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What technique should I use to measure cardiac output?

Curr Opin Crit Care. 2007 Jun;13(3):308-17

Authors: Hofer CK, Ganter MT, Zollinger A

PURPOSE OF REVIEW: Several less invasive cardiac output monitoring techniques are now commercially available and have the potential to replace the pulmonary artery catheter under certain clinical circumstances. The aim of this review is to give a synopsis of the currently available cardiac output measurement methods. This information should help in selecting the appropriate technique in a particular clinical setting. RECENT FINDINGS: An overview is given of the currently available techniques for cardiac output monitoring. Recent validation studies demonstrate that pulse wave analysis may be used reliably as an alternative to the pulmonary artery catheter in different clinical settings. The use of transesophageal echocardiography and Doppler measurements is limited due to high operator dependency, the partial carbon dioxide rebreathing technique should be applied in a precisely defined clinical setting to mechanically ventilated patients only, and pulsed dye densitometry as well as the bioimpedance technique are currently primarily applied in an investigational setting. SUMMARY: Less invasive cardiac output monitoring techniques may replace the pulmonary artery catheter in different clinical settings considering the specific properties of these techniques. The pulmonary artery catheter, however, may still be recommended for cardiac output measurement in specific clinical situations when monitoring of pulmonary artery pressures is desirable.

PMID: 17468564 [PubMed - indexed for MEDLINE]

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Respiratory rate: the neglected vital sign.

Med J Aust. 2008 Jun 2;188(11):657-9

Authors: Cretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A

The level of documentation of vital signs in many hospitals is extremely poor, and respiratory rate, in particular, is often not recorded. There is substantial evidence that an abnormal respiratory rate is a predictor of potentially serious clinical events. Nurses and doctors need to be more aware of the importance of an abnormal respiratory rate as a marker of serious illness. Hospital systems that encourage appropriate responses to an elevated respiratory rate and other abnormal vital signs can be rapidly implemented. Such systems help to raise and sustain awareness of the importance of vital signs.

PMID: 18513176 [PubMed - indexed for MEDLINE]

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Guidelines for management of small bowel obstruction.

J Trauma. 2008 Jun;64(6):1651-64

Authors: Diaz JJ, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, Collier BR, Cullinane DC, Dwyer KM, Griffen MM, Mayberry JC, Jerome R

PMID: 18545135 [PubMed - indexed for MEDLINE]

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Refeeding syndrome: what it is, and how to prevent and treat it.

BMJ. 2008 Jun 28;336(7659):1495-8

Authors: Mehanna HM, Moledina J, Travis J

PMID: 18583681 [PubMed - indexed for MEDLINE]

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Efficacy and safety of high-dose ampicillin/sulbactam vs. colistin as monotherapy for the treatment of multidrug resistant Acinetobacter baumannii ventilator-associated pneumonia.

J Infect. 2008 Jun;56(6):432-6

Authors: Betrosian AP, Frantzeskaki F, Xanthaki A, Douzinas EE

OBJECTIVE: To compare the safety and efficacy of ampicillin/sulbactam (Amp/Sulb) and colistin (COL) in the treatment of multidrug resistant Acinetobacter baumannii ventilator-associated pneumonia (VAP). METHODS: A prospective cohort study in adult critically ill patients with VAP. Patients were randomly assigned to receive Amp/Sulb (9 g every 8h) or COL (3 MIU every 8h) intravenously. Dosage was adjusted according to creatinine clearance. RESULTS: A total of 28 patients were enrolled (15 COL, 13 Amp/Sulb). Resolution of symptoms and signs occurred in 60% (9/15) of the COL group and 61.5% (9/13) of the Amp/Sulb group, improvement in 13.3% (2/15) vs. 15.3% (1/13) and failure in 26.6% (4/15) vs. 23% (3/13), respectively. The difference was not statistically significant. Bacteriologic success was achieved in 66.6% (10/15) vs. 61.5% (8/13) in the COL and Amp/Sulb groups, respectively (p<0.2). Mortality rates (14 days and 28 days) were 15.3% and 30% for the Amp/Sulb and 20% and 33% for the COL group, respectively. Adverse events were 39.6% (including 33% nephrotoxicity) for the COL group and 30.7% (15.3% nephrotoxicity) for the Amp/Sulb group (p=NS). CONCLUSION: Colistin and high-dose ampicillin/sulbactam were comparably safe and effective treatments for critically ill patients with MDR A. baumannii VAP.

PMID: 18501431 [PubMed - indexed for MEDLINE]

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Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out.

Med J Aust. 2008 Jun 2;188(11):633-40

Authors: Grayson ML, Jarvie LJ, Martin R, Johnson PD, Jodoin ME, McMullan C, Gregory RH, Bellis K, Cunnington K, Wilson FL, Quin D, Kelly AM,

OBJECTIVE: To assess the efficacy of a multimodal, centrally coordinated, multisite hand hygiene culture-change program (HHCCP) for reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and disease in Victorian hospitals. DESIGN, PARTICIPANTS AND SETTING: A pilot HHCCP was conducted over a 24-month period (October 2004 to September 2006) in six Victorian health care institutions (4 urban, 2 rural; total beds, 2379). Subsequently, we assessed the efficacy of an identical program implemented throughout Victorian public hospitals over a 12-month period (beginning between March 2006 and July 2006). MAIN OUTCOME MEASURES: Rates of hand hygiene (HH) compliance; rates of MRSA disease (patients with bacteraemia and number of clinical isolates per 100 patient discharges [PD]). RESULTS: Mean HH compliance improved significantly at all pilot program sites, from 21% (95% CI, 20%-22%) at baseline to 48% (95% CI, 47%-49%) at 12 months and 47% (95% CI, 46%-48%; range, 31%-75%) at 24 months. Mean baseline rates for the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates were 0.05/100 PD per month (range, 0.00-0.13) and 1.39/100 PD per month (range, 0.16-2.39), respectively. These were significantly reduced after 24 months to 0.02/100 PD per month for bacteraemia (P = 0.035 for trend; 65 fewer patients with bacteraemia) and 0.73/100 PD per month for MRSA isolates (P = 0.003; 716 fewer isolates). Similar findings were noted 12 months after the statewide roll-out, with an increase in mean HH compliance (from 20% to 53%; P < 0.001) and reductions in the rates of MRSA isolates (P = 0.043) and bacteraemias (P = 0.09). CONCLUSIONS: Pilot and subsequent statewide implementation of a multimodal HHCCP was effective in significantly improving HH compliance and reducing rates of MRSA infection.

PMID: 18513171 [PubMed - indexed for MEDLINE]

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Efficacy and safety of colesevelam in patients with type 2 diabetes mellitus and inadequate glycemic control receiving insulin-based therapy.

Arch Intern Med. 2008 Jul 28;168(14):1531-40

Authors: Goldberg RB, Fonseca VA, Truitt KE, Jones MR

BACKGROUND: Poor glycemic control is a risk factor for microvascular complications in patients with type 2 diabetes mellitus. Achieving glycemic control safely with insulin therapy can be challenging. METHODS: A prospective, 16-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study conducted at 50 sites in the United States and 1 site in Mexico between August 12, 2004, and December 28, 2005. Subjects had type 2 diabetes mellitus that was not adequately controlled (glycated hemoglobin level, 7.5%-9.5%, inclusive) receiving insulin therapy alone or in combination with oral antidiabetes agents. In total 287 subjects (52% men; mean age, 57 years; with a mean baseline glycated hemoglobin level of 8.3%) were randomized: 147 to receive colesevelam hydrochloride, 3.75 g/d, and 140 to receive placebo. RESULTS: Using the least squares method, the mean (SE) change in glycated hemoglobin level from baseline to week 16 was -0.41% (0.07%) for the colesevelam-treated group and 0.09% (0.07%) for the placebo group (treatment difference, -0.50% [0.09%]; 95% confidence interval, -0.68% to -0.32%; P < .001). Consistent reductions in fasting plasma glucose and fructosamine levels, glycemic-control response rate, and lipid control measures were observed with colesevelam. As expected, the colesevelam-treated group had a 12.8% reduction in low-density lipoprotein cholesterol concentration relative to placebo (P < .001). Of recipients of colesevelam and placebo, respectively, 30 and 26 discontinued the study prematurely; 7 and 9 withdrew because of protocol-specified hyperglycemia, and 10 and 4 withdrew because of adverse events. Both treatments were generally well tolerated. CONCLUSIONS: Colesevelam treatment seems to be safe and effective for improving glycemic control and lipid management in patients with type 2 diabetes mellitus receiving insulin-based therapy, and it may provide a novel treatment for improving dual cardiovascular risk factors. Trial Registration clinicaltrials.gov Identifier: NCT00151749.

PMID: 18663165 [PubMed - in process]

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Patient Assessments of the Most Important Medical Decision During a Hospitalization.

J Gen Intern Med. 2008 Jul 29;

Authors: Perneger TV, Charvet-Bérard A, Perrier A

BACKGROUND: How medical decisions are made in real-life situations is largely unexplored. We explored patients’ perceptions of decision-making during a hospitalization and examined the conformity of the decision process with expert recommendations. OBJECTIVE: To describe the conformity of the decision-making process with current expert opinion and examine the associations between various aspects of the decision-making process and a global assessment of the decision. METHODS: Mail survey of patients discharged from a teaching hospital in Geneva, Switzerland. Patients identified the main medical decision during their stay, and rated the decision process (11-item “decision process score”) and their satisfaction with the decision (five-item “decision satisfaction score”). Both scores were scaled between 0 (worst) and 100 (best). PARTICIPANTS: The survey had 1467 respondents. MAIN RESULTS: In total 862 (58.8%) of 1467 respondents reported having made a medical decision while in the hospital. The decision process score (mean 78.5, SD 21.5) and the decision satisfaction score (mean 86.5, SD 20.4) were moderately correlated (r = 0.62). Men, healthier patients, patients discharged from the department of surgery, and those who reported sharing the decision with their doctor gave the highest ratings on both scales. Five process variables were independently associated with high satisfaction with the decision: the doctor explained all possible treatments and examinations, the patient was aware of risks at the time of the decision, the doctor’s explanations were easy to understand, the patient was involved in the decision as much as desired or more, and the patient was not pressured into the decision. CONCLUSIONS: A majority of patients discharged from a general hospital were able to identify and rate a medical decision. Recommended features of the process of medical decision-making were associated with greater satisfaction with the decision.

PMID: 18663541 [PubMed - as supplied by publisher]

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Pleural fluid viscosity may help identifying malignant pleural effusions.

Respirology. 2008 May;13(3):341-5

Authors: Chang LC, Hua CC, Liu YC, Chu CM, Chen HJ, Lee N

BACKGROUND AND OBJECTIVE: Cancer cells are larger in size and more rigid than blood cells. As the size and rigidity of cells contribute to blood viscosity, an association may exist between high pleural fluid viscosity and cancer cells in pleural effusions. The aim of this study was to determine the correlation between pleural fluid viscosity and cell constituents or laboratory data in pleural diseases with different aetiologies. METHODS: Fluid viscosities were determined in pleural effusions obtained via thoracocentesis. Pleural fluid viscosities were correlated with the laboratory data and with the percentages of different cellular constituents as assessed by cytological examination. RESULTS: Pleural fluid viscosity was highest in malignant pleural effusions with positive results on cytological examination, and was correlated with the percentages of tumour cells (Spearman’s rho = 0.24, P = 0.037) and mitotic figures (rho = 0.23, P = 0.041) in the exudates. Multivariate logistic regression analysis showed that pleural fluid viscosity was a significant determinant of positive results on cytological examination (odds ratio (OR) 6.26, 95% confidence interval (CI) 1.32-29.8), as were the levels of protein (OR 1.48, 95% CI 1.01-2.16) and LDH (OR 1.001, 95% CI 1-1.002). CONCLUSION: High pleural fluid viscosity may suggest a potential diagnosis of malignant pleural effusion.

PMID: 18399854 [PubMed - indexed for MEDLINE]

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Midodrine versus albumin in the prevention of paracentesis-induced circulatory dysfunction in cirrhotics: a randomized pilot study.

Am J Gastroenterol. 2008 Jun;103(6):1399-405

Authors: Singh V, Dheerendra PC, Singh B, Nain CK, Chawla D, Sharma N, Bhalla A, Mahi SK

OBJECTIVES: Intravenous albumin has been used to prevent paracentesis-induced circulatory dysfunction (PICD) in cirrhotics; however, its use is costly and controversial. Splanchnic arterial vasodilatation is primarily responsible for PICD. There are no reports of use of midodrine in the prevention of PICD. In this pilot study, we evaluated midodrine and albumin in the prevention of PICD. METHODS: Forty patients with cirrhosis underwent therapeutic paracentesis with midodrine or albumin in a randomized controlled trial at a tertiary center. Effective arterial blood volume was assessed by plasma renin activity. RESULTS: Plasma renin activity at baseline and at 6 days after paracentesis did not differ in the two groups (43.18 +/- 10.73 to 45.90 +/- 8.59 ng/mL/h, P= 0.273 in the albumin group and 44.44 +/- 8.44 to 41.39 +/- 10.21 ng/mL/h, P= 0.115 in the midodrine group). Two patients had an increase in plasma renin activity of more than 50% from baseline in the albumin group, and none in the midodrine group. A significant increase in 24-h urine volume and urine sodium excretion was noted in the midodrine group. Midodrine therapy was cheaper than albumin therapy. CONCLUSIONS: The study suggests that midodrine may be as effective as albumin in preventing PICD in cirrhotics, but at a fraction of the cost, and can be administered orally. Midodrine also resulted in an increase in 24-h urine volume and sodium excretion.

PMID: 18547224 [PubMed - indexed for MEDLINE]

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Evaluating the effect of resident involvement on physician productivity in an academic general internal medicine practice.

Acad Med. 2008 Jul;83(7):670-4

Authors: Johnson T, Shah M, Rechner J, King G

PURPOSE: To estimate the effect of resident involvement across three years of resident training in a general internal medicine practice on the productivity of faculty physicians at Rush University Medical Center. METHOD: Productivity was measured by work relative value units (RVUs) per clinical full-time equivalent attending physician generated in the ambulatory practice between July 2004 and June 2005. Random-effects linear regression models were used to estimate the impact of resident involvement by year of resident on attending physician productivity, controlling for faculty physician demographic characteristics. RESULTS: Resident involvement significantly reduced physician productivity. Each first-year resident was associated with a loss of 0.81 work RVUs per attending physician per four-hour clinic session. Each second-year and third-year resident was associated with a loss of 0.88 work RVUs and 0.49 work RVUs per attending physician per session, respectively. The loss per resident per session translated into a loss of 2,447 work RVUs for the year for the practice. CONCLUSIONS: Physician productivity significantly decreased with resident involvement, but the impact varied across resident training years. The loss in productivity for the year was $164,000 in revenue or $49 per resident per session. Results of this study provide insight into the importance of considering teaching responsibilities when establishing productivity targets, particularly in practices where the level of teaching involvement varies across faculty physicians. External benchmarks with other general internal medicine practices would be more accurate when resident teaching responsibilities are accounted for.

PMID: 18580086 [PubMed - indexed for MEDLINE]

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Does responsibility drive learning? Lessons from intern rotations in general practice.

Med Teach. 2008 May;30(3):254-9

Authors: Cantillon P, Macdermott M

BACKGROUND: The intern (or pre-registration) year has been criticised in the past for its emphasis on service delivery at the expense of educational achievement. It is hoped that new approaches to early postgraduate training such as the foundation programmes in the UK, will make clinical education more structured and effective. Intern placements in non-traditional settings such as general practice have been shown in the past to improve the quality of learning. Little is known however about which features of the general practice learning environment contribute most to the perception of improved learning. AIMS: This aim of this study was to examine the learning environment in general practice from the perspective of interns, (the learners), to determine the factors that contribute most to motivating effective learning in a general practice setting. METHODS: This study used a qualitative case study approach to explore the effects of two different learning environments, (general practice and hospital) on learner motivation amongst a small group of interns. RESULTS: We found that the biggest difference between the hospital and general practice learning environments was the increased individual responsibility for patient care experienced by interns in general practice. Greater responsibility was associated with greater motivation for learning. CONCLUSIONS: Increased intern responsibility for patient care does appear to motivate learning. More work needs to be done on providing interns in hospital posts with greater patient responsibility within an effective supervisory structure.

PMID: 18484451 [PubMed - indexed for MEDLINE]

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Anatomy of the ward round.

Eur J Intern Med. 2008 Jul;19(5):309-13

Authors: O’Hare JA

The ward round has been a central activity of hospital life for hundreds of years. It is hardly mentioned in textbooks. The ward round is a parade through the hospital of professionals where most decision making concerning patient care is made. However the traditional format may be intimidating for patients and inadequate for communication. The round provides an opportunity for the multi-disciplinary team to listen to the patient’s narrative and jointly interpret his concerns. From this unfolds diagnosis, management plans, prognosis formation and the opportunity to explore social, psychological, rehabilitation and placement issues. Physical examination of the patient at the bedside still remains important. It has been a tradition to discuss the patient at the bedside but sensitive matters especially of uncertainty may better be discussed elsewhere. The senior doctor as round leader must seek the input of nursing whose observations may be under-appreciated due to traditional professional hierarchy. Reductions in the working hours of junior doctors and shortened length of stay have reduced continuity of patient care. This increases the importance of senior staff in ensuring continuity of care and the need for the joint round as the focus of optimal decision making. The traditional round incorporates teaching but patient’s right to privacy and their preferences must be respected. The quality and form of the clinical note is underreported but the electronic record is slow to being accepted. The traditional multi-disciplinary round is disappearing in some centres. This may be regrettable. The anatomy and optimal functioning of the ward round deserves scientific scrutiny and experimentation.

PMID: 18549930 [PubMed - indexed for MEDLINE]

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A national survey of the prevalence and impact of Clostridium difficile infection among hospitalized inflammatory bowel disease patients.

Am J Gastroenterol. 2008 Jun;103(6):1443-50

Authors: Nguyen GC, Kaplan GG, Harris ML, Brant SR

BACKGROUND: We sought to determine nationwide, population-based trends in rates of Clostridium difficile (C. difficile) infection among hospitalized inflammatory bowel disease (IBD) patients in the United States, and to determine its mortality and economic impact. METHODS: We analyzed discharge records from the Nationwide Inpatient Sample, and used the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify Crohn’s disease (CD) and ulcerative colitis (UC) cases, and cases of C. difficile infection between 1998 and 2004. Temporal patterns of C. difficile incidence in IBD patients were compared to non-IBD gastroenterology patients and all-hospitalized patients. The impact of C. difficile on in-hospital mortality and resource utilization was quantified using multiple regression analysis. RESULTS: The prevalence of C. difficile among UC patients (37.3 per 1,000, 95% confidence interval [CI] 34.0-40.7 per 1,000) was higher than that among CD patients (10.9 per 1,000, 95% CI 9.9-12.0 per 1,000), non-IBD gastrointestinal (GI) patients (4.8 per 1,000, 95% CI 4.6-5.0 per 1,000), and general medical patients (4.5 per 1,000, 95% CI 4.2-4.7 per 1,000). C. difficile incidence nearly doubled among UC patients (26.6 per 1,000 to 51.2 per 1,000) over 7 yr. After adjustment for confounders, C. difficile infection was associated with greater mortality among patients with UC (odds ratio [OR] 3.79, 95% CI 2.84-5.06), but not CD (OR 1.66, 95% CI 0.75-3.66). C. difficile was also associated with 65% and 46% longer lengths of stay, which correlated with 63% and 46% higher average hospital charges, for CD and UC patients, respectively. CONCLUSIONS: C. difficile infection is a growing public health issue among hospitalized IBD patients, especially those with UC, and is associated with higher mortality and resource utilization, prompting the need for better preventative measures and early detection.

PMID: 18513271 [PubMed - indexed for MEDLINE]

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Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes–proceedings of the HCAP Summit.

Clin Infect Dis. 2008 Apr 15;46 Suppl 4:S296-334; quiz 335-8

Authors: Kollef MH, Morrow LE, Baughman RP, Craven DE, McGowan JE, Micek ST, Niederman MS, Ost D, Paterson DL, Segreti J

Increasingly, patients are receiving treatment at facilities other than hospitals, including long-term-health care facilities, assisted-living environments, rehabilitation facilities, and dialysis centers. As with hospital environments, nonhospital settings present their own unique risks of pneumonia. Traditionally, pneumonia in these facilities has been categorized as community-acquired pneumonia (CAP). However, the new designation for pneumonias acquired in these settings is health care-associated pneumonia (HCAP), which covers pneumonias acquired in health care environments outside of the traditional hospital setting and excludes hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and CAP. Although HCAP is currently treated with the same protocols as CAP, recent evidence indicates that HCAP differs from CAP with respect to pathogens and prognosis and, in fact, more closely resembles HAP and VAP. The HCAP Summit convened national infectious disease opinion leaders for the purpose of analyzing current literature, clinical trial data, diagnostic considerations, therapeutic options, and treatment guidelines related to HCAP. After an in-depth analysis of these areas, the infectious disease investigators participating in the summit were surveyed with regard to 10 clinical practice statements. The results were then compared with results of the same survey as completed by 744 Infectious Diseases Society of America members. The similarities and differences between those survey results are the basis of this publication.

PMID: 18429676 [PubMed - in process]

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