Citations

Ventilator-associated events (VAEs) are associated with increased risk of poor outcomes, including death. Bundle practices including thromboembolism prophylaxis, stress ulcer prophylaxis, oral care, and daily sedation breaks and spontaneous breathing trials aim to reduce rates of VAEs and are endorsed as quality metrics in the intensive care units. We sought to create electronic search algorithms (digital signatures) to evaluate compliance with ventilator bundle components as the first step in a larger project evaluating the ventilator bundle effect on VAE. We developed digital signatures of bundle compliance using a retrospective cohort of 542 ICU patients from 2010 for derivation and validation and testing of signature accuracy from a cohort of random 100 patients from 2012. Accuracy was evaluated against manual chart review. Overall, digital signatures performed well, with median sensitivity of 100% (range, 94.4%–100%) and median specificity of 100% (range, 100%–99.8%). Automated ascertainment from electronic medical records accurately assesses ventilator bundle compliance and can be used for quality reporting and research in VAE.

ABSTRACTBackgroundThe panelists of the Joint National Committee recently published new recommendations for the management of hypertension. Our study aims to evaluate how current practice compares.HypothesisCurrent practice likely deviates from the recent JNC 8 panelists' recommendations.MethodsA survey was sent to cardiology providers at 3 academic medical centers: Mayo Clinic, Jacksonville, Florida; Mayo Clinic, Scottsdale, Arizona; and Mayo Clinic, Rochester, Minnesota. Providers were asked to select which blood‐pressure goal would be deemed appropriate in various cases based on individual practice in both the maintenance of patients already on therapy as well as threshold of when to initiate therapy. Comparisons with current recommendations were made, as well as geographic location and level of experience.ResultsA total of 251 survey requests were sent (May 2014), and 77 responses (30.7%) were received. Cardiologists tended not to practice according to the new guidelines, with most variation seen in patients age >60 years without comorbidities on active treatment. Providers' selection of initial pharmacologic agents in non–African American patients, African American patients, and patients with diabetes mellitus reflected congruency with guidelines.ConclusionsOur study found that clinical practice does not correlate well with the new blood‐pressure goal recommendations published by the Joint National Committee 8 panelists, particularly in patients age >60 years. Practitioners are likely to follow the recommendations in regard to pharmacologic management.

ObjectivesTo determine whether clinical features of bipolar disorder, such as history of psychosis, and cardiovascular disease (CVD) risk factors contribute to a higher risk of CVD among patients with bipolar disorder.MethodsThis cross‐sectional study included a sample of 988 patients with bipolar I or bipolar II disorder or schizoaffective bipolar type confirmed by the Structured Clinical Interview for DSM‐IV‐TR disorders (SCID). Medical comorbidity burden was quantified utilizing the Cumulative Illness Severity Rating Scale (CIRS). This 13‐item organ‐based scale includes cardiac disease severity quantification. Confirmed by medical record review, patients who scored 1 (current mild or past significant problem) or higher in the cardiac item were compared by logistic regression to patients who scored 0 (no impairment), adjusting for CVD risk factors that were selected using a backwards stepwise approach or were obtained from the literature.ResultsIn a multivariate model, age [odds ratio (OR) = 3.03, 95% confidence interval (CI): 1.66–5.54, p < 0.0001], hypertension (OR = 2.43, 95% CI: 1.69–3.55, p < 0.0001), and history of psychosis (OR = 1.48, 95% CI: 1.03–2.13, p = 0.03) were associated with CVD. When CVD risk factors from the literature were added to the analysis, age (OR = 3.19, 95% CI: 1.67–6.10, p = 0.0005) and hypertension (OR = 2.46, 95% CI: 1.61–3.76, p < 0.01) remained significant, with psychosis being at the trend level (OR = 1.43, 95% CI: 0.96–2.13, p = 0.08).ConclusionsThe phenotype of psychotic bipolar disorder may reflect higher illness severity with associated cardiac comorbidity. Further studies are encouraged to clarify the effect of the disease burden (i.e., depression), lifestyle, and treatment interventions (i.e., atypical antipsychotics) on this risk association.

AbstractBackgroundThe incidence of melanoma has been rising in the United States, with conflicting evidence regarding trends in children.MethodsWe identified patients 0 to 17 years old with a diagnosis of melanoma from January 1, 1970, through December 31, 2010, in Olmsted County, Minnesota. Information on survival and demographic characteristics was abstracted, and estimates of true incidence were calculated.ResultsThe estimated true incidence of melanoma in children from 1970 to 2010 was found to be 0.62 per 100,000 girls and 0.45 per 100,000 boys. The incidence of melanoma in this population did not increase with time after adjusting for age and sex. Only one case of metastatic disease (lymph node) was identified. Girls were more commonly affected and the mean age of disease onset was 14 years. Five of the seven melanomas in this population arose in association with a nevus, and none involved the trunk. Overall and disease‐specific survival rates were not calculated because all patients studied were alive at the last follow‐up.ConclusionThe estimated true incidence rates of pediatric melanoma from our population‐based study in Olmsted County, Minnesota, appear stable. This finding is in contrast to our prior research showing rapidly increasing incidence rates of melanoma in young and middle‐aged adults from the same population.

Background: The incidence of distal biceps tendon ruptures was studied more than 10 years ago in a small patient cohort. Recent diagnostic advancements have improved the ability to detect this rare injury. Hypothesis: The incidence of distal biceps tendon ruptures will be significantly greater than previously reported. Study Design: Descriptive epidemiologic study. Methods: A query of the PearlDiver Technologies national database containing public and private insurance patients was used to estimate the national incidence of distal biceps tendon ruptures in the United States. A retrospective chart review of our local population identified demographic groups and risk factors that increased likelihood of injury. Results: The estimated national incidence of distal biceps tendon rupture was 2.55 per 100,000 patient-years. The local incidence was 5.35 per 100,000 patient-years. The mean and median ages of patients in our regional cohort were 46.3 and 46 years, respectively. Males composed the majority of the injured population (national 95%, regional 96%). Smoking and elevated body mass index were found to be associated with increased likelihood of injury, while diabetes mellitus showed no association. Conclusion: The incidence of distal biceps tendon ruptures in this study was higher than previously reported.

Abstract Lichen planopilaris ( LPP ) is a rare form of cicatricial alopecia that has occasionally been reported in children. Because of the limited number of patients reported, little information is available about demographic characteristics, clinical presentation, or treatment options for these patients. A retrospective chart review of LPP cases in patients under 18 years of age from 1976 to 2013 was performed to further define clinicopathologic features of pediatric LPP . Four pediatric LPP patients ages 13 to 16 years were identified (three male, one female). One patient had scalp pruritus and one had other cutaneous findings of lichen planus ( LP ). Perifollicular scale and scarring were the most common physical examination findings, although changes mimicking those of alopecia areata were observed. Three patients were treated with topical or intralesional steroids. One patient was treated with minocycline. Histopathologic findings included perifollicular interface and perifollicular fibrosis in all cases. There was focal interfollicular interface in two cases and mild dermal mucin in one case. LPP is exceedingly rare in children. It may be misdiagnosed as alopecia areata in children because of the lack of symptoms and other features of LP . There should be a high index of suspicion for LPP in children with alopecia that is unresponsive to standard treatment or who have findings that are atypical for more common childhood alopecias.

BACKGROUNDInaccurate or incomplete information in the written portion of the patient handoff, or sign‐out, may be associated with adverse events in hospitalized patients. Little is known about what information providers actually include in written sign‐out documents and how sign‐outs change over time.OBJECTIVES(1) Provide a descriptive analysis of initial and subsequent hospital day‐written sign‐out content, and (2) evaluate the relationship between team workload and sign‐out composition.DESIGNRetrospective review of sign‐out documents from a larger observational study of general medicine patients admitted to housestaff and hospitalist teams at 3 hospitals.MAIN MEASURESThe presence of 13 components of a high‐quality sign‐out. We performed descriptive analyses and compared initial and subsequent day sign‐outs for content.KEY RESULTSWe reviewed 200 patient hospitalizations (200 initial handoffs, 580 subsequent day handoffs). Initial sign‐out entries contained a mean of 7.54 (standard deviation: 2.27) key sign‐out components. Subsequent day sign‐outs contained a higher percentage of certain key elements but had more vague language. The number of elements present in the sign‐out was reduced as patient census increased (r = −0.295, P < 0.01).CONCLUSIONSSign‐out composition changes over time, and is associated with workload. Future interventions to improve quality should take these factors into consideration. Journal of Hospital Medicine 2015;10:534–536. © 2015 Society of Hospital Medicine.

ABSTRACT While posaconazole prophylaxis decreases the risk of invasive fungal infection compared to fluconazole, low bioavailability of the oral-suspension formulation limits its efficacy. A new delayed-release tablet formulation demonstrated an improved pharmacokinetic profile in healthy volunteers. However, serum levels for the two formulations have not been compared in clinical practice. This study compared achievement of therapeutic posaconazole levels in patients taking the delayed-release tablet to those taking the oral suspension. This retrospective cohort study included 93 patients initiated on posaconazole between 2012 and 2014 and had at least one serum posaconazole level measured. The primary measure was the proportion of patients achieving an initial therapeutic level (>700 ng/ml). An initial therapeutic posaconazole level was seen in 29 of 32 (91%) patients receiving tablets and 37 of 61 (61%) patients receiving suspension ( P = 0.003). Among patients with a steady-state level measured 5 to 14 days after initiation, a therapeutic level was observed in 18 of 20 (90%) patients receiving tablets and 25 of 43 (58%) patients receiving suspension ( P = 0.01). In these patients, the median posaconazole level of the tablet cohort (1655 ng/ml) was twice that of the suspension cohort (798 ng/ml) ( P = 0.004). In this cohort study, the improved bioavailability of delayed-release posaconazole tablets translates into a significantly higher proportion of patients achieving therapeutic serum levels than in the cohort receiving the oral suspension. The results of this study strongly support the use of delayed-release tablets over suspension in patients at risk for invasive fungal infection.