Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopu…

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Biomarkers to guide perioperative management.
Postgrad Med J. 2011 Aug;87(1030):5…

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Mortality and associated risk factors in consecutive patients admitted to a UK NHS trust …

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Prescribing errors in hospital inpatients: a three-centre study of their prevalence, type…

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Use of abbreviations by healthcare professionals: what is the way forward?
Postgr…

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Patterns of hospitalisation before and following initiation of haemodialysis: a 5 year single centre study.
Postgrad Med J. 2011 Jun;87(1028):389-93
Authors: Quinn MP, Cardwell CR, Rainey A, McNamee PT, Kee F, Maxwell AP, Foga…

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Speed, accuracy, and confidence in Google, Ovid, PubMed, and UpToDate: results of a randomised trial.

Postgrad Med J. 2010 Aug;86(1018):459-65

Authors: Thiele RH, Poiro NC, Scalzo DC, Nemergut EC

BACKGROUND: The explosion of biomedical information has led to an ‘information paradox’-the volume of biomedical information available has made it increasingly difficult to find relevant information when needed. It is thus increasingly critical for physicians to acquire a working knowledge of biomedical informatics. AIM: To evaluate four search tools commonly used to answer clinical questions, in terms of accuracy, speed, and user confidence. METHODS: From December 2008 to June 2009, medical students, resident physicians, and attending physicians at the authors’ institution were asked to answer a set of four anaesthesia and/or critical care based clinical questions, within 5 min, using Google, Ovid, PubMed, or UpToDate (only one search tool per question). At the end of each search, participants rated their results on a four point confidence scale. One to 3 weeks after answering the initial four questions, users were randomised to one of the four search tools, and asked to answer eight questions, four of which were repeated. The primary outcome was defined as a correct answer with the highest level of confidence. RESULTS: Google was the most popular search tool. Users of Google and UpToDate were more likely than users of PubMed to answer questions correctly. Subjects had the most confidence in UpToDate. Searches with Google and UpToDate were faster than searches with PubMed or Ovid. CONCLUSION: Non-Medline based search tools are not inferior to Medline based search tools for purposes of answering evidence based anaesthesia and critical care questions.

PMID: 20709767 [PubMed - indexed for MEDLINE]

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Do radiologists still need to report chest x rays?

Postgrad Med J. 2009 Jul;85(1005):339-41

Authors: Mehrotra P, Bosemani V, Cox J

OBJECTIVE: Chest x rays (CXRs) are among the most difficult radiographs to interpret accurately. The aim of this study was to assess the ability of different grades and specialities of clinicians to evaluate a series of CXRs correctly. METHODS: 60 clinicians of different grades and from different specialities were randomly recruited to interpret 15 CXRs within 30 min. Radiographs included normal (n = 5) and abnormal images of common medical emergencies (n = 10). Non-parametric statistical tests examined for significant differences in the ability of different grades and specialities of doctors to interpret CXRs. RESULTS: Senior doctors (consultants and registrars, n = 32) attained significantly higher scores than junior doctors (senior house officers, foundation 1 and 2 doctors, n = 28, p = 0.001). Specialists (consultants and registrars in radiology and respiratory medicine, n = 7) achieved significantly higher scores than non-specialists (all other consultants and registrars, n = 25, p = 0.0002). In addition, senior radiologists (consultants and registrars) attained significantly higher scores than senior doctors from other specialities (p = 0.002). CONCLUSION: To improve patient care, we suggest that all chest x rays should be reviewed at an early stage during a patient’s hospital admission by a senior clinician and reported by a radiologist at the earliest opportunity. We also suggest that structured teaching on CXR interpretation should be made available for newly qualified doctors, especially with the introduction of shortened training.

PMID: 19581241 [PubMed - indexed for MEDLINE]

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Delirium in the elderly: a clinical review.

Postgrad Med J. 2009 Aug;85(1006):405-13

Authors: Saxena S, Lawley D

Delirium is a common condition in the elderly, affecting up to 30% of all older patients admitted to hospital. There is a particularly high risk of delirium in surgical inpatients, especially following operations for hip fracture or vascular surgery, but also for patients in the intensive care unit. Patients with delirium have higher morbidity and mortality rates, higher re-admission rates, and a greater risk of long term institutionalisation care, thereby having a significant impact on both health and social care expenditure. Delirium frequently goes unrecognised by clinicians and is often inadequately managed. Recent evidence suggests that a better understanding and knowledge of delirium among health care professionals can lead to early detection, the reduction of modifiable risk factors, and better management of the condition in the acute phase. Many cases of delirium are potentially preventable, and primary and secondary care services should be taking active steps in order to do prevent this condition.

PMID: 19633006 [PubMed - indexed for MEDLINE]

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Interventions to reduce the frequency of exacerbations of chronic obstructive pulmonary disease.

Postgrad Med J. 2009 Mar;85(1001):141-7

Authors: Black PN, McDonald CF

Frequent exacerbations of chronic obstructive pulmonary disease (COPD) are associated with impaired quality of life, and hospital admissions for exacerbations account for a large proportion of the expenditure of COPD. An important objective when treating COPD is to reduce the frequency of exacerbations. Studies published in the last few years have increased our knowledge on how to prevent exacerbations, but a number of questions remain unanswered. Tiotropium, inhaled steroids and long-acting inhaled beta agonists reduce the frequency of exacerbations, but further studies are necessary to determine if combining tiotropium with the other inhaled medicines is more effective than using them separately. There is evidence that mucolytics and prophylactic antibiotics reduce exacerbations, but there is uncertainty how these treatments should be used. Both influenza and pneumococcal vaccination are recommended in guidelines, although evidence for the latter remains controversial. Other interventions including oral bacterial extracts and self-management programmes warrant further study.

PMID: 19351641 [PubMed - indexed for MEDLINE]

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Weight assessment in cardiac patients: implications for prescription of low molecular weight heparin.

Postgrad Med J. 2009 Mar;85(1001):124-7

Authors: Spicer K, Gibson P, Bloe C, Cross SJ, Leslie SJ

BACKGROUND: Many drugs such as low molecular weight heparin (LMWH) are administered at "patient weight adjusted" doses. Obtaining an accurate measurement of a patient's weight may not always be possible. The aim of this study was to assess patterns and accuracy of weight estimation and implications for drug dosing. METHODS: The study comprised three parts: (1) inpatient weight documentation was reviewed over a 4 week period (January 2008); (2) a questionnaire was distributed to healthcare staff; (3) healthcare staff were asked to estimate the weight of patients. These estimates took place in three locations: the coronary care unit, cardiac catheterisation laboratory, and the cardiac outpatient department. RESULTS: (1) In 385 patient notes, only 192 (49.9%) had a record of the patient's weight. The dose of LMWH was correct only 51% of the time. (2) Doctors were more likely to estimate a patient's weight than nurses (85 vs 51%, p = 0.003). (3) 50 healthcare staff made 533 weight estimations on 182 patients. There was a tendency to overestimate the weight of lighter patients and underestimate the weight of heavier patients (p<0.001). Patients were more accurate than healthcare staff at estimating their weight (80% vs 39%, p<0.001) and female patients were more likely to be accurate than men (62% vs 44%, p = 0.035). CONCLUSIONS: In our institution weight estimation occurs and may result in inaccurate prescription of LMWH. Estimating a patient's weight should be discouraged but if necessary the patient reported weight is likely to be most accurate. Unless there is significant investment in improved technology to allow obese or acutely unwell patients to be weighed, the dangerous practice of weight estimation is likely to continue.

PMID: 19351637 [PubMed - indexed for MEDLINE]

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The slipping slipper sign: a marker of severe peripheral diabetic neuropathy and foot sepsis.

Postgrad Med J. 2009 Jun;85(1004):288-91

Authors: Teelucksingh S, Ramdass MJ, Charran A, Mungalsingh C, Seemungal T, Naraynsingh V

BACKGROUND: Peripheral neuropathy is a major contributor to diabetic foot complications including ulceration, sepsis and limb loss. The aim of this study was to document the frequency of this previously undocumented clinical marker of peripheral neuropathy, the "slipping slipper sign" (SSS), characterised by unrecognised loss of slippers from one's feet while walking, and to compare it with traditional clinical tests for peripheral neuropathy. OBJECTIVE: To evaluate the relationship between a positive SSS and diabetic peripheral neuropathy. Subjects and METHODS: The study included 105 diabetic outpatients without active foot problems, 40 diabetic inpatients with active foot sepsis, and 69 other patients with neither diabetes nor active foot sepsis as negative controls. Demographic data, clinical neuropathy scores and the presence or absence of the SSS were obtained. RESULTS: No control subjects had a positive SSS. In contrast, 64 of 145 diabetic patients had severe neuropathy of whom 53 had a positive SSS (83% sensitivity) and 74 of 81 without severe neuropathy had a negative SSS (91% specificity). Diabetic patients with concurrent foot sepsis had a higher frequency of severe neuropathy (70%) and positive SSS (65%) compared with those without (36% and 35%, respectively, p<0.001). Multivariate analysis showed that a positive SSS was strongly related to severity of neuropathy independent of duration of diabetes. CONCLUSION: The SSS reflects severe peripheral neuropathy and is particularly prevalent among those with active foot disease. Patients who have experienced the SSS should be encouraged to seek attention and preventive action taken.

PMID: 19528301 [PubMed - indexed for MEDLINE]

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Approach to critical illness polyneuropathy and myopathy.

Postgrad Med J. 2008 Jul;84(993):354-60

Authors: Pati S, Goodfellow JA, Iyadurai S, Hilton-Jones D

A newly acquired neuromuscular cause of weakness has been found in 25-85% of critically ill patients. Three distinct entities have been identified: (1) critical illness polyneuropathy (CIP); (2) acute myopathy of intensive care (itself with three subtypes); and (3) a syndrome with features of both 1 and 2 (called critical illness myopathy and/or neuropathy or CRIMYNE). CIP is primarily a distal axonopathy involving both sensory and motor nerves. Electroneurography and electromyography (ENG-EMG) is the gold standard for diagnosis. CIM is a proximal as well as distal muscle weakness affecting both types of muscle fibres. It is associated with high use of non-depolarising muscle blockers and corticosteroids. Avoidance of systemic inflammatory response syndrome (SIRS) is the most effective way to reduce the likelihood of developing CIP or CIM. Outcome is variable and depends largely on the underlying illness. Detailed history, careful physical examination, review of medication chart and analysis of initial investigations provides invaluable clues towards the diagnosis.

PMID: 18716014 [PubMed - indexed for MEDLINE]

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Cross-sectional survey of disturbed behaviour in patients in general hospitals in Leeds.

Postgrad Med J. 2008 Aug;84(994):428-31

Authors: Kannabiran M, Deshpande S, Walling A, Alagarsamy J, Protheroe D, Trigwell P

AIM: To describe the prevalence and nature of disturbed behaviour, in the general hospital setting. METHOD: A cross-sectional survey was conducted, from July to October 2006, in all adult inpatient wards within the six general hospitals in Leeds of patients presenting with disturbed behaviour in the preceding 7 days. Disturbed behaviour was defined as behaviour interfering with care of the patient or with that of other patients, or behaviour that placed the patient, the staff or others at risk. Anonymised data were collected using a semi-structured questionnaire. RESULTS: All of the 87 hospital wards were studied, containing a total of 1773 beds. 42 male and 26 female patients (n = 68) were identified by nursing staff as patients with disturbed behaviour in the time period covered, with 33 patients being <or=65 years of age and 35 being elderly (>65 years of age). An almost equal proportion of the younger and older patient groups placed themselves or others at risk. In the majority of cases, aggressive behaviour by patients was directed towards staff rather than other patients. 60 patients required additional staff time due to the disturbed behaviour, 34 required additional medication, and 22 patients were referred to liaison psychiatry. CONCLUSIONS: Disturbed behaviour presents in the general hospital in less than 4% of patients, both above and below the age of 65 years, but consumes a disproportionate amount of resources. Responses required to manage this include additional medication, additional staff time or other interventions. The quantity and nature of disturbed behaviour in the general hospital have implications for effective service provision and development.

PMID: 18832404 [PubMed - indexed for MEDLINE]

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Neurogenic orthostatic hypotension: chasing “the fall”.

Postgrad Med J. 2008 Jan;84(987):6-14

Authors: Gupta D, Nair MD

Orthostatic hypotension (OH) is a frequently encountered problem affecting nearly 30% of the population aged more than 60 years. It can result from neurological and non-neurological derangements which compromise the perfusion of the brain in an erect posture. Neurogenic OH is a manifestation of autonomic failure. It is an important cause of recurrent falls in the elderly, syncopal events and also has been shown to be associated with increased long term mortality from vascular and non-vascular causes. This review will discuss the pathophysiology, aetiology, clinical features and management of neurogenic OH and its differentiation from OH caused by non-neurological causes at each step. A clinician should primarily look for any reversible causes in a patient with neurogenic OH and should not forget that treatment is aimed at restoring the functioning capability of the patient rather than normotension. Co-existent supine hypertension in some patients should be taken into account while treating them.

PMID: 18230746 [PubMed - indexed for MEDLINE]

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