Preoperative Pain Abates, But New Pain Develops After DBS for Parkinson’s Disease
At eight years after implantation of a subthalamic nucleus deep brain stimulation (STN DBS) device, pain is lessened or eliminated, compared with baseline, among patients with Parkinson’s disease, according to research published online ahead of print March 23 in JAMA Neurology. Most patients developed new pain after implantation, however, most of which was musculoskeletal. The results indicate that clinicians should treat musculoskeletal pain independently, researchers said.
Beom S. Jeon, MD, PhD, a neurologist at the Seoul National University Hospital in South Korea, and colleagues evaluated the long-term effect of STN DBS on pain in 24 patients with Parkinson’s disease. Assessments of pain were conducted preoperatively and eight years after surgery. Thirteen patients had additional two-year postoperative data.
The 24 patients (15 men) underwent STN DBS at the Movement Disorder Center at Seoul National University Hospital from June 1, 2005, through March 31, 2006. The inclusion criteria for STN DBS were a clinical diagnosis of idiopathic Parkinson’s disease, levodopa responsiveness with severe motor complications, absence of severe dementia, and normal findings on brain MRI.
Motor symptoms were assessed using the Unified Parkinson’s Disease Rating Scale (UPDRS) and the Hoehn and Yahr staging scale. Pain severity was scored on an ordinal scale from 0 (absent) to 10 (maximal) in seven parts of the body (ie, head, neck, trunk, and the upper and lower extremities on each side of the body). Pain quality was categorized as dystonic, musculoskeletal, radiculoneuritic, or central.
New Pain Developed in 75% of Patients Of the 24 patients, 16 (67%) had pain at baseline when not taking medication, with an average pain score of 6.2. All off-medication baseline pain lessened or disappeared at eight years after surgery. New pain developed, however, in 18 of 24 patients (75%) during the eight-year follow-up, including in five patients who had had no pain at baseline. The average pain score for new pain was 4.4.
The most common body parts with newly developed pain were the lower extremities, followed by the upper extremities. The types of new pain at eight years were musculoskeletal in 11 patients, central in four patients, radiculoneuritic in three patients, and dystonic in one patient.
Overall, the number of patients with off-medication pain increased from 16 at baseline to 20 at eight years. The number of body parts with pain increased from 48 to 60, while average pain scores decreased from 6.2 to 4.8.
“The results of the present study highlight once again that musculoskeletal problems should be considered when predicting the operative outcome before surgery, and continuous evaluation and treatment of musculoskeletal pain should be performed after surgery,” Dr. Jeon and colleagues said.
Average off-medication dystonic pain score increased from 6.3 at baseline to 8.5 at eight years, but the eight-year score was the average score of two patients who had severe dystonic pain because of rigidity, the authors said. In all, the number of patients with dystonic pain decreased from five to two. Average off-medication pain scores decreased by 55% for radiculoneuritic pain, 44% for central pain, and 29% for musculoskeletal pain.
Lack of Control Group Among Study’s Limitations The small number of patients in the study and the lack of a control group treated medically were among the study’s limitations, the authors said. The study also did not evaluate the association between motor UPDRS scores and pain, and it did not measure patients’ overall level of pain, they said.
Despite the study’s limitations, the long follow-up period “provides a novel perspective on the durability of the pain-relieving properties of STN DBS in Parkinson’s disease,” said Richard B. Dewey Jr., MD, Professor of Neurology and Neurotherapeutics, and Pravin Khemani, MD, Assistant Professor of Neurology and Neurotherapeutics, both at the University of Texas Southwestern Medical Center in Dallas, in an accompanying editorial.
“The authors direct our attention to the fact that musculoskeletal pain may emerge years after DBS, warranting individualized treatment. … Although there is a growing consensus that STN DBS decreases the level of pain in people with Parkinson’s disease, the literature is mixed on the subtypes of pain that are responsive to DBS, and the study by Jung and colleagues shows that new pain arising years after the procedure is common,” they continued.
The next step for researchers is to seek a deeper understanding of the mechanism of pain in Parkinson’s disease. Future trials with larger cohorts, longer observational periods, and standard methods will enable effective interpretation of outcomes, concluded Drs. Dewey and Khemani.
—Jake Remaly
References
Suggested Reading Jung YJ, Kim HJ, Jeon BS, et al. An 8-year follow-up on the effect of subthalamic nucleus deep brain stimulation on pain in Parkinson disease. JAMA Neurol. 2015 Mar 23 [Epub ahead of print]. Khemani P, Dewey RB Jr. Deep brain stimulation of the subthalamic nucleus: taking the ouch out of Parkinson disease. JAMA Neurol. 2015 Mar 23 [Epub ahead of print].
At eight years after implantation of a subthalamic nucleus deep brain stimulation (STN DBS) device, pain is lessened or eliminated, compared with baseline, among patients with Parkinson’s disease, according to research published online ahead of print March 23 in JAMA Neurology. Most patients developed new pain after implantation, however, most of which was musculoskeletal. The results indicate that clinicians should treat musculoskeletal pain independently, researchers said.
Beom S. Jeon, MD, PhD, a neurologist at the Seoul National University Hospital in South Korea, and colleagues evaluated the long-term effect of STN DBS on pain in 24 patients with Parkinson’s disease. Assessments of pain were conducted preoperatively and eight years after surgery. Thirteen patients had additional two-year postoperative data.
The 24 patients (15 men) underwent STN DBS at the Movement Disorder Center at Seoul National University Hospital from June 1, 2005, through March 31, 2006. The inclusion criteria for STN DBS were a clinical diagnosis of idiopathic Parkinson’s disease, levodopa responsiveness with severe motor complications, absence of severe dementia, and normal findings on brain MRI.
Motor symptoms were assessed using the Unified Parkinson’s Disease Rating Scale (UPDRS) and the Hoehn and Yahr staging scale. Pain severity was scored on an ordinal scale from 0 (absent) to 10 (maximal) in seven parts of the body (ie, head, neck, trunk, and the upper and lower extremities on each side of the body). Pain quality was categorized as dystonic, musculoskeletal, radiculoneuritic, or central.
New Pain Developed in 75% of Patients Of the 24 patients, 16 (67%) had pain at baseline when not taking medication, with an average pain score of 6.2. All off-medication baseline pain lessened or disappeared at eight years after surgery. New pain developed, however, in 18 of 24 patients (75%) during the eight-year follow-up, including in five patients who had had no pain at baseline. The average pain score for new pain was 4.4.
The most common body parts with newly developed pain were the lower extremities, followed by the upper extremities. The types of new pain at eight years were musculoskeletal in 11 patients, central in four patients, radiculoneuritic in three patients, and dystonic in one patient.
Overall, the number of patients with off-medication pain increased from 16 at baseline to 20 at eight years. The number of body parts with pain increased from 48 to 60, while average pain scores decreased from 6.2 to 4.8.
“The results of the present study highlight once again that musculoskeletal problems should be considered when predicting the operative outcome before surgery, and continuous evaluation and treatment of musculoskeletal pain should be performed after surgery,” Dr. Jeon and colleagues said.
Average off-medication dystonic pain score increased from 6.3 at baseline to 8.5 at eight years, but the eight-year score was the average score of two patients who had severe dystonic pain because of rigidity, the authors said. In all, the number of patients with dystonic pain decreased from five to two. Average off-medication pain scores decreased by 55% for radiculoneuritic pain, 44% for central pain, and 29% for musculoskeletal pain.
Lack of Control Group Among Study’s Limitations The small number of patients in the study and the lack of a control group treated medically were among the study’s limitations, the authors said. The study also did not evaluate the association between motor UPDRS scores and pain, and it did not measure patients’ overall level of pain, they said.
Despite the study’s limitations, the long follow-up period “provides a novel perspective on the durability of the pain-relieving properties of STN DBS in Parkinson’s disease,” said Richard B. Dewey Jr., MD, Professor of Neurology and Neurotherapeutics, and Pravin Khemani, MD, Assistant Professor of Neurology and Neurotherapeutics, both at the University of Texas Southwestern Medical Center in Dallas, in an accompanying editorial.
“The authors direct our attention to the fact that musculoskeletal pain may emerge years after DBS, warranting individualized treatment. … Although there is a growing consensus that STN DBS decreases the level of pain in people with Parkinson’s disease, the literature is mixed on the subtypes of pain that are responsive to DBS, and the study by Jung and colleagues shows that new pain arising years after the procedure is common,” they continued.
The next step for researchers is to seek a deeper understanding of the mechanism of pain in Parkinson’s disease. Future trials with larger cohorts, longer observational periods, and standard methods will enable effective interpretation of outcomes, concluded Drs. Dewey and Khemani.
—Jake Remaly
At eight years after implantation of a subthalamic nucleus deep brain stimulation (STN DBS) device, pain is lessened or eliminated, compared with baseline, among patients with Parkinson’s disease, according to research published online ahead of print March 23 in JAMA Neurology. Most patients developed new pain after implantation, however, most of which was musculoskeletal. The results indicate that clinicians should treat musculoskeletal pain independently, researchers said.
Beom S. Jeon, MD, PhD, a neurologist at the Seoul National University Hospital in South Korea, and colleagues evaluated the long-term effect of STN DBS on pain in 24 patients with Parkinson’s disease. Assessments of pain were conducted preoperatively and eight years after surgery. Thirteen patients had additional two-year postoperative data.
The 24 patients (15 men) underwent STN DBS at the Movement Disorder Center at Seoul National University Hospital from June 1, 2005, through March 31, 2006. The inclusion criteria for STN DBS were a clinical diagnosis of idiopathic Parkinson’s disease, levodopa responsiveness with severe motor complications, absence of severe dementia, and normal findings on brain MRI.
Motor symptoms were assessed using the Unified Parkinson’s Disease Rating Scale (UPDRS) and the Hoehn and Yahr staging scale. Pain severity was scored on an ordinal scale from 0 (absent) to 10 (maximal) in seven parts of the body (ie, head, neck, trunk, and the upper and lower extremities on each side of the body). Pain quality was categorized as dystonic, musculoskeletal, radiculoneuritic, or central.
New Pain Developed in 75% of Patients Of the 24 patients, 16 (67%) had pain at baseline when not taking medication, with an average pain score of 6.2. All off-medication baseline pain lessened or disappeared at eight years after surgery. New pain developed, however, in 18 of 24 patients (75%) during the eight-year follow-up, including in five patients who had had no pain at baseline. The average pain score for new pain was 4.4.
The most common body parts with newly developed pain were the lower extremities, followed by the upper extremities. The types of new pain at eight years were musculoskeletal in 11 patients, central in four patients, radiculoneuritic in three patients, and dystonic in one patient.
Overall, the number of patients with off-medication pain increased from 16 at baseline to 20 at eight years. The number of body parts with pain increased from 48 to 60, while average pain scores decreased from 6.2 to 4.8.
“The results of the present study highlight once again that musculoskeletal problems should be considered when predicting the operative outcome before surgery, and continuous evaluation and treatment of musculoskeletal pain should be performed after surgery,” Dr. Jeon and colleagues said.
Average off-medication dystonic pain score increased from 6.3 at baseline to 8.5 at eight years, but the eight-year score was the average score of two patients who had severe dystonic pain because of rigidity, the authors said. In all, the number of patients with dystonic pain decreased from five to two. Average off-medication pain scores decreased by 55% for radiculoneuritic pain, 44% for central pain, and 29% for musculoskeletal pain.
Lack of Control Group Among Study’s Limitations The small number of patients in the study and the lack of a control group treated medically were among the study’s limitations, the authors said. The study also did not evaluate the association between motor UPDRS scores and pain, and it did not measure patients’ overall level of pain, they said.
Despite the study’s limitations, the long follow-up period “provides a novel perspective on the durability of the pain-relieving properties of STN DBS in Parkinson’s disease,” said Richard B. Dewey Jr., MD, Professor of Neurology and Neurotherapeutics, and Pravin Khemani, MD, Assistant Professor of Neurology and Neurotherapeutics, both at the University of Texas Southwestern Medical Center in Dallas, in an accompanying editorial.
“The authors direct our attention to the fact that musculoskeletal pain may emerge years after DBS, warranting individualized treatment. … Although there is a growing consensus that STN DBS decreases the level of pain in people with Parkinson’s disease, the literature is mixed on the subtypes of pain that are responsive to DBS, and the study by Jung and colleagues shows that new pain arising years after the procedure is common,” they continued.
The next step for researchers is to seek a deeper understanding of the mechanism of pain in Parkinson’s disease. Future trials with larger cohorts, longer observational periods, and standard methods will enable effective interpretation of outcomes, concluded Drs. Dewey and Khemani.
—Jake Remaly
References
Suggested Reading Jung YJ, Kim HJ, Jeon BS, et al. An 8-year follow-up on the effect of subthalamic nucleus deep brain stimulation on pain in Parkinson disease. JAMA Neurol. 2015 Mar 23 [Epub ahead of print]. Khemani P, Dewey RB Jr. Deep brain stimulation of the subthalamic nucleus: taking the ouch out of Parkinson disease. JAMA Neurol. 2015 Mar 23 [Epub ahead of print].
References
Suggested Reading Jung YJ, Kim HJ, Jeon BS, et al. An 8-year follow-up on the effect of subthalamic nucleus deep brain stimulation on pain in Parkinson disease. JAMA Neurol. 2015 Mar 23 [Epub ahead of print]. Khemani P, Dewey RB Jr. Deep brain stimulation of the subthalamic nucleus: taking the ouch out of Parkinson disease. JAMA Neurol. 2015 Mar 23 [Epub ahead of print].
Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?
Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.
Study design: Retrospective cohort study.
Setting: London Health Sciences Centre, Ontario, Canada.
Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.
There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.
The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.
Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.
Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?
Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.
Study design: Retrospective cohort study.
Setting: London Health Sciences Centre, Ontario, Canada.
Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.
There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.
The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.
Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.
Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?
Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.
Study design: Retrospective cohort study.
Setting: London Health Sciences Centre, Ontario, Canada.
Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.
There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.
The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.
Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.
Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?
Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.
Study design: Retrospective analysis.
Setting: Academic hospitalists at a tertiary care medical center.
Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).
This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.
Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.
Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?
Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.
Study design: Retrospective analysis.
Setting: Academic hospitalists at a tertiary care medical center.
Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).
This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.
Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.
Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?
Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.
Study design: Retrospective analysis.
Setting: Academic hospitalists at a tertiary care medical center.
Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).
This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.
Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.
Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?
Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.
Study design: A parallel-controlled, experimental, before-after design.
Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.
Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.
A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).
This method of observation is limited to identified and corrected wrong-patient orders.
Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.
Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?
Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.
Study design: A parallel-controlled, experimental, before-after design.
Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.
Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.
A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).
This method of observation is limited to identified and corrected wrong-patient orders.
Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.
Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?
Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.
Study design: A parallel-controlled, experimental, before-after design.
Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.
Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.
A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).
This method of observation is limited to identified and corrected wrong-patient orders.
Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.
Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?
Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.
Study design: Retrospective cohort study.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.
The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.
The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.
Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.
Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.
Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?
Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.
Study design: Retrospective cohort study.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.
The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.
The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.
Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.
Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.
Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?
Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.
Study design: Retrospective cohort study.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.
The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.
The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.
Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.
Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.
Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?
Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.
Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.
This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.
This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.
Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.
SIX-WEEK DURATION ANTIBIOTIC THERAPY FOR NONSURGICALLY TREATED DIABETIC FOOT OSTEOMYELITIS MAY BE SUFFICIENT
This prospective, randomized trial comparing six-week versus 12-week antibiotic therapy for nonsurgically treated, diabetic foot osteomyelitis demonstrated no significant difference in remission rates.
Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?
Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.
Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.
This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.
This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.
Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.
SIX-WEEK DURATION ANTIBIOTIC THERAPY FOR NONSURGICALLY TREATED DIABETIC FOOT OSTEOMYELITIS MAY BE SUFFICIENT
This prospective, randomized trial comparing six-week versus 12-week antibiotic therapy for nonsurgically treated, diabetic foot osteomyelitis demonstrated no significant difference in remission rates.
Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?
Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.
Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.
Setting: Mayo Clinic, Rochester, Minn.
Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.
This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.
This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.
Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.
SIX-WEEK DURATION ANTIBIOTIC THERAPY FOR NONSURGICALLY TREATED DIABETIC FOOT OSTEOMYELITIS MAY BE SUFFICIENT
This prospective, randomized trial comparing six-week versus 12-week antibiotic therapy for nonsurgically treated, diabetic foot osteomyelitis demonstrated no significant difference in remission rates.
Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?
Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.
Study Design: Retrospective cohort study.
Setting: Fifty-three hospitals in Washington.
Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:
Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
Diabetics may be better adapted to hyperglycemia than nondiabetics.
Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.
COCHRANE REVIEW OF RANDOMIZED CONTROLLED TRIALS EVALUATING THE EPLEY MANEUVER VERSUS PLACEBO, NO TREATMENT, OR OTHER ACTIVE TREATMENT FOR ADULTS DIAGNOSED WITH POSTERIOR CANAL BPPV
Benign paroxysmal positional vertigo (BPPV) can effectively be diagnosed and treated using the Epley maneuver. There do not appear to be serious adverse effects.
HOSPITAL-ACQUIRED INFECTIONS (HAIs) DROPPING, BUT STILL MORE ROOM TO GO
A CDC report reveals an overall decrease in HAIs at the national and state level between 2008 and 2013. Nationally, central-line associated bloodstream infection has dropped 46%; catheter-associated urinary tract infection has modestly increased.
Citation: Centers for Disease Control and Prevention. Healthcare-Associated Infections Progress Report. January 14, 2015. Available at: www.cdc.gov/hai/progress-report/index.html. Accessed March 10, 2015.
Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?
Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.
Study Design: Retrospective cohort study.
Setting: Fifty-three hospitals in Washington.
Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:
Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
Diabetics may be better adapted to hyperglycemia than nondiabetics.
Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.
COCHRANE REVIEW OF RANDOMIZED CONTROLLED TRIALS EVALUATING THE EPLEY MANEUVER VERSUS PLACEBO, NO TREATMENT, OR OTHER ACTIVE TREATMENT FOR ADULTS DIAGNOSED WITH POSTERIOR CANAL BPPV
Benign paroxysmal positional vertigo (BPPV) can effectively be diagnosed and treated using the Epley maneuver. There do not appear to be serious adverse effects.
HOSPITAL-ACQUIRED INFECTIONS (HAIs) DROPPING, BUT STILL MORE ROOM TO GO
A CDC report reveals an overall decrease in HAIs at the national and state level between 2008 and 2013. Nationally, central-line associated bloodstream infection has dropped 46%; catheter-associated urinary tract infection has modestly increased.
Citation: Centers for Disease Control and Prevention. Healthcare-Associated Infections Progress Report. January 14, 2015. Available at: www.cdc.gov/hai/progress-report/index.html. Accessed March 10, 2015.
Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?
Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.
Study Design: Retrospective cohort study.
Setting: Fifty-three hospitals in Washington.
Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:
Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
Diabetics may be better adapted to hyperglycemia than nondiabetics.
Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.
COCHRANE REVIEW OF RANDOMIZED CONTROLLED TRIALS EVALUATING THE EPLEY MANEUVER VERSUS PLACEBO, NO TREATMENT, OR OTHER ACTIVE TREATMENT FOR ADULTS DIAGNOSED WITH POSTERIOR CANAL BPPV
Benign paroxysmal positional vertigo (BPPV) can effectively be diagnosed and treated using the Epley maneuver. There do not appear to be serious adverse effects.
HOSPITAL-ACQUIRED INFECTIONS (HAIs) DROPPING, BUT STILL MORE ROOM TO GO
A CDC report reveals an overall decrease in HAIs at the national and state level between 2008 and 2013. Nationally, central-line associated bloodstream infection has dropped 46%; catheter-associated urinary tract infection has modestly increased.
Citation: Centers for Disease Control and Prevention. Healthcare-Associated Infections Progress Report. January 14, 2015. Available at: www.cdc.gov/hai/progress-report/index.html. Accessed March 10, 2015.
Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?
Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.
Study design: Cross-sectional, anonymous survey study.
Setting: Surveys sent to members of the British Medical Association.
Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.
Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.
Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.
Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?
Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.
Study design: Cross-sectional, anonymous survey study.
Setting: Surveys sent to members of the British Medical Association.
Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.
Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.
Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.
Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?
Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.
Study design: Cross-sectional, anonymous survey study.
Setting: Surveys sent to members of the British Medical Association.
Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.
Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.
Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.
Clinical question: Does delirium contribute to chance of death?
Background: Delirium is a well-recognized predictor of mortality. Prior observational studies have estimated a risk of death two to four times higher in ICU patients with delirium compared with those who do not experience delirium. The degree to which this association reflects a causal relationship is debated.
Study design: Prospective cohort study; used logistic regression and competing risks survival analyses along with a marginal structural model analysis to adjust for both baseline characteristics and severity of illness developing during ICU stay.
Setting: Single ICU in the Netherlands.
Synopsis: Regression analysis of 1,112 ICU patients confirmed the strong association between delirium and mortality; however, additional analysis, adjusting for the severity of illness as it progressed during the ICU stay, attenuated the relationship to nonsignificance. This suggests that both delirium and mortality were being driven by the common underlying illness.
In post hoc analysis, only persistent delirium was associated with a small increase in mortality. Although this observational study can neither prove nor disprove causation, the adjustment for changing severity of illness during the ICU stay was more sophisticated than prior studies. This study suggests that delirium and mortality are likely companions on the road of critical illness but that one may not directly cause the other.
Bottom line: Delirium in the ICU likely does not cause death, but its presence portends increased risk of mortality.
Clinical question: Does delirium contribute to chance of death?
Background: Delirium is a well-recognized predictor of mortality. Prior observational studies have estimated a risk of death two to four times higher in ICU patients with delirium compared with those who do not experience delirium. The degree to which this association reflects a causal relationship is debated.
Study design: Prospective cohort study; used logistic regression and competing risks survival analyses along with a marginal structural model analysis to adjust for both baseline characteristics and severity of illness developing during ICU stay.
Setting: Single ICU in the Netherlands.
Synopsis: Regression analysis of 1,112 ICU patients confirmed the strong association between delirium and mortality; however, additional analysis, adjusting for the severity of illness as it progressed during the ICU stay, attenuated the relationship to nonsignificance. This suggests that both delirium and mortality were being driven by the common underlying illness.
In post hoc analysis, only persistent delirium was associated with a small increase in mortality. Although this observational study can neither prove nor disprove causation, the adjustment for changing severity of illness during the ICU stay was more sophisticated than prior studies. This study suggests that delirium and mortality are likely companions on the road of critical illness but that one may not directly cause the other.
Bottom line: Delirium in the ICU likely does not cause death, but its presence portends increased risk of mortality.
Clinical question: Does delirium contribute to chance of death?
Background: Delirium is a well-recognized predictor of mortality. Prior observational studies have estimated a risk of death two to four times higher in ICU patients with delirium compared with those who do not experience delirium. The degree to which this association reflects a causal relationship is debated.
Study design: Prospective cohort study; used logistic regression and competing risks survival analyses along with a marginal structural model analysis to adjust for both baseline characteristics and severity of illness developing during ICU stay.
Setting: Single ICU in the Netherlands.
Synopsis: Regression analysis of 1,112 ICU patients confirmed the strong association between delirium and mortality; however, additional analysis, adjusting for the severity of illness as it progressed during the ICU stay, attenuated the relationship to nonsignificance. This suggests that both delirium and mortality were being driven by the common underlying illness.
In post hoc analysis, only persistent delirium was associated with a small increase in mortality. Although this observational study can neither prove nor disprove causation, the adjustment for changing severity of illness during the ICU stay was more sophisticated than prior studies. This study suggests that delirium and mortality are likely companions on the road of critical illness but that one may not directly cause the other.
Bottom line: Delirium in the ICU likely does not cause death, but its presence portends increased risk of mortality.
Kathleen Finn, MD, FHM and Jeffrey Greenwald, MD, SFHM engaged the audience with their playful banter while reviewing medical literature of clinical significance for the hospitalist in Update in Hospital Medicine. The studies presented were high-quality, practical and addressed questions that arise in our day-to-day practice. A wide variety of topics were addressed and key points are summarized below.
Key takeaways
In the PARADIGM-HF study, Angiotensin Receptor Blocker (ARB) + Neprilysin Inhibitor decreased cardiovascular mortality and reduced CHF hospitalization by 20% when compared to Enalapril alone in heart failure patients. The combination drug is an alternative choice to ACE inhibitors. FDA approval is forthcoming.
Is the risk of contrast-induced nephrotoxicity really as great as we have come to believe? Review of propensity matched studies suggests that AKI, 30 day need for emergent hemodi
alysis and death are unrelated to contrast. If CT with contrast makes a difference to the patient, consider using it if GFR>30 ml/min.
SAGES trial and Project Recovery developed a delirium screening method in hospitalized patients. The CAM (Confusion Assessment Method) scoring system assesses delirium severity in elderly patients (70+). Hospital and post-hospital outcomes in delirious vs. non-delirious patients showed that the more severe the delirium, the longer the patient stayed in the hospital. Further, the rate of new SNF placement and 90 day mortality was higher in the delirious group. The CAM score correlates with prognosis in medical patients. Addressing long-term goals of care in this patient population may be warranted.
A randomized placebo-controlled trail looked at the preventive effects of Ramelteon (melatonin receptor agonist) on delirium. Ramelteon 8mg was given to patients at 9pm for 7 days (or d/c). Although this was a small and short study, Ramelteon appears to reduce incident delirium in medical and non-intubated ICU patients.
The HELP randomized clinical trial compared Lactulose vs. Polyethylene Glycol (PEG) electrolyte solution for treatment of overt hepatic encephalopathy. Patients received either PEG (4L in 4 hours) or Lactulose (20-30g 3+doses/24hrs). Primary outcome was an improvement in HESA (Hepatic Encephalopathy Scoring Algorithm ) score by 1 at 24 hours. HESA score improved and patients had a shorter length of stay in the PEG group. In addition, patients requested PEG at discharge because it tasted better.
A retrospective study looked at Nonselective beta blockers (NSBB) in patients with Spontaneous Bacterial Peritonitis (SBP). It suggests that the use of NSBB after SBP onset increases the risk of AKI, Hepatorenal Syndrome and mortality by 58%. NSBB appear beneficial before SBP onset suggesting that as cirrhosis becomes more severe, NSBB may not be effective.
A retrospective cohort trial (Michigan Hospital Medicine Safety Consortium) assessed hospital performance of VTE prophylaxis. The rate of clinically evident, confirmed VTE was measured. There was no difference in VTE occurrence during hospitalization, 90 day VTE rates and PE vs. DVT rates. No clear benefit was evident from VTE prophylaxis for medical patients. This could indicate the need to risk stratify patients’ VTE risk.
Direct oral anticoagulants (DOACs) were compared with Vitamin K antagonists (VKA) for treatment of acute VTE in a meta-analysis reviewed by the speakers. Death, safety and bleeding were assessed. DOACs seem to work as well as VKAs for VTE. They also had a better safety profile. In cancer patients, DOACs vs. LMWH study is still needed. In patients with atrial fibrillation (AF), DOACs prevent AF-associated strokes better than VKAs. They also reduce hemorrhagic stroke and intracranial hemorrhage.
In the elderly (75 or older) patient, DOACs are as safe as VKAs and LMWH for AF and VTE treatment.
Randomized control trails compared once weekly Dalbavancin or single-dose Oritavancin vs. daily conventional therapy for acute bacterial skin infections (cellulitis, major abscess, wound infection, 75cm² erythema). Outcomes measured were cessation of spread of erythema and no fever X3 readings in 48-72 hours. Dalbavancin once weekly was non-inferior to Vancomycin in safety profile and outcome measures. Direct cost of Dalbavancin was higher although patients on this drug had shorter length of stays which is cost effective. FDA approved for skin infections.
The presence of family during CPR decreased PTSD, anxiety and depression symptoms in family members. Outcomes were similar when participants were assesses at 90 days and 1 year. While this study was conducted in an out of hospital setting, it may be worthwhile to assess if it is applicable to patients who code in the hospital.
Kathleen Finn, MD, FHM and Jeffrey Greenwald, MD, SFHM engaged the audience with their playful banter while reviewing medical literature of clinical significance for the hospitalist in Update in Hospital Medicine. The studies presented were high-quality, practical and addressed questions that arise in our day-to-day practice. A wide variety of topics were addressed and key points are summarized below.
Key takeaways
In the PARADIGM-HF study, Angiotensin Receptor Blocker (ARB) + Neprilysin Inhibitor decreased cardiovascular mortality and reduced CHF hospitalization by 20% when compared to Enalapril alone in heart failure patients. The combination drug is an alternative choice to ACE inhibitors. FDA approval is forthcoming.
Is the risk of contrast-induced nephrotoxicity really as great as we have come to believe? Review of propensity matched studies suggests that AKI, 30 day need for emergent hemodi
alysis and death are unrelated to contrast. If CT with contrast makes a difference to the patient, consider using it if GFR>30 ml/min.
SAGES trial and Project Recovery developed a delirium screening method in hospitalized patients. The CAM (Confusion Assessment Method) scoring system assesses delirium severity in elderly patients (70+). Hospital and post-hospital outcomes in delirious vs. non-delirious patients showed that the more severe the delirium, the longer the patient stayed in the hospital. Further, the rate of new SNF placement and 90 day mortality was higher in the delirious group. The CAM score correlates with prognosis in medical patients. Addressing long-term goals of care in this patient population may be warranted.
A randomized placebo-controlled trail looked at the preventive effects of Ramelteon (melatonin receptor agonist) on delirium. Ramelteon 8mg was given to patients at 9pm for 7 days (or d/c). Although this was a small and short study, Ramelteon appears to reduce incident delirium in medical and non-intubated ICU patients.
The HELP randomized clinical trial compared Lactulose vs. Polyethylene Glycol (PEG) electrolyte solution for treatment of overt hepatic encephalopathy. Patients received either PEG (4L in 4 hours) or Lactulose (20-30g 3+doses/24hrs). Primary outcome was an improvement in HESA (Hepatic Encephalopathy Scoring Algorithm ) score by 1 at 24 hours. HESA score improved and patients had a shorter length of stay in the PEG group. In addition, patients requested PEG at discharge because it tasted better.
A retrospective study looked at Nonselective beta blockers (NSBB) in patients with Spontaneous Bacterial Peritonitis (SBP). It suggests that the use of NSBB after SBP onset increases the risk of AKI, Hepatorenal Syndrome and mortality by 58%. NSBB appear beneficial before SBP onset suggesting that as cirrhosis becomes more severe, NSBB may not be effective.
A retrospective cohort trial (Michigan Hospital Medicine Safety Consortium) assessed hospital performance of VTE prophylaxis. The rate of clinically evident, confirmed VTE was measured. There was no difference in VTE occurrence during hospitalization, 90 day VTE rates and PE vs. DVT rates. No clear benefit was evident from VTE prophylaxis for medical patients. This could indicate the need to risk stratify patients’ VTE risk.
Direct oral anticoagulants (DOACs) were compared with Vitamin K antagonists (VKA) for treatment of acute VTE in a meta-analysis reviewed by the speakers. Death, safety and bleeding were assessed. DOACs seem to work as well as VKAs for VTE. They also had a better safety profile. In cancer patients, DOACs vs. LMWH study is still needed. In patients with atrial fibrillation (AF), DOACs prevent AF-associated strokes better than VKAs. They also reduce hemorrhagic stroke and intracranial hemorrhage.
In the elderly (75 or older) patient, DOACs are as safe as VKAs and LMWH for AF and VTE treatment.
Randomized control trails compared once weekly Dalbavancin or single-dose Oritavancin vs. daily conventional therapy for acute bacterial skin infections (cellulitis, major abscess, wound infection, 75cm² erythema). Outcomes measured were cessation of spread of erythema and no fever X3 readings in 48-72 hours. Dalbavancin once weekly was non-inferior to Vancomycin in safety profile and outcome measures. Direct cost of Dalbavancin was higher although patients on this drug had shorter length of stays which is cost effective. FDA approved for skin infections.
The presence of family during CPR decreased PTSD, anxiety and depression symptoms in family members. Outcomes were similar when participants were assesses at 90 days and 1 year. While this study was conducted in an out of hospital setting, it may be worthwhile to assess if it is applicable to patients who code in the hospital.
Kathleen Finn, MD, FHM and Jeffrey Greenwald, MD, SFHM engaged the audience with their playful banter while reviewing medical literature of clinical significance for the hospitalist in Update in Hospital Medicine. The studies presented were high-quality, practical and addressed questions that arise in our day-to-day practice. A wide variety of topics were addressed and key points are summarized below.
Key takeaways
In the PARADIGM-HF study, Angiotensin Receptor Blocker (ARB) + Neprilysin Inhibitor decreased cardiovascular mortality and reduced CHF hospitalization by 20% when compared to Enalapril alone in heart failure patients. The combination drug is an alternative choice to ACE inhibitors. FDA approval is forthcoming.
Is the risk of contrast-induced nephrotoxicity really as great as we have come to believe? Review of propensity matched studies suggests that AKI, 30 day need for emergent hemodi
alysis and death are unrelated to contrast. If CT with contrast makes a difference to the patient, consider using it if GFR>30 ml/min.
SAGES trial and Project Recovery developed a delirium screening method in hospitalized patients. The CAM (Confusion Assessment Method) scoring system assesses delirium severity in elderly patients (70+). Hospital and post-hospital outcomes in delirious vs. non-delirious patients showed that the more severe the delirium, the longer the patient stayed in the hospital. Further, the rate of new SNF placement and 90 day mortality was higher in the delirious group. The CAM score correlates with prognosis in medical patients. Addressing long-term goals of care in this patient population may be warranted.
A randomized placebo-controlled trail looked at the preventive effects of Ramelteon (melatonin receptor agonist) on delirium. Ramelteon 8mg was given to patients at 9pm for 7 days (or d/c). Although this was a small and short study, Ramelteon appears to reduce incident delirium in medical and non-intubated ICU patients.
The HELP randomized clinical trial compared Lactulose vs. Polyethylene Glycol (PEG) electrolyte solution for treatment of overt hepatic encephalopathy. Patients received either PEG (4L in 4 hours) or Lactulose (20-30g 3+doses/24hrs). Primary outcome was an improvement in HESA (Hepatic Encephalopathy Scoring Algorithm ) score by 1 at 24 hours. HESA score improved and patients had a shorter length of stay in the PEG group. In addition, patients requested PEG at discharge because it tasted better.
A retrospective study looked at Nonselective beta blockers (NSBB) in patients with Spontaneous Bacterial Peritonitis (SBP). It suggests that the use of NSBB after SBP onset increases the risk of AKI, Hepatorenal Syndrome and mortality by 58%. NSBB appear beneficial before SBP onset suggesting that as cirrhosis becomes more severe, NSBB may not be effective.
A retrospective cohort trial (Michigan Hospital Medicine Safety Consortium) assessed hospital performance of VTE prophylaxis. The rate of clinically evident, confirmed VTE was measured. There was no difference in VTE occurrence during hospitalization, 90 day VTE rates and PE vs. DVT rates. No clear benefit was evident from VTE prophylaxis for medical patients. This could indicate the need to risk stratify patients’ VTE risk.
Direct oral anticoagulants (DOACs) were compared with Vitamin K antagonists (VKA) for treatment of acute VTE in a meta-analysis reviewed by the speakers. Death, safety and bleeding were assessed. DOACs seem to work as well as VKAs for VTE. They also had a better safety profile. In cancer patients, DOACs vs. LMWH study is still needed. In patients with atrial fibrillation (AF), DOACs prevent AF-associated strokes better than VKAs. They also reduce hemorrhagic stroke and intracranial hemorrhage.
In the elderly (75 or older) patient, DOACs are as safe as VKAs and LMWH for AF and VTE treatment.
Randomized control trails compared once weekly Dalbavancin or single-dose Oritavancin vs. daily conventional therapy for acute bacterial skin infections (cellulitis, major abscess, wound infection, 75cm² erythema). Outcomes measured were cessation of spread of erythema and no fever X3 readings in 48-72 hours. Dalbavancin once weekly was non-inferior to Vancomycin in safety profile and outcome measures. Direct cost of Dalbavancin was higher although patients on this drug had shorter length of stays which is cost effective. FDA approved for skin infections.
The presence of family during CPR decreased PTSD, anxiety and depression symptoms in family members. Outcomes were similar when participants were assesses at 90 days and 1 year. While this study was conducted in an out of hospital setting, it may be worthwhile to assess if it is applicable to patients who code in the hospital.
