Cluster Munitions: Should They be Banned?

Cluster munitions have been used in at least 23 countries, produced in 33 and stockpiled in over 70; their submunitions number into the billions. They cause lasting humanitarian problems and have recently been the target of campaigns to ban their use. This article aims to summarize the history, utility, legacy and legislation surrounding cluster munitions

The 3rd Annual Lady Grace Revere Osler Lecture in Surgical Quality

Optimal Pancreatic Surgery At the conclusion of this presentation the participant should be able to: 1. Understand the role of hospital and surgeon volume in pancreatic surgery 2. Report the relative risk of various pancreatic operations 3. Acknowledge the importance of chain management in outcomes. Presentation: 57 minute

Decision Trees for Use in Childhood Mental Disorders

The third edition of The Diagnostic and Statistical Manual ofMental Disorders (DSM-III) (1) provides specific diagnostic categories for use in childhood mental disorders, even though these diagnoses are not limited to children. In addition, many of the diagnostic categories used for adults are considered appropriate for use in children. DSM-I II instructs the clinician to diagnose children by first considering the section Disorders First Evident in Infancy, Childhood, or Adolescence before considering the disorders described elsewhere. However, this may lead to problems because some major diagnostic categories such as affective disorders and schizophrenia are not included in the childhood section. This may lead some clinicians to overlook a more accurate diagnosis outside the childhood section, i.e., using Overanxious Disorder in stead of Major Depression. In an attempt to help the clinician to understand the structure of the classification system, DSM-III contains a set of decision trees. Although these trees may be useful for adult diagnosis, they are not quite as useful in diagnosing children. The main problem is that children generally are brought to psychiatrists with behavioral complaints which are related by their parents. Children are more likely than adults to act out their feelings in non-specific ways. For example, a child\u27s verbalization of worries to his parents may be a symptom of Separation Disorder, Major Depression, or Overanxious Disorder. Use of the decision trees in DSM-III would require the clinician to make an initial distinction between anxious mood and depressed mood. This is difficult with children, who often are unable to verbally label their feelings. Another factor complicating diagnosis in children is their greater imagination leading to the assessment of hallucinations or delusions which may not necessarily indicate psychosis. This article proposes an alternate set of decision trees that may be helpful in the diagnosis of mental disorders in children and adolescents under the age of 18 years. Like the DSM-III decision trees, these trees are only approximations of the actual diagnostic criteria. Thus, they are not meant to replace the actual diagnostic criteria in DSM-II I

From the Desk of the Residency Program Director

It is my pleasure to introduce myself to you for the first time as Program Director, as I also introduce to you our latest edition of The Medicine Forum. Having done my residency training at Jefferson, I am so proud that the tradition of this journal has continued throughout the years despite new residents, new leadership, and new challenges both locally and globally. Our residents’ commitment to not only patient care, but also to scholarship and inquiry remains outstanding and impactful. Tradition, coming from the Latin word “tradere”, means to transmit, to hand over, or to give for safekeeping; a definition that feels incredibly plausible to this journal. From year to year, I am constantly impressed by the breadth and quality of work that our residents “transmit” to our friends and alumni encompassing research, humanities, and medical education. In this peer-reviewed publication, each year the new editors and new chief residents are handed over this responsibility with the expectation of garnering new submissions and collating them into an incredible spectrum of learning and ideas. In many ways, this journal is a prism through which we can see all the brilliant differences, perspectives, and talents that comprise our unique residency. I am grateful to Emily Stewart for being a wonderful mentor and example of how to safeguard many of our wonderful Jefferson residency traditions. Consider this latest edition the first installment in a new chapter at Jefferson, one that promises to celebrate the passion, the talent, the diversity, and the community that our Jefferson residents personify. It is with great pride I submit to you the 24th edition of The Medicine Forum

Impact of in-house specialty pharmacy on access to novel androgen axis inhibitors in men with advanced prostate cancer

Introduction: Novel androgen axis inhibitors are standard of care treatments in advanced prostate cancer. The billed amounts for these medications are often very high, which may create significant financial toxicity for patients and lead to delays in treatment. Our institution implemented an in-house specialty pharmacy in 2014, that provides these medications and evaluates copay assistance options for all patients. We evaluated the program’s impact on out of pocket cost (OOP) and turnaround time (TAT). Methods: We reviewed available internal specialty pharmacy records to identify prescriptions for abiraterone or enzalutamide filled between 1/1/17 and 12/31/18. Payments were stratified by primary payment (amount reimbursed by the patient’s prescription plan based on the benefit’s design) and copayment assistance. Turnaround times (TAT) in business days were stratified by prescriptions requiring intervention (prior authorization, copayment assistance, or insufficient inventory) and clean prescriptions (those requiring no intervention). Results: One thousand four hundred seventeen prescriptions for 175 unique patients requiring abiraterone (n=869, 61.3%) or enzalutamide (n=548, 38.7%) were filled through the institution’s specialty pharmacy. The average amount paid by primary payer was $9,492.96 for a 30 day supply (range:$3,382.48-$12,939.84). Average quoted copay was$577.53 (range $3.08-$10,560.39). 64% of patients received copayment assistance. Average OOP cost per prescription after co-pay assistance was $100.83 (range$0-$8556.64). Three patients declined treatment due to cost (1.7% of overall). Average TAT was 2.98 days for clean prescriptions and 3.36 days for prescriptions needing intervention (p=0.055). Discussion: OOP cost varied significantly based on plan design and copayment assistance eligibility. The majority of patients received copayment assistance, which markedly reduced OOP cost. Cost rarely precluded access to treatment. TAT was not significantly prolonged for prescriptions requiring intervention. Further studies to determine impact of pharmacy type on access to specialty medications are indicated

Improving Understanding Of and Compliance With Anti-Shivering Protocols During Therapeutic Hypothermia with Just-In-Time Training

Therapeutic hypothermia after cardiac arrest has been demonstrated to improve neurologic outcomes and survival rates following cardiac arrest. Shivering during hypothermia increases metabolic demand, increases oxygen consumption and increases difficulty maintaining desired temperatures. Gaps in knowledge can lead to inadequate management of shivering, leading Aims for Improvement To improve understanding of and compliance with anti-shivering protocols during therapeutic hypothermia post-cardiac arrest

Gemella Morbillorum as a Cause of Septic Shock.

The gram-positive bacterium Gemella morbillorum has been recovered from patients with endocarditis but has rarely been associated with acute fulminant infections. We describe two children with a rapid onset of septic shock, which was fatal in one, following infection with this organism. G. morbillorum is a commensal organism of the upper respiratory tract; it gained access to the bloodstreams in these patients, and bacteremia occurred. A clinical drawback is that the initial colonial morphology of this organism leads to presumptive identification as a viridans streptococcus, an organism not commonly associated with septic shock syndrome. Resistance of G. morbillorum to penicillin appears to be common; therefore, initial empirical combination therapy (a beta-lactam agent and an aminoglycoside) or vancomycin treatment should be considered