Background-Patients undergo major physical and psychological changes after implantation of a left ventricular assist device as destination therapy (DT). We sought to qualitatively study outcomes and attitudes of patients after DT. Methods and Results-Ambulatory outpatients with DT at our institution were invited to be interviewed between June and August 2011. In-person interviews were audio-recorded, transcribed, and analyzed qualitatively using thematic analysis.

AimsLeft ventricular assist devices (LVADs) are implanted to support the circulation of patients with advanced heart failure. Patients approaching death, or their surrogates, may request withdrawal of LVAD support. We sought to study the attitudes and practices of heart failure clinicians regarding withdrawal of LVAD support in patients approaching death. Methods and resultsUsing internet-based and secure methods, we surveyed members of the European Society of Cardiology-Heart Failure Association (ESC-HFA), the International Society for Heart and Lung Transplantation (ISHLT), and the Heart Failure Society of America (HFSA) to assess their attitudes and practices regarding LVAD withdrawal for patients approaching death. The results indicated that clinicians have varied attitudes and practices regarding withdrawing LVAD support in these patients. Furthermore, ESC-HFA clinicians (primarily European) and ISHLT and HFSA clinicians (primarily North American) differed in their attitudes and practices regarding withdrawal of LVAD support, particularly its ethical and legal permissibility. For example, more European clinicians than North American clinicians regarded withdrawing LVAD support as a form of euthanasia. ConclusionOpinions and level of comfort with LVAD withdrawal vary among clinicians. Clinicians should be aware of suggested approaches or guidelines for managing requests for withdrawal of LVAD therapy.--

The Food and Drug Administration recently approved topiramate for migraine prevention in adolescents. Given the well-established appetite-suppressant side effects of topiramate, as well as data suggesting a potential comorbidity between migraine and eating disorders, susceptible young migraine patients may be at a greater risk for the development or worsening of eating disorder symptoms with topiramate therapy. This case series comprises 7 adolescent patients in whom serious eating disorders developed or were exacerbated after the initiation of topiramate therapy. Clinical characteristics of these patients are highlighted. In addition, this case series provides guidelines for providers to use in assessing eating disorders before prescribing topiramate for migraine prevention in adolescents.

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Although almost one-third of the patients had an AD, less than half specifically mentioned HPN in it, which suggests that such patients should be encouraged to execute an AD that specifically addresses end-of-life management of HPN.

A unique quality improvement (QI) curriculum was implemented within the Division of General Internal Medicine to improve QI knowledge through multidisciplinary, team-based education, which also met the QI requirement for the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) and the Mayo Quality Fellows program. Participants completed up to 4 QI learning modules, including pretest and posttest assessments. A participant who successfully completed all 4 modules received certification as a Silver Quality Fellow and credit toward the quality requirement for ABIM MOC. Of 62 individuals invited to participate, 33 (53%) completed all 4 modules and corresponding pretests and posttests. Participants substantially improved knowledge in all 4 quality modules. Study group participants' pretest scores averaged 71.0%, and their posttest scores averaged 92.7%. Posttest scores of reference group participants compared favorably, averaging 89.2%. Initial assessments showed substantial knowledge improvements and successful implementation of staff-developed QI projects.

Conclusions. Over one in five older adults in the US experiences dyspnea. Older adults with dyspnea are about 50% more likely to develop new or worsened disability or die during the next 4 years. Implications for Research, Policy, or Practice. There is no perfect test for dyspnea. As with pain, asking about dyspnea should be a routine component of care for older adults. Results. Forty-two (44%) program directors participated in the survey out of 94 ACGME accredited 456 Vol. 49 No.