Faculty Bibliography

Background. Dialysis patients are hospitalized for an average of 15 days per patient-year. Understanding the reasons for hospital admissions and the factors affecting outcomes may suggest strategies to reduce hospital utilization. Methods. The records of all inpatients receiving hemodialysis (HD) at our center between May I and October 31, 2003, were reviewed for patient characteristics, admitting diagnosis, length of stay (LOS), and outcome. Admissions were classified as acute (new HD) or chronic HD admissions. Results. There were 194 inpatient HD admissions, consisting of 147 (76%) chronic and 47 (24%) acute admissions. Cardiovascular disease accounted for 49% of chronic and 40% of acute admissions. The most common admitting diagnoses for chronic admissions were pulmonary edema (20%) and acute coronary syndrome (16%). For acute admissions, the most common diagnoses were renal failure (30%) and acute coronary syndrome (15%). The median LOS for acute admissions was significantly longer than for chronic admissions (17 vs. 8 days, p < 0.001). Eighty-six percent of the patients requiring acute HD had chronic kidney disease (CKD). Conclusions. Cardiovascular disease is a major cause of hospital admission for HD patients. Most patients requiring acute HD have CKD. Strategies to reduce hospital utilization by HD patients include treatment of heart failure, maintenance of dry weight, coronary artery disease risk factor reduction, increased use of arteriouenous fistulas, interventions to reduce vascular access thromboses, and timely initiation of dialysis for patients with CKD. Studies of disease management strategies are warranted to reduce hospital utilization and improve patient outcomes

Drug safety is not as absolute as it has been made to appear in the media. Few drugs on the market are villains, and few are heroes.

BACKGROUND: Randomized controlled trials have demonstrated that fecal occult blood testing (FOBT) reduces colorectal cancer (CRC) mortality. However, patient compliance with FOBT is low and this is one of the major barriers to CRC screening. OBJECTIVE: To determine whether intensive patient education increases FOBT card return rates. DESIGN: Randomized controlled trial. SETTING: Department of Veterans Affairs primary care clinic. PARTICIPANTS: Seven hundred eighty-eight patients who were referred for FOBT. INTERVENTIONS: Patients were randomly allocated to receive either intensive (n=396) or standard (n=392) patient education. Patients in the intensive education group received a one-on-one educational session by primary care nurses on the importance of CRC screening, were instructed on how to properly collect stool specimens for FOBT, and were given a 2-page handout on CRC screening. Patients in the standard education group only received the FOBT cards and written instructions from the manufacturer on how to properly collect stool specimens for FOBT. RESULTS: Patients in the intensive education group were more likely to return the FOBT cards (65.9% vs 51.3%; P<.001) and called the clinic with additional questions less often (1.5% vs 5.9%; P=.001) than the standard education group. The median time to return the FOBT cards was significantly shorter in the intensive education group (36 vs 143 days; P<.001 by log-rank test). However, the proportion of patients who had a positive FOBT did not differ in the two groups (4.6% vs 6.0%; P=.51). CONCLUSIONS: Intensive patient education significantly improved patient compliance with FOBT. Future studies to evaluate additional educational strategies to further improve patient compliance with CRC screening are warranted

Methicillin-resistant Staphylococcus aureus (MRSA) infection was identified in 2 horses treated at a veterinary hospital in 2000, prompting a study of colonization rates of horses and associated persons. Seventy-nine horses and 27 persons colonized or infected with MRSA were identified from October 2000 to November 2002; most isolations occurred in a 3-month period in 2002. Twenty-seven (34%) of the equine isolates were from the veterinary hospital, while 41 (51%) were from 1 thoroughbred farm in Ontario. Seventeen (63%) of 27 human isolates were from the veterinary hospital, and 8 (30%) were from the thoroughbred farm. Thirteen (16%) horses and 1 (4%) person were clinically infected. Ninety-six percent of equine and 93% of human isolates were subtypes of Canadian epidemic MRSA-5, spa type 7 and possessed SCCmecIV. All tested isolates from clinical infections were negative for the Panton-Valentine leukocidin genes. Equine MRSA infection may be an important emerging zoonotic and veterinary disease

OBJECTIVE: The burden of medical comorbidities was compared between older (> or =60 years) and younger patients with serious mental illness. METHODS: Patients (N=8,083) diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder in 2001 were identified from VA facilities in the mid-Atlantic region. Medical comorbidities were identified by an ICD-9-based clinical classification algorithm. RESULTS: Older, versus younger, patients were more likely to be diagnosed with cardiovascular or pulmonary conditions, and less likely to be diagnosed with substance-use disorders or hepatic conditions. CONCLUSIONS: More aggressive detection and management of general-medical comorbidities in older patients with serious mental illness is paramount

The foot and ankle are critical components in our ability to ambulate.Injuries to either can significantly interfere with a patient's ability to carry out normal activities. In severe cases, they can be devastating to a patient's independence. Careful examination of the foot and ankle using established mechanical tests, along with understanding of the anatomy of the complex,is needed to confirm the history and to assist in the diagnosis and treatment of foot and ankle injuries.The following points are key to clinical examination of the foot and ankle: .The examination of the foot and ankle needs to be done with the patient in both weight-bearing and non-weight bearing positions. .The examination of the foot and ankle should include an evaluation of the patient's gait. .Reproduction of a patient's symptoms is the key to making a correct diagnosis. .Although anatomic variants may predispose some individuals to injury,in general, if asymptomatic, no treatment should be done

BACKGROUND: It is not known whether the coronary heart disease (CHD) mortality risk associated with recent (RDM; <10 years) or long-standing diabetes mellitus (LDM; > or =10 years) varies by sex. METHODS: The relationship between diabetes duration and CHD mortality was evaluated among 10 871 adults (aged 35-74 years at baseline) using the 1971-1992 National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. RESULTS: The CHD mortality rates per 1000 person-years in men with no myocardial infarction (MI) or diabetes, MI only, RDM only, LDM only, MI and RDM, and MI and LDM were 5.5 (95% confidence interval, 4.8-6.2), 15.2 (11.6-20.0), 13.2 (7.9-22.1), 11.4 (6.4-20.3), 36.0 (16.7-77.7), and 35.4 (14.0-89.7), respectively. The corresponding rates in women were 2.9 (2.5-3.3), 7.3 (5.0-10.8), 5.2 (3.5-7.7), 10.7 (7.5-15.5), 9.3 (4.3-19.9), and 21.6 (6.1-76.0), respectively. Compared with MI, the multivariate hazard ratios and their 95% confidence intervals (adjusted for age, race, smoking, hypertension, total cholesterol level, and body mass index) for fatal CHD in men with RDM, LDM, MI and RDM, and MI and LDM were 0.7 (0.3-1.3), 0.8 (0.4-1.4), 3.2 (1.4-7.4), and 2.4 (0.8-6.7), respectively. The corresponding ratios in women were 0.9 (0.6-1.3), 1.8 (1.1-3.2), 1.3 (0.5-3.5), and 1.6 (0.2-10.9), respectively. CONCLUSIONS: In men, RDM and LDM were associated with as high a risk for CHD death as MI. In women, although RDM had a CHD mortality risk similar to MI, LDM had an even greater risk. Because women with LDM are at very high risk for CHD mortality, current guidelines may need to be further refined to match intensity of treatment to risk in these women

Recently a memo was sent to all of the physicians in our department by a hospital administrator, a doctor who'd recently taken on a new role. The memo reminded us that mammograms were one of the 'performance indicators' that regulatory agencies use to monitor our hospital's quality of care. 'We realize that the controversial data regarding mammograms for women aged 40-50 are not resolved,' the memo said. 'However, we urge you to order this important screening test for all your patients over the age of 40.' I looked at my patient and wondered if, in the remaining minute of our time, I could do justice to this complicated issue. Could I adequately explain her risk? Could I explain that the oft-mentioned 1-in-8 number is really a lifetime cumulative risk of breast cancer that applies only to women in their 80s who haven't died of anything else? The statistic for women in their 40s is closer to 1 in 67. For women in their 50s, one life will be saved for every 2,500 mammograms. But for women in their 40s, it can take 5,000 to 10,000 mammograms to save a life. And for those women in their 40s, there will be many 'false positives': unnecessary biopsies with their attendant cost, risks and anxiety. Could I explain all that in one minute? Evidence-based medicine is a complicated issue. Meant to ensure more rigorous and consistent science, it often induces more confusion than clarity. In some ways, evidence-based medicine is more about treating populations than individual people. If it takes 5,000 mammograms to save one life, then the value of mammograms depends on who you ask. For that one person whose life was saved, the mammogram was nothing short of the messiah. For the other 4,999, it didn't change much in their lives, and maybe it was an annoyance or an unnecessary expense. And then there will be a few people who were actually harmed in some way by the procedure