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It is becoming increasingly apparent to rehabilitation and health researchers that employment is linked to health-related quality of life (HRQOL) outcomes in people with chronic musculoskeletal pain conditions including those [...]

Importance The CURB-65 score is widely implemented as a prediction tool for identifying patients with community-acquired pneumonia (cap) at increased risk of 30-day mortality. However, since most ingredients of CURB-65 are used as general prediction tools, it is likely that other prediction tools, e.g. the British National Early Warning Score (NEWS), could be as good as CURB-65 at predicting the fate of CAP patients. Objective To determine whether NEWS is better than CURB-65 at predicting 30-day mortality of CAP patients. Design This was a single-centre, 6-month observational study using patients' vital signs and demographic information registered upon admission, survival status extracted from the Danish Civil Registration System after discharge and blood test results extracted from a local database. Setting The study was conducted in the medical admission unit (MAU) at the Hospital of South West Jutland, a regional teaching hospital in Denmark. Participants The participants consisted of 570 CAP patients, 291 female and 279 male, median age 74 (20-102) years. Results The CURB-65 score had a discriminatory power of 0.728 (0.667-0.789) and NEWS 0.710 (0.645-0.775), both with good calibration and no statistical significant difference. Conclusion CURB-65 was not demonstrated to be significantly statistically better than NEWS at identifying CAP patients at risk of 30-day mortality., Author(s): Mikkel Brabrand [sup.1] [sup.2] [sup.3] , Daniel Pilsgaard Henriksen [sup.4] Author Affiliations: (Aff1) 0000 0001 0469 7368, grid.414576.5, Department of Emergency Medicine, Hospital of South West Jutland, , Finsensgade [...]

As the push to implement population health initiatives gets underway, Lonnie Joe, MD, is still mulling over whether his private practice can survive the changes he'll have to make to [...]

Byline: Subhash. TodiRecent literature on the use of vitamin C in critically ill patient with sepsis has generated much interest. Analysing the scientific rationale for the increasing use of this [...]

Purpose Postoperative delirium is a recognized complication in populations at risk. The aim of this study is to assess the prevalence of early postoperative delirium in a population without known risk factors admitted to the ICU for postoperative monitoring after elective major surgery. The secondary outcome investigated is to identify eventual independent risk factors among demographic data and anesthetic drugs used. Methods An observational, prospective study was conducted on a consecutive cohort of patients admitted to our ICU within and for at least 24 h after major surgical procedures. Exclusion criteria were any preexisting predisposing factor for delirium or other potentially confounding neurological dysfunctions. Patients were assessed daily using the confusion assessment method for the ICU scale for 3 days after the surgical procedure. Early postoperative delirium incidence risk factors were then assessed through three different multiple regression models. Results According to the confusion assessment method for the ICU scale, 28 % of patients were diagnosed with early postoperative delirium. The use of thiopentone was significantly associated with an eight-fold-higher risk for delirium compared to propofol (57.1 % vs. 7.1 %, RR = 8.0, [chi square] = 4.256; df = 1; 0.05 < p < 0.02). Conclusion In this study early postoperative delirium was found to be a very common complication after major surgery, even in a population without known risk factors. Thiopentone was independently associated with an increase in its relative risk. Keywords General anesthesia * Complications * Pharmacology, Introduction Delirium is defined as a disturbance of consciousness, accompanied by a change in cognition or the development of perceptual disturbances, with an acute onset and a fluctuating nature, not [...]

Byline: Priya. Sharma, V. Prem, Sakshee. Jain Background and Aims: One potential complication of acute respiratory distress syndrome (ARDS) is reduced dynamic compliance, saturation for peripheral oxygenation (SpO[sub]2) and increased [...]

Byline: Benjamin. Ozumba, Leonard. Ajah, Vitus. Obi, Uche. Umeh, Joseph. Enebe, Kingsley. Obioha Background and Aims: Although pregnancy and labor are considered physiological processes, the potential for catastrophic complications is [...]

Byline: Philippe. Seguin, Harmonie. Perrichet, Estelle. Pabic, Yoann. Launey, Marie. Tiercin, Romain. Corre, Graziella. Brinchault, Bruno. Laviolle Background and Aims: A risk of tracheal mucosa injury induced by subglottic suctioning [...]

Byline: Prakash. Babaliche, Siddharth. Madnani, Sajal. Kamat Background and Aims: Hyponatremia is the predominant electrolyte abnormality with an incidence rate of approximately 22%. It is the leading cause of morbidity [...]

Byline: Veena. Sheshadri, Arathi. Radhakrishnan, Kusuma. Halemani, Venkatesh. Keshavan Background and Aims: Patients with intracranial tumour are usually on anticonvulsants. Patients on phenytoin therapy demonstrate rapid metabolism of nondepolarising muscle [...]

Byline: Imran. Ahmad, Oliver. Keane, Sarah. Muldoon Studies have demonstrated that poor assessment and planning contribute to airway complications and that current airway assessment strategies have a poor diagnostic accuracy [...]

Background: Candidacy for liver transplantation is determined through standardized evaluation. There are limited data on the frequency and reasons for denial of transplantation after assessment; analysis may shed light on the short-term utility of the assessment. We sought to describe the frequency and reasons for ineligibility for liver transplantation among referred adults. Methods: We studied all prospectively followed recipient candidates at a single centre who were deemed unsuitable for liver transplantation after assessment. Inclusion criteria were age 18 years and older and completion of a standard liver transplantation evaluation over a 3-year period. Patients were excluded if they had a history of prior assessment or liver transplantation within the study period. Demographic and baseline clinical data and reasons for recipient ineligibility were recorded. Results: In all, 337 patients underwent their first liver transplantation evaluation during the study period; 166 (49.3%) fulfilled inclusion criteria. The mean age was 55.4 years, and 106 (63.9%) were men. The 3 most common reasons for denial of listing were patient too well (n = 82, 49.4%), medical comorbidities and/or need for medical optimization (n = 43, 25.9%) and need for addiction rehabilitation (n = 28, 16.9%). Conclusion: Ineligibility for transplantation after assessment was common, occurring in nearly half of the cohort. Most denied candidates could be identified with more discriminate screening before the resource-intensive assessment; however, the assessment likely provides unforeseen positive impacts on patient care. Contexte: Les candidats a une greffe du foie sont selectionnes au moyen d'une evaluation standardisee. On dispose de peu de donnees au sujet de la frequence et des motifs des refus de transplantation consecutifs a cette evaluation. Une analyse pourrait faire la lumiere sur l'utilite de l'evaluation a court terme. Nous avons voulu decrire la frequence de ces refus et les raisons pour lesquelles des adultes adresses pour consultation se voient refuser la greffe. Methodes: Nous avons etudie tous les candidats a la greffe suivis prospectivement dans 1 seul centre et a qui, apres evaluation, la greffe du foie a ete refusee. Les criteres d'inclusion etaient l'age de 18 ans et plus et les resultats de l'evaluation standard en vue de la greffe du foie sur une periode de 3 ans. Les patients etaient exclus s'ils avaient deja subi une evaluation ou une greffe du foie au cours de la periode de l'etude. Les donnees demographiques et cliniques de depart, de meme que les raisons de l'exclusion des candidats ont ete consignees. Resultats: En tout, 337 patients ont subi leur premiere evaluation en vue d'une greffe du foie au cours de la periode de l'etude; 166 (49,3 %) repondaient aux criteres d'inclusion. L'age moyen etait de 55,4 ans et 106 (63,9 %) etaient des hommes. Les 3 raisons les plus souvent invoquees pour refuser l'acces a la greffe chez ces candidats etaient qu'ils etaient suffisamment bien (n = 82, 49,4 %), qu'ils presentaient des comorbidites et(ou) qu'ils devaient ameliorer leur etat de sante (n = 43, 25,9 %) ou qu'il leur fallait une cure de desintoxication (n = 28, 16,9 %). Conclusion: De nombreux patients, soit pres de la moitie de la cohorte, ont ete juges mauvais candidats a la greffe apres l'evaluation. Il serait possible de reconnaitre les patients qui sont mauvais candidats a la greffe en faisant un depistage plus precis avant meme d'aller de l'avant avec l'evaluation standard, qui draine d'importantes ressources. Toutefois, l'evaluation a probablement des repercussions positives imprevues sur le soin des patients., In well-selected recipients, liver transplantation is a highly efficacious and cost-effective surgery for which there are established indications and contraindications. (1,2) The discord between the number of patients who require [...]

When patients visit the family practice of Susan Hole, DO, they are entering a kind one-stop shop for primary care. Serving a largely senior population, her Edgewater, Florida, practice offers--among [...]

No matter how long you have been in practice, chances are you have encountered a toxic employee who poisoned the atmosphere of your workplace. If you don't take action fast, [...]

Background: Emerging data suggest asymptomatic gastrointestinal stromal tumours (GISTs) of the upper gastrointestinal (UGI) tract are not uncommon. We sought to determine their incidence in patients undergoing resection for UGI neoplasms and their impact on surgical and adjuvant treatment. Methods: We accessed a database prospectively listing all patients undergoing resection of non-GIST neoplasms of the stomach and esophagus at a single university centre over a 4.5-year period and reviewed pathology reports for the presence of synchronous GISTs in the UGI tract. We compared patient demographic and tumour characteristics, operative procedures and postoperative outcomes. Results: In all, 207 patients undergoing gastrectomy or esophagectomy for nonGIST neoplasms were included. We identified 15 synchronous GISTs in the UGI tract of 11 (5.3%) patients (1 preoperatively, 4 intraoperatively and 10 on final pathology), with an average age of 67 years. Most patients were men. Additional resections were required for GISTs identified pre- or intraoperatively. Final pathology revealed completely resected c-kit positive tumours of an average size of 0.5 (range 0.1-4.0) cm with low or very low risk of malignant potential. No patients received adjuvant therapy for the GISTs. After a median follow-up of 11 (range 2-36) months, 5 patients died from their primary cancer, 3 were alive with primary cancer recurrence, and 3 were alive without disease. No patients experienced GIST recurrence. Conclusion: Incidentally finding a synchronous GIST during resection of UGI neoplasms is not uncommon; it may alter surgical treatment but is unlikely to impact longterm survival. Contexte : De nouvelles donnees indiquent que les tumeurs stromales gastro-intestinales (TSGI) asymptomatiques des voies digestives superieures ne sont pas rares. Nous avons voulu etablir leur incidence chez des patients soumis a une resection pour cancer des voies digestives superieures et leur impact sur le traitement chirurgical et adjuvant. Methodes : Nous avons interroge de maniere prospective une base de donnees regroupant tous les patients soumis a une resection de neoplasie non TSGI de l'estomac et de l'oesophage dans un seul centre universitaire sur une periode de 4,5 ans et nous avons passe en revue les rapports d'anatomopathologie pour relever des indications de la presence de TSGI simultanees au niveau des voies digestives superieures. Nous avons compare les caracteristiques demographiques et tumorales des patients, les interventions et les resultats postoperatoires. Resultats : En tout, nous avons inclus 207 patients soumis a une gastrectomie ou a une oesophagectomie pour neoplasie non TSGI. Nous avons releve 15 TSGI simultanees au niveau des voies digestives superieures de 11 patients (5,3 %; 1 a l'etape preoperatoire, 4 durant l'intervention et 10 lors de l'examen anatomopathologique final). Les patients etaient ages en moyenne de 67 ans et en majorite de sexe masculin. D'autres resections ont ete necessaires pour des TSGI reconnues durant la phase preoperatoire ou peroperatoire. Les analyses anatomopathologiques finales ont revele des tumeurs c-kit entierement resequees d'une taille moyenne de 0,5 (entre 0,1 et 4,0) cm assorties d'un risque de malignite faible ou tres faible. Aucun patient n'a recu de traitement adjuvant pour TSGI. Apres un suivi median de 11 (entre 2 et 36) mois, 5 patients sont decedes des suites de leur cancer primitif, 3 etaient toujours en vie avec recurrence de leur cancer primitif et 3 etaient toujours vivants sans signe de maladie. Aucun patient n'a presente de recurrence de TSGI. Conclusion : Il n'est pas rare de trouver de maniere fortuite une TSGI simultanee lors de la resection d'un cancer des voies digestives superieures; cette decouverte peut modifier le traitement chirurgical, mais risque peu d'influer sur la survie a long terme., Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, accounting for 0.1%-3.0% of all gastrointestinal malignancies. (1-3) These tumours are typically discovered in symptomatic patients [...]

Let's face it--the pressures on private physician practices are continuing to grow. In addition to financial concerns, practices must grapple with new regulations, pay-for-quality initiatives, the effects of doctor shortages, [...]

Abstract This article aims to help practitioners develop an understanding of cellulitis of the lower limb. It focuses on the identification of cellulitis, differentiating it from other common conditions, and [...]

Abstract The article provides an overview of the key issues relating to palliative care for patients with chronic respiratory disease. The need for palliative care in this patient group is [...]

Summary Patient choice and control should be central to the delivery of high-quality, end of life care. Advance care planning (ACP) is a process through which a patient's choices and [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2010.08.001 Byline: Emma Pitchforth (a), Richard J. Lilford (b), Yigzaw Kebede (c), Getahun Asres (c), Charlotte Stanford (d), Jodie Frost (e) Abstract: Ensuring high quality intrapartum care in developing countries is a crucial component of efforts to reduce maternal and neonatal mortality and morbidity. Conceptual frameworks for understanding quality of care have broadened to reflect the complexity of factors affecting quality of health care provision. Yet, the role of social sciences within the assessment and understanding of quality of care in this field has focused primarily on seeking to understand the views and experiences of service users and providers. In this pilot study we aimed to combine clinical and social science perspectives and methods to best assess and understand issues affecting quality of clinical care and to identify priorities for change. Based in one referral hospital in Ethiopia, data collection took place in three phases using a combination of structured and unstructured observations, interviews and a modified nominal group process. This resulted in a thorough and pragmatic methodology. Our results showed high levels of knowledge and compliance with most aspects of good clinical practice, and non-compliance was affected by different, inter-linked, resource constraints. Considering possible changes in terms of resource implications, local stakeholders prioritised five areas for change. Some of these changes would have considerable resources implications whilst others could be made within existing resources. The discussion focuses on implications for informing quality improvement interventions. Improvements will need to address health systems issues, such as supply of key drugs, as well as changes in professional practice to promote the rational use of drugs. Furthermore, the study considers the need to understand broader organizational factors and inter-professional relationships. The potential for greater integration of social science perspectives as part of currently increasing monitoring and evaluation activity around intrapartum care is highlighted. Author Affiliation: (a) LSE Health, London School of Economics and Political Science, London, UK (b) Division of Primary Care, Public and Occupational Health, University of Birmingham, Birmingham, UK (c) Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia (d) Department of Gastroenterology and Internal Medicine, Leicester Royal Infirmary, Leicester, UK (e) Department of Transplant Surgery, Leicester General Hospital, Leicester, UK

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2010.07.041 Byline: Sarah L. Krein (a)(b), Laura J. Damschroder (a), Christine P. Kowalski (a), Jane Forman (a), Timothy P. Hofer (a)(b), Sanjay Saint (a)(b) Abstract: Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve care quality, safety and outcomes. Despite these efforts, we have limited understanding of why quality improvement efforts are successful in some hospitals and not others. Using data collected as part of a multi-center study, we closely examined quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in U.S. hospitals. We compare and contrast the experiences among hospitals to better understand 'how' and 'why' certain hospitals were more successful with practice implementation when taking into consideration specific aspects of the organizational context. This study reveals that among a number of hospitals that focused on implementing practices to prevent CLABSI, the experience and outcomes varied considerably despite using similar implementation strategies. Moreover, our findings provide important insights about how and why different quality improvement strategies might perform across organizations with differing contextual characteristics. Author Affiliation: (a) VA Ann Arbor Healthcare System, HSR&D (11H), 2215 Fuller Road, Ann Arbor, MI 48105, United States (b) University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States

Patients with chronic conditions such as diabetes, COPD, and congestive heart failure are some of the most challenging for physicians to treat. The good news is that there are proven [...]

Extravascular lung water includes all of the fluid within the lung but outside of the vasculature. Lung water increases as a result of increased hydrostatic vascular pressure or from an increase in lung endothelial and epithelial permeability or both. Experimentally, extravascular lung water has been measured gravimetrically. Clinically, the chest radiograph is used to determine whether extravascular lung water is present but is an insensitive instrument for determining the quantity of lung water. Bedside measurement of extravascular lung water in patients is now possible using a single indicator thermodilution method. This review critically evaluates the experimental and clinical evidence supporting the potential value of measuring extravascular lung water in patients using the single indicator method. acute lung injury; acute respiratory distress syndrome; pulmonary edema doi: 10.1152/ajplung.00127.2009

The rules of other consumer commerce sectors somehow do not apply to medical billing. Stop and think about this for a moment. It's easier to make sense of how much [...]

The art of medicine can be as pivotal as the science of medicine when it comes to managing the treatment regimens of patients with cardiometabolic disorders. In most cases, you [...]

Abstract Background: Rosacea is a chronic, relapsing dermatologic condition that affects an estimated 14 million people in the US. However, there is little data in the literature on the healthcare [...]

Byline: Ali. Jendoubi, Ahmed. Abbes, Salma. Ghedira, Mohamed. Houissa Introduction: Pain is highly prevalent in critically ill trauma patients, especially those with a traumatic brain injury (TBI). Behavioral pain tools [...]