Apr 252015
 
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Physical performance measures and polypharmacy among hospitalized older adults: results from the CRIME study.

J Nutr Health Aging. 2014;18(6):616-21

Authors: Sganga F, Vetrano DL, Volpato S, Cherubini A, Ruggiero C, Corsonello A, Fabbietti P, Lattanzio F, Bernabei R, Onder G

Abstract
OBJECTIVE: To investigate the association of polypharmacy and physical performance measures in a sample of elderly patients aged ≥65 years admitted to acute care hospitals.
DESIGN, SETTING AND PARTICIPANTS: Prospective study conducted among 1123 hospitalized older adults participating to the CRiteria to Assess Appropriate Medication Use among Elderly Complex Patients (CRIME) project.
MEASUREMENTS: Physical performance was measured at hospital admission by the 4-meter walking speed (WS) and the grip strength (GS). Polypharmacy was defined as the use of ≥10 drugs during hospital stay.
RESULTS: Mean age of 1123 participants was 81.5±7.4 years and 576 (51.3%) were on polypharmacy. Prevalence of polypharmacy was higher in patients with low WS and GS. After adjusting for potential confounders, participants in the highest tertile of WS were less likely to be on polypharmacy as compared with those in the lowest tertile (OR 0.58; 95% CI 0.35 - 0.96). Similarly, participants in the highest tertile of GS had a significantly lower likelihood of polypharmacy as compared with those in the lowest tertile (OR 0.55; 95% CI 0.36 - 0.84). When examined as continuous variables, WS and GS were inversely associated with polypharmacy (WS: OR 0.77 per 1 SD increment; 95% CI 0.60 - 0.98; GS: OR 0.71 per 1 SD increment; 95% CI 0.56 - 0.90).
CONCLUSION: Among hospitalized older adults WS and GS are inversely related to polypharmacy. These measures should be incorporated in standard assessment of in-hospital patients.

PMID: 24950153 [PubMed - indexed for MEDLINE]

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Apr 252015
 
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Clinical course and outcome of acute severe asthma (status asthmaticus) in adults.

J Pak Med Assoc. 2014 Nov;64(11):1292-6

Authors: Khawaja A, Shahzad H, Kazmi M, Zubairi AB

Abstract
OBJECTIVE: To evaluate the clinical course and outcomes in patients with acute severe asthma in a tertiary care setting.
METHODS: The retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients of age 16 and above who were admitted with a diagnosis of acute severe asthma from January 2000 to December 2013. These patients had undergone clinical evaluation to assess the severity of illness as well as the complications and eventual outcomes. SPSS 16 was used for statistical analysis.
RESULTS: Of the 50 patients in the study, 41 (82%) were females. The overall mean age was 53.1±20.3 years. Ventilator support was required by 37(74%) patients. Presence of acidaemia was associated with the need for invasive ventilation (p<0.033) which in turn was associated with increased hospital stay (p<0.043). Complications were observed in 37(74%) patients, the most common being respiratory failure in 35(70%) and arrhythmias in 8(16%). Use of both non-invasive and invasive ventilation was found to be significantly associated with development of complications (p<0.001 and p<0.009). A total of 4(8%) patients died. Presence of acidaemia was found to be significantly associated with mortality (p<0.032).
CONCLUSION: Overt acidaemia at initial presentation in patients with acute severe asthma was significantly associated with higher rates of invasive ventilation leading to increased hospital stay, complications and higher mortality rate.

PMID: 25831649 [PubMed - indexed for MEDLINE]

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Apr 252015
 
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The OSCE progress test - Measuring clinical skill development over residency training.

Med Teach. 2015 Apr 24;:1-6

Authors: Pugh D, Touchie C, Humphrey-Murto S, Wood TJ

Abstract
PURPOSE: The purpose of this study was to explore the use of an objective structured clinical examination for Internal Medicine residents (IM-OSCE) as a progress test for clinical skills.
METHODS: Data from eight administrations of an IM-OSCE were analyzed retrospectively. Data were scaled to a mean of 500 and standard deviation (SD) of 100. A time-based comparison, treating post-graduate year (PGY) as a repeated-measures factor, was used to determine how residents' performance progressed over time.
RESULTS: Residents' total IM-OSCE scores (n = 244) increased over training from a mean of 445 (SD = 84) in PGY-1 to 534 (SD = 71) in PGY-3 (p < 0.001). In an analysis of sub-scores, including only those who participated in the IM OSCE for all three years of training (n = 46), mean structured oral scores increased from 464 (SD = 92) to 533 (SD = 83) (p < 0.001), physical examination scores increased from 464 (SD = 82) to 520 (SD = 75) (p < 0.001), and procedural skills increased from 495 (SD = 99) to 555 (SD = 67) (p = 0.033). There was no significant change in communication scores (p = 0.97).
CONCLUSIONS: The IM-OSCE can be used to demonstrate progression of clinical skills throughout residency training. Although most of the clinical skills assessed improved as residents progressed through their training, communication skills did not appear to change.

PMID: 25909896 [PubMed - as supplied by publisher]

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Apr 252015
 
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Corticosteroids for the management of cancer-related pain in adults.

Cochrane Database Syst Rev. 2015 Apr 24;4:CD010756

Authors: Haywood A, Good P, Khan S, Leupp A, Jenkins-Marsh S, Rickett K, Hardy JR

Abstract
BACKGROUND: One of the most feared symptoms associated with cancer is pain. Opioids remain the mainstay of pain treatment but corticosteroids are often used concurrently as co- or adjuvant analgesics. Due to their anti-inflammatory mechanism of action, corticosteroids are said to provide effective analgesia for pain associated with inflammation and in the management of cancer-related complications such as brain metastasis and spinal cord compression. However, corticosteroids have a wide range of adverse effects that are dose and time dependent.
OBJECTIVES: To evaluate the efficacy of corticosteroids in treating cancer-related pain in adults.
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 4), MEDLINE (OVID) (1966 to 29 September 2014), EMBASE (OVID) (1970 to 29 September 2014), CINAHL (1982 to 29 September 2014), Science Citation Index (Web of Science) (1899 to 29 September 2014) and Conference Proceedings Citation Index - Science (Web of Science) (1990 to 29 September 2014).
SELECTION CRITERIA: Any randomised or prospective controlled trial that included patients over 18 years with cancer-related pain were eligible for the review. Corticosteroids were compared to placebo or usual treatment and/or supportive care.
DATA COLLECTION AND ANALYSIS: All review authors independently assessed trial quality and extracted data. We used arithmetic means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI).
MAIN RESULTS: Fifteen studies met the inclusion criteria, enrolling 1926 participants. The trial size varied from 20 to 598 patients. Most studies compared corticosteroids, particularly dexamethasone, to standard therapy. We included six studies with data at one week in the meta-analysis for pain intensity; no data were available at that time point for the remaining studies. Corticosteroid therapy resulted in less pain (measured on a scale of 0 to 10 with a lower score indicating less pain) compared to control at one week (MD 0.84 lower pain, 95% CI 1.38 to 0.30 lower; low quality evidence). Adverse events were poorly documented. Factors limiting statistical analysis included the lack of standardised measurements of pain and the use of different agents, dosages, comparisons and routes of drug delivery. Subgroup analysis according to type of cancer was not possible. The quality of this evidence was limited by the risk of bias of the studies and small sample size. The results were also compromised by attrition, with data missing for the enrolled patients.
AUTHORS' CONCLUSIONS: The evidence for the efficacy of corticosteroids for pain control in cancer patients is weak. Significant pain relief was noted in some studies, albeit only for a short period of time. This could be important for patients with poor clinical status. Further trials, with increased numbers of participants, are needed to evaluate the safety and effectiveness of corticosteroids for the management cancer pain in adults, and to establish an ideal dose, duration of therapy and route of administration.

PMID: 25908299 [PubMed - as supplied by publisher]

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Apr 252015
 
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A comparison of outcomes among hospital survivors with and without severe comorbidity admitted to the intensive care unit.

Anaesth Intensive Care. 2015 Mar;43(2):230-7

Authors: Williams TA, McConigley R, Leslie GD, Dobbs GJ, Phillips M, Davies H, Aoun S

Abstract
Little is known about the experiences of patients with severe comorbidity discharged from Intensive Care Units (ICUs). This project aimed to determine the effects of an ICU stay for patients with severe comorbidity by comparing 1) quality of life (QOL), 2) the symptom profile of hospital survivors and 3) health service use after hospital discharge for patients admitted to ICU with and without severe comorbidity. A case-control study was used. Patients with severe comorbidity were matched to a contemporaneous cohort of ICU patients by age and severity of illness. Assessment tools were the Medical Outcome Study 36-item short-form and European Organisation for Research and Treatment of Cancer QLQ-C15-PAL questionnaires for QOL and the Symptom Assessment Scale for symptom distress. A proportional odds assumption was performed using an ordinal regression model. The difference in QOL outcome was the dependent variable for each pair. Health service use after discharge from ICU was monitored with patient diaries. Patients aged 18+ years admitted to an ICU in a metropolitan teaching hospital between 2011 and 2012 were included. We recruited 30 cases and 30 controls. QOL improved over the six months after hospital discharge for patients with and without severe comorbidity (P <0.01) within the groups but there was no difference found between the groups (P >0.3). There was no difference in symptoms or health service use between patients with and without severe comorbidity. ICU admission for people with severe comorbidity can be appropriate to stabilise the patient's condition and is likely to be followed by some overall improvement over the six months after hospital discharge.

PMID: 25735690 [PubMed - indexed for MEDLINE]

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Apr 252015
 
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Performance Improvement-Based Resuscitation Programme Reduces Arrest Incidence and Increases Survival from In-Hospital Cardiac arrest.

Resuscitation. 2015 Apr 20;

Authors: Davis DP, Graham PG, Husa RD, Lawrence B, Minokadeh A, Altieri K, Sell RE

Abstract
BACKGROUND: Traditional resuscitation training models are inadequate to achieving and maintaining resuscitation competency. This analysis evaluates the effectiveness of a novel, performance improvement-based inpatient resuscitation programme.
METHODS: This was a prospective, before-and-after study conducted in an urban, university-affiliated hospital system. All inpatient adult cardiac arrest victims without an active Do Not Attempt Resuscitation order from July 2005 to June 2012 were included. The Advanced Resuscitation Training (ART) programme was implemented in Spring 2007 and included a unique treatment algorithm constructed around the capabilities of our providers and resuscitation equipment, a training programme with flexible format and content including early recognition concepts, and a comprehensive approach to performance improvement feeding directly back into training. Our inpatient resuscitation registry and electronic patient care record were used to quantify arrest rates and survival-to-hospital discharge before and after ART programme implementation. Multiple logistic regression analysis was used to adjust for age, gender, location of arrest, initial rhythm, and time of day.
RESULTS: A total of 556 cardiac arrest victims were included (182 pre- and 374 post-ART). Arrest incidence decreased from 2.7 to 1.2 per 1,000 patient discharges in non-ICU inpatient units, with no change in ICU arrest rate. An increase in survival-to-hospital discharge from 21 to 45 percent (p<0.01) was observed following ART programme implementation. Adjusted odds ratios for survival-to-discharge (OR 2.2, 95% CI 1.4-3.4) and good neurological outcomes (OR 3.0, 95% CI 1.7-5.3) reflected similar improvements. Arrest-related deaths decreased from 2.1 to 0.5 deaths per 1,000 patient discharges in non-ICU areas and from 1.5 to 1.3 deaths per 1,000 patient discharges in ICU areas, and overall hospital mortality decreased from 2.2% to 1.8%.
CONCLUSIONS: Implementation of a novel, performance improvement-based inpatient resuscitation programme was associated with a decrease in the incidence of cardiac arrest and improved clinical outcomes.

PMID: 25906942 [PubMed - as supplied by publisher]

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