Diabetes inpatient management.
Diabetes Educ. 2012 Jan-Feb;38(1):142-6
Authors:
PMID: 22328042 [PubMed - indexed for MEDLINE]
Link to Article at PubMedMay 232012
May 232012
Basal-bolus insulin protocols enter the computer age.
Curr Diab Rep. 2012 Feb;12(1):119-26
Authors: Wei NJ, Wexler DJ
Abstract
Diabetes affects approximately one quarter of all hospitalized patients. Poor inpatient glycemic control has been associated with increased risk for multiple adverse events including surgical site infections, prolonged hospital length of stay, and mortality. Inpatient glycemic control protocols based on physiologic basal-bolus insulin regimens have been shown to improve glycemia and clinical outcomes and are recommended by the American Diabetes Association, the American Association of Clinical Endocrinologists, and the Society of Hospital Medicine for inpatient glycemic management of noncritically ill patients. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act will catalyze widespread computerized medication order entry implementation over the next few years. Here, we focus on the noncritical care setting and review the background on inpatient glycemic management as it pertains to computerized order entry, the translation and efficacy of computerizing glycemic control protocols, and the barriers to computerizing glycemic protocols.
PMID: 22015856 [PubMed - indexed for MEDLINE]
Link to Article at PubMedMay 232012
Impact of atrial fibrillation and oral anticoagulation on hospital costs and length of stay.
Am J Health Syst Pharm. 2012 Feb 15;69(4):329-38
Authors: Song X, Sander SD, Johnson BH, Varker H, Amin AN
Abstract
PURPOSE: The results of a study assessing hospital length of stay (LOS) and inpatient costs associated with nonvalvular atrial fibrillation (AF) and AF-related warfarin use during hospitalization are presented.
METHODS: Managed care administrative claims data were used to construct cohorts of patients hospitalized with AF as a primary (n = 1,868) or secondary (n = 11,200) discharge diagnosis and control groups of patients with similar demographics and clinical characteristics who were hospitalized during the same period (2002-07). Multivariate regression analyses were performed to estimate the incremental impact of AF on hospital LOS and costs per admission, as well as the incremental impact of in hospital warfarin use on the evaluated LOS and cost outcomes.
RESULTS: The cohort of patients with AF as a secondary discharge diagnosis had a mean LOS 1.84 days greater (p < 0.001) and a mean hospital costs $3,146 higher (p < 0.001) than the control cohort; in hospital warfarin use in those patients was associated with a mean increase in LOS of 1.45 days (p < 0.001) and a mean increase in hospital costs of $1,761 per admission (p < 0.001). In the cohort of patients with AF as a primary discharge diagnosis, inpatient warfarin therapy was also associated with longer hospital stays (mean increase, 1.26 days; p < 0.001) and higher hospital costs (mean increase, $678; p = 0.031).
CONCLUSION: Hospitalizations of patients with a secondary diagnosis of AF are significantly longer and more costly than those of patients without a secondary diagnosis of AF, especially when warfarin is used during the hospital stay. Among patients with a primary diagnosis of AF, warfarin therapy during hospitalization is associated with significant increases in mean LOS and hospital costs.
PMID: 22302258 [PubMed - indexed for MEDLINE]
Link to Article at PubMedMay 232012
Management of hyperglycemia during the perioperative period.
Curr Diab Rep. 2012 Feb;12(1):108-18
Authors: Pichardo-Lowden A, Gabbay RA
Abstract
Hyperglycemia is frequently encountered in the inpatient setting and is distinctly associated with poor clinical outcomes. Recent literature suggests an association between stringent glycemic control and increased mortality, thus keeping optimal glycemic targets a relevant subject of debate. In the surgical population, hyperglycemia with or without diabetes mellitus may be unrecognized. Factors contributing to hyperglycemia in the hospital include critical illness, use of certain drugs, use of enteral or parenteral nutrition, and variability in oral or nutritional intake as can occur when patients are prepared for procedures or surgery. A sensible approach to managing hyperglycemia in this population includes preoperative recognition of diabetes mellitus and risks for inpatient hyperglycemia. Judicious control of glycemia during the pre-, intra-, and postoperative time periods with avoidance of hypoglycemia mandates the need for a strategy for patient management that extend to time of discharge. We review the consequences of uncontrolled perioperative hyperglycemia, discuss current clinical guidelines and recent controversies, and provide practical tools for glycemic control in the surgical population.
PMID: 22086363 [PubMed - indexed for MEDLINE]
Link to Article at PubMedMay 232012
Non-severe pulmonary embolism: prognostic CT findings.
Eur J Radiol. 2011 Sep;79(3):452-8
Authors: Moroni AL, Bosson JL, Hohn N, Carpentier F, Pernod G, Ferretti GR
Abstract
The goal of this study was to retrospectively evaluate CT cardiovascular parameters and pulmonary artery clot load score as predictors of 3-month mortality in patients with clinically non-severe pulmonary embolism (PE). We included 226 CT positive for PE in hemodynamically stable patients (112 women; mean age 67.1 years ± 16.9). CT were independently reviewed by two observers. Results were compared with occurrence of death within 3 months using Cox regression. Twenty-four (10.6%) patients died, for whom 9 were considered to be due to PE. Interobserver agreement was moderate for the shape of interventricular septum (? = 0.41), and for the ratio between the diameters of right and left ventricle (RV/LV) (? = 0.76). Observers found no association between interventricular septum shape and death. A RV/LV diameter ratio >1 was predictive of death (OR, 3.83; p < 0.01) only when we also took into account the value of the embolic burden (< 40%). In a multivariate model, CT cardiovascular parameters were not associated with death. Concomitant lower limb DVT and comorbid conditions were important predictors of death. In clinically non-severe PE, a RV/LV diameter ratio >1 is predictive of death when the embolic burden is low (< 40%).
PMID: 20403673 [PubMed - indexed for MEDLINE]
Link to Article at PubMedMay 232012
MR imaging of pulmonary embolism: diagnostic accuracy of contrast-enhanced 3D MR pulmonary angiography, contrast-enhanced low-flip angle 3D GRE, and nonenhanced free-induction FISP sequences.
Radiology. 2012 Apr;263(1):271-8
Authors: Kalb B, Sharma P, Tigges S, Ray GL, Kitajima HD, Costello JR, Chen Z, Martin DR
Abstract
PURPOSE: To evaluate relative detection of pulmonary embolism (PE) with standard bolus-triggered contrast-enhanced breath-hold magnetic resonance (MR) pulmonary angiography, contrast-enhanced recirculation-phase breath-hold low-flip angle three-dimensional (3D) gradient-echo (GRE), and nonenhanced free-induction cardiac- and respiratory-triggered true fast imaging with steady-state precession (FISP) MR sequences.
MATERIALS AND METHODS: The study was HIPAA compliant and institutional review board approved. Twenty-two patients with a computed tomographic (CT) angiography diagnosis of PE underwent MR imaging within 48 hours of CT. MR included three complementary techniques: MR pulmonary angiography, 3D GRE, and triggered true FISP. Each sequence was analyzed separately by two independent reviewers who recorded presence of emboli in categorized pulmonary artery anatomic territories. CT angiography results were analyzed by a third independent reviewer, who retrospectively recorded presence of emboli using the same format; these results served as the reference standard. Sensitivity, specificity, and positive and negative predictive values for PE detection were calculated for each MR technique on a per-embolus basis, and 95% confidence intervals were calculated according to the efficient-score method. A two-sample t test was used to compare values among MR techniques.
RESULTS: Sensitivities for PE detection were 55% for MR pulmonary angiography, 67% for triggered true FISP, and 73% for 3D GRE MR imaging. Combining all three MR sequences improved overall sensitivity to 84%. Specificity was 100% for all detection methods except for MR pulmonary angiography (one false-positive). Agreement between readers was high (? = 0.87). Embolus detection rates were lowest in the lingula branch for all MR sequences compared with remainder of the vascular territories (P = .07).
CONCLUSION: There are complementary benefits to combining standard MR pulmonary angiography, 3D GRE, and triggered true FISP MR examinations for evaluation of PE.
PMID: 22438448 [PubMed - indexed for MEDLINE]
Link to Article at PubMed