The day the residents left: lessons learnt from COVID-19 for ambulatory clinics

As the COVID-19 pandemic began, the residents from our ambulatory clinics were pulled to cover the increasing numbers of hospitalised patients. To provide care for our 40 000 patients, without resident support, we needed to develop quickly a new culture of communication and innovation. We accomplished this by regular, transparent meetings with senior leadership and key stakeholders who were empowered to make rapid decisions. We then convened regular meetings with clinic leadership and frontline providers to receive feedback and implement new practices. These rapid meeting cycles allowed for a nimble response to a changing landscape. We optimised our video-conferencing and telehealth services, reached out to our most vulnerable patients and engaged other providers and medical students who were not engaged in patient care due to social isolation practices. We discuss the implications of these innovations on our future practice.

Physicians Should Play a Role in Ensuring Safe Firearm Ownership

The USA is unique among industrialized nations in its dramatic rate of firearm violence. Unfortunately, firearm-related issues in America are politically divisive and fraught with controversy, thus impeding the study and implementation of safety strategies. Despite the lack of consensus, there is agreement that firearms should be kept away from individuals with criminal intent and those who are dangerous due to medical impairment. While predicting criminal intent remains challenging, assessment of medical impairment remains a viable target. One approach in which physicians could contribute their expertise includes training a subset of doctors to perform specialized medical evaluations as a prerequisite for gun ownership. Such a process is not unprecedented, as physicians currently have a role in protecting the public's safety through assessments for commercial drivers, pilots, and train operators. Certified physician examiners could conduct these evaluations with a focus on evaluating objective, skill-based metrics to limit potential evaluator bias. The results of the medical evaluation would then be considered by an existing regulatory body to determine if disqualifying criteria are present. This proposal provides a mechanism for trained physicians to meaningfully participate in addressing an alarming public health issue, while still working within existing legal frameworks.

Assessing Resident Palliative Care Education: Lessons Learned for Curriculum Mapping in Graduate Medical Education

This article was migrated. The article was marked as recommended. Charged with implementing a new curriculum within an established residency, we describe the application of curriculum mapping, a tool underutilized in GME. As proof of concept, we utilized curriculum mapping to identify existing palliative care didactic content and deficiencies within the Yale Internal Medicine Residency Programs for one academic year. Mapping included three steps: determining core educational venues, identifying and analyzing didactic content, and aligning content with published competencies. The curriculum map contained data for 5 of 9 educational venues, demonstrating gaps in Terminal Care & Bereavement, Spirituality, and Hospice Care. These gaps have informed the new palliative care curriculum. Although curriculum mapping has potential for application in GME, it is limited by available data.

Implementing the patient-centered medical home in residency education

BACKGROUND

In recent years, physician groups, government agencies and third party payers in the United States of America have promoted a Patient-centered Medical Home (PCMH) model that fosters a team-based approach to primary care. Advocates highlight the model's collaborative approach where physicians, mid-level providers, nurses and other health care personnel coordinate their efforts with an aim for high-quality, efficient care. Early studies show improvement in quality measures, reduction in emergency room visits and cost savings. However, implementing the PCMH presents particular challenges to physician training programs, including institutional commitment, infrastructure expenditures and faculty training.

DISCUSSION

Teaching programs must consider how the objectives of the PCMH model align with recent innovations in resident evaluation now required by the Accreditation Council of Graduate Medical Education (ACGME) in the US. This article addresses these challenges, assesses the preliminary success of a pilot project, and proposes a viable, realistic model for implementation at other institutions.

In vitrometabolism andin vivopharmacokinetics of quinoline 3-carboxamide derivatives in various species

The metabolism of a group of quinoline 3-carboxamide derivatives was evaluated in liver microsomes from various species. In addition, metabolism data were compared with in vivo pharmacokinetics in the mouse. The studied compounds were metabolized by cytochrome P450 enzymes. Microsomal clearance was low and seemed independent of a substituent in the quinoline moiety, whereas clearance was enhanced when an ethyl group replaced the methyl group at the carboxamide position. A similar metabolism with hydroxylated and dealkylated metabolites was found in the various species, with quantitative differences due to substituent. As predicted from the in vitro studies, in vivo pharmacokinetics showed low clearance and thus high exposure of the parent compounds in the mouse. The therapeutic effect seen in the acute EAE mouse model for these related compounds seems dependent on the high exposure of parent compound rather than formation of any potentially active metabolites.

A randomized, controlled trial of methotrexate versus placebo in early diffuse scleroderma

OBJECTIVE

Early diffuse scleroderma (systemic sclerosis; SSc) has no proven treatment. This study was undertaken to examine the efficacy of methotrexate (MTX) in improving the skin and other disease parameters in early diffuse SSc.

METHODS

Seventy-one patients with diffuse SSc of <3 years' duration were enrolled in a multicenter, randomized, placebo-controlled, double-blind trial. Thirty-five patients were treated with MTX and 36 with placebo. Treatment was administered for 12 months. The primary outcome measures were skin score (as determined with 2 different indices) and physician global assessment.

RESULTS

At baseline, there were no statistically significant differences in skin scores, carbon monoxide diffusing capacity (DLco), physician global assessment, or other secondary outcome measurements between the 2 treatment groups. At study completion, results slightly favored the MTX group (mean +/- SEM modified Rodnan skin score 21.4+/-2.8 in the MTX group versus 26.3+/-2.1 in the placebo group [P < 0.17]; UCLA skin score 8.8+/-1.2 in the MTX group versus 11.0+/-0.9 in the placebo group [P < 0.15]; DLco in the MTX group 75.7+/-4.6 versus 61.8+/-3.4 in the placebo group [P < 0.2]). In addition, physician global assessment results favored MTX (P < 0.035), whereas patient global assessment did not differ significantly between groups. When between-group differences for changes in scores from baseline to 12 months were examined using intent-to-treat methodology, MTX appeared to have a favorable effect on skin scores (modified Rodnan score -4.3 in the MTX group versus 1.8 in the placebo group [P < 0.009]; UCLA score -1.2 in the MTX group versus 1.2 in the placebo group [P < 0.02]), but differences in the degree of change in the DLco and physician global assessment were not significant. For the UCLA skin score, these differences in results were not statistically significant after adjustment for baseline differences in sex distribution and steroid use. Dropout rates were similar in the 2 groups.

CONCLUSION

Although results of this trial demonstrated a trend in favor of MTX versus placebo in the treatment of early diffuse SSc, the between-group differences were small and the power to rule out false-negative results was only 50%. Our findings do not provide evidence that MTX is significantly effective in the treatment of early diffuse SSc.

Oral iloprost treatment in patients with Raynaud's phenomenon secondary to systemic sclerosis: a multicenter, placebo-controlled, double-blind study

OBJECTIVE

To evaluate the efficacy and tolerability of an oral preparation of iloprost, a prostacyclin analog, in patients with Raynaud's phenomenon (RP) secondary to systemic sclerosis (scleroderma).

METHODS

A multicenter, randomized, parallel-group, placebo-controlled double-blind study was performed at university and community-based medical centers. Patients were randomly assigned to receive either 50 microg of iloprost orally twice daily or an identical gelatin-coated capsule containing placebo for 6 weeks. Outcome measures included average total daily duration of RP attacks, average number of RP attacks, and RP condition scored via a standardized daily diary.

RESULTS

Three hundred eight patients with scleroderma (272 women, 36 men, mean age 49 years [range 18-80]) were enrolled. One hundred fifty seven were assigned to receive iloprost and 151 to receive placebo. One hundred forty-three patients in the iloprost group (91.1%) and 144 in the placebo group (95.4%) completed the 6-week treatment phase. Fifteen of these treated patients (8 iloprost, 7 placebo) failed to complete all of the followup visits. The mean reduction in the average duration of attacks from baseline to week 5-6 was 24.32 minutes in the iloprost group and 34.34 minutes in the placebo group (P = 0.569). Likewise, the mean reduction from baseline to week 5-6 in the daily frequency of attacks was 1.02 in the iloprost group and 0.83 in the placebo group (P = 0.459). The Raynaud's condition score, a patient-completed assessment of the severity of RP attacks, was reduced by 1.32 in the iloprost group and 1.00 in the placebo group (P = 0.323). The lack of significant difference between treatment groups did not change when a variety of factors, including use of other vasodilators, duration of disease, classification of scleroderma (limited versus diffuse), or number of baseline digital ulcers were taken into account. Premature withdrawal from the study due to adverse events occurred in 10 patients (6.4%) in the iloprost group and 3 (2.0%) in the placebo group (P = 0.058).

CONCLUSION

Oral iloprost at a dosage of 50 microg twice daily is no better than placebo for management of RP secondary to scleroderma, either during 6 weeks of treatment or during 6 weeks of posttreatment followup.

Chromosome aberrations and pharmacokinetics in patients receiving tauromustine as either a single or a repeated dose

Tauromustine (TCNU) is an exploratory drug that has demonstrated activity in various solid tumors. We examined chromosome aberrations and plasma levels of the drug in two groups of patients receiving either a single dose of 130 mg/m2 or 40 mg/m2 on 3 consecutive days. Peak plasma concentrations (mean +/- SD) were obtained at a similar time after both treatments, i.e., at 38 +/- 25, 32 +/- 24, 28 +/- 14, and 40 +/- 26 min after administration of 130 mg/m2 on day 1 and after that of 40 mg/m2 on days 1, 2, and 3, respectively. In addition, the cumulative area under the curve (AUC value) determined after administration of 40 mg/m2 x 3 was similar to that noted after treatment with a single dose of 130 mg/m2, i.e., 180 and 179 micrograms min ml-1, respectively. Both treatments induced chromosome aberrations (CAs) in peripheral blood lymphocytes. A dose-dependent increase in the number of CAs was found, with 40 mg/m2 producing 5.5% CAs and 130 mg/m2 yielding 20.9% CAs at 24 h after treatment. In addition, although the drug concentration declined to a level under the detection limit between the daily treatments, drug-induced chromosome damage was cumulative, with the 90-min values increasing from 4.8% on day 1 to 14.3% CAs on day 3. In individual patients, no correlation was found between CAs and kinetic parameters; however, the total mean CA yield was in agreement with the total drug exposure (CAs, 14.3% and 14.6%, AUC 180 +/- 62.8 and 179 +/- 115 micrograms min ml-1, respectively.

The increase in death and disease under "katstroika"

The author describes recent trends in mortality and morbidity in the successor states to the former Soviet Union. Separate consideration is given to mortality under late perestroika (1987-1991) and subsequent mortality trends. The author concludes that "the collapse of the USSR and the problems of the successor states have had severe adverse affects not only on macroeconomic indices but also on the mortality and morbidity of the population.... Since the collapse of the USSR, the mortality situation in the successor states has rapidly and significantly worsened. Between 1991 and 1993 the crude death rate in Russia rose by 26%. As a result, by 1993 the life expectancy at birth of Russian men had fallen to about 59, which is about 6 years below the level of 1987.... By 1993, male life expectancy at birth in Russia had fallen below the level of the medium income countries and had probably fallen to a level about that of Indonesia in the second half of the 1980s. Ukraine has also experienced an increase in mortality since the collapse of the USSR. In other successor states, experiencing serious military conflicts, such as Tadjikstan and Armenia, the proportionate increase in mortality was even larger than in Russia."

Intravenous iloprost infusion in patients with Raynaud phenomenon secondary to systemic sclerosis. A multicenter, placebo-controlled, double-blind study

OBJECTIVE

To evaluate the efficacy and safety of iloprost, a prostacyclin analog, administered intravenously in patients with Raynaud phenomenon secondary to systemic sclerosis.

DESIGN

Multicenter, randomized, parallel placebo-controlled, double-blind study.

SETTING

University medical centers.

PATIENTS

131 patients with systemic sclerosis (101 women, 30 men) ages 20 to 79 years.

INTERVENTION

Patients were randomly assigned to receive one of two parallel treatments of five daily sequential, 6-hour intravenous infusions of iloprost (0.5 to 2.0 ng/kg per min) or to receive a similar volume of placebo.

MEASUREMENTS

Frequency of Raynaud attacks, Raynaud severity score, physician's overall rating of treatment effect, and digital cutaneous lesion healing.

RESULTS

Of the 131 patients enrolled, 126 completed the 5-day infusion and 114 (87%) completed at least 6 weeks of follow-up. Sixty-four patients were randomly assigned to receive iloprost and 67 patients, to receive placebo. The mean weekly number of Raynaud attacks decreased 39.1% with iloprost and 22.2% with placebo (P = 0.005). In addition, the mean percentage of improvement in a global Raynaud severity score during the entire 9-week follow-up was greater in patients given iloprost (34.8%) than in those receiving placebo (19.7%) (P = 0.011). The physician's overall rating of treatment effect showed greater improvement with iloprost than with placebo at week 6 (52.4% compared with 27.4%; P = 0.008) and week 9 (60.9% compared with 26.9%; P < 0.001). At week 3, 14.6% more patients receiving iloprost had 50% or more lesions heal compared with those given placebo (95% CI, 0.9% to 30%). During the infusion, 59 (92%) of the patients receiving iloprost had one or more side effects compared with 38 (57%) of the patients receiving placebo.

CONCLUSION

Iloprost is effective for the short-term palliation of severe Raynaud phenomenon in patients with systemic sclerosis.

Accumulation of estramustine and estromustine in adipose tissue of rats and humans

The tissue distribution of estramustine and estromustine, two cytotoxic lipophilic metabolites of estramustine phosphate (Estracyt, EMP) was studied in rats and humans. A single dose of [3H]-estramustine was given i.v. to groups of rats. At 24 h after administration, the concentration of radioactivity in fat was about 20, 12, and 2 times that in muscle, plasma, and liver, respectively. Liquid chromatography verified that the radioactivity represented estramustine and estromustine. The clinical relevance of these results was investigated in pancreas cancer patients treated with a single oral dose of Estracyt at 12-16 h before surgery. As judged by gas chromatography, the concentration of estromustine, which is the main metabolite in man, was about 13 times higher in fat than in plasma and was also higher in adipose tissue than in muscle and liver. After 5 days of Estracyt treatment, the adipose uptake of estromustine was even higher, namely, about 40 times that in plasma and 8 times that in muscle and liver. Thus, our results demonstrate that estramustine and estromustine are stored in adipose tissue after the administration of EMP; this is important for the pharmacokinetics and, consequently for the therapeutic effects of Estracyt.

Pharmacokinetics of tauromustine in cancer patients. Phase I studies

The pharmacokinetic properties of tauromustine (TCNU) were studied in 31 cancer patients who participated in phase I trials. The patients received single oral doses of tauromustine in the range of 20-170 mg/m2. Plasma samples were taken over 24 h after administration and analysed for tauromustine by reversed-phase liquid chromatography. Parent TCNU could be demonstrated in the plasma of all patients. Its absorption was rapid (tmax = 38 +/- 22 min), the half-life was 57 +/- 22 min (mean +/- SD), and maximal concentration (Cmax) and AUC values were linearly related to the dose level. Thus, our study does not indicate dose-dependent pharmacokinetics for the drug in the range of 20-170 mg/m2. Thrombocytopenia was the dose-limiting toxicity of TCNU; the reduction of platelet counts appeared to be linearly related to the log dose and Cmax and AUC values. TCNU appears to exhibit pharmacokinetic properties that are different from those of other nitrosoureas, which might be important for the clinical effect of the drug.

Localization of the simian virus 40 small t antigen in the nucleus and cytoplasm of monkey and mouse cells

Monkey and mouse cells producing simian virus 40 small t antigen in the absence of clearly detectable intact or truncated large T antigens were subjected to indirect immunofluorescence and biochemical cell compartment analyses. Results revealed specific immunofluorescence and small t polypeptide in both the nucleus and cytoplasm of these cells.

Role of small t antigen in the acute transforming activity of SV40

A plasmid, pHR402, containing SV40 sequences that include a truncated early region bearing an intact t-coding sequence and a functionally intact late region, was introduced into thymidine kinase deficient (tk-) mouse L cells by cotransformation with a cloned tk gene. tk+ cotransformants synthesized SV40 t but not T antigen, and no truncated T-coding sequence products were detected. The viral sequences of pHR402 were reconstituted as a virus in COS1 cells, and acute infection of untransformed mouse cells with this viral stock (SV402) also led to the appearance of t but not T or a truncated T. Abortive transformation assays of such infected cells were negative, as were those performed on the same cells infected with either of two viral mutants (dl883 and dl884), each of which leads to T but not t synthesis. However, mixed infection with SV402 and either dl883 or dl884 led to a clear abortive and permanent transformation response. Thus, at least in part, t and T appear to function in a complementary fashion in eliciting transformation expression by SV40-infected cells.

Metabolism of lofepramine by rat liver microsomes

1. The metabolism of lofepramine in vitro by rat liver microsomes was studied. The enzyme system involved was dependent on cytochrome P-450 and the main metabolites were desmethylimipramine (DMI), formaldehyde and p-chlorobenzoic acid. 2. Microsomes from rats pretreated with phenobarbital or 3-methylcholanthrene showed enhanced lofepramine metabolizing activity. The induction was reflected in increased Vmax values, whereas Km values were not changed. 3. Pretreatment of rats with lofepramine or DMI did not alter the rate of aniline hydroxylation, aminopyrine demethylation or lofepramine metabolism per mg microsomal protein. Nor was the amount of cytochrome P-450 changed. 4. Lofepramine, imipramine and DMI inhibited competitively the microsomal hydroxylation of aniline in vitro. Lofepramine was the most potent inhibitor, which probably reflects the higher lipophilicity of this compound.

Antitumour activity, toxicity and disposition of LS 1727, a nitroso-chloroethyl carbamate of 19-nortestosterone, in rats and mice

LS 1727, a nitroso-chloroethyl carbamate of 19-nortestosterone, given intraperitoneally had a high cytostatic activity against some experimental tumours. In vitro studies showed that the tested tumours differed in their ability to hydrolyze LS 1727. The hydrolytic capacity was related to the sensitivity to treatment with LS 1727. Distribution studies with double-labelled LS 1727 demonstrated that the chloroethyl-part of the molecule was retained in dimethylbenz(a)anthracene-induced mammary tumours in the rat. Our findings suggest that the antitumour activity of LS 1727 is exerted by alkylating metabolites released at hydrolysis of the compound. LS 1727 had no oral antitumour activity probably due to pre-systemic hydrolysis. When given intravenously, hydrolysis of LS 1727 in lungs caused severe pulmonary toxicity already at low doses.