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Academic Medical Center (academic + medical_center)
Kinds of Academic Medical Center Selected AbstractsHealthcare Utilization of Elderly Persons Hospitalized After a Noninjurious Fall in a Swiss Academic Medical CenterJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2006Laurence Seematter-Bagnoud MD OBJECTIVES: To determine the risk of hospital readmission, nursing home admission, and death, as well as health services utilization over a 6-month follow-up, in community-dwelling elderly persons hospitalized after a noninjurious fall. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Swiss academic medical center. PARTICIPANTS: Six hundred ninety persons aged 75 and older hospitalized through the emergency department. MEASUREMENTS: Data on demographics and medical, physical, social, and mental status were collected upon admission. Follow-up data were collected from the state centralized billing system (hospital and nursing home admission) and proxies (death). RESULTS: Seventy patients (10%) were hospitalized after a noninjurious fall. Fallers had shorter hospital stays (median 4 vs 8 days, P<.001) and were more frequently discharged to rehabilitation or respite care than nonfallers. During follow-up, fallers were more likely to be institutionalized (adjusted hazard ratio=1.82, 95% confidence interval=1.03,3.19, P=.04) independent of comorbidity and functional and mental status. Overall institutional costs (averaged per day of follow-up) were similar for both groups ($138.5 vs $148.7, P=.66), but fallers had lower hospital costs and significantly higher rehabilitation and long-term care costs ($55.5 vs $24.1, P<.001), even after adjustment for comorbidity, living situation, and functional and cognitive status. CONCLUSION: Elderly patients hospitalized after a noninjurious fall were twice as likely to be institutionalized as those admitted for other medical conditions and had higher intermediate and long-term care services utilization during follow-up, independent of functional and health status. These results provide direction for interventions needed to delay or prevent institutionalization and reduce subsequent costs. [source] Raloxifene, conjugated oestrogen and endothelial function in postmenopausal womenJOURNAL OF INTERNAL MEDICINE, Issue 1 2003E. J. J. Duschek Abstract., Duschek EJJ, Stehouwer CDA, de Valk-de Roo GW, Schalkwijk CG, Lambert J, Netelenbos C (VU University Medical Center, Amsterdam; Sophia Hospital, Zwolle; The Netherlands). Raloxifene, conjugated oestrogen and endothelial function in postmenopausal women. J Intern Med 2003; 254: 85,94. Objectives., To study the long-term effects of raloxifene, a potential designer oestrogen, and oestrogen monotherapy on endothelial function in healthy postmenopausal women. Design., A 2-year double-blind, randomized and placebo-controlled study in an Academic Medical Center. Fifty-six hysterectomized but otherwise healthy postmenopausal women randomly received raloxifene hydrochloride 60 mg day,1 (n = 15) or 150 mg day,1 (n = 13), conjugated equine oestrogen (CEE) 0.625 mg day,1 (n = 15), or placebo (n = 13). Main outcome measures., Endothelial function as estimated from brachial artery flow-mediated, endothelium-dependent vasodilation and nitroglycerine-induced endothelium-independent vasodilation, and plasma levels of the endothelium-derived regulatory proteins, von Willebrand factor (vWF) and endothelin (ET). Results., Raloxifene 60 mg did not significantly affect endothelial function. As compared with placebo, at 6 months of therapy, raloxifene 150 mg and CEE were associated with a mean increase in vWF of 25.5% point (95% CI 3.6,47.3) and 26.6% point (95% CI 6.9,46.3), respectively. At 24 months of therapy, raloxifene 150 mg was associated with a mean decrease in ET of 0.96 pg mL,1 (95% CI ,1.57 to ,0.36). Raloxifene nor CEE significantly affected endothelium-dependent and/or -independent vasodilation. Conclusions., Our results suggest that long-term therapy with raloxifene or oral CEE does not affect endothelium-dependent vasodilation in healthy postmenopausal women. Raloxifene 150 mg day,1 might have both positive and negative effects on endothelium. The clinical significance of these findings remains to be investigated. [source] Prevalence and significance of cardiovascular risk factors in a large cohort of patients with familial hypercholesterolaemiaJOURNAL OF INTERNAL MEDICINE, Issue 2 2003P. R. W. De Sauvage Nolting Abstract., de Sauvage Nolting PRW, Defesche JC, Buirma RJA, Hutten BA, Lansberg PJ, Kastelein JJP (Academic Medical Center, Amsterdam; Clinical Research, Haarlem; Slotervaart Hospital, Amsterdam; the Netherlands). Prevalence and significance of cardiovascular risk factors in a large cohort of patients with familial hypercholesterolaemia. J Intern Med 2003; 253: 161,168. Objective., Patients with familial hypercholesterolaemia (FH) vary widely in terms of onset of cardiovascular disease (CVD). Design., The association between cardiovascular risk factors and prevalent CVD was examined in a cross-sectional study in order to elucidate their contribution to atherogenesis. Setting and subjects., Patients were recruited from 37 Dutch Lipid Clinics. The diagnosis of FH was based on a uniform diagnostic protocol, confirmed by DNA analysis in 62% of the cases. All patients were investigated free from any lipid-lowering drug for at least 6 weeks. Main outcome measures., Differences in lipids, lipoproteins and other risk factors for CVD were analysed in FH patients with and without CVD. Results., A total of 526 patients were assessed and more than 37% had a history of CVD with a mean age of onset of 46.8 years. Mean LDL cholesterol (LDL-C) levels were severely elevated (8.38 ± 2.13 mmol L,1). In univariate analysis, age, presence of hypertension or diabetes, body mass index, triglycerides (TG) and low HDL cholesterol (HDL-C) were all significantly associated with CVD. Also in multivariate analysis, all these risk factors, except TG and diabetes, were significantly linked to CVD. Conclusion., A high CVD risk in this large well-documented characterized sample of FH patients is not only conferred by elevated LDL-C but also by low HDL-C. [source] Functional and morphological comparison of three primary liver cell types cultured in the AMC bioartificial liverLIVER TRANSPLANTATION, Issue 4 2007Paul P.C. Poyck The selection of a cell type for bioartificial liver (BAL) systems for the treatment of patients with acute liver failure is in part determined by issues concerning patient safety and cell availability. Consequently, mature porcine hepatocytes (MPHs) have been widely applied in BAL systems. The success of clinical BAL application systems is, however, largely dependent on the functionality and stability of hepatocytes. Therefore, we compared herein the general metabolic and functional activities of MPHs with mature human hepatocytes (MHHs) in the Academic Medical Center (AMC)-BAL during a 7-day culture period. We also tested fetal human hepatocytes (FHHs), since their proliferation capacity is higher than MHHs and their function is increased compared to human liver cell lines. The results showed large differences between the 3 cell types. MHHs eliminated 2-fold more ammonia and produced 3-fold more urea than MPHs, whereas FHHs produced ammonia. Lidocaine elimination of FHHs was 3.5-fold higher than MPHs and 6.6-fold higher than of MHHs. Albumin production was not different between the 3 cell types. MPHs and FHHs became increasingly glycolytic, whereas MHHs remained metabolically stable during the whole culture period. MHHs and MPHs formed tissue-like structures inside the AMC-BAL. In conclusion, we propose that FHHs can be considered as a suitable cell type for pharmacological studies inside a bioreactor. However, we conclude that MHHs are the preferred cell source for loading a BAL device for clinical use, because of their high ammonia eliminating capacity and metabolic stability. MPHs should be considered as the best alternative cell source for BAL application, although their phenotypic instability urges application within 1 or 2 days after loading. Liver Transpl 13:589,598, 2007. © 2007 AASLD. [source] The AmRo study: pregnancy outcome in HIV-1-infected women under effective highly active antiretroviral therapy and a policy of vaginal deliveryBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 2 2007K Boer Objective, To explore pregnancy outcome in HIV-1-positive and HIV-negative women, and mother-to-child transmission (MTCT) according to mode of delivery under effective highly active antiretroviral therapy (HAART). Design, Cohort of 143 pregnant HIV-1-infected women including a matched case,control study in a 2:1 ratio of controls to cases (n = 98). Setting, Academic Medical Center in Amsterdam and Erasmus Medical Center in Rotterdam, the Netherlands. Population, Consecutive referred HIV-1 infected pregnant women treated with HAART and matched control not infected pregnant women. Main outcome measures, MTCT, preterm delivery, low birthweight, pre-eclampsia. Results, MTCT was 0% (95% CI 0,2.1%). Seventy-eight percent of HIV-1-infected women commenced and 62% completed vaginal delivery. The calculated number of caesarean sections needed to prevent a single MTCT was 131 or more. Preterm delivery rates were 18% (95% CI 11,27) in women infected with HIV-1 and 9% (95% CI 5,13) in controls (P = 0.03). HAART used at <13 weeks of gestation was associated with a 44% preterm delivery rate compared with 21% when HAART was started at or after 13 weeks and 14% in controls. (Very) low birthweight and incidence of pre-eclampsia were not different between HIV-1 and controls. Conclusions, We have not demonstrated any MTCT after vaginal delivery in women effectively treated by HAART. The HAART-associated increase in preterm delivery rate is mainly seen after first trimester HAART use. [source] Slitlamp integrated OCT, what you can see, is what you can scanACTA OPHTHALMOLOGICA, Issue 2009FD VERBRAAK Purpose To present results of OCT images captured of the posterior and anterior segment of the eye using the SLSCAN-1, a new FD-OCT device integrated into a slit lamp. Methods Patients, seen in the outpatient clinic of the Academic Medical Center, were scanned with the SLSCAN-1, a newly developed OCT scanning device, integrated into a common slit lamp (figure 1). The OCT is a Fourier Domain OCT system (SLD light source, central wavelength 830 nm, bandwidth 30 nm, 1024 pixel CCD camera, scan speed 5k A-scans per second, 1024 A-scans per B-scan). The posterior segment scans have been captured using a standard indirect ophthalmic lens (Volk). A color fundus photography of the observed area is made at the same time (Topcon camera DC1, resolution = 3.24 Mp). Results For posterior segment imaging, the flexible optical arrangement of the slit lamp and the hand-held lens (Volk), allows the user to scan large areas of the retina (>45 degrees), depending on the pupil size of the patient. In all patients the macula and optic disk could be visualized without any difficulty. In the anterior segment mode, the SLSCAN-1 allows imaging of the cornea, anterior chamber, iris and parts of the lens. Conclusion The images made by the SLSCAN-, new slit lamp integrated FD-OCT, could be very useful to examine patients directly, both posterior and anterior, during regular slit lamp examinations. Commercial interest [source] Scanning beyond the limits of standard OCT: OCT scans of the peripheral retina and the anterior chamber angle with a slitlamp integtrated FD-OCT systemACTA OPHTHALMOLOGICA, Issue 2009M STEHOUWER Purpose Exploring the quality of OCT images of the peripheral retina and anterior chamber angle made through a 3-mirror contactlens and a new FD-OCT device integrated into a slit lamp. Methods Patients with peripheral lesions (n=10) and glaucoma (n=10), seen in the outpatient clinic of the Academic Medical Center, were scanned with a Fourier Domain OCT integrated into a common Topcon slitlamp (SLD light source, central wavelength 830 nm, bandwidth 30 nm, 1024 pixel CCD camera, scan speed 5k A-scans per second, up to 1024 A-scans per b-scan). For posterior segment scans a fast Z-tracking system in the reference arm compensates for the dynamic character (movements of patient, handheld lens, slitlamp) of the examination. Scans of peripheral lesions, and the anterior chamber angle were made with a 3-mirror lens, while simultaneously the lesions were observed with the slitlamp. Results Scans of the peripheral retina obtained with a 3-mirror lens with the FD-OCT integrated into the slitlamp were of reasonably good quality and lesions, like peripheral laser scars, could be clearly identified. Compared to stand alone OCT systems, the integrated OCT system reached more peripheral lesions. The anterior chamber angle scanned through a 3-mirror lens enabled scans of the angle structures. Conclusion It is possible to scan the peripheral retina and anterior chamber angle through a 3-mirror contact lens with the slitlamp with integrated OCT. These scans could be of clinical interest in patients with pathology in the peripheral retina pathology or the anterior chamber angle. [source] Changing pattern of imported cutaneous leishmaniasis in the NetherlandsCLINICAL & EXPERIMENTAL DERMATOLOGY, Issue 1 2005J. E. Zeegelaar Summary Cutaneous leishmaniasis (CL) in western countries seems to be appearing more frequently. Our aim was to determine if there has been a shift in countries where CL is acquired and whether the incidence has changed, and to assess current diagnostic procedures and treatment modalities. In a retrospective study medical records of patients with the diagnosis of CL at the Departments of Tropical Dermatology and Tropical Medicine, Academic Medical Center, Amsterdam, the Netherlands, from 1990 to 2000 were analysed. CL was diagnosed in 78 patients. The majority was acquired in Belize, Surinam, French Guyana and Bolivia. Giemsa stains were positive for the parasite in impression smears from 43% and in biopsies from 71%. Seventy-eight per cent of cases were culture-positive and 89% were PCR-positive. Sixty-two patients were treated systemically: pentavalent antimony (32), pentamidine isetionate (11), itraconazole (19), and 13 locally, the majority with a combination of cryosurgery and intralesional pentavalent antimony. Imported CL is becoming more frequent, with South and Middle American countries being important sources of infection. Multiple tests, of which PCR is the most sensitive, are required to confirm the diagnosis. Systemic treatment was given to the majority of the patients. [source] Health Care Reform Requires Renaissance of Flexnerian Academic Medical CentersJOURNAL OF CLINICAL HYPERTENSION, Issue 12 2009Thomas D. Giles MD No abstract is available for this article. [source] Associations Between Lower Extremity Ischemia, Upper and Lower Extremity Strength, and Functional Impairment with Peripheral Arterial DiseaseJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2008Mary M. McDermott MD OBJECTIVES: To identify associations between lower extremity ischemia and leg strength, leg power, and hand grip in persons with and without lower extremity peripheral arterial disease (PAD). To determine whether poorer strength may mediate poorer lower extremity performance in persons with lower arterial brachial index (ABI) levels. DESIGN: Cross-sectional. SETTING: Academic medical centers. PARTICIPANTS: Four hundred twenty-four persons with PAD and 271 without PAD. MEASUREMENTS: Isometric knee extension and plantarflexion strength and handgrip strength were measured using a computer-linked strength chair. Knee extension power was measured using the Nottingham leg rig. ABI, 6-minute walk, and usual and fastest 4-m walking velocity were measured. Results were adjusted for potential confounders. RESULTS: Lower ABI values were associated with lower plantarflexion strength (P trend=.04) and lower knee extension power (P trend <.001). There were no significant associations between ABI and handgrip or knee extension isometric strength. Significant associations between ABI and measures of lower extremity performance were attenuated after additional adjustment for measures of strength. CONCLUSION: These results are consistent with the hypothesis that lower extremity ischemia impairs strength specifically in distal lower extremity muscles. Associations between lower extremity ischemia and impaired lower extremity strength may mediate associations between lower ABI values and greater functional impairment. [source] Advanced Heart Failure: Prognosis, Uncertainty, and Decision MakingCONGESTIVE HEART FAILURE, Issue 5 2007Jane G. Zapka ScD Heart failure is a serious clinical management challenge for both patients and primary care physicians. The authors studied the perceptions and practices of internal medicine residents and faculty at an academic medical center in the Southeast to guide design of strategies to improve heart failure care. Data were collected via a self-administered survey. Eighty-nine faculty and resident physicians in general internal medicine and geriatrics participated (74% response rate). Items measured perceived skills and barriers, adherence to guidelines, and physician understanding of patient prognosis. Case studies explored practice approaches. Clinical knowledge and related scales were generally good and comparable between physician groups. Palliative care and prognostic skills were self-rated with wide variance. Physicians rated patient noncompliance and low lifestyle change motivation as major barriers. Given the complexities of caring for elderly persons with heart failure and comorbid conditions, there are significant opportunities for improving physician skills in decision making, patient-centered counseling, and palliative care. [source] Providers' Beliefs, Attitudes, and Behaviors before Implementing a Computerized Pneumococcal Vaccination ReminderACADEMIC EMERGENCY MEDICINE, Issue 12 2006Judith W. Dexheimer MS Abstract Background The emergency department (ED) has been recommended as a suitable setting for offering pneumococcal vaccination; however, implementations of ED vaccination programs remain scarce. Objectives To understand beliefs, attitudes, and behaviors of ED providers before implementing a computerized reminder system. Methods An anonymous, five-point Likert-scale, 46-item survey was administered to emergency physicians and nurses at an academic medical center. The survey included aspects of ordering patterns, implementation strategies, barriers, and factors considered important for an ED-based vaccination initiative as well as aspects of implementing a computerized vaccine-reminder system. Results Among 160 eligible ED providers, the survey was returned by 64 of 67 physicians (96%), and all 93 nurses (100%). The vaccine was considered to be cost effective by 71% of physicians, but only 2% recommended it to their patients. Although 98% of physicians accessed the computerized problem list before examining the patient, only 28% reviewed the patient's health-maintenance section. Physicians and nurses preferred a computerized vaccination-reminder system in 93% and 82%, respectively. Physicians' preferred implementation approach included a nurse standing order, combined with physician notification; nurses, however, favored a physician order. Factors for improving vaccination rates included improved computerized documentation, whereas increasing the number of ED staff was less important. Relevant implementation barriers for physicians were not remembering to offer vaccination, time constraints, and insufficient time to counsel patients. The ED was believed to be an appropriate setting in which to offer vaccination. Conclusions Emergency department staff had favorable attitudes toward an ED-based pneumococcal vaccination program; however, considerable barriers inherent to the ED setting may challenge such a program. Applying information technology may overcome some barriers and facilitate an ED-based vaccination initiative. [source] Accuracy and definitive interpretation of preoperative technetium 99m sestamibi imaging based on the discipline of the reader,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 5 2009Ayesha N. Khalid MD Abstract Background. Technetium 99m sestamibi scans have become a principal means of localizing parathyroid adenomas. Its accuracy and reliability has allowed for the proliferation of minimal access parathyroidectomy. Localizing interpretation of these scans often drives referral of hyperparathyroid patients for surgery. Interpretation of these scans may differ between nuclear medicine physicians and surgeons. Methods. We reviewed patients (N = 65) with digital images from an academic medical center with the diagnosis of primary hyperparathyroidism. We assessed the willingness to define an adenoma's location, the interrater reliability, and the accuracy of technetium (Tc-99m) sestamibi read by a surgeon and a nuclear medicine physician. Results. There was poor correlation between both readers for assessment of quality of images (k = 0.54, 0.07) but very good correlation for adenoma location (k = 0.81). Conclusion. Both readers had good accuracy in predicting the location of the parathyroid adenoma. The surgeon was more likely to call a scan positive. © 2008 Wiley Periodicals, Inc. Head Neck, 2009 [source] Vitiligo in an urban academic setting,INTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 1 2010Taraneh Paravar MD Background, Vitiligo is a depigmenting disease of unknown etiology. A more complete understanding of vitiligo and associated conditions will provide better insight into the etiology and potential treatment options for this condition. We sought to gather information regarding associated conditions and other epidemiologic data on vitiligo. Methods, A retrospective chart review was performed of 135 patients with vitiligo seen between July 1, 2002 and June 30, 2005 at an academic medical center. Epidemiologic characteristics were recorded. Results, The patient population consisted of 80 women and 55 men with mean age of presentation of 36.8 years and average disease duration of 5.7 years. Vitiligo vulgaris was the predominant type of vitiligo and hypothyroidism was the most common co-morbidity. Anti-thyroid peroxidase and anti-thyroglobulin antibodies were found in 37% and 18% of patients, respectively. The highest proportion of thyroid abnormalities was found in age of onset category 21,30. Anti-nuclear antibodies were found in 33% of patients. Conclusion, The prevalence of anti-nuclear and anti-thyroid peroxidase antibodies was higher in our vitiligo study than that reported elsewhere. In addition, autoimmune thyroid disease may be more common in adult-onset vitiligo. [source] The Overlap Syndrome of Depression and Delirium in Older Hospitalized PatientsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2009Jane L. Givens MD OBJECTIVES: To measure the prevalence, predictors, and posthospitalization outcomes associated with the overlap syndrome of coexisting depression and incident delirium in older hospitalized patients. DESIGN: Secondary analysis of prospective cohort data from the control group of the Delirium Prevention Trial. SETTING: General medical service of an academic medical center. Follow-up interviews at 1 month and 1 year post-hospital discharge. PARTICIPANTS: Four hundred fifty-nine patients aged 70 and older who were not delirious at hospital admission. MEASUREMENTS: Depressive symptoms assessed at hospital admission using the 15-item Geriatric Depression Scale (cutoff score of 6 used to define depression), daily assessments of incident delirium from admission to discharge using the Confusion Assessment Method, activities of daily living at admission and 1 month postdischarge, and new nursing home placement and mortality determined at 1 year. RESULTS: Of 459 participants, 23 (5.0%) had the overlap syndrome, 39 (8.5%) delirium alone, 121 (26.3%) depression alone, and 276 (60.1%) neither condition. In adjusted analysis, patients with the overlap syndrome had higher odds of new nursing home placement or death at 1 year (adjusted odds ratio (AOR)=5.38, 95% confidence interval (CI)=1.57,18.38) and 1-month functional decline (AOR=3.30, 95% CI=1.14,9.56) than patients with neither condition. CONCLUSION: The overlap syndrome of depression and delirium is associated with significant risk of functional decline, institutionalization, and death. Efforts to identify, prevent, and treat this condition may reduce the risk of adverse outcomes in older hospitalized patients. [source] Two-Minute Mental Health Care for Elderly Patients: Inside Primary Care VisitsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2007(See editorial comments by Drs. Charles Reynolds, Bruce L. Rollman), Carrie Farmer Teh, Mario Cruz OBJECTIVES: To assess how care is delivered for mental disorders using videotapes of office visits involving elderly patients. DESIGN: Mixed-method observational analysis of the nature of the topics discussed, content of discussion, and the time spent on mental health. SETTINGS: Three types of settings: an academic medical center, a managed care group, and fee-for-service solo practitioners. PARTICIPANTS: Thirty-five primary care physicians and 366 of their elderly patients. MEASUREMENTS: Videotapes of 385 visits covering 2,472 diverse topics were analyzed. Coding of the videotapes identified topics, determined talk time, and coded the dynamics of talk. RESULTS: Mental health topics occurred in 22% of visits, although patient survey indicated that 50% of the patients were depressed. A typical mental health discussion lasted approximately 2 minutes. Qualitative analysis suggested wide variations in physician effort in providing mental health care. Referrals to mental health specialists were rare even for severely depressed and suicidal patients. CONCLUSION: Little time is spent on mental health care for elderly patients despite heavy disease burdens. Standards of care based on a count of visits "during which a mental health problem is discussed" may need to be supplemented with guidelines about what should happen during the visit. System-level interventions are needed. [source] Using Assessing Care of Vulnerable Elders Quality Indicators to Measure Quality of Hospital Care for Vulnerable EldersJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2007Vineet M. Arora MD OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs). DESIGN: Prospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: Subjects aged 65 and older hospitalized on the University of Chicago general medicine inpatient service who were defined as vulnerable using the Vulnerable Elder Survey-13 (VES-13), a validated tool based on age, self-reported health, and functional status. MEASUREMENTS: Inpatient interview and chart review using ACOVE-based process-of-care measures referring to 16 QIs in general hospital care and geriatric-prevalent conditions (e.g., pressure ulcers, dementia, and delirium); adherence rates calculated for type of care process (screening, diagnosis, and treatment) and type of provider (doctor, nurse). RESULTS: Six hundred of 845 (71%) older patients participated. Of these, 349 (58%) were deemed vulnerable based on VES-13 score. Three hundred twenty-eight (94%) charts were available for review. QIs for general medical care were met at a significantly higher rate than for pressure ulcer care (81.5%, 95% confidence interval (CI)=79.3,83.7% vs 75.8%, 95% CI=70.5,81.1%, P=.04) and for delirium and dementia care (81.5%, 95% CI=79.3,83.7 vs 31.4% 95% CI=27.5,35.2%, P<.01). According to standard nursing assessment forms, nurses were responsible for high rates of adherence to certain screening indicators (pain, nutrition, functional status, pressure ulcer risk; P<.001 when compared with physicians), although in patients with functional limitations, nurse admission assessments of functional limitations often did not agree with reports of limitations by patients on admission. CONCLUSION: Adherence to geriatric-specific QIs is lower than adherence to general hospital care QIs. Hospital care QIs that focus on screening may overestimate performance by detecting standard nursing or protocol-driven care. [source] Healthcare Utilization of Elderly Persons Hospitalized After a Noninjurious Fall in a Swiss Academic Medical CenterJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2006Laurence Seematter-Bagnoud MD OBJECTIVES: To determine the risk of hospital readmission, nursing home admission, and death, as well as health services utilization over a 6-month follow-up, in community-dwelling elderly persons hospitalized after a noninjurious fall. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Swiss academic medical center. PARTICIPANTS: Six hundred ninety persons aged 75 and older hospitalized through the emergency department. MEASUREMENTS: Data on demographics and medical, physical, social, and mental status were collected upon admission. Follow-up data were collected from the state centralized billing system (hospital and nursing home admission) and proxies (death). RESULTS: Seventy patients (10%) were hospitalized after a noninjurious fall. Fallers had shorter hospital stays (median 4 vs 8 days, P<.001) and were more frequently discharged to rehabilitation or respite care than nonfallers. During follow-up, fallers were more likely to be institutionalized (adjusted hazard ratio=1.82, 95% confidence interval=1.03,3.19, P=.04) independent of comorbidity and functional and mental status. Overall institutional costs (averaged per day of follow-up) were similar for both groups ($138.5 vs $148.7, P=.66), but fallers had lower hospital costs and significantly higher rehabilitation and long-term care costs ($55.5 vs $24.1, P<.001), even after adjustment for comorbidity, living situation, and functional and cognitive status. CONCLUSION: Elderly patients hospitalized after a noninjurious fall were twice as likely to be institutionalized as those admitted for other medical conditions and had higher intermediate and long-term care services utilization during follow-up, independent of functional and health status. These results provide direction for interventions needed to delay or prevent institutionalization and reduce subsequent costs. [source] Multidimensional Attitudes of Medical Residents and Geriatrics Fellows Toward Older PeopleJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2005Ming Lee PhD Objectives: To examine dimensions of a validated instrument measuring geriatric attitudes of primary care residents and performances on these dimensions between residents and fellows. Design: Cross-sectional and longitudinal studies. Setting: An academic medical center. Participants: Two hundred thirty-eight primary care residents (n=177) and geriatrics fellows (n=61) participated in the study from 1995 to 2000. Measurements: A 14-item, 5-point Likert scale previously validated for measuring primary care residents' attitudes toward older people and geriatric patient care was used. Results: Factor analysis showed four dimensions of the scale, labeled Social Value, Medical Care (MC), Compassion (CP), and Resource Distribution, which demonstrated acceptable reliability. Both groups of subjects showed significantly (P<.001) positive (mean>3) attitudes across the dimensions and times, except for residents, who had near-neutral (mean=3) attitudes on MC. Residents' mean attitude scores on the overall scale and the MC and CP subscales were significantly (P<.001) lower than those of fellows over time. Residents and fellows showed different change patterns in attitudes over time. Residents' attitudes generally improved during the first 2 years of training, whereas fellows' attitudes declined slightly. Personal experience was a strong predictor of residents' attitudes toward older patients. Ethnicity, academic specialty, professional experience, and career interest in geriatrics were also associated with residents' attitude scores. Conclusion: The multidimensional analysis of the scale contributes to better understanding of medical trainees' attitudes and sheds light on educational interventions. [source] Development and Validation of a Geriatric Knowledge Test for Medical StudentsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2004Ming Lee PhD Objectives: To assesses the reliability and validity of a geriatrics knowledge test designed for medical students. Design: Cross-sectional studies. Setting: An academic medical center. Participants: A total of 343 (86% of those sampled) medical students participated in the initial study, including 137 (76%) first-year, 163 (96%) third-year, and 43 (86% of those sampled) fourth-year students in the 2000,2001 academic year. To cross-validate the instrument, another 165 (92%) third-year and 137 (76%) first-year students participated in the study in the 2001,2002 academic year. Measurements: An 18-item geriatrics knowledge test was developed. The items were selected from a pool of 23 items. An established instrument assessing the clinical skills of medical students was included in the validation procedure. Results: The instrument demonstrated good reliability (Cronbach ,=0.80) and known-groups and concurrent validity. Geriatrics knowledge scores increased progressively with the higher level of medical training (mean percentage correct=31.3, 65.3, and 66.5 for the first-year, third-year, and fourth-year classes, respectively, P<.001). A significant (P<.01) relationship was found between the third-year students' geriatrics knowledge and their clinical skills. Similar results, except the relationship between knowledge and clinical skills, were found in the cross-validation study, supporting the reliability and known-groups validity of the test. Conclusion: The 18-item geriatrics knowledge test demonstrated sound reliability and validity. The average scores of the student groups indicated substantial room for growth. The relationship between geriatrics knowledge and overall clinical skills needs further investigation. [source] Comparing academic and community-based hospitalists,JOURNAL OF HOSPITAL MEDICINE, Issue 6 2010David Malkenson BS Abstract In 2006, hospitalist programs were formally introduced at both an academic and community hospital in the same city providing an opportunity to study the similarities and differences in workflows in these two settings. The data were collected using a time-flow methodology allowing the two workflows to be compared quantitatively. The results showed that the hospitalists in the two settings devoted similar proportions of their workday to the task categories studied. Most of the time was spent providing indirect patient care followed by direct patient care, travel, personal, and other. However, after adjusting for patient volumes, the data revealed that academic hospitalists spent significantly more time per patient providing indirect patient care (Academic: 54.7 ± 11.1 min/patient, Community: 41.9 ± 9.8 min/patient, p < 0.001). Additionally, we found that nearly half of the hospitalists' time at both settings was spent multitasking. Although we found subtle workflow differences between the academic and community programs, their similarities were more striking as well as greater than their differences. We attribute these small differences to the higher case mix index at the academic program as well greater complexity and additional communication hand-offs inherent to a tertiary academic medical center. It appears that hospitalists, irrespective of their work environment, spend far more time documenting, communicating and coordinating care than they do at the bedside raising the question, is this is a necessary feature of the hospitalist care model or should hospitalists restructure their workflow to improve outcomes? Journal of Hospital Medicine 2010;5:349,352. © 2010 Society of Hospital Medicine. [source] Predictors of serious injury among hospitalized patients evaluated for falls,,JOURNAL OF HOSPITAL MEDICINE, Issue 2 2010Sara M. Bradley MD Abstract BACKGROUND: Inpatient falls are common and result in significant patient morbidity. OBJECTIVE: To identify predictors of serious injury being found on imaging studies of inpatients evaluated after a fall. DESIGN: Retrospective study. SETTING: An 1171-bed urban academic medical center. PATIENTS: All inpatients who fell on thirteen medical and surgical units from January 1 to December 31, 2006. MEASUREMENTS: Patient characteristics, circumstances surrounding falls, fall-related injuries, and length of stay were collected through review of incident reports and computerized medical records. Primary outcome of fall-related injury was determined by evidence of injury on imaging studies within two weeks of the fall. Univariate and multivariate logistic regression were used to calculate adjusted odds ratios (ORs) for injury after an inpatient fall. RESULTS: A total of 513 patients had 636 falls during the study time period. Fall incidence rate was 1.97 falls per 1,000 patient days. 95 patients (19%) fell multiple times (range, 2-6 events); 74% of the falls occurred in patients who were previously assessed as being "at risk" by the nursing staff. Multivariate analysis, adjusting for age and sex, found evidence of trauma after a fall (OR = 24.6, P < 0.001) and ambulatory status (OR = 7.3, P < 0.01) to be independent predictors of injury being found on imaging studies. CONCLUSIONS: Inpatient falls are common despite high-risk patients being identified. After adjusting for age and sex, evidence of trauma and ambulatory status were independent predictors of an injury being found on imaging studies after an inpatient fall. Journal of Hospital Medicine 2010;5:63,68. © 2010 Society of Hospital Medicine. [source] The Effects of Heparin Versus Normal Saline for Maintenance of Peripheral Intravenous Locks in Pregnant WomenJOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 4 2003Kathryn M. Niesen MSN, RN director of clinical nursing Objective: To compare the efficacy of two available preparations (heparin, 10 U/mL, 1 mL, vs. normal saline, 1 mL) used for maintaining patency in peripheral intravenous (IV) locks during pregnancy. Design: Prospective, randomized, and double-blind. Eligible patients who were to receive a peripheral intermittent IV lock were randomly assigned to receive either heparin flushes or normal saline flushes for IV lock maintenance. IV locks were flushed after each medication administration, or at least every 24 hours, with the assigned blinded flush solution. Intermittent IV lock sites were also evaluated every 12 hours for the development of phlebitis. Setting: A large academic medical center in the Midwest that has both community-based and regional-referral obstetric practices with more than 2,000 deliveries per year. Participants: A convenience sample included 73 hospitalized pregnant women who were between 24 and 42 weeks gestation. Exclusions from the study were women with significant abnormalities in the fetal heart tracing on admission, cervical dilation > 4 cm, presence of hypersensitivity to heparin, presence of clotting abnormalities, and anticoagulation therapy (including low-dose aspirin). Results: Data indicate there were no statistically significant differences in IV lock patency nor in phlebitis between heparin or normal saline flushes. Conclusions: This study provides support that both normal saline and heparin in the doses studied may be equally effective in the maintenance of peripheral IV locks. Due to small sample size, additional studies are needed to determine optimal therapy over time. [source] The validity and feasibility of saliva melatonin assessment in the elderlyJOURNAL OF PINEAL RESEARCH, Issue 2 2003Nalaka S. Gooneratne Abstract: Recent work in young and middle-aged subjects suggests that melatonin levels in saliva may represent a viable alternative to serum melatonin measurement. We hypothesized that it may be a valid measure of melatonin levels in older adults as well, but features unique to the elderly may limit its utility. To study this, subjects were admitted to an academic medical center where saliva and serum specimens were collected concurrently in dim light conditions during a 14-hr overnight study period and analyzed for melatonin levels with radioimmunoassays (RIAs). Eighty-five subjects over the age of 65 with a broad range of medical conditions participated in the study. Subjects with dementia, depression and anemia were excluded. We found that saliva volume was inadequate for analysis (<200 ,L) in 23.6% of specimens, with the majority of inadequate volume specimens occurring after midnight and inadequate specimens occurring more frequently in females than in males. The correlation coefficient for saliva melatonin and serum melatonin was r = 0.659 (Spearman, P < 0.001), and r = 0.466 for saliva dim light melatonin onset (DLMO) and serum DLMO. Saliva melatonin levels were 30.9% of serum melatonin levels, with a wide range of ratios noted between subjects. Overall melatonin levels influenced both the correlation and ratio of saliva melatonin to serum melatonin; higher correlations and lower ratios were noted when melatonin levels were high. Saliva specimens provide an economical and practical method for melatonin assessment, however, in older adults, issues such as hyposalivation and low melatonin levels limit the feasibility and validity, respectively, of saliva melatonin. [source] Knowledge and educational needs of individuals with the factor V Leiden mutationJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 11 2003E. A. Hellmann Summary.,Background:,Genetic testing for factor (F)V Leiden is widely performed in an effort to prevent thrombosis-related morbidity. The implications of a positive test for patients' health perception and the extent of patients' understanding of results are not known. Objectives:,This study examined patient experience of genetic testing for FV Leiden. Patients and methods:,The study was a cross-sectional, mailed survey of 110 patients who tested positive for the FV Leiden gene mutation at an academic medical center between 1995 and 2001. Patient knowledge about FV Leiden, satisfaction with available information, and psychosocial reactions to testing were assessed and the influence of demographic and clinical characteristics on outcome measured. Results:,The magnitude of thrombosis risk associated with FV Leiden was incorrectly estimated by 79% of participants. Many patients (64%) stated that they had not been given much information about FV Leiden and 68% still had many questions. Most patients (53%) felt that their healthcare providers do not understand FV Leiden. Patients who had been seen by a hematologist or in a specialized thrombosis clinic were more knowledgeable and had less information need. Most patients (88%) were glad to know genetic test results, despite negative psychosocial implications such as increased worry (43%). Conclusions:,Knowledge of genetic status increases awareness of thrombosis risk among patients, but magnitude of risk is often overestimated. Affected individuals indicate that there is a lack of available information about FV Leiden and that additional educational resources are needed. [source] Assessment of Celiac Plexus Block and Neurolysis Outcomes and Technique in the Management of Refractory Visceral Cancer PainPAIN MEDICINE, Issue 1 2010Michael A. Erdek MD ABSTRACT Objective., To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. Design., Retrospective clinical data analysis. Setting., A tertiary care, academic medical center. Patients., Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions., Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. Outcome Measures., A successful treatment was predefined as >50% pain relief sustained for ,1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation. Results., Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using <20 mL of local anesthetic for the diagnostic block. Conclusions., Celiac plexus neurolysis may provide intermediate pain relief to a significant percentage of cancer sufferers. Both careful selection of candidates based on clinical variables, and technical factors aimed at enhancing the specificity of blocks may lead to improved outcomes. [source] Ethnic Differences in Pain Among Outpatients with Terminal and End-Stage Chronic IllnessPAIN MEDICINE, Issue 3 2005Michael W. Rabow MD ABSTRACT Objective., To explore ethnic and country of origin differences in pain among outpatients with terminal and end-stage chronic illness. Design., Cohort study within a year-long trial of a palliative care consultation. Setting., Outpatient general medicine practice in an academic medical center. Patients., Ninety patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer, and with a prognosis between 1 and 5 years. Outcome Measures., Patients' report of pain using the Brief Pain Inventory and analgesic medications prescribed by primary care physicians. Differences in pain report and treatment were assessed at study entry, at 6 and 12 months. Results., The overall burden of pain was high. Patients of color reported more pain than white patients, including measures of least pain (P = 0.02), average pain (P = 0.05), and current pain (P = 0.03). No significant ethnic group differences in pain were found comparing Asian, black, and Latino patients. Although nearly all patients who were offered opioid analgesics reported using them, opioids were rarely prescribed to any patient. There were no differences in pain between patients born in the U.S. and immigrants. Conclusions., Pain is common among outpatients with both terminal and end-stage chronic illness. There do not appear to be any differences in pain with regard to country of origin, but patients of color report more pain than white patients. Patients of all ethnicities are inadequately treated for their pain, and further study is warranted to explore the relative patient and physician contributions to the finding of unequal symptom burden and inadequate treatment effort. [source] Relationship of age to symptom severity, psychiatric comorbidity and health care utilization in persons with borderline personality disorderPERSONALITY AND MENTAL HEALTH, Issue 1 2008Nancee Blum Background,The objective of the study was to test the association of age with symptom severity, frequency and pattern of psychiatric comorbidity, health care utilization and quality of life in subjects with borderline personality disorder (BPD). Methods,The analysis is based on a sample of subjects with Diagnostic and Statistical Manual of Mental Disroders, Fourth Edition (DSM-IV) BPD (n = 163) recruited for participation in a clinical trial at an academic medical center. The subjects were assessed using structured and semi-structured instruments of known reliability. Results,Tests of trend with age showed relationships with important variables assessing symptom severity, comorbidity, quality of life and health care utilization. As expected, younger subjects were less likely to be married, to be employed or to receive disability payments. The frequency of most lifetime comorbid Axis I disorders was not related to age, although posttraumatic stress disorder was more frequent in the 35- to 44-year age group, and younger patients were more likely to have comorbid histrionic and narcissistic personality disorders. Baseline severity variables were mostly unrelated to age, with the exception of impulsivity, which was more common in younger patients, as were acts of deliberate self-harm. As expected, older patients reported poorer quality of life in categories indicating worse health perception and greater pain levels, and tended to use more health care resources than younger patients. Conclusion,Most characteristics of patients with BPD are unrelated to age, yet impulsivity and acts of deliberate self-harm were less frequent in older patients. Expected age-related changes, such as reports of worse physical health, greater pain levels and greater health care utilization, were observed in older subjects. Copyright © 2008 John Wiley & Sons, Ltd. [source] Integrating education into primary care quality and cost improvement at an academic medical centerTHE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, Issue 4 2006R. Van Harrison PhD Abstract Introduction: In 1996 the University of Michigan Health System created the Guidelines Utilization, Implementation, Development, and Evaluation Studies (GUIDES) unit to improve the quality and cost-effectiveness of primary care for common medical problems. GUIDES's primary functions are to oversee the development of evidence-based, practical clinical guidelines for common medical conditions; measure and provide feedback on physicians' performance; and facilitate systemic changes to support appropriate care. Various methods are used to improve care, including evidence reviews, formal education, informal clinical "opinion leaders," feedback, reminders, and procedure changes. Twenty-four common medical conditions have been addressed through this process. More than 30 measures of clinical performance have been developed and reported. Methods: This case study describes a systematic, multifaceted program to improve the quality and cost-effectiveness of primary care. Results: Illustrative results for clinical performance are presented for 2 measures of chronic care, 2 measures of preventive care, and 2 measures of acute care. All 6 measures show general improvement in performance across years, with performance near or above the National Committee for Quality Assurance's 90th percentile for Health Plan Employer Data and Information Set measures. Discussion: A systematic approach involving all relevant components of a health system integrates the synthesis of information, education about the information and how to implement it, and addressing operational barriers. Benefits include a curriculum that is shared across faculty, residents, and medical students and more uniform quality of care that faculty model for physicians-in-training. [source] Improvement of Chronic Pain by Treatment of Erectile DysfunctionTHE JOURNAL OF SEXUAL MEDICINE, Issue 12 2008Jalil Arabkheradmand MD ABSTRACT Introduction., Pain specialists, who do not routinely examine patients regarding their sexual medicine problems, need to be aware that sexual problems can and do aggravate the patient's pain. Patients may refuse to admit suffering from erectile dysfunction (ED) but complain about continuous or progressive severe pain. These patients may be best managed by the combined team effort of a sexual medicine specialist and pain specialist. Aim., This report documents the management of three cases with long-term intractable pain after severe trauma. Treatment of occult ED led to significant improvement of their pain. Main Outcome Measures., The association of the treatment of uncovered ED and improvement of chronic severe pain. Methods., Three case reports of patients with severe pain who attended a pain clinic in an academic medical center. Results., Three men suffering from chronic pain due to severe trauma were observed for several years by different physicians as well as pain specialists. In spite of different treatments, including administration of several analgesics, psychotherapy, and physical therapy, pain was not alleviated. After finding ED problems, patients were referred to the family health clinic. Using different therapies such as psychosexual therapy, correction of sexual misconceptions, relaxation training, treatment of interpersonal difficulties, and pharmacological intervention ED was cured. Treatment of ED was accompanied by a significant reduction of chronic pain in all three patients. Conclusion., The present report indicates that uncovered ED in patients suffering from chronic pain may trigger their somatic pain or reduce its threshold. Significant improvement in sexual functioning may improve the pain and reduce its complications. Arabkheradmand J, Foroutan SK, Ranjbar S, Abbasi T, Hessami S, and Gorji A. Improvement of chronic pain by treatment of erectile dysfunction. J Sex Med **;**:**,**. [source] | |||||||||||||||||||||||||||||||