Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification

BACKGROUND

Clinicians caring for patients seeking alcohol detoxification face many challenges, including lack of evidence-based guidelines for treatment and high recidivism rates.

OBJECTIVES

To develop a standardized protocol for determining which alcohol dependent patients seeking detoxification need inpatient versus outpatient treatment, and to study the protocol’s implementation.

DESIGN

Review of best evidence by ad hoc task force and subsequent creation of standardized protocol. Prospective observational evaluation of initial protocol implementation.

PARTICIPANTS

Patients presenting for alcohol detoxification.

INTERVENTION

Development and implementation of a protocol for evaluation and treatment of patients requesting alcohol detoxification.

MAIN MEASURES

Number of admissions per month with primary alcohol related diagnosis (DRG), 30-day readmission rate, and length of stay, all measured before and after protocol implementation.

RESULTS

We identified one randomized clinical trial and three cohort studies to inform the choice of inpatient versus outpatient detoxification, along with one prior protocol in this population, and combined that data with clinical experience to create an institutional protocol. After implementation, the average number of alcohol related admissions was 15.9 per month, compared with 18.9 per month before implementation (p?=?0.037). There was no difference in readmission rate or length of stay.

CONCLUSIONS

Creation and utilization of a protocol led to standardization of care for patients requesting detoxification from alcohol. Initial evaluation of protocol implementation showed a decrease in number of admissions.     

Drugs for Prevention and Treatment of Aortic Stenosis: How Close Are We?

Aortic stenosis is one of the most common cardiovascular diseases in the world. Extensive work on the underlying pathophysiology responsible for calcific aortic valve disease and its progression to aortic stenosis has described a complex process involving inflammation, lipid deposition, mineralisation, and genetic factors such as elevated lipoprotein(a). With the advancement of gene silencing technology and development of novel therapeutic agents, we may now be closer than ever to having medical therapies that prevent, or at least slow the progression of aortic stenosis. In this review, we highlight the pathophysiology and risk factors of calcific aortic valve disease, along with current, potential, and emerging novel medical therapies. We also provide potential explanations for the failure of statin trials and suggest new avenues for research and new randomised trials in this area.     

Breast Cancer Treatment Decision-Making: Are We Asking Too Much of Patients?

OBJECTIVE

Physicians are mandated to offer treatment choices to patients, yet not all patients may want the responsibility that entails. We evaluated predisposing factors for, and long-term consequences of, too much and not enough perceived decision-making responsibility among breast cancer patients.

DESIGN

Longitudinal assessment, with measurements collected just after surgical treatment (baseline) and 6-month follow-up.

PARTICIPANTS

Women with early-stage breast cancer treated surgically at eight NYC hospitals, recruited for a randomized controlled trial of patient assistance to improve receipt of adjuvant treatment.

MEASUREMENTS

Using logistic regression, we explored multivariable-adjusted associations between perceived treatment decision-making responsibility and a) baseline knowledge of treatment benefit and b) 6-month decision regret.

RESULTS

Of 368 women aged 28–89 years, 72 % reported a “reasonable amount”, 21 % “too much”, and 7 % “not enough” responsibility for treatment decision-making at baseline. Health literacy problems were most common among those with “not enough” (68 %) and “too much” responsibility (62 %). Only 29 % of women had knowledge of treatment benefits; 40 % experienced 6-month decision regret. In multivariable analysis, women reporting “too much” vs. “reasonable amount” of responsibility had less treatment knowledge ([OR] = 0.44, [95 % CI] = 0.20–0.99; model c?=?0.7343;p?<?0.01) and more decision regret ([OR] = 2.,91 [95 % CI] = 1.40–6.06; model c?=?0.7937;p?<?0.001). Findings were similar for women reporting “not enough” responsibility, though not statistically significant.

CONCLUSION

Too much perceived responsibility for breast cancer treatment decisions was associated with poor baseline treatment knowledge and 6-month decision regret. Health literacy problems were common, suggesting that health care professionals find alternative ways to communicate with low health literacy patients, enabling them to assume the desired amount of decision-making responsibility, thereby reducing decision regret.     

Resynchronization Therapy for Patients with Congenital Heart Disease: Are We Ready for Prime Time?

Purpose of Review

This review aims to summarize and provide an update of evidence for cardiac resynchronization therapy (CRT) in pediatric and adult congenital heart disease (CHD).

Recent Findings

CRT is a valuable tool in the treatment of heart failure in the setting of CHD. Current evidence points toward the ability of this therapy to increase hemodynamic parameters and reduce heart failure-related symptoms. Within the CHD population, patients with systemic left ventricles appear to benefit the most from CRT. Utilization of CRT in CHD has been technically difficult due to the complexity and variety of anatomic substrates. However, lateral thoracotomies and other advances have made implantation more feasible.

Summary

The most up-to-date evidence continues to support the use of CRT in the heterogeneous population of CHD with careful and individualized patient selection. Further studies are needed to evaluate the utility of CRT for specific anatomic substrates within this population.

     

The Quality of Podium Presentations at The American Society of Colon and Rectal Surgeons: Does a Decade Make a Difference?

PURPOSE The technology of the seven-minute scientific presentation has changed greatly with the universal acceptance of computerized slides and graphics. We performed this study to see whether the quality of delivery has improved pari passu with technical advances in presentation of data.METHODS In 1993 and in 2003 a sample of the podium presentations given at The American Society of Colon and Rectal Surgeons annual scientific meeting was analyzed. Number of slides, type of slides, time of presentation, and quality of presentation were recorded. Quality was scored by the presence of poor presentation techniques such as presenting too fast for the slide to be comprehended, presenting data that were different to what was on the slide, using fonts that were too small to be read, and reading the exact wording of the slide. One point was awarded for each transgression and for any talk lasting more than 7.9 minutes; the higher the score, the worse the presentation.RESULTS Thirty-eight presentations were analyzed from the 1993 meeting in Orlando and 40 were analyzed from the 2003 meeting in New Orleans. There was no difference in mean time of the presentation (1993, 7.5 minutes ± 1.5 standard deviation vs. 2003, 7.2 minutes ± 0.7 standard deviation), in mean number of slides used per presentation (1993, 16.4 ± 3.3 standard deviation vs. 2003, 17.1 ± 5.4 standard deviation), or in slides per minute (1993, 2.3 ± 0.8 standard deviation vs. 2003, 2.5 ± 1.0 standard deviation). Presentation technique was much worse in 1993, however, with a mean quality score of 2.2 ± 1.1 standard deviation vs. 0.8 ± 0.9 standard deviation in 2003 (P < 0.001). The most common fault in both years was presenting a slide too rapidly, a fault more pervasive in 1993 than in 2003 (1993, 30/38 presentations vs. 2003, 16/40). Only ten presentations went over the allotted time in 2003, by an average of one minute. In 1993, 18 presentations were too long, by an average of 1.8 minutes each.CONCLUSIONS The basic structure of the seven-minute podium presentation has changed little over the last ten years, despite major advances in technology. The most notable improvements have been in the technique of delivering the talk.Reprints are not available.     

Evidence for Oncolytic Virotherapy: Where Have We Got to and Where Are We Going?

The last few years have seen an increased interest in immunotherapy in the treatment of malignant disease. In particular, there has been significant enthusiasm for oncolytic virotherapy, with a large amount of pre-clinical data showing promise in animal models in a wide range of tumour types. How do we move forward into the clinical setting and translate something which has such potential into meaningful clinical outcomes? Here, we review how the field of oncolytic virotherapy has developed thus far and what the future may hold.     

Palliative Care Consultations for Heart Failure Patients: How Many,When, and Why?

ObjectiveIn preparation for development of a palliative care intervention for patients with heart failure (HF) and their caregivers, we aimed to characterize the HF population receiving palliative care consultations (PCCs).Methods and ResultsReviewing charts from January 2006 to April 2011, we analyzed HF patient data including demographic and clinical characteristics, Seattle Heart Failure scores, and PCCs. Using Atlas qualitative software, we conducted a content analysis of PCC notes to characterize palliative care assessment and treatment recommendations. There were 132 HF patients with PCCs, of which 37% were New York Heart Association functional class III and 50% functional class IV. Retrospectively computed Seattle Heart Failure scores predicted 1-year mortality of 29% [interquartile range (IQR) 19–45] and median life expectancy of 2.8 years [IQR 1.6–4.2] years. Of the 132 HF patients, 115 (87%) had died by the time of the audit. In that cohort the actual median time from PCC to death was 21 [IQR 3–125] days. Reasons documented for PCCs included goals of care (80%), decision making (24%), hospice referral/discussion (24%), and symptom management (8%).ConclusionsDespite recommendations, PCCs are not being initiated until the last month of life. Earlier referral for PCC may allow for integration of a broader array of palliative care services.