Apr 202014
 
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What is a hospital? Future roles and prospects for success: the business of medicine: a course for physician leaders.

Yale J Biol Med. 2013 Sep;86(3):413-24

Authors: Shalowitz J

Abstract
As hospitals consolidate and take on more financial and clinical risk, they face numerous obstacles. While the past can provide answers to solving many of the challenges, some issues are new and require innovative approaches. This article, from a speech delivered to The Business of Medicine: A Course for Physician Leaders symposium presented by Yale-New Haven Hospital and the Medical Directors Leadership Council at Yale University in November 2012, discusses the models for these hospital organizations and the pitfalls they will face in coordinating care. The insights will help these systems overcome potential problems and enhance their chances of success.

PMID: 24058316 [PubMed - indexed for MEDLINE]

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Apr 202014
 
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Transfer of Patients with ST-Elevation Myocardial Infarction for Primary Percutaneous Coronary Intervention: A Province-Wide Evaluation of "Door-in to Door-Out" Delays at the First Hospital.

Circulation. 2014 Apr 17;

Authors: Lambert LJ, Brown KA, Boothroyd LJ, Segal E, Maire S, Kouz S, Ross D, Harvey R, Rinfret S, Xiao Y, Nasmith J, Bogaty P

Abstract
BACKGROUND: Inter-hospital transfer of patients with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PPCI) is associated with longer delays to reperfusion, related partly to turnaround ('door-in' to 'door-out', DIDO) time at the initial hospital. As part of a systematic, province-wide evaluation of STEMI care, we examined DIDO times and associations with patient, hospital and process-of-care factors.
METHODS AND RESULTS: We performed medical chart review for STEMI patients transferred for PPCI during a 6-month period (October 1, 2008 - March 31, 2009), and linked these data to ambulance service databases. Two core laboratory cardiologists reviewed presenting ECGs to identify left bundle branch block (LBBB) and, in absence of LBBB, "definite STEMI" (according to both) or an "ambiguous" reading. Median DIDO time was 51 minutes (25(th) - 75(th) percentile: 35 - 82); 14.1% of the 988 patients had a timely DIDO interval (≤30 minutes as guideline-recommended). The "data-to-decision" delay was the major contributor to DIDO time. Female sex, more comorbidities, longer symptom duration, arrival by means other than ambulance, arrival at a hospital not exclusively transferring for PPCI, arrival at a low STEMI volume center and an ambiguous ECG were independently associated with longer DIDO time. When turnaround was timely, 70% of patients received timely PPCI (door-to-device ≤90 minutes), versus 14% if not (p<0.0001).
CONCLUSIONS: Benchmark DIDO times for STEMI patients transferred for PPCI were rarely achieved. Interventions aimed at facilitating the transfer decision, particularly when faced with 'difficult-to-interpret' ECGs, are likely to have the best impact on reducing delay to reperfusion.

PMID: 24744277 [PubMed - as supplied by publisher]

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Apr 202014
 
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Comparison of In-Hospital Outcomes for Beta-Blocker Use Versus Non-Beta Blocker Use in Patients Presenting With Cocaine-Associated Chest Pain.

Am J Cardiol. 2014 Mar 15;

Authors: Fanari Z, Kennedy KK, Lim MJ, Laddu AA, Stolker JM

Abstract
Beta blockers are indicated for management of acute coronary syndromes, but they generally are withheld in patients with cocaine-associated chest pain because of concerns for adverse outcomes related to the unique physiological effects of cocaine. Because few clinical studies have evaluated this interaction, we identified patients with toxicology screen results positive for cocaine treated for chest pain at 2 academic hospitals. Clinical characteristics and in-hospital outcomes were compared between patients with and without β-blocker therapy. We then constructed propensity scores to evaluate the independent relation between β-blocker use and the composite primary end point of myocardial infarction, stroke, ventricular arrhythmia, or all-cause mortality after adjusting for clinical characteristics. Of 376 consecutive patients with cocaine-related chest pain, β blockers were used in 164 (44%). Compared with no β blockers, patients treated with β blockers were more likely to describe anginal chest pain, to have known cardiovascular risk factors, and to receive other antiatherosclerotic therapies. Despite these higher risk clinical characteristics, patients treated with β blockers experienced similar peak troponin levels, individual adverse events, and rates of the composite primary end point (15.9% vs 12.3%, p = 0.32). The primary end point also was similar after propensity score analysis (odds ratio 1.37, 95% confidence interval 0.64 to 2.93, p = 0.42), including specific comparisons of beta-1 selective (odds ratio 1.83, 95% confidence interval 0.79 to 4.24) and nonselective (odds ratio 0.90, 95% confidence interval 0.33 to 2.42) β blockers, when compared with patients not receiving β blockers. In conclusion, no differences in outcomes were observed between patients treated versus not treated with β-blocker therapy in the setting of cocaine-related chest pain.

PMID: 24742472 [PubMed - as supplied by publisher]

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Apr 202014
 
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Oral iodinated activated charcoal improves lung function in patients with COPD.

Respir Med. 2014 Mar 12;

Authors: Skogvall S, Erjefält JS, Olin AI, Ankerst J, Bjermer L

Abstract
The effect of 8 weeks treatment with oral iodinated activated charcoal (IAC) on lung function of patients with moderate chronic obstructive pulmonary disease (COPD) was examined in a double blind randomized placebo controlled parallel group study with 40 patients. In the IAC group, patients showed a statistically significant improvement of FEV1 baseline by 130 ml compared to placebo, corresponding to 8.2% improvement (p = 0.031*). Correlation statistics revealed that the improvement of FEV1 baseline was significantly correlated both to FEV1 post-bronchodilator (p = 0.0020**) and FEV1 post-exercise (0.033*) values. This demonstrates that the improved baseline lung function by IAC did not inhibit a further beta2-adrenoceptor relaxation, and thus that patients did not reach a limit for maximal improvement of the lung function after IAC treatment. Eight patients in the IAC group developed abnormal thyroid hormone levels transiently during the treatment. This side effect was not correlated to improvement of lung function (p = 0.82). No serious adverse effects directly related to the treatment were recorded. In summary, this study demonstrates that iodinated activated charcoal surprisingly and significantly improved lung function of patients with moderate COPD. The underlying mechanism of action is unclear, but is likely to be different from the drugs used today. The immediate conclusion is that further studies are now justified in order to determine clinical efficacy of IAC in COPD and explore possible mechanisms of action.

PMID: 24742364 [PubMed - as supplied by publisher]

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Apr 202014
 
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A real-time electronic alert to improve detection of acute kidney injury in a large teaching hospital.

Nephrol Dial Transplant. 2014 Apr 16;

Authors: Porter CJ, Juurlink I, Bisset LH, Bavakunji R, Mehta RL, Devonald MA

Abstract
BACKGROUND: Acute kidney injury (AKI) is a common and serious problem in hospitalized patients. Early detection is critical for optimal management but in practice is currently inadequate. To improve outcomes in AKI, development of early detection tools is essential.
METHODS: We developed an automated real-time electronic alert system employing algorithms which combined internationally recognized criteria for AKI [Risk, Injury, Failure, Loss, End-stage kidney disease (RIFLE) and Acute Kidney Injury Network (AKIN)]. All adult patients admitted to Nottingham University Hospitals were included. Where a patient's serum creatinine increased sufficiently to define AKI, an electronic alert was issued, with referral to an intranet-based AKI guideline. Incidence of AKI Stages 1-3, in-hospital mortality, length of stay and distribution between specialties is reported.
RESULTS: Between May 2011 and April 2013, 59 921 alerts resulted from 22 754 admission episodes, associated with 15 550 different patients. Overall incidence of AKI for inpatients was 10.7%. Highest AKI stage reached was: Stage 1 in 7.2%, Stage 2 in 2.2% and Stage 3 in 1.3%. In-hospital mortality for all AKI stages was 18.5% and increased with AKI stage (12.5, 28.4, 35.7% for Stages 1, 2 and 3 AKI, respectively). Median length of stay was 9 days for all AKI.
CONCLUSIONS: This is the first fully automated real time AKI e-alert system, using AKIN and RIFLE criteria, to be introduced to a large National Health Service hospital. It has provided one of the biggest single-centre AKI datasets in the UK revealing mortality rates which increase with AKI stage. It is likely to have improved detection and management of AKI. The methodology is transferable to other acute hospitals.

PMID: 24744280 [PubMed - as supplied by publisher]

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Apr 202014
 
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Glycopeptide use is associated with increased mortality in Enterococcus faecalis bacteraemia.

J Antimicrob Chemother. 2014 Apr 16;

Authors: Foo H, Chater M, Maley M, van Hal SJ

Abstract
OBJECTIVES: Enterococci are an important cause of nosocomial and community-acquired infections, with bacteraemia being one of the most common presentations. Although inappropriate antimicrobial therapy has been associated with poorer outcomes in Enterococcus faecalis (EF) bacteraemia, the impact of antimicrobial choice, namely β-lactam versus glycopeptide therapy, has not been well described. We sought to determine whether choice of antibiotic affects patient outcomes in EF bacteraemia.
PATIENTS AND METHODS: This retrospective cohort study was conducted at Liverpool and Bankstown Lidcombe Hospitals, Sydney, Australia between 2006 and 2013. Medical records and laboratory data for consecutive EF bacteraemias were reviewed. Clinical and microbiological data were obtained for all patients who received appropriate antimicrobial therapy with either a β-lactam or a glycopeptide antibiotic. Outcomes and predictors of mortality were determined and treatment groups were compared.
RESULTS: One hundred and seventy-two episodes of clinically significant EF bacteraemias received appropriate antimicrobial therapy with a β-lactam (n = 126) or a glycopeptide (n = 46). All-cause 30 day mortality was 15.1%, with mortality significantly higher in patients receiving glycopeptide therapy compared with β-lactam therapy (26.1% versus 11.1%, P = 0.015). Glycopeptide therapy remained an independent predictor of 30 day mortality [OR 2.46 (95% CI 1.01-6.02), P = 0.048]. APACHE II score [OR 1.10 (95% CI 1.02-1.18), P = 0.011] and malignancy [OR 2.58 (95% CI 1.03-6.49), P = 0.044] were also independent predictors of 30 day mortality.
CONCLUSIONS: Glycopeptide use is associated with increased mortality in patients with EF bacteraemia. In the treatment of β-lactam-susceptible EF bacteraemia, β-lactams should be considered first-line therapy.

PMID: 24744303 [PubMed - as supplied by publisher]

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