Development of a medical subspecialty in palliative medicine: progress report

There is significant interest in seeking professional recognition of expertise in caring for people with serious life-threatening illness and their families through creation of a specialty in palliative medicine. Certification of physicians and accreditation of training programs are key elements for formal recognition. The American Board of Hospice and Palliative Medicine was established to achieve these goals. The next step in the maturation of the subspecialty of palliative medicine is to have both the certification and the accreditation recognized by the professional self-governing bodies in organized medicine. This paper answers common questions about obtaining recognition by the Accreditation Council of Graduate Medical Education, the American Board of Medical Specialties and its member boards. Formal recognition of the subspecialty of palliative medicine is sought in order to extend the knowledge and skills inherent in the domains of palliative medicine. Such recognition will also encourage more physicians to enter the field and assure standards of care for those patients and their families who need it.     

A prospective, physician self-reported adverse incident audit on a general medical unit

There is some evidence that physician self-reporting is an efficient and effective way of collecting data on adverse incidents in health care. This study tested a simple prospective adverse incident audit, self-reported by physicians, on a general medical unit. A total of 158 reports were collected over a 6-month period covering a wide range of quality issues, including, but not limited to, safety issues. One-third of reported incidents occurred within 48 h of hospitalization. One-half of incidents were associated with harm or inconvenience to patients. Reported incidents fell into easily classifiable groups, and the data was used as a platform for a coordinated approach to quality improvement within the department. It is concluded that this technique is an easily implementable addition to the more traditional methods used for quality improvement within general medicine.     

Cognition and expertise: acquisition of medical competence

The cognitive study of expertise in knowledge domains has generated a great deal of knowledge that can be used in the education and training of health care providers. This research has looked at the development and characteristics of expert performance. Design of medical and health education systems that are informed by this research can be powerful tools to improve the quality of medical education.     

The recognition and use of patient expertise on a unit for older people

There is growing recognition in health care of the expertise patients bring to the management of their own illness or condition. But some patient groups, including older people, may need encouragement to see their own coping strategies as expertise, and nurses have an important role to play in ensuring that patients' experiences are acknowledged and made central to the care offered. This article describes a study of patients' and professionals' views of patient expertise. It concludes that although disruption can occur when older people are admitted to hospital, this can be minimised if they are perceived as experts in their own condition and information supplied to them is based upon such acknowledgement.     

The significance of gross elevations of the erythrocyte sedimentation rate in a general medical unit

One hundred consecutive patients with an ESR of 100 mm or more in the first hour admitted to a general medical unit were studied. Their mean age was 67 years and forty-seven were male. Three patients recovered without a satisfactory diagnosis. In thirty-three of the remainder a single diagnosis was considered responsible for the elevation of the ESR, and in the others multiple diagnoses were found. Infection was found in 60% of patients, malignancy in 28% (including 7% with myelomatosis), rheumatoid disease in 20% and renal disease in 11%. 34% of patients died within 6 months of entry into the study. In the absence of rheumatoid disease or a paraproteinaemia, elevation of the ESR in excess of 60 mm in the first hour at 1 month or longer was associated with a particularly poor prognosis. This study has shown the diagnostic implications of an ESR of 100 mm or more in the first hour and the prognostic significance of a persistent elevation of the ESR.     

Admission hyperlactatemia: causes, incidence, and impact on outcome of patients admitted in a general medical intensive care unit

Purpose

The aim of this study was to evaluate the causes, incidence, and impact on outcome of admission hyperlactatemia in patients admitted to a general medical intensive care unit (ICU).

Methods

A retrospective cohort study was done in an 8-bed general ICU of tertiary care hospital over 15 months. Data regarding patient demographics, probable cause of hyperlactatemia, presence of shock, need for organ support, and ICU outcome were recorded. Patients were divided into 2 groups based on admission lactate levels as follows: high lactate (>2 mmol/L) and normal lactate (<2 mmol/L). Patients were compared in terms of need for organ support and ICU mortality.

Results

Admission hyperlactatemia was present in 199 of 653 (30.47%) patients. Shock was the commonest cause, 53.3% patients, followed by respiratory and renal failure in 26 (13.1%) and 16 (8%) patients, respectively. Mean ± SD lactate levels in survivors and nonsurvivors were 1.64 ± 1.56 and 4.77 ± 4.72 mmol/L, respectively (P = .000). Receiver operating characteristic curve for lactate was 0.803 (95% confidence interval [CI], 0.753-0.853). Sensitivity and specificity of lactate (>2 mmol/L) to predict ICU mortality was 74.8% and 77.8%, respectively. Odds ratio for dying in patients with hyperlactatemia was 10.39 (95% CI, 6.378-16.925) with a relative risk of 1.538 (95% CI, 1.374-1.721). On subgroup analysis, in patients without hypotension too, ICU mortality was significantly increased in patients with hyperlactatemia (1.3% vs 6.45%, P = .009).

Conclusions

Admission hyperlactatemia is common in a general ICU and is associated with increased mortality, irrespective of presence of hypotension. Shock was the commonest cause for hyperlactatemia, followed by respiratory and renal failures.     

Acute orbital pseudotumor: ocular emergency on a general medical service

We have reported a case of acute orbital pseudotumor, an idiopathic inflammatory process that usually responds dramatically to corticosteroids. Untreated, severe proptosis and eventual optic neuropathy may result. Although its signs and symptoms may cause confusion with infectious, endocrinologic, traumatic, allergic, and neoplastic ophthalmopathies, the acute onset, rapid progression, and characteristic CT picture are nearly pathognomonic of orbital pseudotumor. When both the clinical and CT findings are compatible with this diagnosis, a therapeutic trial of oral corticosteroids can be undertaken. It is important for the primary physician to be aware of this disease to facilitate appropriate diagnosis and treatment, avoiding unnecessary surgical intervention and possible complications.