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Background Prompt, complete, and accurate information transfer at the time of discharge between hospital-based and primary care providers (PCPs) is needed for the provision of safe and effective care. Purpose of the Study To evaluate timeliness, quality, and interventions to improve timeliness and quality of hospital discharge summaries. Data Sources PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus database published in English between January 2007 and February 2014 were searched. We also hand-searched bibliographies of relevant articles. Study Selection Observational studies investigating transfer of information at hospital discharge (n = 7) and controlled studies evaluating interventions to improve timeliness and quality of discharge information (n = 12) were included. Data Extraction We extracted data on availability, timeliness, and content of hospital discharge summaries and on the effectiveness of interventions targeting discharge summaries. Results of studies are presented narratively and using descriptive statistics. Data Synthesis Across the studies, discharge summaries were completed within 48 hours in a median of 67% and were available to PCPs within 48 hours only 55% of the time. Most of the time, discharge summaries included demographics, primary diagnosis, hospital course, and discharge instructions. However, information was limited to pending test results (25%), diagnostic tests performed (60%), and postdischarge medications (78%). In 6 interventional studies, implementation of electronic discharge summaries was associated with improvement in timeliness but not quality. Conclusions Delayed or insufficient transfer of discharge information between hospital-based providers and PCPs remains common. Creation of electronic discharge summaries seems to improve timeliness and availability but does not consistently improve quality.

Atypical antipsychotics are very widely used for various psychiatric ailments because of their less extrapyramidal side effects. Various reports of disturbances in glucose metabolism in the form of new onset diabetes mellitus, exacerbation of preexisting diabetes mellitus, diabetic ketoacidosis, hyperosmolar nonketotic coma, acute pancreatitis, and increased adiposity have been reported. We present a case of new onset diabetic ketoacidosis in a patient without a history of glucose intolerance who was being treated with olanzapine for bipolar disorder. He presented in hyperglycemic, hyperosmolar, hyperketotic state with hyperkalemia, and peaked T waves on electrocardiogram. He was treated with vigorous intravenous hydration, insulin, and kaexylate which stabilized his metabolic profile. He was discontinued off of his olanzapine and started on resperidol for his bipolar disorder. Over the course of 6 months, the patient was discontinued off of his insulin and has been doing well on his follow-up appointments. This case highlights the necessity of close blood glucose monitoring of patient on atypical antipsychotic medications irrespective of their diabetic status.

BACKGROUNDPrior studies suggest that high workload among attending physicians may be associated with reduced teaching effectiveness and poor patient outcomes, but these relationships have not been investigated using objective measures of workload and safety.OBJECTIVETo examine associations between attending workload, teaching effectiveness, and patient safety, hypothesizing that higher workload would be associated with lower teaching effectiveness and negative patient outcomes.DESIGN, SETTING, AND PARTICIPANTSWe conducted a retrospective study of 69,386 teaching evaluation items submitted by 543 internal medicine residents for 107 attending physicians who supervised inpatient teaching services from July 2, 2005 to July 1, 2011.MEASUREMENTSAttending workload measures included hospital service census, patient length of stay, daily admissions, daily discharges, and concurrent outpatient duties. Teaching effectiveness was measured using residents' evaluations of attendings. Patient outcomes considered were applicable patient safety indicators (PSIs), intensive care unit transfers, cardiopulmonary resuscitation/rapid response team calls, and patient deaths. Mixed linear models and generalized linear regression models were used for statistical analysis.RESULTSWorkload measures of midnight census and daily discharges were associated with lower teaching evaluation scores (both β = −0.026, P < 0.0001). The number of daily admissions was associated with higher teaching scores (β = 0.021, P = 0.001) and increased PSIs (odds ratio = 1.81, P = 0.0001).CONCLUSIONSeveral measures of attending physician workload were associated with slightly lower teaching effectiveness, and patient safety may be compromised when teams are managing new admissions. Ongoing efforts by residency programs to optimize the learning environment should include strategies to manage the workload of supervising attendings. Journal of Hospital Medicine 2016;11:169–173. © 2016 Society of Hospital Medicine

The clinical utility of microbiome biomarkers depends on the reliable and reproducible nature of comparative results. Underappreciation of the variation associated with common demographic, health, and behavioral factors may confound associations of interest and generate false positives. Here, we present the Midwestern Reference Panel (MWRP), a resource for comparative gut microbiome studies conducted in the Midwestern United States. We analyzed the relationships between demographic and health behavior-related factors and the microbiota in this cohort, and estimated their effect sizes. Most variables investigated were associated with the gut microbiota. Specifically, body mass index (BMI), race, sex, and alcohol use were significantly associated with microbial β-diversity (P < 0.05, unweighted UniFrac). BMI, race and alcohol use were also significantly associated with microbial α-diversity (P < 0.05, species richness). Tobacco use showed a trend toward association with the microbiota (P < 0.1, unweighted UniFrac). The effect sizes of the associations, as quantified by adjusted R 2 values based on unweighted UniFrac distances, were small (< 1% for all variables), indicating that these factors explain only a small percentage of overall microbiota variability. Nevertheless, the significant associations between these variables and the gut microbiota suggest that they could still be potential confounders in comparative studies and that controlling for these variables in study design, which is the main objective of the MWRP, is important for increasing reproducibility in comparative microbiome studies.

AbstractThe rapid clinical implementation of cell‐free DNA (cfDNA) screening, a non‐invasive method of prenatal genetic screening, has outpaced research on its social and ethical implications. This study is the first to compare the ethical and practical views of Spanish‐ and English‐speaking pregnant women in the United States about cfDNA screening. Semi‐structured interviews were conducted with diverse Spanish‐ and English‐speaking women who had received prenatal care at a large academic medical center. Of the 24 interviewees, ten were Latinas who were interviewed in Spanish; English‐language interviews were conducted with seven non‐Hispanic Asian and seven non‐Hispanic White women. Participants held positive opinions concerning the accuracy of cfDNA screening and often noted that it would enhance preparedness. Participants also expressed concerns about the possibility of inaccurate results and the potentially negative effects of cfDNA screening on the experience of pregnancy. Differences emerged between Spanish and English speakers in their portrayals of their relationships with prenatal health care providers, the extent to which they questioned providers’ advice, their ethical concerns, and their informational needs. We emphasize the importance of customizing prenatal test counseling to the needs of the individual patient, providing educationally appropriate counseling and literature, and mitigating potential language barriers.