Literature Review

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Clinical question: Can a nurse-driven early ambulation program aimed at all hospitalized adults increase patient mobility and decrease length of stay?

Background: Many adults experience decline of functional abilities during their hospitalization. Interventions to increase early mobilization of patients in the ICU have been associated with decreased length of stay, decreased costs, and improved patient satisfaction. Previous studies of interventions in non-ICU patients have used specialized staff or have targeted select patient populations.

Study design: Before-after cohort study.

Setting: Patients admitted to two general medical units at a single large academic hospital.

Synopsis: The authors implemented a 12-month multidisciplinary quality improvement project in 3,352 patients, with the goal of mobilizing patients three times per day. Additional goals included consistently documenting daily mobility, setting daily goals to increase activity, and standardizing the description of mobility across disciplines. Ambulation, documentation, and goal setting were assigned to regular nursing staff and targeted at each of the patients admitted to these units during the study period. Highest level of mobility was documented using a locally derived simple eight-point ordinal scale. Daily documentation rate of mobility averaged 85% over the 12 months of the project. Comparing the four-month study period at the beginning of the project implementation to the four-month period after implementation, more patients ambulated (70% versus 43%), patients with improved mobility scores increased from 32% to 45%, and length of stay declined by 0.40 days. All of these differences were statistically significant. There was no increase in falls with injury.

Bottom line: A nurse-driven early mobility program aimed at all patients admitted to general medical services may improve mobility and decrease length of stay.

Citation: Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project [published online ahead of print February 5, 2016]. J Hosp Med. doi:10.1002/jhm.2546.

Short Take

Prednisolone is Equivalent to NSAIDs in the Treatment of Acute Gout

In a multicenter, double-blind, randomized equivalence trial of 416 patients presenting to the emergency department with symptoms of acute gout, treatment with prednisolone was equivalent to indomethacin for pain treatment without any difference in adverse events.

Citation: Rainer TH, Cheng CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout: a pragmatic, multicenter, double-blind, randomized trial. Ann Intern Med. 2016;164(7):464-471. doi:10.7326/M14-2070.

Clinical question: Can a nurse-driven early ambulation program aimed at all hospitalized adults increase patient mobility and decrease length of stay?

Background: Many adults experience decline of functional abilities during their hospitalization. Interventions to increase early mobilization of patients in the ICU have been associated with decreased length of stay, decreased costs, and improved patient satisfaction. Previous studies of interventions in non-ICU patients have used specialized staff or have targeted select patient populations.

Study design: Before-after cohort study.

Setting: Patients admitted to two general medical units at a single large academic hospital.

Synopsis: The authors implemented a 12-month multidisciplinary quality improvement project in 3,352 patients, with the goal of mobilizing patients three times per day. Additional goals included consistently documenting daily mobility, setting daily goals to increase activity, and standardizing the description of mobility across disciplines. Ambulation, documentation, and goal setting were assigned to regular nursing staff and targeted at each of the patients admitted to these units during the study period. Highest level of mobility was documented using a locally derived simple eight-point ordinal scale. Daily documentation rate of mobility averaged 85% over the 12 months of the project. Comparing the four-month study period at the beginning of the project implementation to the four-month period after implementation, more patients ambulated (70% versus 43%), patients with improved mobility scores increased from 32% to 45%, and length of stay declined by 0.40 days. All of these differences were statistically significant. There was no increase in falls with injury.

Bottom line: A nurse-driven early mobility program aimed at all patients admitted to general medical services may improve mobility and decrease length of stay.

Citation: Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project [published online ahead of print February 5, 2016]. J Hosp Med. doi:10.1002/jhm.2546.

Short Take

Prednisolone is Equivalent to NSAIDs in the Treatment of Acute Gout

In a multicenter, double-blind, randomized equivalence trial of 416 patients presenting to the emergency department with symptoms of acute gout, treatment with prednisolone was equivalent to indomethacin for pain treatment without any difference in adverse events.

Citation: Rainer TH, Cheng CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout: a pragmatic, multicenter, double-blind, randomized trial. Ann Intern Med. 2016;164(7):464-471. doi:10.7326/M14-2070.

Clinical question: Can a nurse-driven early ambulation program aimed at all hospitalized adults increase patient mobility and decrease length of stay?

Background: Many adults experience decline of functional abilities during their hospitalization. Interventions to increase early mobilization of patients in the ICU have been associated with decreased length of stay, decreased costs, and improved patient satisfaction. Previous studies of interventions in non-ICU patients have used specialized staff or have targeted select patient populations.

Study design: Before-after cohort study.

Setting: Patients admitted to two general medical units at a single large academic hospital.

Synopsis: The authors implemented a 12-month multidisciplinary quality improvement project in 3,352 patients, with the goal of mobilizing patients three times per day. Additional goals included consistently documenting daily mobility, setting daily goals to increase activity, and standardizing the description of mobility across disciplines. Ambulation, documentation, and goal setting were assigned to regular nursing staff and targeted at each of the patients admitted to these units during the study period. Highest level of mobility was documented using a locally derived simple eight-point ordinal scale. Daily documentation rate of mobility averaged 85% over the 12 months of the project. Comparing the four-month study period at the beginning of the project implementation to the four-month period after implementation, more patients ambulated (70% versus 43%), patients with improved mobility scores increased from 32% to 45%, and length of stay declined by 0.40 days. All of these differences were statistically significant. There was no increase in falls with injury.

Bottom line: A nurse-driven early mobility program aimed at all patients admitted to general medical services may improve mobility and decrease length of stay.

Citation: Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project [published online ahead of print February 5, 2016]. J Hosp Med. doi:10.1002/jhm.2546.

Short Take

Prednisolone is Equivalent to NSAIDs in the Treatment of Acute Gout

In a multicenter, double-blind, randomized equivalence trial of 416 patients presenting to the emergency department with symptoms of acute gout, treatment with prednisolone was equivalent to indomethacin for pain treatment without any difference in adverse events.

Citation: Rainer TH, Cheng CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout: a pragmatic, multicenter, double-blind, randomized trial. Ann Intern Med. 2016;164(7):464-471. doi:10.7326/M14-2070.

Clinical question: Given advances in the understanding and treatment of sepsis, can sepsis be better defined?

Background: Definitions of sepsis and septic shock were last revised in 2001. The current definitions are based on a constellation of clinical signs and symptoms in a patient with suspected infection. Recent studies suggest that the definitions have low sensitivity and specificity, and they do not correlate well with patient outcomes.

Study design: Consensus guidelines.

Setting: Task force of 19 critical care, infectious disease, surgical, and pulmonary specialists convened in 2014 by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine.

Synopsis: The task force recommended that sepsis be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection and that it be identified by a change of more than one point in the Sequential Organ Failure Assessment (SOFA) score. This score incorporates the Glasgow Coma Scale, mean arterial blood pressure (MAP), PaO2/FiO2, platelet count, creatinine, and bilirubin. Septic shock is defined as a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities, and it’s identified by serum lactate level >2 mmol/L and vasopressor requirement to maintain a MAP of ≥65 mm Hg in the absence of hypovolemia. These new definitions have higher sensitivity and specificity and can predict mortality more accurately. Patients with these definitions of sepsis and septic shock have in-hospital mortality >10% and >40%, respectively. The presence of two or more quick SOFA (qSOFA) elements (altered mentation, systolic blood pressure ≤100 mm Hg, and respiratory rate ≥22/min) identifies adult patients with suspected infection who need more extensive laboratory testing to exclude sepsis.

Bottom line: Defining sepsis now requires more laboratory testing but provides more diagnostic consistency and more accurately predicts outcomes.

Citation: Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.

Clinical question: Given advances in the understanding and treatment of sepsis, can sepsis be better defined?

Background: Definitions of sepsis and septic shock were last revised in 2001. The current definitions are based on a constellation of clinical signs and symptoms in a patient with suspected infection. Recent studies suggest that the definitions have low sensitivity and specificity, and they do not correlate well with patient outcomes.

Study design: Consensus guidelines.

Setting: Task force of 19 critical care, infectious disease, surgical, and pulmonary specialists convened in 2014 by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine.

Synopsis: The task force recommended that sepsis be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection and that it be identified by a change of more than one point in the Sequential Organ Failure Assessment (SOFA) score. This score incorporates the Glasgow Coma Scale, mean arterial blood pressure (MAP), PaO2/FiO2, platelet count, creatinine, and bilirubin. Septic shock is defined as a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities, and it’s identified by serum lactate level >2 mmol/L and vasopressor requirement to maintain a MAP of ≥65 mm Hg in the absence of hypovolemia. These new definitions have higher sensitivity and specificity and can predict mortality more accurately. Patients with these definitions of sepsis and septic shock have in-hospital mortality >10% and >40%, respectively. The presence of two or more quick SOFA (qSOFA) elements (altered mentation, systolic blood pressure ≤100 mm Hg, and respiratory rate ≥22/min) identifies adult patients with suspected infection who need more extensive laboratory testing to exclude sepsis.

Bottom line: Defining sepsis now requires more laboratory testing but provides more diagnostic consistency and more accurately predicts outcomes.

Citation: Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.

Clinical question: Given advances in the understanding and treatment of sepsis, can sepsis be better defined?

Background: Definitions of sepsis and septic shock were last revised in 2001. The current definitions are based on a constellation of clinical signs and symptoms in a patient with suspected infection. Recent studies suggest that the definitions have low sensitivity and specificity, and they do not correlate well with patient outcomes.

Study design: Consensus guidelines.

Setting: Task force of 19 critical care, infectious disease, surgical, and pulmonary specialists convened in 2014 by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine.

Synopsis: The task force recommended that sepsis be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection and that it be identified by a change of more than one point in the Sequential Organ Failure Assessment (SOFA) score. This score incorporates the Glasgow Coma Scale, mean arterial blood pressure (MAP), PaO2/FiO2, platelet count, creatinine, and bilirubin. Septic shock is defined as a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities, and it’s identified by serum lactate level >2 mmol/L and vasopressor requirement to maintain a MAP of ≥65 mm Hg in the absence of hypovolemia. These new definitions have higher sensitivity and specificity and can predict mortality more accurately. Patients with these definitions of sepsis and septic shock have in-hospital mortality >10% and >40%, respectively. The presence of two or more quick SOFA (qSOFA) elements (altered mentation, systolic blood pressure ≤100 mm Hg, and respiratory rate ≥22/min) identifies adult patients with suspected infection who need more extensive laboratory testing to exclude sepsis.

Bottom line: Defining sepsis now requires more laboratory testing but provides more diagnostic consistency and more accurately predicts outcomes.

Citation: Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.

Patients with non-acquired focal epilepsy are more likely to experience seizures while asleep, when compared to patients with generalized epilepsy. An analysis of nearly 1400 patients enrolled in the Epilepsy Phenome/Genome Project also revealed that these sleep/wake patterns applied to both convulsive and nonconvulsive seizures. The study further found that seizures occurring within an hour of awakening were more likely to happen in patients with generalized epilepsy, for both convulsive and nonconvulsive seizures. The researchers also discovered that the timing of seizures in first degree relatives predicted the timing of seizures in the proband, suggesting a genetic underpinning to the correlations. 

Winawer MR, Shih J, Beck ES, Hunter JE, Epstein MP; EPGP Investigators. Genetic effects on sleep/wake variation on seizures. Epilepsia. 2016;57(4):557-665. 

Patients with non-acquired focal epilepsy are more likely to experience seizures while asleep, when compared to patients with generalized epilepsy. An analysis of nearly 1400 patients enrolled in the Epilepsy Phenome/Genome Project also revealed that these sleep/wake patterns applied to both convulsive and nonconvulsive seizures. The study further found that seizures occurring within an hour of awakening were more likely to happen in patients with generalized epilepsy, for both convulsive and nonconvulsive seizures. The researchers also discovered that the timing of seizures in first degree relatives predicted the timing of seizures in the proband, suggesting a genetic underpinning to the correlations. 

Winawer MR, Shih J, Beck ES, Hunter JE, Epstein MP; EPGP Investigators. Genetic effects on sleep/wake variation on seizures. Epilepsia. 2016;57(4):557-665. 

Patients with non-acquired focal epilepsy are more likely to experience seizures while asleep, when compared to patients with generalized epilepsy. An analysis of nearly 1400 patients enrolled in the Epilepsy Phenome/Genome Project also revealed that these sleep/wake patterns applied to both convulsive and nonconvulsive seizures. The study further found that seizures occurring within an hour of awakening were more likely to happen in patients with generalized epilepsy, for both convulsive and nonconvulsive seizures. The researchers also discovered that the timing of seizures in first degree relatives predicted the timing of seizures in the proband, suggesting a genetic underpinning to the correlations. 

Winawer MR, Shih J, Beck ES, Hunter JE, Epstein MP; EPGP Investigators. Genetic effects on sleep/wake variation on seizures. Epilepsia. 2016;57(4):557-665. 

Misconceptions about epilepsy abound in the Western world. An analysis of English language publications revealed that many people have “socially exclusionary attitudes” toward persons with epilepsy, are ignorant about proper treatment, and tend to overgeneralize about people with epilepsy in a way that stigmatizes them. The literature review also found that intervention studies have been effective in improving attitudes about the disease but concluded that “many were targeted to healthcare and education settings, were time intensive, and impractical for broad general population implementation.” 

Herrman LK, Welter E, Berg AT, et al. Epilepsy misconceptions and stigma reduction: current status in Western countries. Epilepsy Behav. 2016;60:165-173.

Misconceptions about epilepsy abound in the Western world. An analysis of English language publications revealed that many people have “socially exclusionary attitudes” toward persons with epilepsy, are ignorant about proper treatment, and tend to overgeneralize about people with epilepsy in a way that stigmatizes them. The literature review also found that intervention studies have been effective in improving attitudes about the disease but concluded that “many were targeted to healthcare and education settings, were time intensive, and impractical for broad general population implementation.” 

Herrman LK, Welter E, Berg AT, et al. Epilepsy misconceptions and stigma reduction: current status in Western countries. Epilepsy Behav. 2016;60:165-173.

Misconceptions about epilepsy abound in the Western world. An analysis of English language publications revealed that many people have “socially exclusionary attitudes” toward persons with epilepsy, are ignorant about proper treatment, and tend to overgeneralize about people with epilepsy in a way that stigmatizes them. The literature review also found that intervention studies have been effective in improving attitudes about the disease but concluded that “many were targeted to healthcare and education settings, were time intensive, and impractical for broad general population implementation.” 

Herrman LK, Welter E, Berg AT, et al. Epilepsy misconceptions and stigma reduction: current status in Western countries. Epilepsy Behav. 2016;60:165-173.

Persons with epilepsy are less likely to use the Internet compared with the general public. The recent CDC study that arrived at that conclusion suggested that this disparity may put patients with epilepsy at a disadvantage because it limits their access to online tools that can optimize their self-care and improve their quality of life. The study was based on data from the 2013 National Health Interview Survey, which confirmed that the disparity existed in all three age groups analyzed: 18-44 years, 45-59 years, 60 years and older.  

US Centers for Disease Control and Prevention Epilepsy Program. Internet use and looking up information online in adults with epilepsy varies by epilepsy status — 2013 National Health Interview Survey. Epilepsy Behav. 2016;54:47-49. 

Persons with epilepsy are less likely to use the Internet compared with the general public. The recent CDC study that arrived at that conclusion suggested that this disparity may put patients with epilepsy at a disadvantage because it limits their access to online tools that can optimize their self-care and improve their quality of life. The study was based on data from the 2013 National Health Interview Survey, which confirmed that the disparity existed in all three age groups analyzed: 18-44 years, 45-59 years, 60 years and older.  

US Centers for Disease Control and Prevention Epilepsy Program. Internet use and looking up information online in adults with epilepsy varies by epilepsy status — 2013 National Health Interview Survey. Epilepsy Behav. 2016;54:47-49. 

Persons with epilepsy are less likely to use the Internet compared with the general public. The recent CDC study that arrived at that conclusion suggested that this disparity may put patients with epilepsy at a disadvantage because it limits their access to online tools that can optimize their self-care and improve their quality of life. The study was based on data from the 2013 National Health Interview Survey, which confirmed that the disparity existed in all three age groups analyzed: 18-44 years, 45-59 years, 60 years and older.  

US Centers for Disease Control and Prevention Epilepsy Program. Internet use and looking up information online in adults with epilepsy varies by epilepsy status — 2013 National Health Interview Survey. Epilepsy Behav. 2016;54:47-49. 

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does the use of disinfection caps on catheter hubs on central venous catheters (CVCs) reduce central-line-associated bloodstream infection (CLABSI) and blood culture contamination (BCC) in hematology-oncology patients?

Background: CVCs have facilitated the administration of chemotherapy, blood products, and fluids in cancer patients; however, their use has also brought about risk of infections. Use of an antiseptic barrier cap may result in decreased rates of CLABSI and BCC.

Study design: Multiphase prospective study

Setting: Memorial Sloan Kettering Cancer Center, New York City.

Synopsis: Disinfection caps on CVCs were sequentially introduced on high-risk units (HRUs) followed by hospital-wide implementation. The primary outcome was hospital-wide and unit-specific rates of hospital-acquired (HA) CLABSI. In Phase 1 and 2, the CDC guidelines for catheter maintenance were followed. In Phase 3, the intervention was implemented in the HRUs. In Phase 4, the intervention extended hospital-wide. HA-CLABSI declined significantly compared to baseline only in HRUs. A possible explanation is that reduction in CLABSI on general wards was not apparent due to the short follow-up period as opposed to the longer follow-up period for the HRUs. The secondary outcome was that the rates of BCC declined significantly in Phase 3 and 4 when compared to Phase 1 and 2. As for limitations, the study is not a randomized controlled trial; variable follow-up periods may have contributed to different outcomes observed on the different units.

Bottom line: Implementation of disinfection caps significantly reduces rates of CLABSI in HRUs and reduces BCCs in both HRUs and general oncology units, with substantial clinical and cost-savings implications.

Citation: Kamboj M, Blair R, Bell N, et al. Use of disinfection cap to reduce central-line-associated bloodstream infection and blood culture contamination among hematology-oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401-1408.

Short Take

High Workload among Attending Physicians Has Negative Outcomes

Retrospective study found associations between higher attending physician workload and lower teaching evaluation scores from residents as well as increased risks to patient safety.

Citation: Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. Associations between attending physician workload, teaching effectiveness, and patient safety. J Hosp Med. 2016;11(3):169-173.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: Does inhaled isopropyl alcohol alleviate nausea as compared to inhaled saline solution among patients presenting to the ED with a chief complaint of nausea?

Background: Nausea and vomiting account for 4.8 million ED visits each year; however, antiemetics have not shown superiority compared to placebo. Isopropyl alcohol nasal inhalation is more effective than saline solution in treating postoperative nausea and vomiting; however, there have been no investigations of this therapy in the ED setting.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Emergency department at the San Antonio Military Medical Center, Texas.

Synopsis: Investigators randomized a convenience sample of 80 patients in the ED presenting with nausea or vomiting to either inhaled isopropyl alcohol (37) or saline solution (43). Subjects would nasally inhale at 0, 2, and 4 minutes. Nausea outcomes were self-rated on a scale of 0–10, with 0 being no nausea and 10 being worst nausea imaginable. Responses were taken at 0, 2, 4, 6, and 10 minutes postintervention. Primary outcome was the score at 10 minutes postintervention. The minimally significant difference was two points.

Patients in the intervention arm reported lower scores during every study period than the patients in the placebo arm. Median nausea scores at 10 minutes postintervention were lower by three in the intervention arm compared to placebo arm (P<0.001). Limitations include the short (10-minute) evaluation period, which limits identification of any adverse events; limited information on duration of symptom relief and whether the isopropyl alcohol effect persisted; possible selection bias due to utilizing a convenience sample; and use of a subjective scale for the primary outcome.

Bottom line: Isopropyl alcohol inhalation is effective in reducing nausea 10 minutes after intervention as compared with placebo in the ED setting.

Citation: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for nausea in the emergency department: a randomized controlled trial [published online ahead of print November 21, 2015]. Ann Emerg Med. doi:10.1016/j.annemergmed.2015.09.031.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.

Clinical question: What is the association between proton pump inhibitor (PPI) use and incident chronic kidney disease (CKD)?

Background: Medication use may play a potential role in the increasing prevalence of CKD. PPIs are commonly prescribed, and several observational studies have linked their use with multiple adverse outcomes, including acute interstitial nephritis. The risk for CKD with PPI use has never been evaluated.

Study design: Prospective cohort study.

Setting: U.S., multi-center.

Synopsis: Among 10,482 patients in the Atherosclerosis Risk in Communities study (ARIC) with an estimated glomerular filtration rate of at least 60 mL/min/1.73 m2, PPI use was associated with a 1.50 times risk of incident CKD (95% CI, 1.14–1.96; P=0.003) and a 1.64 times risk of incident acute kidney injury (95% CI, 1.22–2.21; P<0.001) when compared to nonusers. PPI use continued to have an association with incident CKD even when compared directly with H2 receptor antagonist users (adjusted HR, 1.39; 95% CI, 1.01–1.91). Findings were replicated in a cohort of 248,751 patients in the Geisinger Health System, and in all analyses, PPI use was associated with CKD.

One limitation is that this was an observational study and causality between PPI use and CKD cannot be established.

Bottom line: PPIs are associated with risk for CKD, and in patients on therapy, its use should be reevaluated.

Citation: Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246.