Ms R is a 76-year-old woman who experienced delirium following complicated surgery for removal of a polyp of the colon. A self-employed, active therapist, she lives alone with children nearby. She has no family history of dementia. She does not smoke and does not abuse alcohol or other substances. She has Medicare and supplemental insurance. For many years, Ms R received care at a hospital-based primary care unit.
Some forms of acute vital organ injury leading to death or severe disability have appropriately attracted significant attention among clinicians, researchers, and the public.
The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min).
Paul S. Chan, MD, MSc; Brahmajee K. Nallamothu, MD, MPH. JAMA. 2012;307(18):1917-1918.
Approximately 200 000 US patients annually experience in-hospital cardiac arrest,1 yet clinicians continue to have poor understanding about how to improve patient survival after these events. In part, this is because cardiac arrest is an unexpected event that is difficult to predict with certainty. Moreover, cardiac arrest involves heterogeneous groups of patients necessitating the engagement of numerous physician specialties, hospital floors, and allied health care personnel to improve resuscitation outcomes.
James Tsai, MD, MPH; Scott D. Grosse, PhD; Althea M. Grant, PhD; W. Craig Hooper, PhD; Hani K. Atrash, MD, MPH. Arch Intern Med. Published online April 2, 2012. doi:10.1001/archinternmed.2012.198
Pulmonary embolism (PE) is a potentially life-threatening condition that typically occurs when a thrombus from deep veins in the leg, pelvis, arms, or heart embolizes to the lungs.1-2 Recent data linked PE to approximately 247 000 hospitalizations in the United States in 2006.3 To our knowledge, the case-fatality rate and estimated number of in-hospital deaths among a national representative example of hospitalizations that encompass first-listed and any-listed PE diagnoses in the United States are limited. Therefore, we report nationally representative estimates of in-hospital deaths (ie, annual number and case-fatality rate) among hospitalizations with a PE diagnosis (ie, first-listed and any-listed) in the United States by analyzing data from the 2001-2008 National Hospital Discharge Survey (NHDS).4
A Metaphor for Medicine in the Evidence-Based Medicine Era V
Arch Intern Med. Published online April 2, 2012. doi:10.1001/archinternmed.2012.195
Background The history of pulmonary embolism (PE) provides a fascinating portrait of a well-established diagnosis and standard of care treatment moving into the age of evidence-based medicine.
Daniel K. Nishijima, MD, MAS; David L. Simel, MD, MHS; David H. Wisner, MD; James F. Holmes, MD, MPH. JAMA. 2012;307(14):1517-1527.
Context Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma.
Henry T. Stelfox, MD, PhD, FRCPC; Brenda R. Hemmelgarn, MD, PhD, FRCPC; Sean M. Bagshaw, MD, MSc, FRCPC; Song Gao, MSc; Christopher J. Doig, MD, MSc, FRCPC; Cheri Nijssen-Jordan, MD, MBA, FRCPC; Braden Manns, MD, MSc, FRCPC
Arch Intern Med. 2012;172(6):467-474.
Background Intensive care unit (ICU) beds, a scarce resource, may require prioritization of admissions when demand exceeds supply. We evaluated the effect of ICU bed availability on processes and outcomes of care for hospitalized patients with sudden clinical deterioration.
Objectives To examine the specific injuries, need for operative intervention, and clinical outcomes of patients with blunt thoracoabdominal trauma.
Craig D. Blinderman, MD, MA; Eric L. Krakauer, MD, PhD; Mildred Z. Solomon, EdD. JAMA. 2012;307(9):917-918.
In US hospitals, cardiopulmonary resuscitation (CPR) is the de facto default option—patients must “opt out” by requesting or consenting to a do-not-attempt-resuscitation order. Despite its worthy intent, requiring all patients or their surrogates to consent to a do-not-attempt-resuscitation order to avoid CPR has resulted in an ethically unjustifiable practice that exposes many patients to substantial harms.
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network*
Online First. JAMA. Published online February 5, 2012.
Context The amount of enteral nutrition patients with acute lung injury need is unknown.
Objective To determine if initial lower-volume trophic enteral feeding would increase ventilator-free days and decrease gastrointestinal intolerances compared with initial full enteral feeding.
Arch Surg. 2012;147(1):49-55. doi:10.1001/archsurg.2011.790
Objective To examine outcomes in patients who receive small amounts of intraoperative blood transfusion.
2012 Jan - Factors Associated With 30-Day Readmission Rates After Percutaneous Coronary Intervention
Arch Intern Med. 2012;172(2):112-117
Background Thirty-day readmission rates have become a publicly reported quality performance measure for congestive heart failure, acute myocardial infarction, and percutaneous coronary intervention (PCI). However, little is known regarding the factors associated with 30-day readmission after PCI.
Writing Committee for the American Lung Association Asthma Clinical Research Centers
Authors/Writing Committee: The following investigators of the American Lung Association Asthma Clinical Research Centers take authorship responsibility for the study results: Janet T. Holbrook, MPH, PhD, Center for Clinical Trials, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Robert A. Wise, MD, Johns Hopkins University School of Medicine; Benjamin D. Gold, MD, Children's Center for Digestive Healthcare, Atlanta, Georgia; Kathryn Blake, PharmD, Nemours Children's Clinic, Jacksonville, Florida; Ellen D. Brown, MS, Center for Clinical Trials, Johns Hopkins School of Public Health; Mario Castro, MD, Washington University School of Medicine, St Louis, Missouri; Allen J. Dozor, MD, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla; John J. Lima, PharmD, Nemours Children's Clinic; John G. Mastronarde, MD, Ohio State University Medical Center, Davis Heart and Lung Research Institute, Columbus; Marianna M. Sockrider, MD, DrPH, Baylor College of Medicine, Texas Children's Hospital, Houston; and W. Gerald Teague, MD, University of Virginia School of Medicine, Charlottesville.
Asymptomatic gastroesophageal reflux (GER) is prevalent in children with asthma. Untreated GER has been postulated to be a cause of inadequate asthma control in children despite inhaled corticosteroid treatment, but it is not known whether treatment with proton pump inhibitors improves asthma control.
Arch Neurol. 2012;69(1):46-50. doi:10.1001/archneurol.2011.232
Background Imaging is used as a surrogate for clinical outcome in early-phase stroke trials. Assessment of infarct growth earlier than the standard 90 days used for clinical end points may be equally accurate and more practical.
Background A recent post hoc analysis of a large randomized trial in patients with cerebrovascular disease suggested that statins may increase the risk of intracerebral hemorrhage (ICH).
To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions.
Clinical practice guidelines recommend maintaining serum potassium levels between 4.0 and 5.0 mEq/L in patients with acute myocardial infarction (AMI). These guidelines are based on small studies that associated low potassium levels with ventricular arrhythmias in the pre−β-blocker and prereperfusion era. Current studies examining the relationship between potassium levels and mortality in AMI patients are lacking.
Erik K. Fromme, MD;Dana Zive, MPH;Terri A. Schmidt, MD, MS;Elizabeth Olszewski, MPH;Susan W. Tolle, MD. JAMA. 2012;307(1):34-35.
To the Editor: The Physician Orders for Life Sustaining Treatment (POLST) form augments traditional methods for advance care planning by translating treatment preferences into medical orders, including for cardiopulmonary resuscitation (CPR), scope of treatment, artificial nutrition by tube, and in some states, antibiotic use.
2011 Dec 28 - CYP2C19 Genotype, Clopidogrel Metabolism, Platelet Function, and Cardiovascular Events A Systematic Review and Meta-analysis
Objective To appraise evidence on the association of CYP2C19 genotype and clopidogrel response through systematic review and meta-analysis.