Clinical Assistant Professor, Medicine
View details for Web of Science ID 000439063900020
Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.
View details for DOI 10.1016/j.mcna.2017.12.006
View details for PubMedID 29650066
Laboratory costs of thrombophilia testing exceed an estimated $650 million (in US dollars) annually. Quantifying the prevalence and financial impact of potentially inappropriate testing in the inpatient hospital setting represents an integral component of the effort to reduce healthcare expenditures. We conducted a retrospective analysis of our electronic medical record to evaluate 2 years' worth of inpatient thrombophilia testing measured against preformulated appropriateness criteria. Cost data were obtained from the Centers for Medicare and Medicaid Services 2016 Clinical Laboratory Fee Schedule. Of the 1817 orders analyzed, 777 (42.7%) were potentially inappropriate, with an associated cost of $40,422. The tests most frequently inappropriately ordered were Factor V Leiden, prothrombin gene mutation, protein C and S activity levels, antithrombin activity levels, and the lupus anticoagulant. Potentially inappropriate thrombophilia testing is common and costly. These data demonstrate a need for institution-wide changes in order to reduce unnecessary expenditures and improve patient care.
View details for DOI 10.12788/jhm.2819
View details for PubMedID 28914278
Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).We successfully implemented a novel high value care curriculum that specifically targets intern physicians.
View details for DOI 10.1136/postgradmedj-2016-134617
View details for PubMedID 28663352
The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.
View details for DOI 10.1002/jhm.2590
View details for PubMedID 27079160
The USA Medical Licensing Examination Step 1 is a computerised multiple-choice examination that tests the basic biomedical sciences. It is administered after the second year in a traditional four-year MD programme. Most Step 1 scores fall between 140 and 260, with a mean (SD) of 227 (22). Step 1 scores are an important selection criterion for residency choice. Little is known about which study habits are associated with a higher score.To identify which self-reported study habits correlate with a higher Step 1 score.A survey regarding Step 1 study habits was sent to third year medical students at Tulane University School of Medicine every year between 2009 and 2011. The survey was sent approximately 3 months after the examination.256 out of 475 students (54%) responded. The mean (SD) Step 1 score was 229.5 (22.1). Students who estimated studying more than 8-11 h per day had higher scores (p<0.05), but there was no added benefit with additional study time. Those who reported studying <40 days achieved higher scores (p<0.05). Those who estimated completing >2000 practice questions also obtained higher scores (p<0.01). Students who reported studying in a group, spending the majority of study time on practice questions or taking >40 preparation days did not achieve higher scores.Certain self-reported study habits may correlate with a higher Step 1 score compared with others. Given the importance of achieving a high Step 1 score on residency choice, it is important to further identify which characteristics may lead to a higher score.
View details for DOI 10.1136/postgradmedj-2014-133081
View details for Web of Science ID 000355010900004
View details for PubMedID 25910497
In the setting of acute ischemic stroke (AIS), leukocytosis has been shown to be an indicator of inflammatory response. Although leukocytosis on admission has been shown to correlate with initial stroke severity in AIS patients, no work has been done to assess if there are differences in transient or persistent leukocytosis in patients without infection. The objective of this study is to determine the clinical significance of persistent versus transient leukocytosis during the early phase of AIS.Patients who presented with AIS to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review. Patients were included if they had leukocytosis on admission (defined as white blood cell count >11,000/μL based on laboratory reference range values). A logistic regression model was used to evaluate persistent leukocytosis (leukocytosis 48 hours after admission) as a predictor of several outcome measures, including good functional outcome (discharge modified Rankin Scale score of 0-2). Marginal effects were used to estimate the probability of poor functional outcome.Of the 438 patients screened, 49 had leukocytosis on admission and of those 24 (49%) had persistent leukocytosis. NIHSS score correlated significantly with persistence of leukocytosis (r = .306; P = .0044). More people with transient leukocytosis (leukocytosis lasting <48 hours) had a good functional outcome (44% versus 16%; P = .006). After adjusting for baseline NIHSS score, persistent leukocytosis was not a significant independent predictor of good functional outcome, but showed an association (OR, 2.5; 95% CI, .562-10.7; P = .2322). Persistent leukocytosis after adjusting for age and NIHSS score at admission is associated with a poor functional outcome, but it is not statistically significant (OR, 2.43; 95% CI, .59-9.87; P = .2151). After controlling for age and NIHSS score on admission, for patients with persistent leukocytosis, the probability of having poor functional outcome at discharge was increased by 16 percentage points.Persistent leukocytosis is associated with higher baseline NIHSS scores. Persistent leukocytosis is tightly linked with baseline stroke severity and is associated with poor patient outcomes. Our study found that patients with persistent leukocytosis are more likely to present with severe strokes and maintain a high NIHSS score at 24 hours after admission, unlike patients without leukocytosis or patients with transient leukocytosis. Furthermore, it appears that persistent leukocytosis outside the setting of an infection negatively impacts the short-term functional outcome of AIS patients. Identifying patients with persistent leukocytosis could help to prognosticate and target patients that may benefit from future anti-inflammatory interventions.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2014.02.004
View details for Web of Science ID 000341484400028
View details for PubMedID 24784010
To date, few studies have assessed the influence of infections present on admission (POA) compared with hospital-acquired infections (HAIs) on neurologic deterioration (ND) and other outcome measures in acute ischemic stroke (AIS).Patients admitted with AIS to our stroke center (July 2010 to December 2010) were retrospectively assessed. The following infections were assessed: urinary tract infection, pneumonia, and bacteremia. Additional chart review was performed to determine whether the infection was POA or HAI. We assessed the relationship between infections in ischemic stroke patients and several outcome measures including ND and poor functional outcome. A mediation analysis was performed to assess the indirect effects of HAI, ND, and poor functional outcome.Of the 334 patients included in this study, 77 had any type of infection (23 POA). After adjusting for age, National Institutes of Health Stroke Scale at baseline, glucose on admission, and intravenous tissue plasminogen activator, HAI remained a significant predictor of ND (odds ratio [OR]=8.8, 95% confidence interval [CI]: 4.2-18.7, P<.0001) and poor functional outcome (OR=41.7, 95% CI: 5.2-337.9, P=.005), whereas infections POA were no longer associated with ND or poor functional outcome. In an adjusted analysis, we found that 57% of the effect from HAI infections on poor functional outcome is because of mediation through ND (P<.0001).Our data suggests that HAI in AIS patients increases the odds of experiencing ND and subsequently increases the odds of being discharged with significant disability. This mediated effect suggests a preventable cause of ND that can thereby decrease the odds of poor functional outcomes after an AIS.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2013.07.020
View details for Web of Science ID 000327719000048
View details for PubMedID 23954599
Neurologic deterioration (ND) after acute ischemic stroke (AIS) has been shown to result in poor outcomes. ND is thought to arise from penumbral excitotoxic cell death caused in part by leukocytic infiltration. Elevated admission peripheral leukocyte levels are associated with poor outcomes in stroke patients who suffer ND, but little is known about the dynamic changes that occur in leukocyte counts around the time of ND. We sought to determine if peripheral leukocyte levels in the days surrounding ND are correlated with poor outcomes.Patients with AIS who presented to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review and screened for ND (defined as an increase in National Institutes of Health Stroke Scale score ≥ 2 within a 24-hour period). Patients were excluded for steroid use during hospitalization or in the month before admission and infection within the 48 hours before or after ND. Demographics, daily leukocyte counts, and poor functional outcome (modified Rankin Scale score 3-6) were investigated.Ninety-six of the 292 (33%) patients screened had ND. The mean age was 69.5 years; 62.5% were male and 65.6% were black. Patients with a poor functional outcome had significantly higher leukocyte and neutrophil levels 1 day before ND (P = .048 and P = .026, respectively), and on the day of ND (P = .013 and P = .007, respectively), compared to patients with good functional outcome.Leukocytosis at the time of ND correlates with poor functional outcomes and may represent a marker of greater cerebral damage through increased parenchymal inflammation.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.08.008
View details for Web of Science ID 000325874200018
View details for PubMedID 23031742
Neurologic deterioration (ND) after ischemic stroke has been shown to impact short-term functional outcome and is associated with in-hospital mortality.Patients with acute ischemic stroke who presented between July 2008 and December 2010 were identified and excluded for in-hospital stroke, presentation >48 hours since last seen normal, or unknown time of last seen normal. Clinical and laboratory data, National Institutes of Health Stroke Scale (NIHSS) scores, and episodes of ND (increase in NIHSS score ≥ 2 within a 24-hour period) were investigated.Of the 596 patients screened, 366 were included (median age 65 years; 42.1% female; 65.3% black). Of these, 35.0% experienced ND. Patients with ND were older (69 v 62 years; P < .0001), had more severe strokes (median admission NIHSS score 12 v 5; P < .0001), carotid artery stenosis (27.0% v 16.8%; P = .0275), and coronary artery disease (26.0% v 16.4%; P = .0282) compared to patients without ND. Patients with ND had higher serum glucose on admission than patients without ND (125.5 v 114 mg/dL; P = .0036). After adjusting for crude variables associated with ND, age >65 years, and baseline NIHSS score >14 remained significant independent predictors of ND. In a logistic regression analysis adjusting for age and serum glucose, each 1-point increase in admission NIHSS score was associated with a 7% increase in the odds of ND (odds ratio 1.07; 95% confidence interval 1.04-1.10; P < .0001).Older patients and patients with more severe strokes are more likely to experience ND. Initial stroke severity was the only significant, independent, and modifiable risk factor for ND, amenable to recanalization and reperfusion.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.11.006
View details for Web of Science ID 000325874200031
View details for PubMedID 23246190
Neurologic deterioration (ND) occurs in one-third of patients with stroke. However, the true incidence of ND and risk for adverse outcomes remains unknown because no standardized definition of ND exists. Our study compared the prognostic value of a range of definitions for ND in patients with acute ischemic stroke (AIS).All patients who presented to our center with AIS within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified. Patient demographics, National Institutes of Health Stroke Scale (NIHSS) scores, etiologies of ND, and outcome measures were compared between patients according to a range of ND definitions using receiver operating characteristic analyses.Three hundred forty-seven patients were included. The 2 definitions of ND with the highest sensitivity and specificity for several outcome measures were tested against each other: an increase in the NIHSS score by ≥2 or ≥4 points in a 24-hour period. More than one third (36.9%) of patients experienced ≥2-point ND versus 17.3% with ≥4-point ND. Patients who experienced ND by either definition had prolonged hospitalization (P < .001), poorer functional outcome (discharge modified Rankin Scale score >2; P < .001), and higher discharge NIHSS score (P < .001) compared to patients without ND. Compared to patients without ND, a ≥2-point ND was associated with a 3-fold risk of death (odds ratio 3.120; 95% confidence interval 1.231-7.905; P < .0165) after adjusting for admission NIHSS score, serum glucose, and age.A ≥2-point ND is a sensitive indicator of poor outcome and in-hospital mortality. An accepted definition of ND is needed to systematically study and compare results across trials for ND in patients with stroke.
View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.04.012
View details for Web of Science ID 000321550000014
View details for PubMedID 22727922