Faculty Bibliography

OBJECTIVE:The need for clinical staff to reliably identify patients with a shortened life expectancy is an obstacle to improving palliative and end-of-life care. We developed and evaluated the feasibility of an automated tool to identify patients with a high risk of death in the next year to prompt treating physicians to consider a palliative approach and reduce the identification burden faced by clinical staff. METHODS:Two-phase feasibility study conducted at two quaternary healthcare facilities in Toronto, Canada. We modified the Hospitalised-patient One-year Mortality Risk (HOMR) score, which identifies patients having an elevated 1-year mortality risk, to use only data available at the time of admission. An application prompted the admitting team when patients had an elevated mortality risk and suggested a palliative approach. The incidences of goals of care discussions and/or palliative care consultation were abstracted from medical records. RESULTS:Our model (C-statistic=0.89) was found to be similarly accurate to the original HOMR score and identified 15.8% and 12.2% of admitted patients at Sites 1 and 2, respectively. Of 400 patients included, the most common indications for admission included a frailty condition (219, 55%), chronic organ failure (91, 23%) and cancer (78, 20%). At Site 1 (integrated notification), patients with the notification were significantly more likely to have a discussion about goals of care and/or palliative care consultation (35% vs 20%, p = 0.016). At Site 2 (electronic mail), there was no significant difference (45% vs 53%, p = 0.322). CONCLUSIONS:Our application is an accurate, feasible and timely identification tool for patients at elevated risk of death in the next year and may be effective for improving palliative and end-of-life care.

OBJECTIVE:Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents. METHODS:A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs. RESULTS:Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED). CONCLUSIONS:Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

BACKGROUND:QT dispersion, maximal interlead difference in QT interval on 12-lead electrocardiogram (ECG), measures cardiac repolarization abnormalities. Data are conflicting whether QT dispersion predicts adverse outcome in acute ischemic stroke (AIS) patients. Our objective is to determine if QT dispersion predicts: (1) short-term clinical outcome in AIS, and (2) stroke location (insular versus noninsular cortex). METHODS:Admission ECGs from 412 consecutive patients with acute stroke symptoms from 2 university-based stroke centers were reviewed. QT dispersion was measured. A neuroradiologist reviewed brain imaging for insular cortex involvement. Favorable clinical outcomes at discharge were modified Rankin Scale (mRS) score of 0-1, discharge National Institutes of Health Stroke Scale (NIHSS) score less than 2, and discharge to home. Multiple logistic regressions were performed for each outcome measure and to determine the association between insular infarct and QT dispersion. RESULTS:Of 145 subjects in the final analysis, median age was 65 years (interquartile range [IQR] 56-75), male patients were 38%, black patients were 68%, median QT dispersion was 78 milliseconds (IQR 59-98), and median admission NIHSS score was 4 (IQR 2-6). QT dispersion did not predict short-term clinical outcome for mRS score (odds ratio [OR] = 1.001, 95% confidence interval [CI] .99-1.01, P = .85), NIHSS at discharge (OR = .994, 95% CI .98-1.01, P = .30), or discharge disposition (OR = 1.001, 95% CI .99-1.01, P = .81). Insular cortex involvement did not correlate with QT dispersion magnitude (OR = 1.009, 95% CI .99-1.02, P = .45). CONCLUSIONS:We could not demonstrate that QT dispersion is useful in predicting short-term clinical outcome at discharge in AIS. Further, the magnitude of QT dispersion did not predict insular cortical stroke location.

OBJECTIVE:To outline symptom management in, as well as offer a home-based protocol for, patients with advanced heart failure (HF). SOURCES OF INFORMATION/METHODS:were searched in PubMed and relevant databases. All articles were reviewed. The specific medical management protocol was developed by the "HeartFull" collaborative team at the Temmy Latner Centre for Palliative Care in Toronto, Ont. MAIN MESSAGE/RESULTS:Educating patients about advanced HF and helping them understand their illness and illness trajectory can foster end-of-life discussions. Home-based care of patients with advanced HF that includes optimizing diuresis can lead to improved symptom management. It is also hoped that it can reduce both patient and health care system burden and result in greater health-related quality of life for patients with advanced HF. CONCLUSION/CONCLUSIONS:

BACKGROUND:Hyperprolactinemia can be caused by medications, primarily antipsychotics, or by anterior pituitary tumors. The consequences of hyperprolactinemia including gynecomastia, galactorrhea, and sexual dysfunction are very disturbing for males and females. It is sometimes difficult to differentiate the etiology of hyperprolactinemia from a clinical perspective. OBJECTIVE:Identification of the etiology of hyperprolactinemia requires a careful review of the causes and appropriate work-up. METHODS:A 55-year-old African American male with extensive psychiatric history and non-adherence to treatment was admitted from nursing home for aggression and psychotic symptoms. The patient was noted to have mild bilateral breast enlargement about ten days after hospitalization. Prolactin level done on August 26, 2014 was 93.8 ng/mL, and on September 5, 2014 was 112 ng/mL. The patient's medications included haloperidol decanoate 150 mg q28d, haloperidol 10 mg po bid and benztropine 0.5 mg po bid. He did not have any other clinical signs or symptoms of hyperprolactinemia. He was also seen by an endocrinologist. MRI of the pituitary gland done on September 3, 2014, showed a 2.4 mm pituitary microadenoma. Bromocriptine was started at 1.25 mg qhs and titrated to 2.5 mg bid. RESULTS:Prolactin level dropped from 112 ng/mL on September 5, 2014 to 99 ng/mL on September 9, 2014, 61.2 ng/mLon September 23, 2014 and 3.0 ng/mL on February 9, 2015. CONCLUSION/CONCLUSIONS:Diagnosis and etiology of hyperprolactinemia were complicated by the minimal nature of clinical symptoms, the type of antipsychotic agent and the prolactin level. The MRI facilitated the diagnosis of pituitary microadenoma and further treatment option with bromocriptine. MRI of the pituitary is indicated for patients with hyperprolactinemia where the etiology is not clearly due to medication.

We assessed the association between asthma and suicidality in a nationally representative sample of US high school students. Data came from the 2007, 2009, and 2011 Youth Risk Behavioral Surveys. Weighted prevalence estimates and adjusted odds ratios were calculated. Subjects with asthma are more likely to report 2-week sadness (35.2%) compared to those without asthma (26.7%). Teens with asthma are also more likely to report suicide ideation (20.1% vs. 15%), planning (15.7% vs. 12.1%), attempt (10.1% vs. 6.9%), and treatment for attempt (3.5% vs. 2%). Although the unadjusted association between lifetime asthma and suicide attempts is statistically significant (crude odds ratio 1.5 (95% CI 1.3-1.8)), after controlling for confounders, that association is no longer statistically significant (AOR 1.2 (1-1.6)). Thus, this increase in suicidality seems to be due to the increased prevalence of sadness among teens with asthma. Similar patterns were seen in the 2007 and 2009 surveys.

BACKGROUND:QT dispersion (QTd) has been proposed as an indirect electrocardiography (ECG) measure of heterogeneity of ventricular repolarization. The predictive value of QTd in acute stroke remains controversial. We aimed to clarify the relationship between QTd and acute stroke and stroke prognosis. METHODS:A systematic review of the literature was performed using prespecified medical subjects heading terms, Boolean logic, and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eligible studies included ischemic or hemorrhagic stroke and provided QTd measurements. RESULTS:Two independent reviewers identified 553 publications. Sixteen articles were included in the final analysis. There were a total of 888 stroke patients: 59% ischemic and 41% hemorrhagic. There was considerable heterogeneity in study design, stroke subtypes, ECG assessment time, control groups, and comparison groups. Nine studies reported a significant association between acute stroke and baseline QTd. Two studies reported that QTd increases are specifically related to hemorrhagic strokes, involvement of the insular cortex, right-side lesions, larger strokes, and increases in 3,4-dihydroxyphenylethylene glycol in hemorrhagic stroke. Three studies reported QTd to be an independent predictor of stroke mortality. One study each reported increases in QTd in stroke patients who developed ventricular arrhythmias and cardiorespiratory compromise. CONCLUSIONS:There are few well-designed studies and considerable variability in study design in addressing the significance of QTd in acute stroke. Available data suggest that stroke is likely to be associated with increased QTd. Although some evidence suggests a possible prognostic role of QTd in stroke, larger and well-designed studies need to confirm these findings.