2012 July 19

The Use of Skype in a Community Hospital Inpatient Palliative Medicine Consultation Service.

Jul 192012

The Use of Skype in a Community Hospital Inpatient Palliative Medicine Consultation Service.

J Palliat Med. 2012 Jul 17;

Authors: Brecher DB

Abstract

Abstract Skype™, an Internet-based communication tool, has enhanced communication under numerous circumstances. As telemedicine continues to be an increasing part of medical practice, there will be more opportunities to use Skype and similar tools. Numerous scenarios in the lay literature have helped to highlight the potential uses. Although most commonly used to enhance physician-to-patient communication, there has been limited reported use of Skype for patient-to-family communication, especially in end of life and palliative care. Our inpatient Palliative Medicine Consultation Service has offered and used this technology to enhance our patients' quality of life. The objective was to provide another tool for our patients to use to communicate with family and/or friends, especially under circumstances in which clinical symptoms, functional status, financial concerns, or geographic limitations preclude in-person face-to face communication.

PMID: 22803591 [PubMed - as supplied by publisher]

Link to Article at PubMed

Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care.

Int J Clin Pract Start a Discussion »

Jul 192012

Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care.

Int J Clin Pract. 2012 Aug;66(8):767-773

Authors: Ahrens D, Behrens G, Himmel W, Kochen MM, Chenot JF

Abstract

Background:? Inappropriate prescriptions of proton pump inhibitors (PPI) in hospital and primary care have been widely reported. Recommendations from hospital have been implicated as one reason for inappropriate prescriptions of PPI in primary care. Objective:? To quantify the amount of appropriate PPI recommendations in hospital discharge letters and the influence of these recommendations on general practitioners' (GPs') PPI-prescriptions. Materials and Methods:? This is an observational study in 31 primary care practices. We identified patients discharged from hospital with PPI recommendation between 2006 and 2007 and assessed practice records and PPI prescription six months prior and after hospital admission. Hospital recommendation for continuous PPI-treatment and continuation by GPs was classified as appropriate, inappropriate or uncertain. Logistic regression analysis was used to calculate factors associated with indicated and non-indicated PPI continuation. Results:? In 263 (58%) out of 506 patients discharged from 35 hospitals with a PPI recommendation no indication could be found. Non-indicated PPIs were continued by GPs in 58% for at least 1?month. Indicated PPIs were discontinued in 33%. Two thirds of non-indicated PPIs were initiated in hospital. The strongest factor associated with non-indicated continuation was a PPI-prescription prior to hospital admission [OR: 3.0; 95% confidence interval (CI): 1.7-5.4]. This was also the strongest factor for continuation of an indicated PPI medication (OR: 3.2; 95% CI: 1.4-7.5). Conclusions:? We found a strong influence of hospital recommendations and previous prescriptions on PPI prescriptions after discharge. Hospitals should critically review their practice of recommending PPI and document indications. GPs should carefully assess hospital recommendations and their medication prior to admission to avoid over- and under-prescribing.

PMID: 22805269 [PubMed - as supplied by publisher]

Link to Article at PubMed

Delirium in Critically Ill Patients: Epidemiology, Pathophysiology, Diagnosis and Management.

Drugs Start a Discussion »

Jul 192012

Delirium in Critically Ill Patients: Epidemiology, Pathophysiology, Diagnosis and Management.

Drugs. 2012 Jul 17;

Authors: Zaal IJ, Slooter AJ

Abstract

Delirium is commonly observed in critically ill patients and is associated with negative outcomes. The pathophysiology of delirium is not completely understood. However, alterations to neurotransmitters, especially acetylcholine and dopamine, inflammatory pathways and an aberrant stress response are proposed mechanisms leading to intensive care unit (ICU) delirium. Detection of delirium using a validated delirium assessment tool makes early treatment possible, which may improve prognosis. Patients at high risk of delirium, especially those with cognitive decline and advanced age, should be identified in the first 24 hours of admission to the ICU. Whether these high-risk patients benefit from haloperidol prophylaxis deserves further study. The effectiveness of a multicomponent, non-pharmacological approach is shown in non-ICU patients, which provides proof of concept for use in the ICU. The few studies on this approach in ICU patients suggest that the burden of ICU delirium may be reduced by early mobility, increased daylight exposure and the use of earplugs. In addition, the combined use of sedation, ventilation, delirium and physical therapy protocols can reduce the frequency and severity of adverse outcomes and should become part of routine practice in the ICU, as should avoidance of deliriogenic medication such as anticholinergic drugs and benzodiazepines. Once delirium develops, symptomatic treatment with antipsychotics is recommended, with haloperidol being the drug of first choice. However, there is limited evidence on the safety and effectiveness of antipsychotics in ICU delirium.

PMID: 22804788 [PubMed - as supplied by publisher]

Link to Article at PubMed

Hypertension: management perspectives.

Expert Opin Pharmacother Start a Discussion »

Jul 192012

Hypertension: management perspectives.

Expert Opin Pharmacother. 2012 Jul 18;

Authors: Borghi C, Cicero AF

Abstract

Introduction: The increasing worldwide prevalence of hypertension and the related increase in cost due to diagnosis, management and negative outcomes forces public health institutions and clinical researchers to find new strategies to improve blood pressure (BP) control. So what are the possible future perspectives for high BP management? Areas covered: Three main points are briefly discussed in this article: individualized therapy, the known genetic contribution to hypertension development and control, and the improvement of disease management, including perspectives on new antihypertensive drug development. Expert opinion: It is likely that the integration of the best available current knowledge with recent diagnostic and therapeutic achievements for the management of hypertension prevention and treatment will lead to the early detection of at-risk conditions, early diagnosis, and individualized and efficacious treatment. The most promising antihypertensive drugs currently in development are innovative renin-angiotensin-aldosterone system modulators. Further drugs have potentially interesting mechanisms of action, but renalase analogs are in the very early phases of development, and available endothelin antagonists have a poor safety profile.

PMID: 22803769 [PubMed - as supplied by publisher]

Link to Article at PubMed

Sensitive cardiac troponin in the diagnosis and risk stratification of acute heart failure.

J Intern Med Start a Discussion »

Jul 192012

Sensitive cardiac troponin in the diagnosis and risk stratification of acute heart failure.

J Intern Med. 2012 Jun;271(6):598-607

Authors: Arenja N, Reichlin T, Drexler B, Oshima S, Denhaerynck K, Haaf P, Potocki M, Breidthardt T, Noveanu M, Stelzig C, Heinisch C, Twerenbold R, Reiter M, Socrates T, Mueller C

Abstract

BACKGROUND: The aim of our study was to investigate the diagnostic and prognostic value of a sensitive cardiac troponin I (s-cTnI) assay in patients with acute heart failure (AHF).

METHODS: Sensitive cardiac troponin I was measured in 667 consecutive patients at presentation to the emergency department with acute dyspnoea. Three s-cTnI strata were predefined: below the limit of detection (<0.01??g?L(-1) , undetectable), detectable but still within the normal range (0.01-0.027??g?L(-1) ) and increased (?0.028??g?L(-1) , ?99th percentile). The final diagnosis was adjudicated by two independent cardiologists blinded to the s-cTnI levels. Median follow-up in patients with AHF was 371?days.

RESULTS: Levels of s-cTnI were higher in patients with AHF (n?=?377, 57%) compared to patients with noncardiac causes of acute dyspnoea (median 0.02 vs. <0.01??g?L(-1) , P?<?0.001). In patients with AHF, in-hospital mortality increased with increasing s-cTnI in the three strata (2%, 5% and 14%, P?<?0.001). One-year mortality also increased with increasing s-cTnI (21%, 33% and 47%, P?<?0.001). s-cTnI remained an independent predictor of 1-year mortality [adjusted odds ratio 1.03 for each increase of 0.1??g?L(-1) , 95% confidence interval (CI) 1.02-1.05, P?<?0.001] after adjustment for other risk factors including B-type natriuretic peptide. The net reclassification improvement was 68% (P?<?0.001), and absolute integrated discrimination improvement was 0.18 (P?<?0.001). The diagnostic accuracy of s-cTnI for the diagnosis of AHF as quantified by the area under the receiver operating characteristic curve was 0.78 (95% CI, 0.75-0.82).

CONCLUSIONS: Sensitive cardiac troponin I is a strong predictor of short- and long-term prognosis in AHF that helps to reclassify patients in terms of mortality risk. Detectable levels of s-cTnI, even within the normal range, are independently associated with mortality.

PMID: 21988283 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Low-grade systolic murmurs in healthy middle-aged individuals: innocent or clinically significant? A 35-year follow-up study of 2014 Norwegian men.

J Intern Med Start a Discussion »

Jul 192012

Low-grade systolic murmurs in healthy middle-aged individuals: innocent or clinically significant? A 35-year follow-up study of 2014 Norwegian men.

J Intern Med. 2012 Jun;271(6):581-8

Authors: Bodegard J, Skretteberg PT, Gjesdal K, Pyörälä K, Kjeldsen SE, Liestøl K, Erikssen G, Erikssen J

Abstract

OBJECTIVE: To determine whether a low-grade systolic murmur, found at heart auscultation, in middle-aged healthy men influences the long-term risk of aortic valve replacement (AVR) and death from cardiovascular disease (CVD). Setting and subjects.? During 1972-1975, 2014 apparently healthy men aged 40-59?years underwent an examination programme including case history, clinical examination, blood tests and a symptom-limited exercise ECG test. Heart auscultation was performed under standardized conditions, and murmurs were graded on a scale from I to VI. No men were found to have grade V/VI murmurs. Participants were followed for up to 35?years.

RESULTS: A total of 1541 men had no systolic murmur; 441 had low-grade murmurs (grade I/II) and 32 had moderate-grade murmurs (grade III/IV). Men with low-grade murmurs had a 4.7-fold [95% confidence interval (CI) 2.1-11.1] increased age-adjusted risk of AVR, but no increase in risk of CVD death. Men with moderate-grade murmurs had an 89.3-fold (95% CI 39.2-211.2) age-adjusted risk of AVR and a 1.5-fold (95% CI 0.8-2.5) age-adjusted increased risk of CVD death.

CONCLUSIONS: Low-grade systolic murmur was detected at heart auscultation in 21.9% of apparently healthy middle-aged men. Men with low-grade murmur had an increased risk of AVR, but no increase in risk of CVD death. Only 1.6% of men had moderate-grade murmur; these men had a very high risk of AVR and a 1.5-fold albeit non-significant increase in risk of CVD death.

PMID: 22061296 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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