlling for false discovery rate (FDR), frPSI was uniquely related to increased dilatation of the inferior lateral ventricle and decreased MRI volumes in the hippocampus, precuneus, superior parietal region, and other AD prone areas. In contrast, other LASSI-L indices and standard memory tests were not related to volumetric findings. Conclusions Despite equivalent performance on traditional memory measures, the frPSI distinguished between PreMCI and CN elders and was associated with reductions in brain volume in numerous AD-relevant brain regions.

Background Residents perform invasive bedside procedures in most training programs. To date, there is no universal approach for determining competency and ensuring quality and safety of care. Objective We developed and implemented an assessment of central venous catheter insertion competency for internal medicine and internal medicine–pediatrics residents, using measurements for knowledge, skill, and attitude and linking them to procedural outcomes. Methods We conducted a cohort study of a 4-week, resident-run procedure service from July 2007 through June 2011 at a large academic medical center. Knowledge was assessed by using a written test, technical skill by using a checklist, and attitude by self- and supervisor assessments of residents' confidence and capability. Competence was defined as (1) a minimum written test score (70%); (2) a perfect checklist score; (3) a resident's self-assessed confidence and capability scores of 4 or 5 of 5; and (4) faculty rating of the resident's confidence and capability as 5 of 5. A composite success rate was based on procedural outcomes (eg, completed procedures, less than 3 forward needle passes, and complication rate) and was compared to the checklist scores. Results A total of 148 internal medicine and medicine–pediatrics residents inserted 639 catheters, and 53 (36%) achieved competence by the end of 4 weeks. Residents judged to be competent by checklist scores had a higher composite success rate than those deemed not competent. Conclusions Our multi-factorial criteria used to define central venous catheter insertion competency effectively discriminated between residents judged to be competent and those judged not competent, using data from procedural outcomes.

Focused ultrasound (US) is being incorporated across all levels of medical education. Although many comprehensive US courses exist, their scope is broad, requiring expert instructors, access to simulation, and extensive time commitment by the learner. We aim to compare learning across levels of training and specialties using a goal-directed, web-based course without live skills training.A prospective observational study of students and residents from medicine, surgery, and anesthesiology. Analysis compared pretests and posttests assessing 3 competencies. Individual mean score improvement (MSI) was compared by paired-sample t-tests and MSI among cohorts by analysis of variance, with significance set at p ≤ 0.05. McNemar test compared those who agreed or strongly agreed with survey items with those who did not before and after intervention.Jackson Memorial Hospital, Miami, FL residency training programs in Medicine, Surgery, and Anesthesiology.A total of 180 trainees participated. A significant MSI was noted in each of 3 competencies in all 3 cohorts. Students' (S) MSI was significantly higher than residents' (R) and interns' (I) in US "knobology" and window recognition [S = 2.28 ± 1.29/5 vs R = 1.63 ± 1.21/5 (p = 0.014); vs I = 1.59 ± 1.12/5 (p = 0.032)]; students' total score MSI was significantly higher than residents [7.60 ± 3.43/20 vs 5.78 ± 3.08/20 (p0.008)]. All cohorts reported improved comfort in using transthoracic US and improved ability to recognize indications for use. More than 81% of all participants reported improved confidence in performing transthoracic US; more than 91% reported interest in additional training; and more than 88% believed course length was appropriate.Learners across levels of medical training and specialties can benefit from a brief, goal-directed, web-based training with early incorporation producing maximal yield.

Objective: Determine the impact of three stepwise interventions on the rate of central catheter-associated bloodstream infections. Design: Quasi-experimental study. Setting: Three surgical intensive care units (general surgery, trauma, and neurosurgery) at a 1500-bed county teaching hospital in the Miami metro area. Patients: All consecutive central catheter-associated bloodstream infection cases as determined by the Infection Control Department. Interventions: Three interventions aimed at catheter maintenance were implemented at different times in the units: chlorhexidine “scrub-the-hub,” chlorhexidine daily baths, and daily nursing rounds aimed at assuring compliance with an intensive care unit goal-oriented checklist. Measurements and Main Results: The primary outcome was the monthly intensive care unit rate of central catheter-associated bloodstream infections (infections per 1000 central catheter days). Over 33 months of follow-up (July 2008 to March 2011), we found decreased rates in each of the three intensive care units evaluated during the interventions, especially after implementation of chlorhexidine daily baths. rates in unit A decreased from a rate of 8.6 to 0.5, unit B from 6.9 to 1.6, and unit C from 7.8 to 0.6. secondary bloodstream infection rates remained unchanged throughout the observation period in units A and B; however, unit C had a decrease in its rates over time. Conclusions: We report the progressive reduction of central catheter-associated bloodstream infection rates after the stepwise implementation of chlorhexidine “scrub-the-hub” and daily baths in surgical intensive care units, suggesting effectiveness of these interventions. (Crit Care Med 2012; 40: 1464–1469)

Prevention of venous thromboembolism (VTE) is often overlooked in clinical practice, despite being a frequent and serious complication of various medical conditions and surgical procedures. The need to reduce hospital-acquired VTE is becoming increasingly recognized in the United States, and various quality-improvement initiatives have been developed. Prevention of VTE through evidence-based, practice-informed pathways includes assessing the patient's risk of VTE and provision of VTE at different stages: at admission, during hospitalization, and after hospital discharge. A multidisciplinary approach, involving physicians working with pharmacists, nurses, and other staff, can ensure that VTE prevention is routinely addressed. Patients admitted to hospitals should undergo VTE risk assessment, and the appropriate dose, type, and duration of medication should be administered with regular monitoring for VTE events and bleeding complications. Venous thromboembolism risk assessment should continue throughout hospitalization with appropriate prophylaxis when necessary. Patients may need to continue anticoagulation into the outpatient setting to achieve adequate prophylaxis duration. Useful approaches to ensure successful transition of care include patient education and support, with the accurate and timely transfer of information from the hospital to the primary care physician. Various strategies and tools are available to help physicians establish good VTE practices at each stage, including risk assessment models, reminders, clinical decision support systems, educational programs, and online resources, such as those from the Society of Hospital Medicine. Effective use of these strategies by physicians, with the engagement and support of nurses and pharmacists, should help to improve current practices and to reduce the considerable burden of VTE.

Guidelines governing healthcare workers' (HCW) hand hygiene (HH) behavior are well established. Despite known hazards of healthcare-associated infection to both HCW and patients, hand hygiene compliance (HHC) rates remain dismally low. To evaluate a potential solution to this ongoing challenge, we used a simulated patient encounter in an actual hospital room to test the efficacy of individual HH triggers.One hundred fifty HCW (75 physicians and 75 nurses) participated in this study and were randomly assigned to one of five equal-size groups. Each participant performed a focused physical examination on a standardized patient and was expected to maintain HH before and after the examination. Using two rooms on a medical-surgical unit in a tertiary care teaching hospital, various cues were employed, and the impact on pre- and postexamination HHC was recorded. In the control group, the hand sanitizer dispenser was in its usual location (Baseline). In one group, the dispenser was relocated to direct line of sight (Line-of-Sight) on entering the room; in another, flashing lights were affixed to the dispenser in its usual location (BaselineFlicker); and in a third group, the dispenser was relocated to the line of sight, and flashing lights were attached (Line-of-SightFlicker). In the last group, a large warning sign (Warning Sign) was affixed to the door, informing the healthcare provider that the room was under electronic surveillance, and failure to perform HHC would trigger an alarm. Data were analyzed using a generalized linear model to perform a repeated measures logistic regression; P0.05 was considered statistically significant.In the control group (Baseline), pre- and postexamination HHC rates were 36.7% and 33.3%, respectively. All interventions improved HHC preintervention compared with baseline (Line-of-Sight=53.3%, BaselineFlicker=60%, Line-of-SightFlicker=66%, Warning Sign=93.3%), but only the Line-of-SightFlicker and the Warning Sign produced statistically significant increased pre-examination HHC (P=0.022 and P0.001, respectively). Only the Warning Sign produced statistically significant increased HHC postexamination (P0.001).Visual cues can improve HHC, but their efficacy varies. A warning sign informing of a surveillance system with subsequent reporting of noncompliance resulted in the most significant improvement in HHC. Using a standardized patient in an actual hospital room was a helpful tool in assessing the impact of various interventions designed to improve HHC and patient safety.

In this position paper, the American College of Physicians (ACP) examines the challenges women face in the U.S. health care system across their lifespans, including access to care; sex- and gender-specific health issues; variation in health outcomes compared with men; underrepresentation in research studies; and public policies that affect women, their families, and society. ACP puts forward several recommendations focused on policies that will improve the health outcomes of women and ensure a health care system that supports the needs of women and their families over the course of their lifespans.

Background Residency is a critical transition during which individuals acquire lifelong behaviors important for professionalism and optimal patient care. One behavior is proper hand hygiene (HH), yet poor compliance with accepted HH practices remains a critical issue in many settings. This study explored the factors affecting hand hygiene compliance (HHC) in a diverse group of interns at the beginning of graduate training. Methods During a required patient safety course, we observed HH behaviors using a standardized patient encounter. Interns were instructed to perform a focused exam in a simulated inpatient environment with HH products available and clearly visible. Participants were blinded to the HH component of the study. An auditory alert was triggered if participants failed to perform prepatient encounter HH. Compliance rates and the number of alerts were recorded. All encounters were videotaped. Results The HHC among the 169 participants was 37.9% pre-encounter and was higher among female interns than males, although this difference was not statistically significant (41.6% versus 31.5%, P = .176). International medical graduates had significantly lower HHC compared with US graduates (23.2% versus 45.1%, P = .006). Most initially noncompliant participants performed HH after 1 alert (87.6%). Discussion The initial low rate of HHC in our sample is comparable to other studies. Using direct video surveillance and auditory alarms, we improved our success rates for prepatient encounter HHC. Our study identified medical school origin as an important factor for HHC, and the significantly lower compliance for international medical graduates compared with US graduates has not been previously reported. These findings should be considered in designing interventions such as intern orientation and clinical education programs to improve HH behaviors.

The hospitalized medical patient in the US today has multiple risk factors for venous thromboembolism (VTE) and is therefore at a significant risk of developing this condition both during hospitalization and after discharge. The American College of Chest Physicians (ACCP) guidelines recommend pharmacologic prophylaxis unless there are contraindications. Low-molecular-weight heparins (LMWH) are the preferred class of drugs due to multiple advantages, including daily dosing and a decreased risk of heparin-induced thrombocytopenia, to name a few. Several emerging oral anticoagulants, including Factor Xa inhibitors and direct thrombin inhibitors, are currently being evaluated in Phase III clinical trials as prophylaxis against VTE in medically ill patients and may some day replace parenteral drugs. Mt Sinai J Med 75:449–453, 2008. © 2008 Mount Sinai School of Medicine

Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia and patients with AF have a higher risk for stroke than the general population. The prevalence of AF is increasing, which underscores the importance of understanding the therapeutic options available for stroke prevention in the primary care setting. This article examines evidence for the use of novel oral anticoagulant (OAC) therapy, including the direct thrombin inhibitor dabigatran and the activated factor X inhibitors rivaroxaban and apixaban for stroke prevention in patients with AF. Although warfarin therapy is the gold standard for prevention of stroke, its use is associated with significant challenges related to drug-drug and food-drug interactions. Warfarin use also requires frequent blood monitoring to maintain anticoagulation within a narrow therapeutic window. Overall, the novel OACs are as good as, or better than, warfarin therapy for stroke prevention in patients with AF, and they have a comparable or reduced risk of associated major bleeding. In addition, the novel OACs have fewer drug-drug and food-drug interactions and do not require continuous blood monitoring. Integration of the novel OACs into clinical practice offers patients with AF new treatment options, and as therapeutic use of the novel OACs increases, real-world experience will add to our understanding of the value of these agents.

Objective: This study assessed the impact of a blended, standardized curriculum for invasive bedside procedural training on medical knowledge and technical skills for Internal Medicine residents. Methods: The investigators developed a curriculum in procedural instruction and performance for Internal Medicine house staff, and implemented the program at a tertiary care academic medical center with a primary affiliation with a US medical school. The investigators chose procedures recommended for technical competence by the American Board of Internal Medicine: lumbar puncture, thoracentesis, paracentesis, central venous catheter insertion, and knee arthrocentesis. The program included: (1) assessment of baseline medical knowledge and technical proficiency on mannequins, (2) video instruction of procedure, (3) faculty-led discussion of critical concepts, (4) faculty demonstration of the procedure on mannequin, (5) individual practice on simulators, (6) post-intervention knowledge evaluation, and (7) post-intervention skills evaluation. The performance achieved during the initial skills evaluation on a mannequin was compared to the performance achieved on the first patient subsequent to the instructional portion. Results: All participants with complete data demonstrated a statistically significant pre-intervention to post-intervention improvement ( p5 0.05) in comprehensive medical knowledge and procedural skills. Conclusion: A blended, standardized curriculum in invasive bedside procedural instruction can significantly improve performance in participants’ medical knowledge and technical skills.

Traditionally, an apprenticeship model has been used for the instruction of invasive bedside procedures. Because this approach is subject to nonuniform application, a new model was established to determine the impact of a standardized curriculum on medical students' and residents' medical knowledge and technical skills.A procedural instruction curriculum for medical students and residents was developed, and a pilot program with the curriculum was incorporated into an internal medicine residency program. Five common procedures in osteopathic and allopathic internal medicine training programs were included: central venous catheterization, knee arthrocentesis, lumbar puncture, paracentesis, and thoracentesis. An initial assessment of participants' baseline knowledge and skills was obtained. Teaching methods included video instruction; discussion of key concepts; faculty-led, hands-on, simulation-based instruction; and individual deliberate practice. Postinstruction knowledge and skills were evaluated, respectively, through a written test and a quantified assessment (ie, checklist) using direct observation. Participants were asked to provide written feedback at the conclusion of each instructional module.A total of 60 participants, all in allopathic medicine, underwent the training component. Fifty-two participants were internal medicine residents (including 2 from an outside program); 4 were trainees in a combined internal medicine-pediatrics residency; and 4 were medical students (1 from an outside program). Participants demonstrated a statistically significant improvement (P.001) in medical knowledge, as evidenced by preinstruction vs postinstruction test scores. Comparison of initial baseline procedural checklist scores with postinstruction checklist scores, during participants' performance on the first live patient, also showed statistically significant improvement (P.001).A simulation-based, standardized curriculum in invasive bedside procedural instruction significantly improved the medical knowledge and technical skills of novice physicians.

Context and setting Because there is a lack of standardised methodology to teach invasive bedside procedures, the incidence of associated complications remains unacceptably high and variations in teaching may be a contributing factor. Successful interventions are needed to change these poor outcomes and improve patient safety. Therefore, the University of Miami-Jackson Memorial Hospital Center for Patient Safety (CPS) launched an innovative educational initiative. Specifically designed to fill the training gap, the programme provides a standardised curriculum for procedural instruction. Why the idea was necessary At academic medical centres throughout the USA, residents perform the majority of invasive bedside procedures. By contrast with the apparent flaws in the outdated and frequently unsafe ‘see one, do one, teach one’ model of training, standardised procedural training targets hands-on learning and direct observation as the keystones for building confidence and competence. What was done To capitalise on this educational opportunity, a uniform teaching method was created incorporating the six Accreditation Council for Graduate Medical Education core competencies: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism, and systems-based practice. We developed a simulation-based curriculum for those procedures recently listed by the American Board of Internal Medicine as necessitating technical competence (central venous catheter insertion, lumbar puncture, paracentesis, thoracentesis), tailored for residents who will be asked to deliver these critical aspects of patient care. Our initiative combines the established, efficacious use of simulators, practice with ultrasound and the utility of checklists in ensuring patient-safe practices. To date, we have trained anaesthesiology, emergency medicine, internal medicine, neurology and surgery residents and medical students. The four pillars of the procedural training include

To evaluate the safety, efficacy, and durability of bevacizumab for the treatment of subfoveal choroidal neovascularization (CNV) in patients with neovascular age-related macular degeneration (AMD).Open-label, single-center, uncontrolled clinical study.Age-related macular degeneration patients with subfoveal CNV (n = 18) and best-corrected visual acuity (VA) letter scores of 70 to 20 (approximate Snellen equivalent, 20/40-20/400).Patients were treated at baseline with an intravenous infusion of bevacizumab (5 mg/kg) followed by 1 or 2 additional doses given at 2-week intervals. Safety assessments were performed at all visits. Ophthalmologic evaluations included protocol VA measurements, ocular examinations, and optical coherence tomography (OCT) imaging at each visit. Retreatment with bevacizumab was performed if there was evidence of recurrent CNV.Assessments of safety and changes from baseline in VA scores and OCT measurements were performed through 24 weeks.No serious ocular or systemic adverse events were identified through 24 weeks. The only adverse event identified was a mild elevation of mean systolic and diastolic blood pressure measurements (+11 mmHg, P = 0.004; +8 mmHg, P0.001) evident by 3 weeks and easily controlled with antihypertensive medications. By 24 weeks, the systolic and diastolic mean blood pressures were at or below baseline measurements. Visual acuity in the study eyes improved within the first 2 weeks, and by 24 weeks, the mean VA letter score increased by 14 letters in the study eyes (P0.001), and the mean OCT central retinal thickness measurement decreased by 112 microm (P0.001). By 24 weeks, retreatment was needed for only 6 of the 18 study eyes, and after retreatment, the recurrent leakage was eliminated, with restoration of any lost VA.Systemic bevacizumab therapy for neovascular AMD was well tolerated and effective for all 18 patients through 24 weeks. By 6 months, most patients did not require any additional treatment beyond the initial 2 or 3 infusions. Despite these impressive results, it is unlikely that systemic bevacizumab will be studied in a large clinical trial because of the potential risks associated with systemic anti-VEGF therapy and the perception that intravitreal therapy is safer.

More than 190,000 sexual assaults involving persons aged 12 years or older occur annually in the United States. For these victims, a forensic examination is the first step in the process to justice. Assessment and treatment of victims, as well as the meticulous collection and documentation of evidence, are vital for a strong case. Providing timely services 24/7 by qualified professionals can be taxing on schedules and budgets. Using in-house resources to cross-train ED personnel, we developed a program that introduced novice forensic examiners to common clinical scenarios encountered in the treatment of victims and provided a framework for the evaluation and management of each case.Seventeen ED personnel attended statewide sexual assault nurse examination training and participated in four simulation scenarios and debriefings. Pre-tests and post-tests were administered, and a checklist was used to assess competence in performing examinations independently.The majority of participants achieved competence (≥85% on the checklist) with their first case and had statistically significant gains in knowledge between pre-test and post-test (pre-test mean score [±SE] of 69.1 ± 1.7 vs. post-test mean score of 84.4 ± 2.6, P.001). Course evaluations were favorable, with a mean score of 91.3%.Our results validated the use of simulation technology and in-house resources for cross-training in a sexual assault forensic examination program, together with a checklist to assess competence in performing examinations independently. Benefits of having a sexual assault forensic examination program in the emergency department are standardized and timely care for victims, as well as enhanced evidence collection and increased reporting and prosecution of crimes.

Purpose To evaluate the safety, efficacy, and durability of bevacizumab for the treatment of subfoveal choroidal neovascularization (CNV) in patients with neovascular age-related macular degeneration (AMD). Design Open-label, single-center, uncontrolled clinical study. Participants Age-related macular degeneration patients with subfoveal CNV (n = 18) and best-corrected visual acuity (VA) letter scores of 70 to 20 (approximate Snellen equivalent, 20/40–20/400). Methods Patients were treated at baseline with an intravenous infusion of bevacizumab (5 mg/kg) followed by 1 or 2 additional doses given at 2-week intervals. Safety assessments were performed at all visits. Ophthalmologic evaluations included protocol VA measurements, ocular examinations, and optical coherence tomography (OCT) imaging at each visit. Retreatment with bevacizumab was performed if there was evidence of recurrent CNV. Main Outcome Measures Assessments of safety and changes from baseline in VA scores and OCT measurements were performed through 24 weeks. Results No serious ocular or systemic adverse events were identified through 24 weeks. The only adverse event identified was a mild elevation of mean systolic and diastolic blood pressure measurements (+11 mmHg, P = 0.004; +8 mmHg, P P P Conclusions Systemic bevacizumab therapy for neovascular AMD was well tolerated and effective for all 18 patients through 24 weeks. By 6 months, most patients did not require any additional treatment beyond the initial 2 or 3 infusions. Despite these impressive results, it is unlikely that systemic bevacizumab will be studied in a large clinical trial because of the potential risks associated with systemic anti-VEGF therapy and the perception that intravitreal therapy is safer.