The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis

ContextMedical errors are associated with feelings of distress in physicians, but little is known about the magnitude and direction of these associations.ObjectiveTo assess the frequency of self-perceived medical errors among resident physicians and to determine the association of self-perceived medical errors with resident quality of life, burnout, depression, and empathy using validated metrics.Design, Setting, and ParticipantsProspective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic Rochester. Data were provided by 184 (84%) of 219 eligible residents. Participants began training in the 2003-2004, 2004-2005, and 2005-2006 academic years and completed surveys quarterly through May 2006. Surveys included self-assessment of medical errors and linear analog scale assessment of quality of life every 3 months, and the Maslach Burnout Inventory (depersonalization, emotional exhaustion, and personal accomplishment), Interpersonal Reactivity Index, and a validated depression screening tool every 6 months.Main Outcome MeasuresFrequency of self-perceived medical errors was recorded. Associations of an error with quality of life, burnout, empathy, and symptoms of depression were determined using generalized estimating equations for repeated measures.ResultsThirty-four percent of participants reported making at least 1 major medical error during the study period. Making a medical error in the previous 3 months was reported by a mean of 14.7% of participants at each quarter. Self-perceived medical errors were associated with a subsequent decrease in quality of life (P = .02) and worsened measures in all domains of burnout (P = .002 for each). Self-perceived errors were associated with an odds ratio of screening positive for depression at the subsequent time point of 3.29 (95% confidence interval, 1.90-5.64). In addition, increased burnout in all domains and reduced empathy were associated with increased odds of self-perceived error in the following 3 months (P=.001, P<.001, and P=.02 for depersonalization, emotional exhaustion, and lower personal accomplishment, respectively; P=.02 and P=.01 for emotive and cognitive empathy, respectively).ConclusionsSelf-perceived medical errors are common among internal medicine residents and are associated with substantial subsequent personal distress. Personal distress and decreased empathy are also associated with increased odds of future self-perceived errors, suggesting that perceived errors and distress may be related in a reciprocal cycle.

https://jamanetwork.com/journals/jama/articlepdf/203249/joc60109.pdf

Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.

DivisionofGeneralInternalMedi-cine, Department of Medicine (Dr West), Division ofBiostatistics, Department of Health Sciences Re-search(DrSloan,MsHuschka,andMrNovotny),Di-vision of Gastroenterology and Hepatology, Depart-ment of Medicine (Dr Kolars) and Division ofHematology, Department of Medicine (DrsHabermann and Shanafelt), Mayo Clinic College ofMedicine, Rochester, Minn.

Association of Perceived Medical Errors With Resident Distress and Empathy

Background Burnout is very common in internal medicine residents. Effective July 2003, all residents were restricted to work less than an average of 80 hours per week and no more than 30 hours of continuous duty for patient care and educational obligations. We evaluated rates of burnout in internal medicine residents before and after the implementation of the new work-hour restriction. Methods University of Colorado Health Science Center internal medicine residents were surveyed in May 2003 and May 2004. The survey contained the Maslach Burnout Inventory, organized into 3 subscales (ie, emotional exhaustion, depersonalization, and personal accomplishment); the Primary Care Evaluation of Mental Disorders depression screen; and self-reported quality of care and education. Results The response rate was 87% (121 of 139 residents) and 74% (106 of 143 residents) in 2003 and 2004, respectively. Self-reported hours worked decreased from a mean of 74.6 to 67.1 ( P  = .003). In 2004, 13% fewer residents experienced high emotional exhaustion (42% vs 29%; P  = .03). There was a trend toward fewer residents with high depersonalization (61% vs 55%; P  = .13) and fewer residents with a positive depression screen (51% vs 41%; P  = .11). Personal accomplishment did not change. The assessment of self-reported quality of care did not significantly change from 2003 to 2004. Residents reported attending fewer educational conferences per month (18.99 vs 15.56; P  = .01). Overall residency satisfaction decreased 6 mm on a 100-mm visual analogue score ( P  = .02). Conclusions Burnout continues to be a major problem. Reducing hours may be the first step to reduce burnout but may also affect education and quality of care.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/766796/ioi50118.pdf

Burnout and Internal Medicine Resident Work-Hour Restrictions

The benefits of warfarin are well established but offset by the risk of major hemorrhage, which occurs at 2.2% rate per year, with a 13% case fatality rate.1 Bleeding may occur at therapeutic international normalized ratios (INR) but is much more likely to occur as the INR rises beyond therapeutic levels.2,3 Antibiotic interactions are recognized as a major cause of overanticoagulation.4–8 However, few data on the incidence of this interaction and the degree to which it induces changes in the INR are available, so we investigated this interaction in a population of acutely infected, otherwise stable outpatients for 3 commonly used antibiotics—azithromycin, levofloxacin, and trimethoprim/sulfamethoxazole (TMP/SMX).

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1525-1497.2005.0136.x

The risk of overanticoagulation with antibiotic use in outpatients on stable warfarin regimens.

BACKGROUND
United States academic hospitals have rapidly adopted the hospitalist model of care. Academic hospitalists have taken on much of the clinical and teaching responsibilities at many institutions, yet little is known about their academic productivity and promotion.

/pdf/mentorship-productivity-and-promotion-among-academic-41pfopz53l.pdf

Mentorship, Productivity, and Promotion Among Academic Hospitalists

T he number of hospitalists in academic medical centers has grown rapidly, producing a field with few senior members, potentially impeding the academic success and career sustainability of academic hospitalists, not to mention contributing to burnout. However, little is known about career promotion, job satisfaction, stress, and rates of burnout in academic hospital medicine or how these factors affect scholarly success and productivity.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/487022/ilt0425_782_785.pdf

Career satisfaction and burnout in academic hospital medicine.

Discharge from the acute care hospital is increasingly recognized as a time of heightened vulnerability for lapses in safety and quality. The capacity of patients to understand and execute discharge instructions is critical to promote effective self-care. This study explores factors that predict understanding and execution of discharge instructions in a sample of 237 recently discharged older adults. A study nurse conducted a postdischarge home visit to ascertain patient understanding and assess execution of instructions. Health literacy, cognition, and self-efficacy were important predictors of successful understanding and execution of instructions. Neither discharge diagnosis nor complexity of discharge instructions was found to be a significant predictor of these outcomes. Results indicate a need to implement reliable protocols that identify patients at risk for poor understanding and execution of hospital discharge instructions and provide customized approaches to meet them at their respective levels.

Jeffrey J. Glasheen

Papers

Burnout and Internal Medicine Resident Work-Hour Restrictions

The risk of overanticoagulation with antibiotic use in outpatients on stable warfarin regimens.

Mentorship, Productivity, and Promotion Among Academic Hospitalists

Career satisfaction and burnout in academic hospital medicine.

Understanding and Execution of Discharge Instructions