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Hepatorenal syndrome: current diagnostic and therapeutic concepts.

Nephrol Dial Transplant. 2007 Sep;22 Suppl 8:viii2-viii4

Authors: Schepke M

PMID: 17890258 [PubMed - indexed for MEDLINE]

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Inpatient insulin therapy.

Curr Opin Endocrinol Diabetes Obes. 2008 Apr;15(2):159-66

Authors: Braithwaite SS

PURPOSE OF REVIEW: In a 2001 report from a surgical intensive care unit in Leuven, Belgium, intravenous insulin infusion targeting blood glucose 80-110 mg/dl reduced patient mortality and morbidities. Subsequent research has failed to define glycemic targets necessary or sufficient for attainment of desired health outcomes in other inpatient settings, but a large body of evidence suggests hospital outcomes are related to hyperglycemia. RECENT FINDINGS: Recent literature describes observational evidence for hypoglycemia as an independent predictor of mortality in a general medical intensive care unit; superiority of performance of computerized intravenous insulin algorithms in comparison to earlier manual algorithms; acceptability of early transition to scheduled basal prandial correction subcutaneous insulin analog therapy for maintenance of glycemic targets after induction of euglycemia by intravenous insulin infusion, among cardiothoracic surgery patients; inferiority of sliding scale insulin compared to basal prandial correction therapy; and feasibility of diabetes patient self-management in the hospital setting. SUMMARY: With development of improved insulin administration strategies problems of hypoglycemia and variability of glycemic control are reduced. Investigators and care providers need to achieve glycemic targets to optimize patient outcomes.

PMID: 18316952 [PubMed - indexed for MEDLINE]

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Prevention and treatment of health care-acquired infections.

Med Clin North Am. 2008 Mar;92(2):295-313, viii

Authors: Gasink LB, Lautenbach E

Health care-acquired infections present a tremendous challenge to the care of hospitalized patients. Unfortunately, the risk of acquiring a health care-associated infection (HAI) is rising. The vast majority of HAI are of four types: urinary tract infections, surgical site infections, bloodstream infections, and pneumonia. This chapter aims to provide current data and strategies relating to the prevention of HAIs among hospitalized patients.

PMID: 18298980 [PubMed - indexed for MEDLINE]

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Diagnosis and management of venous thromboembolism.

Med Clin North Am. 2008 Mar;92(2):443-65, x

Authors: Minichiello T, Fogarty PF

Venous thromboembolic disease is a common disease associated with significant morbidity and mortality. Accurate and timely diagnosis should be guided by the use of validated clinical prediction rules. The mainstay of therapy is anticoagulation, although alternative approaches, such as use of concurrent thrombolysis or placement of vena caval filters, may be appropriate in selected patients. Determination of duration of anticoagulation requires a detailed assessment of the risk factors associated with the event allowing estimation of recurrence risk, and careful assessment of bleeding risk. Although extremely effective, anticoagulants have a narrow therapeutic window; systems should be in place to reduce risk of adverse events associated with these agents.

PMID: 18298988 [PubMed - indexed for MEDLINE]

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Medical informed consent: general considerations for physicians.

Mayo Clin Proc. 2008 Mar;83(3):313-9

Authors: Paterick TJ, Carson GV, Allen MC, Paterick TE

Medical informed consent is essential to the physician’s ability to diagnose and treat patients as well as the patient’s right to accept or reject clinical evaluation, treatment, or both. Medical informed consent should be an exchange of ideas that buttresses the patient-physician relationship. The consent process should be the foundation of the fiduciary relationship between a patient and a physician. Physicians must recognize that informed medical choice is an educational process and has the potential to affect the patient-physician alliance to their mutual benefit. Physicians must give patients equality in the covenant by educating them to make informed choices. When physicians and patients take medical informed consent seriously, the patient-physician relationship becomes a true partnership with shared decision-making authority and responsibility for outcomes. Physicians need to understand informed medical consent from an ethical foundation, as codified by statutory law in many states, and from a generalized common-law perspective requiring medical practice consistent with the standard of care. It is fundamental to the patient-physician relationship that each partner understands and accepts the degree of autonomy the patient desires in the decision-making process.

PMID: 18315998 [PubMed - indexed for MEDLINE]

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Effect of perioperative insulin infusion on surgical morbidity and mortality: systematic review and meta-analysis of randomized trials.7.

Mayo Clin Proc. 2008 Apr;83(4):418-30

Authors: Gandhi GY, Murad MH, Flynn DN, Erwin PJ, Cavalcante AB, Bay Nielsen H, Capes SE, Thorlund K, Montori VM, Devereaux PJ

OBJECTIVE: To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of perioperative insulin infusion on outcomes important to patients. PATIENTS AND METHODS: We used 6 search strategies including an electronic database search of MEDLINE, EMBASE, and Cochrane CENTRAL, from their inception up to May 1, 2006, and included RCTs of perioperative insulin infusion (with or without glucose targets) measuring outcomes in patients undergoing any surgery. Pairs of reviewers working independently assessed the methodological quality and characteristics of included trials and abstracted data on perioperative outcomes (ie, outcomes that occurred during hospitalization or within 30 days of surgery). RESULTS: We identified 34 eligible trials. In the 14 trials that assessed mortality, there were 68 deaths among 2192 patients randomized to insulin infusion compared with 98 deaths among 2163 patients randomized to control therapy (random-effects pooled relative risk, 0.69; 95% confidence interval [CI], 0.51-0.94; 99% CI, 0.46-1.04; I2, 0%; 95% CI, 0.0%-47.4%). Hypoglycemia increased in the intensively treated group (20 trials, 119/1470 patients in insulin infusion vs 48/1476 patients in control group; relative risk, 2.07; 95% CI, 1.29-3.32; 99% CI, 1.09-3.88; I2, 31.5%; 95% CI, 0.0%-59.0%). No significant effect was seen in any other outcomes. The available mortality data represent only 40% of the optimal information size required to reliably detect a plausible treatment effect; potential methodological and reporting biases weaken inferences. CONCLUSION: Perioperative insulin infusion may reduce mortality but increases hypoglycemia in patients who are undergoing surgery; however, mortality results require confirmation in large and rigorous RCTs.

PMID: 18380987 [PubMed - indexed for MEDLINE]

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Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care.

Med Clin North Am. 2008 Mar;92(2):387-406, ix

Authors: Podrazik PM, Whelan CT

A significant portion of hospital care involves elderly patients who have frequent and severe disease presentations, higher risk of iatrogenic injury during hospitalization, and greater baseline vulnerability. These risks frequently result in longer and more frequent hospitalizations. The frailty and complication rates of the elderly population underscore the importance of hospital-based programs of education and screening for cognitive and functional impairments to determine risk and needed additional care and services during hospitalization and at discharge. In addition, physicians are needed to take the lead in instituting programs of prevention and improving the systems of care. It is such a multi-tiered approach, with interventions in the areas of education, screening, prevention, and systems of care improvements, that is needed to improve the clinical care and outcomes of the hospitalized elderly patient.

PMID: 18298985 [PubMed - indexed for MEDLINE]

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Infectious disease emergencies.

Med Clin North Am. 2008 Mar;92(2):427-41, x

Authors: Nicolasora N, Kaul DR

This article reviews principles of recognition and management of a selection of commonly encountered infectious disease emergencies, including sepsis, necrotizing soft tissue infections, acute meningitis, and the emerging issue of severe Clostridium difficile colitis. Less common but potentially deadly environmentally acquired or zoonotic pathogens are discussed, as are special patient populations, including the febrile returning traveler and the asplenic patient.

PMID: 18298987 [PubMed - indexed for MEDLINE]

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Do palliative consultations improve patient outcomes?

J Am Geriatr Soc. 2008 Apr;56(4):593-9

Authors: Casarett D, Pickard A, Bailey FA, Ritchie C, Furman C, Rosenfeld K, Shreve S, Chen Z, Shea JA

OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care. DESIGN: Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life. SETTING: Five VA Medical Centers or their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey. MEASUREMENTS: The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items). RESULTS: Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62-66) versus 54 (95% CI=51-56; P<.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (beta=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support. CONCLUSION: Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.

PMID: 18205757 [PubMed - indexed for MEDLINE]

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Hospital medicine. Preface.

Med Clin North Am. 2008 Mar;92(2):xi-xii

Authors: Flanders SA, Parekh VI, Halasyamani L

PMID: 18298977 [PubMed - indexed for MEDLINE]

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The state of hospital medicine in 2008.

Med Clin North Am. 2008 Mar;92(2):265-73, vii

Authors: Wachter RM

In the mid 1990s, a new model for hospital care began to take hold in the United States, in which a separate physician, who I dubbed a “hospitalist,” assumed the responsibility for managing the inpatient stay in place of the primary care physician. A 2006 American Hospital Association survey indicated that there are more than 20,000 hospitalists in the United States, making this the fastest growing medical specialty in American medical history. In this article, I briefly trace the reasons for the field’s remarkable growth, describe some of hospital medicine’s key issues and concerns, and speculate about the future shape of the field.

PMID: 18298978 [PubMed - indexed for MEDLINE]

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Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital.

Mayo Clin Proc. 2008 Mar;83(3):274-9

Authors: Hecksel KA, Bostwick JM, Jaeger TM, Cha SS

OBJECTIVE: To determine if hospitalized medical and surgical patients were placed inappropriately on symptom-triggered therapy (STT) for alcohol withdrawal syndrome (AWS) and if certain conditions were more likely to be associated with inappropriate STT use or adverse events. PATIENTS AND METHODS: We randomly selected 124 (25%) of the 495 Mayo Clinic inpatients who received STT according to the Revised Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-Ar) protocol in 2003 and assessed them for STT appropriateness, defined as having both intact verbal communication and recent alcohol use. Adverse events, including delirium tremens, seizures, or death, were correlated with CIWA-Ar appropriateness. RESULTS: Of the 124 randomly selected patients, only 60 (48%) met both inclusion criteria. Of the remaining 64 patients, 9 (14%) were drinkers but could not communicate, and 35 (55%) could communicate but had not been drinking. Twenty (31%) met neither criterion. Univariate analysis identified a significant association between inappropriate initiation and chronic heart failure, postoperative status (POS), liver disease (LD), nonmetastatic cancer, and chemical dependency consultation. On multivariate analysis, only LD (P equals .02) and POS (P equals .01) retained significance, with LD more and POS less likely to predict appropriateness. Seven of 11 patients who experienced adverse events had received STT according to the CIWA-Ar protocol (P equals .05). Univariate analysis identified a significant association between adverse events and a history of alcohol dependence or AWS. Multivariate analysis showed significance only for a history of alcohol dependence (P equals .049). CONCLUSION: Fewer than half of the randomly selected patients met both of the inclusion criteria for the CIWA-Ar instrument, leading us to conclude that more stringent evaluation is needed. Particularly postoperatively, alternative explanations for putative AWS should be sought. Health care professionals should more aggressively seek information on recent alcohol use from medical records, family members, and patients themselves.

PMID: 18315992 [PubMed - indexed for MEDLINE]

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Implementing patient safety interventions in your hospital: what to try and what to avoid.

Med Clin North Am. 2008 Mar;92(2):275-93, vii-viii

Authors: Ranji SR, Shojania KG

Hospitalists play an important role in improving patient safety through clinical expertise and leadership in hospital quality improvement activities. The evidence base in patient safety remains incomplete, despite an increasing body of published research in recent years. Thus, physicians must consider other factors in addition to the strength of evidence supporting a practice when deciding which patient safety interventions to implement. These factors include the prevalence of the safety problem targeted, the potential for unintended consequences of the intervention, the costs and complexity of implementing the intervention, and the potential of the intervention to generate momentum for further safety initiatives. In this article, the authors define a framework for evaluating patient safety interventions and discuss specific interventions hospitalists should consider.

PMID: 18298979 [PubMed - indexed for MEDLINE]

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Care transitions for hospitalized patients.

Med Clin North Am. 2008 Mar;92(2):315-24, viii

Authors: Arora VM, Farnan JM

Ensuring safe care transitions is a core part of hospital medicine. These transitions include inpatient-outpatient transitions and in-hospital transitions. To ensure safe care during these transitions, clinicians should be aware of the types of transitions and the way in which these transitions can impede safe patient care. With this knowledge, strategies to ensure patient safety during care transitions can be adopted and training directed at teaching physicians safe hands-off practices could be developed and supported.

PMID: 18298981 [PubMed - indexed for MEDLINE]

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Perioperative medicine for the hospitalized patient.

Med Clin North Am. 2008 Mar;92(2):325-48, viii

Authors: Grant PJ, Wesorick DH

Given the increasing complexity of hospitalized patients and the increasing specialization among surgeons, there is greater reliance on hospitalists for preoperative assessment. Several institutions have developed surgery/medicine comanagement teams that jointly care for patients in the perioperative setting. Despite a growing body of evidence, it is important to recognize there are many gaps in the perioperative literature. This has led to considerable dependence on consensus statements and expert opinion when evaluating patients perioperatively. This review focuses on the preoperative cardiovascular and pulmonary evaluation of the hospitalized patient: the two systems responsible for the greatest morbidity and mortality. Prevention of postoperative venous thromboembolism and management of perioperative hyperglycemia are also discussed.

PMID: 18298982 [PubMed - indexed for MEDLINE]

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