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CAUTION! Consider cancer: common symptoms and signs for early detection of cancer in young adults.

Semin Oncol. 2009 Jun;36(3):207-12

Authors: Bleyer A

Because young adults frequently have longer delays in diagnosis of their cancers than younger or older persons, healthcare providers who encounter this age group should become more aware of diagnostic clues for early detection. The spectrum of cancer types and their relative frequencies is distinctly different in young adults than the array in younger and older persons, such that the symptoms and signs in aggregate are distinctly different. Of potential value in recognizing manifestations of cancer in young adults is a mnemonic-friendly list of seven symptoms each represented by a letter in CAUTION, and seven sites of signs starting with the letter B. These aids have the potential of assisting in early detection, accurate diagnosis, longer survival, and a reduced risk of premature death.

PMID: 19460578 [PubMed - indexed for MEDLINE]

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‘It depends’: medical residents’ perspectives on working with nurses.

Am J Nurs. 2009 Jul;109(7):34-43; quiz 44

Authors: Weinberg DB, Miner DC, Rivlin L

OBJECTIVE: Using the theory of relational coordination, which holds that in high-pressure settings such as hospitals, high-quality communication and strong relationships are necessary for coordinated action, we sought to determine the quality of the nurse-physician relationship by examining the communication and interaction between nurses and residents from the residents’ perspective. METHODS: A sample of 20 medical and surgical residents, selected by a snowball sampling technique, were interviewed about the quality of their communication and relationships with nurses in the workplace. RESULTS: Residents’ responses were influenced by their perceptions of nurses’ cooperativeness and competence, and their impressions of nurses’ professional preparation and demeanor varied widely. Although 19 of 20 residents reported instances of poor communication or problematic relationships with nurses, most believed that this posed no significant threat to patient care because the nurses’ role, as they saw it, was one of simply following orders. CONCLUSIONS: Given the strong doubts some residents expressed about nurses’ cooperativeness and competence, the nursing profession should consider strengthening nursing education and clearly delineating nurses’ roles and competencies.

PMID: 19546639 [PubMed - indexed for MEDLINE]

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The origin of the recent swine influenza A(H1N1) virus infecting humans.

Euro Surveill. 2009;14(17):

Authors: Trifonov V, Khiabanian H, Greenbaum B, Rabadan R

Preliminary analysis of the genome of the new H1N1 influenza A virus responsible for the current pandemic indicates that all genetic segments are related closest to those of common swine influenza viruses.

PMID: 19422769 [PubMed - indexed for MEDLINE]

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Neurologic complications associated with novel influenza A (H1N1) virus infection in children – Dallas, Texas, May 2009.

MMWR Morb Mortal Wkly Rep. 2009 Jul 24;58(28):773-8

Authors:

Neurologic complications, including seizures, encephalitis, encephalopathy, Reye syndrome, and other neurologic disorders, have been described previously in association with respiratory tract infection with seasonal influenza A or B viruses, but not with novel influenza A (H1N1) virus. On May 28, 2009, the Dallas County Department of Health and Human Services (DCHHS) notified CDC of four children with neurologic complications associated with novel influenza A (H1N1) virus infection admitted to hospitals in Dallas County, Texas, during May 18-28. This report summarizes the clinical characteristics of those four cases. Patients were aged 7-17 years and were admitted with signs of influenza-like illness (ILI) and seizures or altered mental status. Three of the four patients had abnormal electroencephalograms (EEGs). In all four patients, novel influenza A (H1N1) viral RNA was detected in nasopharyngeal specimens but not in cerebrospinal fluid (CSF). Antiviral therapy included oseltamivir (four patients) and rimantadine (three patients). All four patients recovered fully and had no neurologic sequelae at discharge. These findings indicate that, as with seasonal influenza, neurologic complications can occur after respiratory tract infection with novel influenza A (H1N1) virus. For children who have ILI accompanied by unexplained seizures or mental status changes, clinicians should consider acute seasonal influenza or novel influenza A (H1N1) virus infection in the differential diagnosis, send respiratory specimens for appropriate diagnostic testing, and promptly initiate empirical antiviral treatment, especially in hospitalized patients.

PMID: 19629027 [PubMed - indexed for MEDLINE]

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In the clinic. Preoperative evaluation.

Ann Intern Med. 2009 Jul 7;151(1):ITC1-15, quiz ITC16

Authors: Laine C, Williams SV, Wilson JF

The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians’ Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP’s Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic. The information contained herein should never be used as a substitute for clinical judgment. CME OBJECTIVE: To review strategies to evaluate and reduce perioperative risk.

PMID: 19581642 [PubMed - indexed for MEDLINE]

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Computerized physician order entry in critical care.

Best Pract Res Clin Anaesthesiol. 2009 Mar;23(1):27-38

Authors: Colpaert K, Decruyenaere J

Computerized physician order entry means prescribing of medication and ordering laboratory tests or radiology examinations in an electronic way instead of using paper forms. In itself, it offers advantages such as legible orders, faster order completion, inventory management and automatic billing. If combined with clinical decision support, the real benefits of CPOE become apparent in the first place by prevention of medication errors and adverse drug events. On the contrary, if CPOE configuration is not done carefully, adverse drug events can be facilitated. Therefore, and for reasons of end-user acceptance, implementation is challenging. CPOE has the potential for significant economic saving. However, the initial implementation cost is high.

PMID: 19449614 [PubMed - indexed for MEDLINE]

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The interrelationships between working conditions, job satisfaction, burnout and mental health among hospital physicians in Japan: a path analysis.

Ind Health. 2009 Apr;47(2):166-72

Authors: Tokuda Y, Hayano K, Ozaki M, Bito S, Yanai H, Koizumi S

A growing number of physicians are leaving their hospitals because of painful working conditions in hospitals throughout Japan. We set out to analyze the interrelationships between working conditions, job satisfaction, burnout and mental health among Japanese physicians. A cross-sectional survey was conducted in 2007 for hospital physicians throughout Japan. A path analysis based on structural equation modeling was utilized for examining the interrelationships between work control, on-call duty volume, job satisfaction (the Japan Hospital Physicians Satisfaction Scale), burnout (the Japanese version of the Maslach Burnout Inventory) and mental health (the General Health Questionnaire). Of 336 physicians who received a solicitation E-mail, 236 participated in our study (response rate, 70%). Sixty physicians (25.4%) were women with a mean age of 41 yr. In the path analysis, burnout and poor mental health were related directly to job dissatisfaction and short sleeping time, while they were related indirectly to poor work control and heavy on-call duty. In the multi-group path analysis of both genders, sleeping time was related to job satisfaction more likely among female physicians but less among male physicians. Healthcare policy makers need to implement immediate, extensive and decisive measures to improve work condition and to reduce overwork among hospital physicians.

PMID: 19367046 [PubMed - indexed for MEDLINE]

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Smoking among hospitalized patients in a general hospital.

J Bras Pneumol. 2008 Nov;34(11):936-41

Authors: Oliveira MV, Oliveira TR, Pereira CA, Bonfim AV, Leitão Filho FS, Voss LR

OBJECTIVE: To determine the frequency of smoking among hospitalized patients in a general hospital, and to evaluate their profile. METHODS: A random representative sample of 111 patients, classified as nonsmokers, former smokers or smokers, was evaluated. The smokers were submitted to the Fagerström test and measurement of expired carbon monoxide. Expired carbon monoxide higher than 6 ppm was considered a significant indicator of recent smoking. RESULTS: Of the 111 patients in the sample, 60 (54%) were female. The mean age was 70 years. Of the 111 patients, 56 (51%) had never smoked, 36 (32%) were former smokers, and 19 (17%) were smokers. All of the smokers were male. The smokers were younger (58 +/- 17 years) than the nonsmokers (68 +/- 14 years) and the former smokers (73 +/- 14 years)–ANOVA: F = 6.57 (p = 0.002). Among the smokers, the mean tobacco intake was 43 pack-years and the mean Fagerström score was 5.0. Of the 19 smokers, 11 (58%) had respiratory symptoms and 3 had withdrawal symptoms. The mean expired carbon monoxide in the smokers was 5.0 ppm. Expired carbon monoxide levels were higher than 6 ppm in 8 (42%) of the smokers. There was a higher prevalence of smokers in some wards: 70% of all smokers were hospitalized on only five wards. CONCLUSIONS: In a large tertiary hospital, 17% of the hospitalized patients were smokers, and 7% had smoked within the last 8 hours. The smokers were younger men, hospitalized on specific wards.

PMID: 19099100 [PubMed - indexed for MEDLINE]

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Medication errors resulting from computer entry by nonprescribers.

Am J Health Syst Pharm. 2009 May 1;66(9):843-53

Authors: Santell JP, Kowiatek JG, Weber RJ, Hicks RW, Sirio CA

PURPOSE: The characteristics of medication errors associated with the use of computer order-entry systems by nonprescribers are discussed. METHODS: A retrospective analysis of records submitted to MEDMARX was conducted for the period from July 1, 2001, to December 31, 2005, to identify all computer-related medication errors made by nonprescribers. Quantitative analysis of the records included the severity of each error, the origin within the medication-use process, the type of error, principal causes, the location within the facility where the error was made, and the therapeutic drug classes frequently involved. Similar data from the University of Pittsburgh Medical Center (UPMC) were also analyzed and compared with the national data set. RESULTS: During the 4.5 years, 693 unique facilities submitted 90,001 medication error records that were the result of computer entry by nonprescribers. The national data set and the UPMC data had similar findings for error severity, error origin, and type of error but showed some differences in the rank ordering of error causes, location where the error occurred, and drug classes frequently associated with such errors. The percentage of harm associated with computer-entry errors was small for both the national data set and UPMC data (0.99% and 0.80%, respectively). Both data sets cited performance deficit as the leading cause of computer-entry errors, but large percentage differences were seen with other causes, including inaccurate or omitted transcription (30% versus 12.6%, respectively), documentation (19.5% versus 10.6%, respectively), and procedure or protocol not followed (21.7% versus 30.3%, respectively). Both data sets implicated the inpatient pharmacy department as the location where most computer-entry errors occurred (49.3% versus 69.0%, respectively). CONCLUSION: Analysis of the characteristics of medication errors associated with the use of computer-entry systems by non-prescribers from both MEDMARX and an individual health system database demonstrated that computer systems create new opportunities for errors to occur. Working closely with information technology personnel dedicated to assisting pharmacy departments and vendors, adequate training of pharmacy staff, and development of national standards for drug information displays in computer order-entry systems may help minimize such errors.

PMID: 19386948 [PubMed - indexed for MEDLINE]

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Respiratory care of the hospitalized patient with cystic fibrosis.

Respir Care. 2009 Jun;54(6):769-75; discussion 775-6

Authors: Newton TJ

Hospitalization can occur at any age for patients with cystic fibrosis (CF). The leading cause for admission is an acute worsening of signs and symptoms that can be called a pulmonary exacerbation. The reasons for admission are usually the need for intravenous antibiotics and aggressive airway clearance with good nutritional support. Respiratory therapists (RTs) play a key role in the care of CF patients in the out-patient clinics and taking care of the patients while hospitalized. Following the CF pulmonary guidelines, they administer aerosol delivery and airway clearance while also providing education to patients and families. The RT should have the skills to perform and teach all manners of airway clearance and understand the medications and delivery devices that make up a CF treatment. As CF lung disease progresses, so does the chance that these patients may develop complications such as pneumothorax and hemoptysis, which may require different strategies, especially when airway clearance is performed. The RT needs to have the skills that can take the patient from simple oxygen therapy as lung function deteriorates to the point where chronic oxygen or noninvasive ventilation is needed, or to the point where the end-stage patient waits for a lung transplant. An important aspect of the hospitalization is the interaction between the RT and the patient. To give good therapy is to be a great coach. From infection control to following proper nebulizer protocol, to consistency with airway clearance, to education, the CF RT is there for the life of the patient.

PMID: 19467163 [PubMed - indexed for MEDLINE]

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Interexpert agreement on diagnosis of bacteriuria and urinary tract infection in hospitalized older adults.

J Am Osteopath Assoc. 2009 Apr;109(4):220-6

Authors: Gau JT, Shibeshi MR, Lu IJ, Rafique M, Heh V, Meyer D, Carlsen WR

CONTEXT: Although bacteriuria with acute coexisting illness is common in hospitalized older adults, distinguishing it from urinary tract infection (UTI) can be challenging. OBJECTIVES: To examine the rate of agreement between two geriatricians in distinguishing UTI from asymptomatic bacteriuria (ASB). To analyze the incidence of associated acute comorbidities and determine if an association exists between clinical manifestations and bacteriuria status on acute hospital admission. METHODS: Two physicians conducted a retrospective analysis of 296 inpatient records, including 142 records from age- and condition-matched nonbacteriuria control subjects. Using consensus criteria to diagnose UTI vs ASB, these independent experts evaluated inpatient records, including admission and discharge diagnoses as well as urinalysis results. A kappa statistic was used to determine reviewer agreement. Risk assessment was measured by odds ratio with a 95% confidence interval. RESULTS: Expert agreement for the diagnosis of UTI and ASB was 98% and 44%, respectively. Agreement was reached at a level greater than chance (z=6.74, P<.001, kappa=0.49). In the 30 cases where interexpert agreement was not reached, half of the subjects had acute pulmonary disease. Symptom crossover for this comorbid condition is the likely cause for lack of diagnostic agreement. Among other conditions observed, delirium was most common in UTI subjects. CONCLUSION: Limited interexpert agreement seemed to result from difficulty in diagnosing patients who had no local symptoms but acute comorbid conditions with potential symptom crossover. Among the conditions observed in our sample population, delirium was most closely associated with UTI.

PMID: 19369509 [PubMed - indexed for MEDLINE]

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The association between the serum sodium level and the severity of complications in liver cirrhosis.

Korean J Intern Med. 2009 Jun;24(2):106-12

Authors: Kim JH, Lee JS, Lee SH, Bae WK, Kim NH, Kim KA, Moon YS

BACKGROUND/AIMS: Dilutional hyponatremia associated with liver cirrhosis is caused by impaired free water clearance. Several studies have shown that serum sodium levels correlate with survival in cirrhotic patients. Little is known, however, regarding the relationship between the degree of dilutional hyponatremia and development of cirrhotic complications. The aim of this study was to evaluate the association between the serum sodium level and the severity of complications in liver cirrhosis. METHODS: Data of inpatients with cirrhotic complications were collected retrospectively. The serum sodium levels and severity of complications of 188 inpatients were analyzed. RESULTS: The prevalence of dilutional hyponatremia, classified as serum sodium concentrations of <or=135 mmol/L, <or=130 mmol/L, and <or=125 mmol/L, were 20.8%, 14.9%, and 12.2%, respectively. The serum sodium level was strongly associated with the severity of liver function impairment as assessed by Child-Pugh and MELD scores (p<0.0001). Even a mild hyponatremia with a serum sodium concentration of 131-135 mmol/L was associated with severe complications. Sodium levels less than 130 mmol/L indicated the existence of massive ascites (OR, 2.685; CI, 1.316-5.477; p=0.007), grade III or higher hepatic encephalopathy (OR, 5.891; CI, 1.490-23.300; p=0.011), spontaneous bacterial peritonitis (OR, 2.562; CI, 1.162-5.653; p=0.020), and hepatic hydrothorax (OR, 5.723; CI, 1.889-17.336; p=0.002). CONCLUSIONS: Hyponatremia, especially serum levels <or=130 mmol/L, may indicate the existence of severe complications associated with liver cirrhosis.

PMID: 19543488 [PubMed - indexed for MEDLINE]

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Economic and clinical evaluation of fondaparinux vs. enoxaparin for thromboprophylaxis following general surgery.

Curr Med Res Opin. 2009 May;25(5):1081-7

Authors: Farias-Eisner R, Horblyuk R, Franklin M, Lunacsek OE, Happe LE

PURPOSE: Patients undergoing general surgical procedures are at increased risk for venous thromboembolism (VTE). Compliance rates with established guidelines for VTE thromboprophylaxis in patients at moderate-to-high risk are notably low. Recent literature has demonstrated that fondaparinux is associated with lower costs and fewer VTEs than enoxaparin in patients undergoing major orthopedic surgery (MOS), but data are limited in patients undergoing general surgery. This study was conducted to evaluate the cost implications and relative real-world effectiveness of fondaparinux vs. enoxaparin in general surgery patients. METHODS: Data were obtained from inpatient billing records from over 500 hospitals using Premier's Perspective Comparative Database. Patients hospitalized for general surgery between July 1, 2003 and January 31, 2006 were eligible for inclusion. Eligible patients were included if they received fondaparinux or enoxaparin after their general surgery date. Patients were excluded if they received both anticoagulants on their first day of therapy, were <18 years of age on the surgery date, or did not have data 6 months prior and 1 month post hospitalization. Included patients were stratified into two cohorts based on their first anticoagulant, fondaparinux or enoxaparin. Patients were matched in each group on 1:1 case-control matching based on propensity scores. RESULTS: A total of 5364 patients were included (n = 2682 for each cohort) from 326 unique hospitals. Average total costs per patient for the fondaparinux group were significantly lower than the enoxaparin group ($15 156 vs. 17 741, p < 0.0001). Patients receiving fondaparinux were significantly less likely to experience a VTE (2.80 vs. 3.77%, p = 0.046, a 35% relative risk reduction). No significant differences in bleeding events between the cohorts were observed (p = 0.6047), and no significant differences in all-cause inpatient death were noted (p = 0.3673). CONCLUSION: Fondaparinux was associated with significantly lower costs and fewer VTEs compared to enoxaparin without an increase in bleed rates or all-cause inpatient mortality. The findings from this study are limited by the retrospective study design and should only be generalized to a similar patient population.

PMID: 19298219 [PubMed - indexed for MEDLINE]

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Incidence and temporal pattern of hospital readmissions for patients with atrial fibrillation.

Curr Med Res Opin. 2009 May;25(5):1215-20

Authors: Kim MH, Lin J, Hussein M, Battleman D

BACKGROUND: Atrial fibrillation (AF) is prevalent and has a high cost burden. Among the main drivers of cost is inpatient care; however, little is known about patterns of hospital readmissions for AF. OBJECTIVE: To evaluate the incidence and temporal pattern of readmission in AF patients. METHODS: This retrospective, cohort analysis used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database for 2002-2006. Patients hospitalized for AF (primary discharge diagnosis) were identified. Data on the first readmission for AF over 1 year following an index hospitalization were analyzed for chronic AF (any AF-related claims in 1 year before index hospitalization) and newly-diagnosed AF patients (no prior AF-related claims). RESULTS: Overall, 4174 patients hospitalized with primary AF were identified; 1637 had chronic AF and 2537 newly-diagnosed AF. Mean age of chronic AF patients was 62.4 years and 61.2% were male; for newly-diagnosed AF, mean age was 61.4 years and 57.8% were male. In the year following index hospitalization, 12.5% of chronic AF patients were readmitted for AF, with a mean time to readmission of 142.5 days (median 108 days). Among newly-diagnosed AF patients, 10.1% were readmitted for AF, with a mean time to readmission of 133.8 days (median 112 days). For chronic AF, 17.6%, 43.4%, and 65.8% of readmissions occurred within 1, 3, and 6 months, respectively, versus 22.7%, 44.5%, and 67.2%, respectively, for newly-diagnosed AF. LIMITATIONS: Limited data were available on patients’ clinical profile, treatment patterns, or the reasons for hospitalization/readmission. The term chronic AF only captured patients with a history of AF and data were not available to classify patients according to the presence of paroxysmal, permanent, or persistent AF. CONCLUSIONS: Patients with newly-diagnosed or chronic AF are often readmitted in the year following hospitalization with most readmissions occurring within 6 months of the index hospitalization.

PMID: 19327101 [PubMed - indexed for MEDLINE]

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Management of procedural pain: empowering nurses to care for patients through clinical nurse specialist consultation and intervention.

Clin Nurse Spec. 2009 May-Jun;23(3):131-7

Authors: Rawe C, Trame CD, Moddeman G, O’Malley P, Biteman K, Dalton T, Miller A, Sillaman B, Walker S

OBJECTIVE: The purpose of this study was to assess the incidence of pain in inpatient and outpatient populations experiencing invasive procedures. BACKGROUND: Nursing staff consulted the clinical nurse specialist regarding a patient they assessed who was not medicated appropriately and experienced significant procedural pain. As a result, a Procedural Pain Task Force was created to research the incidence of procedural pain and create evidence-based practice protocols. METHODS: A convenience sample of 358 patients undergoing diagnostic or therapeutic invasive procedures (surgery excluded) was studied. Variables for analysis included demographic data, procedure type, medication, and perceived pain before, during, and after the procedures. RESULTS: Patients who were not premedicated had lower mean pain scores (mean, 1.81) than patients who did receive medication before a potentially painful procedure (mean, 3.64). Age was negatively correlated with perceived pain; thus, the greater the patient age, the lower the pain score. Sex, premedication, and type of procedure were positively correlated with perceived pain scores. Sixty-three subjects reporting pain scores of 5 or greater during a procedure were further evaluated. CONCLUSIONS: Results were used to develop procedural pain guidelines and a physician order set as well as a medication reference grid to assist clinicians in the management of procedural pain. Furthermore, nurses were empowered by the revised guidelines to advocate for relief of pain based on the nursing assessment.

PMID: 19395889 [PubMed - indexed for MEDLINE]

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