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The Ending the HIV Epidemic (EHE) Initiative targets a subset of United States (US) priority jurisdictions hardest hit by HIV. It remains unclear which emergency departments (EDs) are the most appropriate targets for EHE-related efforts. To explore this, we used the 2001–2019 National Emergency Department Inventories (NEDI)-USA as a framework to characterize all US EDs, focusing on those in priority jurisdictions and those affiliated with a teaching hospital. We then incorporate multivariable regression to explore the association between ED characteristics and location in an HIV priority jurisdiction. Further, to provide context on the communities these EDs serve, demographic and socioeconomic information and sexually transmitted infection case rate data were included. This reflected 2019 US Census Bureau data on age, race, ethnicity, and proportion uninsured and living in poverty along with 2001–2019 Centers for Disease Control and Prevention case rate data on chlamydia, gonorrhea, and syphilis. We found that EDs in priority jurisdictions (compared to EDs not in priority jurisdictions) more often served populations emphasized in HIV-related efforts (i.e., Black or African American or Hispanic or Latino populations), communities with higher proportions uninsured and living in poverty, and counties with higher rates of chlamydia, gonorrhea, and syphilis. Further, of the groups studied, EDs with teaching hospital affiliations had the highest visit volumes and had steady visit volume growth. In regression, ED annual visit volume was associated with an increased odds of an ED being located in a priority jurisdiction. Our results suggest that geographically targeted screening for HIV in a subset of US priority jurisdiction EDs with a teaching hospital affiliation could be an efficient means to reach vulnerable populations and reduce the burden of undiagnosed HIV in the US. [ABSTRACT FROM AUTHOR]

Big data promises to spark new discoveries but may also distort clinical research. Large datasets that permit numerous analyses could increase the number of spurious findings and threaten the reproducibility and validity of clinical research. The publication of unreproducible research is incentivized by a scientific culture that rewards novelty over rigor. Introducing preprint publication to clinical research could change the culture. The first clinical preprint platform, medRxiv, allows researchers to publish working papers in advance of peer-review to more easily share preliminary findings. Preprint publishing aims to be fast and frictionless, which fundamentally changes the incentive structure of academic publishing. Preprints offer a relatively weak reward (a preprint publication) for substantially less effort than peer-review publication. By reducing barriers to publication, preprints may help encourage scientists to publish null findings, which could mitigate publication bias. By enabling scientists to share preliminary work and publish evolving versions of manuscripts, preprints may also facilitate "workshopping" of ideas and detailed methodological review. This would better reflect the iterative nature of observational research than peer-reviewed publications, which immutably document the "final" results of a study. Preprint platforms are a timely innovation that may buffer the undesired effects of big data on clinical research. [ABSTRACT FROM AUTHOR]

Medical journal publishing has changed dramatically over the past decade. The shift from print to electronic distribution altered the industry's economic model. This was followed by open access mandates from funding organizations and the subsequent imposition of article processing charges on authors. The medical publishing industry is large and while there is variation across journals, it is overall highly profitable. As journals have moved to digital dissemination, advertising revenues decreased and publishers shifted some of the losses onto authors by way of article processing charges. The number of open access journals has increased substantially in recent years. The open access model presents an equity paradox; while it liberates scientific knowledge for the consumer, it presents barriers to those who produce research. This emerging "pay-to-publish" system offers advantages to authors who work in countries and at institutes with more resources. Finally, the medical publishing industry represents an unusual business model; the people who provide both the content and the external peer review receive no payment from the publisher, who generates revenue from the content. The very unusual economic model of this industry makes it vulnerable to disruptive change. The economic model of medical publishing is rapidly evolving and this will lead to disruption of the industry. These changes will accelerate dissemination of science and may lead to a shift away from lower-impact journals towards pre-print servers. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses key tenets of developing diagnostic acumen, including gathering and integrating data, applying iterative bayesian thinking, choosing the format of communication, and determining the urgency of diagnosis. [ABSTRACT FROM AUTHOR]

In advance of a safety campaign on 17 March 2017, Donald Redelmeier and Allan Detsky call on physicians and clinical colleagues to reduce the chances that patients will drive drunk. [ABSTRACT FROM AUTHOR]

The article discusses the importance of taxi service in the U.S. healthcare industry which highlights the business growth of multinational online taxi dispatch company Uber Technologies Inc. Uber has responded to the country's shortcomings of urban taxis and limousine services by introducing a rider-driver matching service. The restriction of driver licenses to vehicle drivers, the limited supply of cabs and taxicab monopolies are also mentioned.

This Viewpoint describes the Canadian experience and response to the larger second and third waves of COVID-19 infections. [ABSTRACT FROM AUTHOR]

PURPOSE We investigated whether erectile dysfunction, a marker for future cardiovascular disease, is associated with undiagnosed cardiometabolic risk factors among US men. Identifying the presence of these risk factors could lead to earlier initiation of treatment for primary prevention of cardiovascular disease. METHODS We analyzed cross-sectional data from men aged 20 years and older who participated in the National Health and Nutrition Examination Survey during 2001-2004. Erectile dysfunction was determined by a single, validated survey question. We used logistic regression analyses to investigate the relationship between erectile dysfunction and undiagnosed hypertension, hypercholesterolemia, and diabetes. RESULTS After multivariate adjustment, men with erectile dysfunction had more than double the odds of having undiagnosed diabetes (odds ratio = 2.20; 95% CI, 1.10-4.37), whereas no association was seen for undiagnosed hypertension or undiagnosed hypercholesterolemia. For the average man aged 40 to 59 years, the predicted probability of having undiagnosed diabetes increased from 1 in 50 in the absence of erectile dysfunction to 1 in 10 in the presence of erectile dysfunction. CONCLUSIONS Our results underscore the importance of erectile dysfunction as a marker of undiagnosed diabetes. Erectile dysfunction should be a trigger to initiate diabetes screening, particularly among middle-aged men. [ABSTRACT FROM AUTHOR]

The authors focus on the training of medical residents to make decisions on their own during night shifts. Topics discussed include changes in the model of graded autonomy caused by the 1984 death of patient Libby Zion in a New York emergency department, studies showing that resident-training methods involving shorter work hours and lesser autonomy did not help improve patient safety, and transitions that occur when physicians become independent practitioners.

About 5 years later, I told this story to another endocrinologist who wondered if the benign diagnosis of the initial nodule was correct. Bollinger et al. teach us that, like my story, it is very hard to predict what patients want to know when retrospective error is discovered; an interesting and important line of investigation. Compliance with Ethical Standards Conflict of Interest Dr. Detsky has no financial conflicts of interest, though as the patient in this story, he clearly has a personal one. [Extracted from the article]

Starting around 9 pm, we heard the following overhead announcement: "Doctor Leaf, Doctor Alex Leaf. When Dr. Leaf didn't call back after several hours, he was sent to the minor med desk with a chief complaint of "chronic abdominal pain", where Pam finally saw him around midnight. And then I hear myself say, "You are not bothering me, this is what I'm here for." Acknowledgments I thank Raphael Rush, MD (University of Toronto), and Pam Hartzband, MD (Harvard Medical School), for their comments on an earlier draft. [Extracted from the article]

Medical Education 2010: 44: 468–474 Objectives Selection criteria for applicants to the internal medicine programme at the University of Toronto have included the number and quality of scholarly items published. We sought to determine whether previous publishing record correlated with resident performance as measured by in-training evaluation reports (ITERs) and global impressions of clinical competency by site programme directors and senior educators (global impression). Methods Data on the total number, quality and type of items published, as well as the timing of publishing with regard to pre-MD training, were abstracted from the curricula vitae of individuals who applied for residency during 2001–2005. These were correlated with overall, Expert and Scholar role ITER scores, and with global impression, using Spearman rank correlation scores. Results We gathered publishing history data on 181 residents, for 162 of whom ITER data were available. Overall, 68.5% of residents had published, but only 14.9% had published during medical school. There was a weak correlation of borderline significance (ρ = 0.15, P = 0.055) between overall ITER score and number of items published. No such correlation was found with CanMEDS Medical Expert and Scholar role scores. Global impression classified 33.9% of residents as top-rated. More top-rated residents had published (76.7% versus 65.1%; P = 0.07), but the number of items published during medical school were similar between top-rated and non-top-rated residents (16.1% versus 12.3%; P = 0.46). Conclusions Our results do not support publishing record as a predictor of residents’ clinical performance. Surprisingly, the correlation between publishing record and Scholar role scores was also weak, possibly indicating an inability of the ITER to capture this competency. Further research is needed to identify predictors and measures of performance in scholarly activities. [ABSTRACT FROM AUTHOR]

The author discusses aspects of Physician leaders in medical industry who leads national medical organizations like the American Board of Internal Medicine and Royal College of Physicians and Surgeons of Canada. Topic discussed includes direct patient care, maintaining clinical skills and clinical environment.

Introduction: Morning report is a traditional core teaching session in most departments of internal medicine where learners present cases to a facilitator who uses the material to teach clinical reasoning. It instills fear in both learners and teachers because they may embarrassingly miss diagnostic possibilities including even the actual diagnosis.Aim: The two teaching tips described here enable the learner and the teacher to fall back on a routine approach to arriving at a differential diagnosis list.Description: The first tip describes how to elicit the ten "focal findings" in the case that best summarize the data used to derive a diagnosis list. The second tip describes a matrix of etiologies and systems that can be used to generate the diagnostic probabilities.Discussion: This approach is easy to teach and, where all else fails when coming up with a diagnosis, can be used to prompt the discussion of what is wrong with the patient. [ABSTRACT FROM AUTHOR]

This editorial offers an opinion on the relevance of cost-effectiveness analysis to clinicians and medical policy makers. The author asks if cost-effectiveness information is useful in actual decision making and if the information is used correctly. The article maintains that cost-effectiveness analysis requires allocation of a fixed budget across all competing programs and that is not possible in the field of health care.

This Viewpoint summarizes federal, provincial, and regional responses to the COVID-19 pandemic in Canada and explores reasons for differences in pandemic outcomes in Canada and the US. [ABSTRACT FROM AUTHOR]

Presents comments on how high cost of prescription drugs in the U.S. Percentage of Americans who have trouble paying for medication; Decision many make to get their prescriptions in Canada where drugs are cheaper; Reasons why the U.S. Food and Drug Administration is against the practice of drug reimportation; Inability of the FDA to assure the safety of imported drugs; How drug reimportation represents a substantial departure from the existing structure of the North American pharmaceutical market.

Part VII. Shows how to interpret the results and generalizability of a clinical decision analysis in the case of a patient with heart failure from an idiopathic dilated cardiomyopathy. Strategy as a source of clinically important gain for patients; Strength of evidence used in the analysis; Effect of uncertainty in the evidence.

Part VII. Discusses validity guides for clinical decision analysis. Fitness of decision model to the clinical problem; Comparison of clinical strategies; Consideration of all clinically relevant outcomes; Identification, selection and combination of the evidence into probabilities; Source of ratings of decision outcomes; Exploration of uncertainty arising from lack of valid evidence.

Presents a guide on how to perform nutritional status assessment on a patient. Rationale for nutritional assessment; Clinical scenario; Determination of weight loss; Dietary intake in relation to the patient's usual pattern; Presence of significant gastrointestinal symptoms; Patient's functional capacity or energy; Accuracy of nutritional assessment.

Examines the accuracy of magnetic resonance imaging (MRI) in a patient population clinically suspected of having multiple sclerosis (MS). Double-dose, contrast-enhanced computed tomography (CT); Comparing the diagnostic accuracy of MRI and CT; Visualizing lesions; Insufficiency of the predictive value of a negative MRI result.

Presents a study which focused on the evaluation and conduct of risk from patients with coronary artery disease. Purpose of the study; Methodology used to conduct the study; Findings of the study.

Assesses the economic attractiveness of clinical research. Measurement of the cost-effectiveness of seven selected randomized trials; Consideration of the cost of performing a trial and the benefits to the health status of a target population; Range of incremental cost-effectiveness.

Purpose: To review the methods used for preoperative cardiac risk stratification of patients having peripheral vascular surgery.Data Sources: Relevant studies published before August 1991 were identified using a MEDLINE search of the English-language literature, followed by a manual search of the references of all identified articles.Study Selection: All clinical studies evaluating methods used for preoperative cardiac risk stratification of patients having peripheral vascular surgery.Data Extraction: The key data extracted from each article included the inclusion and exclusion criteria of the study patients, the techniques used for testing and the corresponding definitions of positive test results, and the clinical outcomes of the tested patients. Data were analyzed using a Bayesian conceptual framework, and pretest probabilities were converted to post-test probabilities using calculation of likelihood ratios.Results: Patients with high scores on clinical cardiac risk indexes (Goldman index greater than 12 or Detsky index greater than 15), or more than three of the criteria identified by Eagle (age greater than 70 years, diabetes, angina, Q waves on electrocardiogram, or ventricular arrhythmias) are likely to be at higher risk for cardiac death and myocardial infarction after vascular surgery. Those with both low scores and none of Eagle's criteria may be at lower risk, but this result has not been reproduced by independent studies. Neither group of patients would benefit from further investigation for cardiac risk stratification. Patients with one or two of these criteria may be at intermediate risk and would benefit most from further testing for the purposes of risk stratification. Most of the published evidence shows that the absence of redistribution on dipyridamole-thallium scanning identifies a low risk for postoperative cardiac complications, whereas the presence of redistribution predicts a high risk. Preliminary reports suggest that preoperative monitoring for silent myocardial ischemia may also be useful in identifying a high-risk subset of patients.Conclusions: Patients identified clinically to be at either very low or high risk for cardiac complications after peripheral vascular surgery are unlikely to benefit from further risk stratification. Dipyridamole-thallium scanning is the test of choice for further evaluation of patients at intermediate clinical risk because studies have shown that it is sensitive enough to rule out a high-risk status for patients who do not have redistribution. [ABSTRACT FROM AUTHOR]

Cost-effectiveness analysis can be used to help set priorities for funding health care programs. For each intervention, the costs and clinical outcomes associated with that strategy must be compared with an alternate strategy for treating the same patients. If an intervention results in improved outcomes but also costs more, the incremental cost per incremental unit of clinical outcome should be calculated. The incremental cost-effectiveness ratios for various programs can be ranked to set funding priorities. By using this list, the person responsible for allocating resources can maximize the net health benefit for a target population derived from a fixed budget. Clinicians may not share this objective because, individually, they are appropriately concerned solely with the effectiveness of a specific intervention for their patients and are not concerned with the benefit derived from spending those resources on other patients in the target population. In addition, allocation may be driven by distributional and political objectives. Nevertheless, cost-effectiveness analysis demonstrates the consequences of allocation decisions. Because clinicians should participate in policy making, they must understand d the role of this technique in setting funding priorities. [ABSTRACT FROM AUTHOR]

Discusses design and statistical issues surrounding the use of meta-analysis in clinical research. Definition of meta-analysis; Main objective of meta-analysis for clinical research; Basis of studies chosen for meta-analysis; Assessment of study quality.

Presents a study that used a meta-analysis protocol to evaluate the results of controlled trials that measured the effectiveness of perioperative total parenteral nutrition. Description of parenteral feeding; Prevalence and consequences of malnutrition in surgical patients; Rate of developing iatrogenic complications secondary to total parenteral nutrition; Efficacy and effectiveness of perioperative parenteral nutrition in reducing the rate of iatrogenic complications from major surgery.

This Viewpoint highlights logistical and methodological challenges complicating the use of randomized clinical trials (RCTs) to evaluate medical procedures and proposes standards of evidence for adopting new procedures in the absence of RCT data, including use of observational surveillance data to confirm the procedures' effectiveness in real-world settings. [ABSTRACT FROM AUTHOR]

The article describes the case of an 86-year old woman with history of low back pain, rigors, anorexia, difficulty ambulating and urinary retention. Findings from the magnetic resonance imaging (MRI) of the patient's lumbar spine, blood cultures and radiographs of hands and feet are presented. The patient received treatment for inflammatory arthritis including intravenous piperacillin-tazobactam, oral prednisone and methylprednisolone injections. She demonstrated risk factors for gout.

Personalized medicine promises to represent a transformation in clinical care that will be ushered in by the unprecedented growth and development in the field of human genetics. Further examination of the scientific foundations of this new hope reveals a great number of challenges that lie ahead. While basic science research feverishly races to produce solutions, we continue to wait for the translation of deliverables. Products that have and will come to market may leave our clinical communities and systems exposed and unprepared. At each step, from basic science research to infrastructure development, a great deal of creativity and investment are required before the arsenal of more personalized tools can be assimilated into our current models of health care. This commentary seeks to share perspectives on the current status of personalized medicine from the vantage point of several potential investors, and integrate them into a common set of goals and understanding. We conclude that the stylized model of personalized medicine is more akin to a marketing tool than a literal prediction of the future. [ABSTRACT FROM AUTHOR]

Individuals who take on leadership positions in academic health science centers help facilitate the mission of those institutions. However, they are often chosen on the basis of success in the core activities in research, education and patient care rather than on the basis of demonstrated leadership and management skills. Indeed, most academic leaders in the past have "learned on the job." This commentary provides practical advice on how to be an effective leader on the basis of the author's experiences as a Division Head and Chief of Medicine. It covers six themes (vision, managerial style, knowledge, people skills, organizational orientation and personal development) and offers 21 specific suggestions, one for each year of the author's leadership. It is hoped that this experience-derived advice will help future leaders in academic medicine. [ABSTRACT FROM AUTHOR]

In this article the authors discuss health care reform efforts and efforts to establish universal health insurance coverage in the U.S. in 2009. They are critical of statistics which show that while the U.S. spends more than any other industrialized nation, the medical outcomes of its citizens are no better than that of the citizens in other countries. Also discussed are the health care reform plans of U.S. President Barack Obama and the impact a recession is having on U.S. health care workers.

In this article the author discusses pimping, which is the practice of having an attending physician ask a series of difficult medical questions to a medical student or medical resident. He is critical of the motives of some attending physicians who use pimping. Also discussed are methods which can be used by physicians and medical students to ensure that the pimping process is not one which is overly uncomfortable. INSET: Pimping Protection Procedures.

The article discusses four examples in which physicians have claimed ownership rights to performing certain tasks. The author explains that the ownership rights constitute professional monopolies. Examples include physician opposition to the expanded prescribing powers of pharmacists and competition between physician groups over which group should treat specific conditions. The causes of the conflicts and methods for solving the problem, such as government regulation, are addressed.

The article presents a comparison of Mount Sinai Hospital in New York City and Mount Sinai Hospital in Toronto, Ontario. The hospitals' history and traditions, patient and physician experiences, and future challenges are discussed. The daily schedule for physicians and involvement of medical students and residents is discussed. Physician billing in U.S. and Canadian hospitals is discussed. The author explains that both hospitals face similar challenges for the future.

The article discusses the import of prescription medicine into the U.S. from lower-income countries, comparing the benefits and risks of such a policy to the American consumer. India's rapidly increasing share in the global pharmaceutical market is noted by the authors. Topics include the rapid development of indigenous pharmaceutical industries in lower-income countries and manufacturing facilities outside the U.S. approved by the U.S. Food and Drug Administration (FDA). Also discussed are aggressive challenges to drug patents made by firms in India.

The article investigates research into medical conflicts-of-interest and the psychological nature of unintentionally succumbing to bias. A review of studies concerning the neuropsychology, behavioral economics, cognitive psychology, and clinical epidemiology associated with medical bias is presented. The practice of post hoc rationalization of biased actions in order to appear objective is analyzed. How individual judgments can be influenced by the first information encountered is examined. The effect disclosure has on conflict-of-interest perception and professional bias is assessed.

The article presents an overview of osteoporosis and stress fractures which are caused by it. A discussion of methods which can be used to predict bone fracture in osteoporosis and of methods, including the use of bisphosphonates, which can be used to prevent fractures in osteoporosis patients, is presented. A discussion of the role the measurement of bone mineral density plays in the diagnosis of osteoporosis is presented. The important role that exercise training and research play in the prevention of bone fracture in osteoporosis patients is discussed.

The author reflects on instant mobile communication and its impact on the quality of life. He suggests that the advantages of mobile instant communication (cellular telephones) in business, health care and personal life are obvious. He argues that the use of cellular telephones has led to observations that people in today's society have become invasive, impolite and disruptive, despite the fact that research has indicated that the use of cellular telephones increases efficiency in communication.

This article offers advice on how to run a successful academic medical practice plan. The first piece of advice is to pin down the objectives of the plan and get "buy in" from its members. Plans should be structured to reward success through financial incentives. Plans should also have a mechanism for rewarding excellence and hard work. The authors advise that developing explicit rules of operation including a formal appeals process in addition to obtaining external reviews of business processes are important steps to success.

The authors offer advice to medical students and mentors on conducting research projects. They suggest students to make a commitment in conducting a research project and select an area that interest them. They advise them to select a supervisor that have a good track record in supporting their student's projects in a timely manner. They recommend developing a contingency plan in order to be prepared to all the possible problems that may occur at all stages of the project.

The article presents the perspectives of a student who has an experience in publication and that of a senior clinician and researcher who has guided several medical students and residents through the process of doing health care research. The information as obtained from the two respondents primarily aims to encourage medical students to do research and write papers about medicine. Details and a summary of both student and the faculty member are posted.

This article offers a commentary on how to give and how to get academic mentoring. Advice is offered to both mentee and mentor. The authors suggest that most important is the discovery of how the mentee likes to spend time. They urge that mentors not try to be friends with the mentees since the individuals can never be equal in terms of power. They recommend that mismatching relationships should be ended rather than endured.

The article discusses pitfalls of prioritizing cost-effectiveness in the assessment of medical innovation. Topics discussed include heath technology assessment (HTA) of robotic-assisted radical prostatectomy (RARP) undertaken by Health Quality Ontario (HQO), randomized controlled trial showing minimal difference between RP and RARP, and Markov model to make a judgement about economic attractiveness of RARP.

Despite enormous changes in medicine over the last 50 years, the oral presentation of newly admitted patients remains a core activity in academic teaching hospitals. With increased pace and complexity of care, it is time to refresh this tradition, as its efficiency and utility in contemporary practice are open to question. In this paper, we suggest a revised structure to help presenters organize their thoughts before the oral presentation and provide an online tool for doing so. We then offer tips on how to present the facts and inferences to the team in a compelling and memorable fashion; how to tell a story. Organizing information and oral presentation are advanced skills that require repeated practice to learn. [ABSTRACT FROM AUTHOR]

The article discusses Nobel Prize-winning physicist Paul Dirac's views about mathematical beauty in relation to aesthetic expression in various fields such as athletics and medicine. A search for beauty is addressed, along with diagnostic imaging and laparoscopy procedures, cosmetic surgical techniques, and discoveries of innovative therapies in medicine. The treatment of chronic myelogenous leukemia is assessed, as well as aesthetic forms of research and practice.