MADRID – Whole blood multiplex polymerase chain reaction (PCR) holds considerable promise as a rapid noninvasive test to improve diagnosis of life-threatening bacterial infections in children with suspected sepsis yet negative blood cultures, Clare Thakker, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

There are several disadvantages with blood cultures – the current diagnostic standard. The turnaround time is 48 hours or longer. Moreover, false-negative culture results are common because of prior antibiotic therapy. And blood cultures require a considerable amount of blood, which becomes an issue in younger children with small blood volumes. Whole blood PCR is unfettered by these limitations, and it could reduce the need for invasive sampling, such as pleural or joint aspiration or CSF sampling, in blood culture–negative children, observed Dr. Thakker of Imperial College London.

Bruce Jancin/Frontline Medical News

[email protected]

MADRID – Whole blood multiplex polymerase chain reaction (PCR) holds considerable promise as a rapid noninvasive test to improve diagnosis of life-threatening bacterial infections in children with suspected sepsis yet negative blood cultures, Clare Thakker, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

There are several disadvantages with blood cultures – the current diagnostic standard. The turnaround time is 48 hours or longer. Moreover, false-negative culture results are common because of prior antibiotic therapy. And blood cultures require a considerable amount of blood, which becomes an issue in younger children with small blood volumes. Whole blood PCR is unfettered by these limitations, and it could reduce the need for invasive sampling, such as pleural or joint aspiration or CSF sampling, in blood culture–negative children, observed Dr. Thakker of Imperial College London.

Bruce Jancin/Frontline Medical News

[email protected]

MADRID – Whole blood multiplex polymerase chain reaction (PCR) holds considerable promise as a rapid noninvasive test to improve diagnosis of life-threatening bacterial infections in children with suspected sepsis yet negative blood cultures, Clare Thakker, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

There are several disadvantages with blood cultures – the current diagnostic standard. The turnaround time is 48 hours or longer. Moreover, false-negative culture results are common because of prior antibiotic therapy. And blood cultures require a considerable amount of blood, which becomes an issue in younger children with small blood volumes. Whole blood PCR is unfettered by these limitations, and it could reduce the need for invasive sampling, such as pleural or joint aspiration or CSF sampling, in blood culture–negative children, observed Dr. Thakker of Imperial College London.

Bruce Jancin/Frontline Medical News

[email protected]

A risk assessment score could help identify individuals with type 1 diabetes who are at higher risk of driving mishaps and who may benefit from interventions to reduce their risk, a new study suggests.

Writing in the June edition of Diabetes Care, Daniel J. Cox, MD, of the University of Virginia, Charlottesville, and his coauthors reported on their efforts to develop and validate a “Risk Assessment of Diabetic Drivers” (RADD) scoring system.

In the first part of the two-part study, 1,371 drivers with type 1 diabetes filled out a series of questionnaires about diabetes and driving, then recorded their driving mishaps over the subsequent year (Diabetes Care. 2017;40:742-50).

This revealed that annual driving distance, peripheral neuropathy, number of past hypoglycemia-related driving mishaps, and the degree to which the individual is bothered by hypoglycemia in general were all significantly associated with a risk of future driving incidents.

Based on this, the authors developed a scoring system using these factors and identified the optimum cut-off point for maximum sensitivity and specificity.

“The area under the curve, a global measure of model performance, was estimated to be 0.73, indicating that the model performed better than chance at classifying participants into the two risk categories,” the authors wrote.

When applied to the original participants, the model classified 37.5% of them as being high-risk. This group had an average of 3.03 driving mishaps over the 12-month follow-up, compared with 0.87 mishaps in the participants who fell into the lowest 37.5% of risk (P = .002).

In the second part of the study, 1,737 drivers with type 1 diabetes completed a version of the scoring questionnaire online, and 118 low-risk and 372 high-risk individuals were recruited.

The high-risk individuals were randomized either to a 2-month online intervention that aimed at helping people with type 1 diabetes anticipate, prevent, detect, and treat hypoglycemia while driving, as well as a program of motivational interviewing, the online intervention alone, or routine care, with 12 months of follow-up. The low-risk individuals all received routine care only.

As with the first part of the study, researchers saw a significantly lower number of driving mishaps in the low-risk participants, compared with the high-risk participants (1.65 mishaps per driver per year vs. 4.26 mishaps per driver per year; P less than .001).

After adjusting for other factors such as age, sex, method of insulin delivery, and hypoglycemia awareness, the rate of mishaps was still 2.83 times higher in the high-risk group, compared with the low-risk group (P less than .001).

The authors noted that their RADD scoring system did have a false-negative rate of 24%, classifying people as low-risk even though they reported more than one driving mishap in the following 12 months.

“This illustrates that any driver has a risk of being involved in a collision or receiving a citation, and any driver with type 1 diabetes has the additional risk of experiencing disruptive extreme [blood glucose (BG)] that can result in a mishap while driving,” they wrote. “While, ideally, all drivers with type 1 diabetes should measure their BG before driving, they should at least be counseled that, whenever they take more insulin, eat fewer carbohydrates, or engage in more physical activity than usual, they should measure their BG before driving.”

With respect to the impact of the intervention and motivational interviewing, researchers found no significant differences in the rate of mishaps between the groups who received intervention plus interview and those who received the intervention alone, and, as a result, combined these two groups into one.

The high-risk group who underwent the online intervention had fewer driving mishaps than did the high-risk group who received routine care. However, they still had 1.58 times more incidents than did the low-risk individuals who received routine care.

The intervention decreased the risk of mishaps associated with hypoglycemia in high-risk individuals, compared with that in those who recieved routine care, but these individuals still had a higher incidence of hypoglycemia-associated mishaps, compared with the low-risk individuals.

“It is also important to note that [the online intervention] only affected hypoglycemia-related driving mishaps, not hyperglycemia- or nondiabetes-related mishaps,” the authors wrote.

The study was funded by the National Institutes of Health and supported in-kind by LifeScan, Abbott Laboratories, MyGlu.com, dLife.com, and Dex4.com.

A risk assessment score could help identify individuals with type 1 diabetes who are at higher risk of driving mishaps and who may benefit from interventions to reduce their risk, a new study suggests.

Writing in the June edition of Diabetes Care, Daniel J. Cox, MD, of the University of Virginia, Charlottesville, and his coauthors reported on their efforts to develop and validate a “Risk Assessment of Diabetic Drivers” (RADD) scoring system.

In the first part of the two-part study, 1,371 drivers with type 1 diabetes filled out a series of questionnaires about diabetes and driving, then recorded their driving mishaps over the subsequent year (Diabetes Care. 2017;40:742-50).

This revealed that annual driving distance, peripheral neuropathy, number of past hypoglycemia-related driving mishaps, and the degree to which the individual is bothered by hypoglycemia in general were all significantly associated with a risk of future driving incidents.

Based on this, the authors developed a scoring system using these factors and identified the optimum cut-off point for maximum sensitivity and specificity.

“The area under the curve, a global measure of model performance, was estimated to be 0.73, indicating that the model performed better than chance at classifying participants into the two risk categories,” the authors wrote.

When applied to the original participants, the model classified 37.5% of them as being high-risk. This group had an average of 3.03 driving mishaps over the 12-month follow-up, compared with 0.87 mishaps in the participants who fell into the lowest 37.5% of risk (P = .002).

In the second part of the study, 1,737 drivers with type 1 diabetes completed a version of the scoring questionnaire online, and 118 low-risk and 372 high-risk individuals were recruited.

The high-risk individuals were randomized either to a 2-month online intervention that aimed at helping people with type 1 diabetes anticipate, prevent, detect, and treat hypoglycemia while driving, as well as a program of motivational interviewing, the online intervention alone, or routine care, with 12 months of follow-up. The low-risk individuals all received routine care only.

As with the first part of the study, researchers saw a significantly lower number of driving mishaps in the low-risk participants, compared with the high-risk participants (1.65 mishaps per driver per year vs. 4.26 mishaps per driver per year; P less than .001).

After adjusting for other factors such as age, sex, method of insulin delivery, and hypoglycemia awareness, the rate of mishaps was still 2.83 times higher in the high-risk group, compared with the low-risk group (P less than .001).

The authors noted that their RADD scoring system did have a false-negative rate of 24%, classifying people as low-risk even though they reported more than one driving mishap in the following 12 months.

“This illustrates that any driver has a risk of being involved in a collision or receiving a citation, and any driver with type 1 diabetes has the additional risk of experiencing disruptive extreme [blood glucose (BG)] that can result in a mishap while driving,” they wrote. “While, ideally, all drivers with type 1 diabetes should measure their BG before driving, they should at least be counseled that, whenever they take more insulin, eat fewer carbohydrates, or engage in more physical activity than usual, they should measure their BG before driving.”

With respect to the impact of the intervention and motivational interviewing, researchers found no significant differences in the rate of mishaps between the groups who received intervention plus interview and those who received the intervention alone, and, as a result, combined these two groups into one.

The high-risk group who underwent the online intervention had fewer driving mishaps than did the high-risk group who received routine care. However, they still had 1.58 times more incidents than did the low-risk individuals who received routine care.

The intervention decreased the risk of mishaps associated with hypoglycemia in high-risk individuals, compared with that in those who recieved routine care, but these individuals still had a higher incidence of hypoglycemia-associated mishaps, compared with the low-risk individuals.

“It is also important to note that [the online intervention] only affected hypoglycemia-related driving mishaps, not hyperglycemia- or nondiabetes-related mishaps,” the authors wrote.

The study was funded by the National Institutes of Health and supported in-kind by LifeScan, Abbott Laboratories, MyGlu.com, dLife.com, and Dex4.com.

A risk assessment score could help identify individuals with type 1 diabetes who are at higher risk of driving mishaps and who may benefit from interventions to reduce their risk, a new study suggests.

Writing in the June edition of Diabetes Care, Daniel J. Cox, MD, of the University of Virginia, Charlottesville, and his coauthors reported on their efforts to develop and validate a “Risk Assessment of Diabetic Drivers” (RADD) scoring system.

In the first part of the two-part study, 1,371 drivers with type 1 diabetes filled out a series of questionnaires about diabetes and driving, then recorded their driving mishaps over the subsequent year (Diabetes Care. 2017;40:742-50).

This revealed that annual driving distance, peripheral neuropathy, number of past hypoglycemia-related driving mishaps, and the degree to which the individual is bothered by hypoglycemia in general were all significantly associated with a risk of future driving incidents.

Based on this, the authors developed a scoring system using these factors and identified the optimum cut-off point for maximum sensitivity and specificity.

“The area under the curve, a global measure of model performance, was estimated to be 0.73, indicating that the model performed better than chance at classifying participants into the two risk categories,” the authors wrote.

When applied to the original participants, the model classified 37.5% of them as being high-risk. This group had an average of 3.03 driving mishaps over the 12-month follow-up, compared with 0.87 mishaps in the participants who fell into the lowest 37.5% of risk (P = .002).

In the second part of the study, 1,737 drivers with type 1 diabetes completed a version of the scoring questionnaire online, and 118 low-risk and 372 high-risk individuals were recruited.

The high-risk individuals were randomized either to a 2-month online intervention that aimed at helping people with type 1 diabetes anticipate, prevent, detect, and treat hypoglycemia while driving, as well as a program of motivational interviewing, the online intervention alone, or routine care, with 12 months of follow-up. The low-risk individuals all received routine care only.

As with the first part of the study, researchers saw a significantly lower number of driving mishaps in the low-risk participants, compared with the high-risk participants (1.65 mishaps per driver per year vs. 4.26 mishaps per driver per year; P less than .001).

After adjusting for other factors such as age, sex, method of insulin delivery, and hypoglycemia awareness, the rate of mishaps was still 2.83 times higher in the high-risk group, compared with the low-risk group (P less than .001).

The authors noted that their RADD scoring system did have a false-negative rate of 24%, classifying people as low-risk even though they reported more than one driving mishap in the following 12 months.

“This illustrates that any driver has a risk of being involved in a collision or receiving a citation, and any driver with type 1 diabetes has the additional risk of experiencing disruptive extreme [blood glucose (BG)] that can result in a mishap while driving,” they wrote. “While, ideally, all drivers with type 1 diabetes should measure their BG before driving, they should at least be counseled that, whenever they take more insulin, eat fewer carbohydrates, or engage in more physical activity than usual, they should measure their BG before driving.”

With respect to the impact of the intervention and motivational interviewing, researchers found no significant differences in the rate of mishaps between the groups who received intervention plus interview and those who received the intervention alone, and, as a result, combined these two groups into one.

The high-risk group who underwent the online intervention had fewer driving mishaps than did the high-risk group who received routine care. However, they still had 1.58 times more incidents than did the low-risk individuals who received routine care.

The intervention decreased the risk of mishaps associated with hypoglycemia in high-risk individuals, compared with that in those who recieved routine care, but these individuals still had a higher incidence of hypoglycemia-associated mishaps, compared with the low-risk individuals.

“It is also important to note that [the online intervention] only affected hypoglycemia-related driving mishaps, not hyperglycemia- or nondiabetes-related mishaps,” the authors wrote.

The study was funded by the National Institutes of Health and supported in-kind by LifeScan, Abbott Laboratories, MyGlu.com, dLife.com, and Dex4.com.

Antibody responses in children born to vaccinated mothers were lower because of earlier administration of their first measles vaccine dose at 12 months of age or younger, compared with 15 months of age or older, said Sara Carazo Perez, MD, PhD, of Laval University, Quebec City, and her associates.

Studies suggest that measles elimination “requires the maintenance of population immunity above 92%-94%.” So, “the additional protection of 3%-5% of vaccinated children against secondary vaccine failures by postponing the first dose from 12 to 15 months of age would be significant, and the risk would be minimal in countries that achieved elimination” of measles, said Dr. Perez and her colleagues.

CDC/Molly Kurnit, M.P.H.

[email protected]

Antibody responses in children born to vaccinated mothers were lower because of earlier administration of their first measles vaccine dose at 12 months of age or younger, compared with 15 months of age or older, said Sara Carazo Perez, MD, PhD, of Laval University, Quebec City, and her associates.

Studies suggest that measles elimination “requires the maintenance of population immunity above 92%-94%.” So, “the additional protection of 3%-5% of vaccinated children against secondary vaccine failures by postponing the first dose from 12 to 15 months of age would be significant, and the risk would be minimal in countries that achieved elimination” of measles, said Dr. Perez and her colleagues.

CDC/Molly Kurnit, M.P.H.

[email protected]

Antibody responses in children born to vaccinated mothers were lower because of earlier administration of their first measles vaccine dose at 12 months of age or younger, compared with 15 months of age or older, said Sara Carazo Perez, MD, PhD, of Laval University, Quebec City, and her associates.

Studies suggest that measles elimination “requires the maintenance of population immunity above 92%-94%.” So, “the additional protection of 3%-5% of vaccinated children against secondary vaccine failures by postponing the first dose from 12 to 15 months of age would be significant, and the risk would be minimal in countries that achieved elimination” of measles, said Dr. Perez and her colleagues.

CDC/Molly Kurnit, M.P.H.

[email protected]

It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.

Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.

Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.

Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Clinical Question: Does the use and timing of probiotics in hospitalized adult patients with Clostridium difficile infection (CDI) improve clinical outcomes?

Background: The incidence of CDI in hospitalized patients has increased significantly over the past years, resulting in significant morbidity and mortality. Improved prevention of CDI could have substantial public health benefits.

Study design: Systematic review and metaregression analysis.

Setting: 19 studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for randomized controlled trials (RCTs) evaluating probiotic effects on CDI in hospitalized adults taking antibiotics.

Comprising 6261 subjects, 19 RCTs were analyzed. The incidence of CDI was lower in the probiotic cohort than in the control group (1.6% vs. 3.9%; P less than 0.001). The pooled relative risk of CDI in probiotic users was 0.42 (95% CI, 0.30-0.57). Metaregression analysis demonstrated that probiotics were significantly more effective if given closer to the first antibiotic dose, with a decrease in efficacy for every day of delay in starting probiotics (P = .04). Probiotics given within 2 days of antibiotic initiation produced a greater reduction of risk for CDI (RR, 0.32; 95% CI, 0.22-0.48) than later administration (RR, 0.70; 95% CI, 0.40-1.23; P = .02). There was no increased risk for adverse events among patients receiving probiotics.

Limitations included high risk of bias because of missing data, attrition, restricted patient population, lack of placebo, and conflict of interest.

Bottom Line: Administration of probiotics soon after the first dose of antibiotic reduces the risk of CDI by more than 50% in hospitalized adults without any increased risk of adverse events.

Reference: Shen NT, Maw A, Tmanova LL et al. Timely use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review with Meta-Regression Analysis. Gastroenterology. Published on 9 Feb 2017. doi: 10.1053/j.gastro.2017.02.003.
 

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: Does the use and timing of probiotics in hospitalized adult patients with Clostridium difficile infection (CDI) improve clinical outcomes?

Background: The incidence of CDI in hospitalized patients has increased significantly over the past years, resulting in significant morbidity and mortality. Improved prevention of CDI could have substantial public health benefits.

Study design: Systematic review and metaregression analysis.

Setting: 19 studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for randomized controlled trials (RCTs) evaluating probiotic effects on CDI in hospitalized adults taking antibiotics.

Comprising 6261 subjects, 19 RCTs were analyzed. The incidence of CDI was lower in the probiotic cohort than in the control group (1.6% vs. 3.9%; P less than 0.001). The pooled relative risk of CDI in probiotic users was 0.42 (95% CI, 0.30-0.57). Metaregression analysis demonstrated that probiotics were significantly more effective if given closer to the first antibiotic dose, with a decrease in efficacy for every day of delay in starting probiotics (P = .04). Probiotics given within 2 days of antibiotic initiation produced a greater reduction of risk for CDI (RR, 0.32; 95% CI, 0.22-0.48) than later administration (RR, 0.70; 95% CI, 0.40-1.23; P = .02). There was no increased risk for adverse events among patients receiving probiotics.

Limitations included high risk of bias because of missing data, attrition, restricted patient population, lack of placebo, and conflict of interest.

Bottom Line: Administration of probiotics soon after the first dose of antibiotic reduces the risk of CDI by more than 50% in hospitalized adults without any increased risk of adverse events.

Reference: Shen NT, Maw A, Tmanova LL et al. Timely use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review with Meta-Regression Analysis. Gastroenterology. Published on 9 Feb 2017. doi: 10.1053/j.gastro.2017.02.003.
 

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: Does the use and timing of probiotics in hospitalized adult patients with Clostridium difficile infection (CDI) improve clinical outcomes?

Background: The incidence of CDI in hospitalized patients has increased significantly over the past years, resulting in significant morbidity and mortality. Improved prevention of CDI could have substantial public health benefits.

Study design: Systematic review and metaregression analysis.

Setting: 19 studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for randomized controlled trials (RCTs) evaluating probiotic effects on CDI in hospitalized adults taking antibiotics.

Comprising 6261 subjects, 19 RCTs were analyzed. The incidence of CDI was lower in the probiotic cohort than in the control group (1.6% vs. 3.9%; P less than 0.001). The pooled relative risk of CDI in probiotic users was 0.42 (95% CI, 0.30-0.57). Metaregression analysis demonstrated that probiotics were significantly more effective if given closer to the first antibiotic dose, with a decrease in efficacy for every day of delay in starting probiotics (P = .04). Probiotics given within 2 days of antibiotic initiation produced a greater reduction of risk for CDI (RR, 0.32; 95% CI, 0.22-0.48) than later administration (RR, 0.70; 95% CI, 0.40-1.23; P = .02). There was no increased risk for adverse events among patients receiving probiotics.

Limitations included high risk of bias because of missing data, attrition, restricted patient population, lack of placebo, and conflict of interest.

Bottom Line: Administration of probiotics soon after the first dose of antibiotic reduces the risk of CDI by more than 50% in hospitalized adults without any increased risk of adverse events.

Reference: Shen NT, Maw A, Tmanova LL et al. Timely use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review with Meta-Regression Analysis. Gastroenterology. Published on 9 Feb 2017. doi: 10.1053/j.gastro.2017.02.003.
 

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: In patients hospitalized for a lower gastrointestinal bleeding (LGIB), does an urgent colonoscopy (less than 24 hours after admission) result in any clinical benefits, compared with waiting for an elective colonoscopy?

Background: LGIB is a common cause of morbidity and mortality, often requiring hospitalization. While colonoscopy is necessary for appropriate work-up and treatment, it remains unclear if time to colonoscopy (urgent vs. elective) confers any clinical benefit in hospitalized patients.

Study Design: Systematic review and meta-analysis.

Setting: Twelve studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for appropriate studies, and 12 met inclusion criteria, resulting in a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy.

Outcome measures included bleeding source identified on colonoscopy, therapeutic endoscopic interventions performed, patients requiring blood transfusions, rebleeding, adverse events, and mortality.

Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (relative risk, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, 0.92-1.25), adverse event rates (RR, 1.05; 95% CI, 0.65-1.71), rebleeding rates (RR, 1.14; 95% CI, 0.74-1.78), transfusion requirement (RR, 1.02; 95% CI, 0.73-1.41), or mortality (RR, 1.17; 95% CI, 0.45-3.02) between urgent and elective colonoscopy.

Limitations of the study comprise of inclusion of small number of studies, underpowered statistical analysis, and possible variation in quality assessment of articles evaluated.

Bottom Line: Urgent colonoscopy is safe and usually well tolerated in hospitalized patients with LGIB, but, compared with elective colonoscopy, there is no clear evidence it alters important clinical outcomes.

Reference: Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: A systematic review and meta-analysis. Gastrointest Endosc. Published online Feb 4, 2017. doi: 10.1016/j.gie.2017.01.035.

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: In patients hospitalized for a lower gastrointestinal bleeding (LGIB), does an urgent colonoscopy (less than 24 hours after admission) result in any clinical benefits, compared with waiting for an elective colonoscopy?

Background: LGIB is a common cause of morbidity and mortality, often requiring hospitalization. While colonoscopy is necessary for appropriate work-up and treatment, it remains unclear if time to colonoscopy (urgent vs. elective) confers any clinical benefit in hospitalized patients.

Study Design: Systematic review and meta-analysis.

Setting: Twelve studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for appropriate studies, and 12 met inclusion criteria, resulting in a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy.

Outcome measures included bleeding source identified on colonoscopy, therapeutic endoscopic interventions performed, patients requiring blood transfusions, rebleeding, adverse events, and mortality.

Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (relative risk, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, 0.92-1.25), adverse event rates (RR, 1.05; 95% CI, 0.65-1.71), rebleeding rates (RR, 1.14; 95% CI, 0.74-1.78), transfusion requirement (RR, 1.02; 95% CI, 0.73-1.41), or mortality (RR, 1.17; 95% CI, 0.45-3.02) between urgent and elective colonoscopy.

Limitations of the study comprise of inclusion of small number of studies, underpowered statistical analysis, and possible variation in quality assessment of articles evaluated.

Bottom Line: Urgent colonoscopy is safe and usually well tolerated in hospitalized patients with LGIB, but, compared with elective colonoscopy, there is no clear evidence it alters important clinical outcomes.

Reference: Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: A systematic review and meta-analysis. Gastrointest Endosc. Published online Feb 4, 2017. doi: 10.1016/j.gie.2017.01.035.

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: In patients hospitalized for a lower gastrointestinal bleeding (LGIB), does an urgent colonoscopy (less than 24 hours after admission) result in any clinical benefits, compared with waiting for an elective colonoscopy?

Background: LGIB is a common cause of morbidity and mortality, often requiring hospitalization. While colonoscopy is necessary for appropriate work-up and treatment, it remains unclear if time to colonoscopy (urgent vs. elective) confers any clinical benefit in hospitalized patients.

Study Design: Systematic review and meta-analysis.

Setting: Twelve studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for appropriate studies, and 12 met inclusion criteria, resulting in a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy.

Outcome measures included bleeding source identified on colonoscopy, therapeutic endoscopic interventions performed, patients requiring blood transfusions, rebleeding, adverse events, and mortality.

Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (relative risk, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, 0.92-1.25), adverse event rates (RR, 1.05; 95% CI, 0.65-1.71), rebleeding rates (RR, 1.14; 95% CI, 0.74-1.78), transfusion requirement (RR, 1.02; 95% CI, 0.73-1.41), or mortality (RR, 1.17; 95% CI, 0.45-3.02) between urgent and elective colonoscopy.

Limitations of the study comprise of inclusion of small number of studies, underpowered statistical analysis, and possible variation in quality assessment of articles evaluated.

Bottom Line: Urgent colonoscopy is safe and usually well tolerated in hospitalized patients with LGIB, but, compared with elective colonoscopy, there is no clear evidence it alters important clinical outcomes.

Reference: Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: A systematic review and meta-analysis. Gastrointest Endosc. Published online Feb 4, 2017. doi: 10.1016/j.gie.2017.01.035.

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

SAN DIEGO – Oral, once-daily treatment with canagliflozin significantly reduced the risk of cardiovascular events, compared with placebo, among more than 10,000 patients with type 2 diabetes at high risk of cardiovascular disease.

After an average of 188 weeks of follow-up, the combined rate of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke was 26.9 events per 1,000 person-years of canagliflozin treatment and 31.5 events per 1,000 person-years of placebo treatment (hazard ratio, 0.86; 95% confidence interval, 0.75-0.97; P less than .001 for noninferiority; P = .02 for superiority) in the Canagliflozin Cardiovascular Assessment Study (CANVAS) and its sister trial, CANVAS-R, investigators reported at the annual scientific sessions of the American Diabetes Association. The report was published simultaneously in the New England Journal of Medicine (N Engl J Med. 2017 Jun 12. doi: 10.1056/NEJMoa1611925).

SAN DIEGO – Oral, once-daily treatment with canagliflozin significantly reduced the risk of cardiovascular events, compared with placebo, among more than 10,000 patients with type 2 diabetes at high risk of cardiovascular disease.

After an average of 188 weeks of follow-up, the combined rate of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke was 26.9 events per 1,000 person-years of canagliflozin treatment and 31.5 events per 1,000 person-years of placebo treatment (hazard ratio, 0.86; 95% confidence interval, 0.75-0.97; P less than .001 for noninferiority; P = .02 for superiority) in the Canagliflozin Cardiovascular Assessment Study (CANVAS) and its sister trial, CANVAS-R, investigators reported at the annual scientific sessions of the American Diabetes Association. The report was published simultaneously in the New England Journal of Medicine (N Engl J Med. 2017 Jun 12. doi: 10.1056/NEJMoa1611925).

SAN DIEGO – Oral, once-daily treatment with canagliflozin significantly reduced the risk of cardiovascular events, compared with placebo, among more than 10,000 patients with type 2 diabetes at high risk of cardiovascular disease.

After an average of 188 weeks of follow-up, the combined rate of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke was 26.9 events per 1,000 person-years of canagliflozin treatment and 31.5 events per 1,000 person-years of placebo treatment (hazard ratio, 0.86; 95% confidence interval, 0.75-0.97; P less than .001 for noninferiority; P = .02 for superiority) in the Canagliflozin Cardiovascular Assessment Study (CANVAS) and its sister trial, CANVAS-R, investigators reported at the annual scientific sessions of the American Diabetes Association. The report was published simultaneously in the New England Journal of Medicine (N Engl J Med. 2017 Jun 12. doi: 10.1056/NEJMoa1611925).

The Diagnosis: Nevus Lipomatosus Cutaneous Superficialis

A punch biopsy was obtained from a skin lesion, which showed orthokeratosis, irregular acanthosis, papillomatosis, intense edema in the upper dermis, and mature fat lobules that dissected collagen fibers in the reticular dermis (Figure). Classical-type nevus lipomatosus cutaneous superficialis (NLCS) was diagnosed based on these clinical and histopathological findings. The patient was referred to the plastic surgery clinic for total excision of all lesions.

Nevus lipomatosus cutaneous superficialis is a rare hamartoma characterized by ectopic deposition of mature adipose tissue in the dermis.¹ It was first described by Hoffmann and Zurhelle² in 1921. Clinically, NLCS is classified into 2 subtypes: classical (multiple) and solitary. Classical-type NLCS is characterized by multiple pedunculated or sessile, soft, cerebriform, yellowish papules and nodules, especially in the pelvic area. Solitary-type NLCS presents as a sessile papule or nodule with no predilection for localization. Although the classical form of NLCS generally occurs in the first 2 decades of life, the solitary form usually appears in adulthood.³ Nevus lipomatosus cutaneous superficialis has no gender predilection and there is no genetic or congenital defect association.^1,4

The pathogenesis of NLCS still is unknown, but some theories have been proposed, such as the development of adipose metaplasia secondary to degeneration of connective tissue, the formation of a true nevus resulting from heterotopic development of adipose tissue, and the development of mature adipocytes from pericytes in dermal vessels.^1,5 

Histopathology of NLCS shows clusters of ectopic mature adipose tissue in varying rates (10%-50%) between collagen bundles in the dermis. Characteristically, there is no connection between the ectopic mature adipose tissue and the subcutaneous adipose tissue.³ The differential diagnosis of NLCS includes neurofibroma, lymphangioma, sebaceous nevus, fibroepithelial polyps, leiomyoma, and lipomas.^1,6

Treatment of NLCS generally involves basic surgical excision; however, patients treated with CO₂ laser also have been reported in the literature.⁵ Because of the growth tendency and the large size of the classical form of NLCS, recurrence may occur, as in our case. In such cases, gradual surgical excision is recommended.⁵ We present this case to indicate that undesirable surgical results or relapse may occur in untreated patients because of lesion growth and delayed diagnosis.

The Diagnosis: Nevus Lipomatosus Cutaneous Superficialis

A punch biopsy was obtained from a skin lesion, which showed orthokeratosis, irregular acanthosis, papillomatosis, intense edema in the upper dermis, and mature fat lobules that dissected collagen fibers in the reticular dermis (Figure). Classical-type nevus lipomatosus cutaneous superficialis (NLCS) was diagnosed based on these clinical and histopathological findings. The patient was referred to the plastic surgery clinic for total excision of all lesions.

Nevus lipomatosus cutaneous superficialis is a rare hamartoma characterized by ectopic deposition of mature adipose tissue in the dermis.¹ It was first described by Hoffmann and Zurhelle² in 1921. Clinically, NLCS is classified into 2 subtypes: classical (multiple) and solitary. Classical-type NLCS is characterized by multiple pedunculated or sessile, soft, cerebriform, yellowish papules and nodules, especially in the pelvic area. Solitary-type NLCS presents as a sessile papule or nodule with no predilection for localization. Although the classical form of NLCS generally occurs in the first 2 decades of life, the solitary form usually appears in adulthood.³ Nevus lipomatosus cutaneous superficialis has no gender predilection and there is no genetic or congenital defect association.^1,4

The pathogenesis of NLCS still is unknown, but some theories have been proposed, such as the development of adipose metaplasia secondary to degeneration of connective tissue, the formation of a true nevus resulting from heterotopic development of adipose tissue, and the development of mature adipocytes from pericytes in dermal vessels.^1,5 

Histopathology of NLCS shows clusters of ectopic mature adipose tissue in varying rates (10%-50%) between collagen bundles in the dermis. Characteristically, there is no connection between the ectopic mature adipose tissue and the subcutaneous adipose tissue.³ The differential diagnosis of NLCS includes neurofibroma, lymphangioma, sebaceous nevus, fibroepithelial polyps, leiomyoma, and lipomas.^1,6

Treatment of NLCS generally involves basic surgical excision; however, patients treated with CO₂ laser also have been reported in the literature.⁵ Because of the growth tendency and the large size of the classical form of NLCS, recurrence may occur, as in our case. In such cases, gradual surgical excision is recommended.⁵ We present this case to indicate that undesirable surgical results or relapse may occur in untreated patients because of lesion growth and delayed diagnosis.

The Diagnosis: Nevus Lipomatosus Cutaneous Superficialis

A punch biopsy was obtained from a skin lesion, which showed orthokeratosis, irregular acanthosis, papillomatosis, intense edema in the upper dermis, and mature fat lobules that dissected collagen fibers in the reticular dermis (Figure). Classical-type nevus lipomatosus cutaneous superficialis (NLCS) was diagnosed based on these clinical and histopathological findings. The patient was referred to the plastic surgery clinic for total excision of all lesions.

Nevus lipomatosus cutaneous superficialis is a rare hamartoma characterized by ectopic deposition of mature adipose tissue in the dermis.¹ It was first described by Hoffmann and Zurhelle² in 1921. Clinically, NLCS is classified into 2 subtypes: classical (multiple) and solitary. Classical-type NLCS is characterized by multiple pedunculated or sessile, soft, cerebriform, yellowish papules and nodules, especially in the pelvic area. Solitary-type NLCS presents as a sessile papule or nodule with no predilection for localization. Although the classical form of NLCS generally occurs in the first 2 decades of life, the solitary form usually appears in adulthood.³ Nevus lipomatosus cutaneous superficialis has no gender predilection and there is no genetic or congenital defect association.^1,4

The pathogenesis of NLCS still is unknown, but some theories have been proposed, such as the development of adipose metaplasia secondary to degeneration of connective tissue, the formation of a true nevus resulting from heterotopic development of adipose tissue, and the development of mature adipocytes from pericytes in dermal vessels.^1,5 

Histopathology of NLCS shows clusters of ectopic mature adipose tissue in varying rates (10%-50%) between collagen bundles in the dermis. Characteristically, there is no connection between the ectopic mature adipose tissue and the subcutaneous adipose tissue.³ The differential diagnosis of NLCS includes neurofibroma, lymphangioma, sebaceous nevus, fibroepithelial polyps, leiomyoma, and lipomas.^1,6

Treatment of NLCS generally involves basic surgical excision; however, patients treated with CO₂ laser also have been reported in the literature.⁵ Because of the growth tendency and the large size of the classical form of NLCS, recurrence may occur, as in our case. In such cases, gradual surgical excision is recommended.⁵ We present this case to indicate that undesirable surgical results or relapse may occur in untreated patients because of lesion growth and delayed diagnosis.

An investigational quadrivalent flu vaccine formulated to be less pyrogenic had noninferior immunogenicity, compared with a U.S.-licensed vaccine, in children aged 5-17 years, Jolanta Airey, MD, of Seqirus in Parkville, Australia, and her associates reported.

In 2010, in Australia and New Zealand, use of a trivalent flu vaccine was associated with unexpected reports of fever and febrile seizures in children aged younger than 9 years. Research into the issue suggested that “degraded RNA fragments delivered by residual lipids activated the release of proinflammatory cytokines, which stimulated the pyrogenic response in children,” the study authors noted. “Increasing the level of sodium taurodeoxycholate (TDOC) to split the B strain in particular resulted in decreased levels of residual lipids and attenuated proinflammatory cytokine signals.”

copyright luiscar/Thinkstock

[email protected]

An investigational quadrivalent flu vaccine formulated to be less pyrogenic had noninferior immunogenicity, compared with a U.S.-licensed vaccine, in children aged 5-17 years, Jolanta Airey, MD, of Seqirus in Parkville, Australia, and her associates reported.

In 2010, in Australia and New Zealand, use of a trivalent flu vaccine was associated with unexpected reports of fever and febrile seizures in children aged younger than 9 years. Research into the issue suggested that “degraded RNA fragments delivered by residual lipids activated the release of proinflammatory cytokines, which stimulated the pyrogenic response in children,” the study authors noted. “Increasing the level of sodium taurodeoxycholate (TDOC) to split the B strain in particular resulted in decreased levels of residual lipids and attenuated proinflammatory cytokine signals.”

copyright luiscar/Thinkstock

[email protected]

An investigational quadrivalent flu vaccine formulated to be less pyrogenic had noninferior immunogenicity, compared with a U.S.-licensed vaccine, in children aged 5-17 years, Jolanta Airey, MD, of Seqirus in Parkville, Australia, and her associates reported.

In 2010, in Australia and New Zealand, use of a trivalent flu vaccine was associated with unexpected reports of fever and febrile seizures in children aged younger than 9 years. Research into the issue suggested that “degraded RNA fragments delivered by residual lipids activated the release of proinflammatory cytokines, which stimulated the pyrogenic response in children,” the study authors noted. “Increasing the level of sodium taurodeoxycholate (TDOC) to split the B strain in particular resulted in decreased levels of residual lipids and attenuated proinflammatory cytokine signals.”

copyright luiscar/Thinkstock

[email protected]

As lifelong learners, physicians are encouraged and expected to share their knowledge base with budding residents and students. Effective communication is essential to the utmost delivery of clinical knowledge and pearls. Lecture delivery is important for all stages of learning, and adapting efficient techniques early in one's career is critical for the transmission of ideas and teaching points. These tips were created to help formulate guidelines for physician presentations and are open for interpretation. These well-meaning suggestions can be integrated into one's toolbox to foster an enthusiastic educational arena.

Step 1: Know Your Key Message 

First and foremost, one should ruminate over the overall message of the lecture. Consider at least 3 main points you want the learner to gain and remember on completion of the lecture. Additionally, it is crucial to think about the audience who will be present for your message and how to deliver your ideas clearly and effectively. Be cognizant of the knowledge base of your listeners and gauge how much initial background information is needed; conversely, if the audience is familiar with the material, excessive introductory material may be unnecessary and cause inattentiveness. Simplicity, both within the inherent message itself and the content and layout, can ameliorate the transmission of data regardless of the audience. A mentor once told me that no slide should contain more than 13 lines of text. Furthermore, if you are counting the number of lines, then you likely need to reduce the text and simplify the slide. Each slide should contain a maximum of 3 or 4 bullet points.¹ Convoluted figures should be avoided and key points should be highlighted. Overall, know your take-home message and provide the listener with simplistic text and images to convey the key ideas at their educational level.

Step 2: Prepare

Preparation is of utmost importance. Reading over the slides several times prior to the presentation is vital. You are the assumed expert on the topic and meticulously knowing the subject matter helps with the confidence of your delivery. Ease of subject matter also helps you, as the presenter, to rely less on verbatim reading of the slides and allows you to interact more with your audience. It is important to be familiar with the order of your presentation as well as the phrases and figures provided.² Flipping back and forth through slides can be distracting to the audience and can make the order of your presentation seem incongruous, presenting as a hastily constructed lecture. If you are prepared, you can engage your audience and provide additional information that is not on the slides to maintain interest. Remember that reading the slides can reduce your voice to a monotone, subtracting enthusiasm and energy from the delivery of your talk.² Rehearsal helps give you the freedom to confidently and proudly present your subject material.

Step 3: Be Animated 

You are the main attraction and the performer of this lecture. Radiate the confidence you gained from being prepared with the ability to engage in eye contact and gestures as needed to convey your point. Regularly shift your focus around the room to attempt to involve as many people as possible in your talk.² Your main focus should be your audience and not your slides; the slides should simply help guide your talk.³ During your presentation, you also can ask rhetorical questions that you can then answer to keep the group engaged (eg, "So, what does this tell us?" or "What would you do next?"). These questions demonstrate to your audience that you are interested in their attention and can help reciprocate the enthusiasm. Use language that involves your audience as a group participant. For example, when looking at visual aids, introduce them by saying "If we look at this table, we can see that . . ." or "This figure shows us that . . ."^2,3 Additionally, be cognizant of the volume and pace of your voice. During key points, you may want to slightly raise your voice and slow your pace for emphasis. Anxiety can make all presenters speed through their material; however, try to be mindful of the rhythm of your speech. With preparation you should be able to accurately gauge the length of your presentation but also adapt to the necessary time constraints if too much time is spent on one point early on. Most would believe that all good lectures end at least a few minutes early to allow for questions and comprehension of the material as well as to provide your audience with time to move on to their next engagement or clinical duty. 

Step 4: Encourage Active Participation

Active audience participation is shown by a multitude of studies to provide the highest level of comprehension.^4,5 In a crossover study conducted by Bleske et al,⁴ 30 students were divided into 2 groups and were taught 6 therapeutic topics, with 3 topics provided by conventional lecture and 3 topics taught by team-based learning. At the end of the educational series, the students were surveyed to evaluate their confidence and attitudes. Students demonstrated not only higher examination scores with team-based learning but higher confidence in their ability to transmit the information garnered through therapeutic recommendations.⁴ Although small, this study highlights the intuitive notion that active learning with subject material, either by sharing ideas with colleagues or having small brainstorming discussions throughout lectures, helps consolidate the information for long-term memory and comprehension.

Additionally, teaching in a medical environment can present unique challenges, as participants may feel anxiety over having right or wrong answers due to fear of inadequacy among their scholarly peers. Neher et al⁶ proposed a 5-step "microskills" model for teaching young physicians, and although it is intended for a clinical setting, it also can be applied to engaging and answering questions from a medical audience in general. Their model focuses on the teacher, or in our case the lecturer, asking a question and then applying the following model: (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes.⁶ After asking your question, the student commits to an answer and must then provide supporting details for their choice, thus feeling more responsible for their collaborative role in problem-solving. Based on their answer, you can then teach your general rule, provide positive feedback on what the student said accurately, and ultimately correct any erroneous information. This prototype of learning is best utilized in the clinical setting but also can enhance participant engagement in lectures while maintaining an inviting educational environment. 

Step 5: Summarize 

Lastly, conclude your presentation with at least 3 memorable points. What was the point of the presentation? What message do you want your audience to take with them and apply to clinical care? Reiterating the key points through repetition is crucial for long-term memory. Leave the audience with additional thoughts for exploration and subsequent discussion. How can your work or topic be further translated into additional projects for investigation? If the lecture material contains abundant clinical information beyond 3 points, a handout can be helpful to avoid having learners struggling to keep up with notes. This piece of take-home material can serve as a tool for subsequent study and to stimulate enhanced memory of the subject material provided. A strong concluding message can consolidate and remind learners of the scope of the topic and highlight the vital information that should be retained.

Final Thoughts

In summary, the clinical lecturer provides a unique teaching experience, and all physicians should feel proficient in formulating and delivering an educational lecture. These simple tips that call for the teacher to know and prepare his/her key message to deliver an animated and engaged presentation and then to summarize key findings are suggestions for the utmost transmission of data and ideas for all learners.

Acknowledgment
A special thank you to Joan E. St. Onge, MD (Miami, Florida), for her help providing resources for this topic. 

As lifelong learners, physicians are encouraged and expected to share their knowledge base with budding residents and students. Effective communication is essential to the utmost delivery of clinical knowledge and pearls. Lecture delivery is important for all stages of learning, and adapting efficient techniques early in one's career is critical for the transmission of ideas and teaching points. These tips were created to help formulate guidelines for physician presentations and are open for interpretation. These well-meaning suggestions can be integrated into one's toolbox to foster an enthusiastic educational arena.

Step 1: Know Your Key Message 

First and foremost, one should ruminate over the overall message of the lecture. Consider at least 3 main points you want the learner to gain and remember on completion of the lecture. Additionally, it is crucial to think about the audience who will be present for your message and how to deliver your ideas clearly and effectively. Be cognizant of the knowledge base of your listeners and gauge how much initial background information is needed; conversely, if the audience is familiar with the material, excessive introductory material may be unnecessary and cause inattentiveness. Simplicity, both within the inherent message itself and the content and layout, can ameliorate the transmission of data regardless of the audience. A mentor once told me that no slide should contain more than 13 lines of text. Furthermore, if you are counting the number of lines, then you likely need to reduce the text and simplify the slide. Each slide should contain a maximum of 3 or 4 bullet points.¹ Convoluted figures should be avoided and key points should be highlighted. Overall, know your take-home message and provide the listener with simplistic text and images to convey the key ideas at their educational level.

Step 2: Prepare

Preparation is of utmost importance. Reading over the slides several times prior to the presentation is vital. You are the assumed expert on the topic and meticulously knowing the subject matter helps with the confidence of your delivery. Ease of subject matter also helps you, as the presenter, to rely less on verbatim reading of the slides and allows you to interact more with your audience. It is important to be familiar with the order of your presentation as well as the phrases and figures provided.² Flipping back and forth through slides can be distracting to the audience and can make the order of your presentation seem incongruous, presenting as a hastily constructed lecture. If you are prepared, you can engage your audience and provide additional information that is not on the slides to maintain interest. Remember that reading the slides can reduce your voice to a monotone, subtracting enthusiasm and energy from the delivery of your talk.² Rehearsal helps give you the freedom to confidently and proudly present your subject material.

Step 3: Be Animated 

You are the main attraction and the performer of this lecture. Radiate the confidence you gained from being prepared with the ability to engage in eye contact and gestures as needed to convey your point. Regularly shift your focus around the room to attempt to involve as many people as possible in your talk.² Your main focus should be your audience and not your slides; the slides should simply help guide your talk.³ During your presentation, you also can ask rhetorical questions that you can then answer to keep the group engaged (eg, "So, what does this tell us?" or "What would you do next?"). These questions demonstrate to your audience that you are interested in their attention and can help reciprocate the enthusiasm. Use language that involves your audience as a group participant. For example, when looking at visual aids, introduce them by saying "If we look at this table, we can see that . . ." or "This figure shows us that . . ."^2,3 Additionally, be cognizant of the volume and pace of your voice. During key points, you may want to slightly raise your voice and slow your pace for emphasis. Anxiety can make all presenters speed through their material; however, try to be mindful of the rhythm of your speech. With preparation you should be able to accurately gauge the length of your presentation but also adapt to the necessary time constraints if too much time is spent on one point early on. Most would believe that all good lectures end at least a few minutes early to allow for questions and comprehension of the material as well as to provide your audience with time to move on to their next engagement or clinical duty. 

Step 4: Encourage Active Participation

Active audience participation is shown by a multitude of studies to provide the highest level of comprehension.^4,5 In a crossover study conducted by Bleske et al,⁴ 30 students were divided into 2 groups and were taught 6 therapeutic topics, with 3 topics provided by conventional lecture and 3 topics taught by team-based learning. At the end of the educational series, the students were surveyed to evaluate their confidence and attitudes. Students demonstrated not only higher examination scores with team-based learning but higher confidence in their ability to transmit the information garnered through therapeutic recommendations.⁴ Although small, this study highlights the intuitive notion that active learning with subject material, either by sharing ideas with colleagues or having small brainstorming discussions throughout lectures, helps consolidate the information for long-term memory and comprehension.

Additionally, teaching in a medical environment can present unique challenges, as participants may feel anxiety over having right or wrong answers due to fear of inadequacy among their scholarly peers. Neher et al⁶ proposed a 5-step "microskills" model for teaching young physicians, and although it is intended for a clinical setting, it also can be applied to engaging and answering questions from a medical audience in general. Their model focuses on the teacher, or in our case the lecturer, asking a question and then applying the following model: (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes.⁶ After asking your question, the student commits to an answer and must then provide supporting details for their choice, thus feeling more responsible for their collaborative role in problem-solving. Based on their answer, you can then teach your general rule, provide positive feedback on what the student said accurately, and ultimately correct any erroneous information. This prototype of learning is best utilized in the clinical setting but also can enhance participant engagement in lectures while maintaining an inviting educational environment. 

Step 5: Summarize 

Lastly, conclude your presentation with at least 3 memorable points. What was the point of the presentation? What message do you want your audience to take with them and apply to clinical care? Reiterating the key points through repetition is crucial for long-term memory. Leave the audience with additional thoughts for exploration and subsequent discussion. How can your work or topic be further translated into additional projects for investigation? If the lecture material contains abundant clinical information beyond 3 points, a handout can be helpful to avoid having learners struggling to keep up with notes. This piece of take-home material can serve as a tool for subsequent study and to stimulate enhanced memory of the subject material provided. A strong concluding message can consolidate and remind learners of the scope of the topic and highlight the vital information that should be retained.

Final Thoughts

In summary, the clinical lecturer provides a unique teaching experience, and all physicians should feel proficient in formulating and delivering an educational lecture. These simple tips that call for the teacher to know and prepare his/her key message to deliver an animated and engaged presentation and then to summarize key findings are suggestions for the utmost transmission of data and ideas for all learners.

Acknowledgment
A special thank you to Joan E. St. Onge, MD (Miami, Florida), for her help providing resources for this topic. 

As lifelong learners, physicians are encouraged and expected to share their knowledge base with budding residents and students. Effective communication is essential to the utmost delivery of clinical knowledge and pearls. Lecture delivery is important for all stages of learning, and adapting efficient techniques early in one's career is critical for the transmission of ideas and teaching points. These tips were created to help formulate guidelines for physician presentations and are open for interpretation. These well-meaning suggestions can be integrated into one's toolbox to foster an enthusiastic educational arena.

Step 1: Know Your Key Message 

First and foremost, one should ruminate over the overall message of the lecture. Consider at least 3 main points you want the learner to gain and remember on completion of the lecture. Additionally, it is crucial to think about the audience who will be present for your message and how to deliver your ideas clearly and effectively. Be cognizant of the knowledge base of your listeners and gauge how much initial background information is needed; conversely, if the audience is familiar with the material, excessive introductory material may be unnecessary and cause inattentiveness. Simplicity, both within the inherent message itself and the content and layout, can ameliorate the transmission of data regardless of the audience. A mentor once told me that no slide should contain more than 13 lines of text. Furthermore, if you are counting the number of lines, then you likely need to reduce the text and simplify the slide. Each slide should contain a maximum of 3 or 4 bullet points.¹ Convoluted figures should be avoided and key points should be highlighted. Overall, know your take-home message and provide the listener with simplistic text and images to convey the key ideas at their educational level.

Step 2: Prepare

Preparation is of utmost importance. Reading over the slides several times prior to the presentation is vital. You are the assumed expert on the topic and meticulously knowing the subject matter helps with the confidence of your delivery. Ease of subject matter also helps you, as the presenter, to rely less on verbatim reading of the slides and allows you to interact more with your audience. It is important to be familiar with the order of your presentation as well as the phrases and figures provided.² Flipping back and forth through slides can be distracting to the audience and can make the order of your presentation seem incongruous, presenting as a hastily constructed lecture. If you are prepared, you can engage your audience and provide additional information that is not on the slides to maintain interest. Remember that reading the slides can reduce your voice to a monotone, subtracting enthusiasm and energy from the delivery of your talk.² Rehearsal helps give you the freedom to confidently and proudly present your subject material.

Step 3: Be Animated 

You are the main attraction and the performer of this lecture. Radiate the confidence you gained from being prepared with the ability to engage in eye contact and gestures as needed to convey your point. Regularly shift your focus around the room to attempt to involve as many people as possible in your talk.² Your main focus should be your audience and not your slides; the slides should simply help guide your talk.³ During your presentation, you also can ask rhetorical questions that you can then answer to keep the group engaged (eg, "So, what does this tell us?" or "What would you do next?"). These questions demonstrate to your audience that you are interested in their attention and can help reciprocate the enthusiasm. Use language that involves your audience as a group participant. For example, when looking at visual aids, introduce them by saying "If we look at this table, we can see that . . ." or "This figure shows us that . . ."^2,3 Additionally, be cognizant of the volume and pace of your voice. During key points, you may want to slightly raise your voice and slow your pace for emphasis. Anxiety can make all presenters speed through their material; however, try to be mindful of the rhythm of your speech. With preparation you should be able to accurately gauge the length of your presentation but also adapt to the necessary time constraints if too much time is spent on one point early on. Most would believe that all good lectures end at least a few minutes early to allow for questions and comprehension of the material as well as to provide your audience with time to move on to their next engagement or clinical duty. 

Step 4: Encourage Active Participation

Active audience participation is shown by a multitude of studies to provide the highest level of comprehension.^4,5 In a crossover study conducted by Bleske et al,⁴ 30 students were divided into 2 groups and were taught 6 therapeutic topics, with 3 topics provided by conventional lecture and 3 topics taught by team-based learning. At the end of the educational series, the students were surveyed to evaluate their confidence and attitudes. Students demonstrated not only higher examination scores with team-based learning but higher confidence in their ability to transmit the information garnered through therapeutic recommendations.⁴ Although small, this study highlights the intuitive notion that active learning with subject material, either by sharing ideas with colleagues or having small brainstorming discussions throughout lectures, helps consolidate the information for long-term memory and comprehension.

Additionally, teaching in a medical environment can present unique challenges, as participants may feel anxiety over having right or wrong answers due to fear of inadequacy among their scholarly peers. Neher et al⁶ proposed a 5-step "microskills" model for teaching young physicians, and although it is intended for a clinical setting, it also can be applied to engaging and answering questions from a medical audience in general. Their model focuses on the teacher, or in our case the lecturer, asking a question and then applying the following model: (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes.⁶ After asking your question, the student commits to an answer and must then provide supporting details for their choice, thus feeling more responsible for their collaborative role in problem-solving. Based on their answer, you can then teach your general rule, provide positive feedback on what the student said accurately, and ultimately correct any erroneous information. This prototype of learning is best utilized in the clinical setting but also can enhance participant engagement in lectures while maintaining an inviting educational environment. 

Step 5: Summarize 

Lastly, conclude your presentation with at least 3 memorable points. What was the point of the presentation? What message do you want your audience to take with them and apply to clinical care? Reiterating the key points through repetition is crucial for long-term memory. Leave the audience with additional thoughts for exploration and subsequent discussion. How can your work or topic be further translated into additional projects for investigation? If the lecture material contains abundant clinical information beyond 3 points, a handout can be helpful to avoid having learners struggling to keep up with notes. This piece of take-home material can serve as a tool for subsequent study and to stimulate enhanced memory of the subject material provided. A strong concluding message can consolidate and remind learners of the scope of the topic and highlight the vital information that should be retained.

Final Thoughts

In summary, the clinical lecturer provides a unique teaching experience, and all physicians should feel proficient in formulating and delivering an educational lecture. These simple tips that call for the teacher to know and prepare his/her key message to deliver an animated and engaged presentation and then to summarize key findings are suggestions for the utmost transmission of data and ideas for all learners.

Acknowledgment
A special thank you to Joan E. St. Onge, MD (Miami, Florida), for her help providing resources for this topic.