Use of a palliative care order set to improve resident comfort with symptom management in palliative care

Although one-fourth of all medicare dollars are spent during the last year of life, symptom management for terminal hospitalized patients has continued to be inadequate. Quality end-of-life care is often overlooked, seldom taught and rarely measured within Internal Medicine Residency Programmes. We studied the effects of a palliative care order set and educational e-mail on resident comfort. Survey of residents showed that only 54% were comfortable across nine aspects of palliative care. Three months after release, 88% of residents were using the order set and 63% believed it increased their comfort with palliative care. Resident comfort managing palliative symptoms increased an average 10% (P = 0.02). First-year residents exposed to this order set increased in comfort from 40% to 65% (P < 0.0001), which significantly surpassed the 48% of second-year residents who reported being comfortable (P = 0.002). Introducing a palliative care order set improves resident comfort with symptom management in dying patients.     

A qualitative study exploring infant feeding decision‐making between birth and 6 months among HIV‐positive mothers

Despite efforts to support breastfeeding for HIV‐positive mothers in South Africa, being HIV‐positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision‐making about infant feeding practices among HIV‐positive mothers in a rural and urban settings in KwaZulu‐Natal, South Africa. HIV‐positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in‐depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV‐positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.     

Bladder injuries during cesarean section in a University Hospital: a 25-year review

Objectives  The objective was to determine the prevalence of bladder injury during cesarean section (CS) and identify the risk factors causing these injuries, their management and the outcome. Methods  We retrospectively reviewed the medical records of all the patients who had bladder injury during CS over a period of 25 years (1983–2007) at the King Fahad Hospital, Al-Khobar, Saudi Arabia. Demographic data, obstetric, surgical details, mechanism of injury, anatomic location, diagnosis, management and outcome were assessed. Results  Thirty-four cases of bladder injury were identified among 7,708 cesarean deliveries performed during this period with an overall incidence of 0.44%. Primary CS was found in 41.2% of the patients and 58.8% had repeat CS giving an incidence of 0.27 and 0.81%, respectively. Bladder injury occurred when surgical difficulties were encountered during opening of the peritoneal cavity and while developing the bladder flap over the lower uterine segment, mainly due to adhesions and scar tissue resulting from previous abdominal surgery. All the bladder injuries were recognized intraoperatively and repaired with an overall satisfactory outcome. Repeat CS and presence of adhesions were found to be statistically significant risk factors in the study, while operator experience and emergency nature of the CS were considered risk factors in a few cases of bladder injury. Conclusions  Data presented in this study indicates that bladder injury when adequately repaired is rarely associated with any complications. Multiple cesarean deliveries is a significant risk factor for bladder injury at the time of repeat CS and patients should be counseled regarding this risk before surgery.     

Novel functional risk factors for the prediction of cardiovascular events in vulnerable patients following acute coronary syndrome

Over the years there has been considerable improvement in the clinical outcomes of patients treated for acute coronary syndrome (ACS). Despite a significant reduction in acute mortality, a large percentage of patients post ACS continue to experience adverse cardiovascular (CV) events, with high long-term mortality rates and overall suboptimal medical management. Long-term risk prediction tools rely on traditional CV risk factors and are developed and validated in specific populations. Established CV risk factors, however, only explain half or fewer of CV events. These risk models may thus not be optimal in determining individual risk for long-term adverse outcomes or in helping to identify individual patients who do not respond to therapy. Identifying the specific plaque characteristics associated with increased likelihood for thrombotic complications and rapid progression has led to the concept of the vulnerable plaque. Recently, "vulnerable myocardium" (ie, myocardium that is prone to myocardial ischemia and fatal arrhythmia) has been shown to play an important role in outcome. Both vulnerable plaque and vulnerable myocardium are associated with functional vascular abnormalities, such as endothelial dysfunction, which are considered a key event in the initiation, progression and complications of coronary artery disease. Endothelial dysfunction may serve as an underlying unifying mechanism that would independently predict long-term outcome in patients with ACS undergoing revascularization.     

Syphilis, gonorrhoea and genital chlamydial infection in a Somali village.

A total of 767 sera were collected from 187 men, 200 women and 380 children in a Somali village, Jambaluul. All sera were tested for syphilis serological markers by Venereal Diseases Research Laboratory (VDRL) and Treponema pallidum Haemagglutination Assay (TPHA). Sera positive for both or either of these tests were further analysed for the presence of specific IgM antibodies by Solid Phase Haemadsorption Assay (SPHA). A high and almost equal prevalence of TPHA positivity was found in men and women; 24% and 22.5%, respectively, and IgM antibodies were found in 3% and 4%, respectively. TPHA positivity significantly increased with age. Thus more than half of the villagers at the age of 45 years or more were TPHA positive. One percent of the children were TPHA positive. From all adults aged 15 years and above urogenital specimens were also taken for Chlamydia trachomatis antigen detection with an enzyme-amplified immunoassay (IDEIA) and Neisseria gonorrhoeae culture. Chlamydial genital infection was found in 6% of the men and 18% of the women. All gonococcal cultures were negative.     

Associations of Environmental Factors With Elderly Health and Mortality in China

Objectives. We examined the effects of community socioeconomic conditions, air pollution, and the physical environment on elderly health and survival in China.Methods. We analyzed data from a nationally representative sample of 15 973 elderly residents of 866 counties and cities with multilevel logistic regression models in which individuals were nested within each county or city.Results. After control for individual-level factors, communities'' gross domestic product per capita, adult labor force participation rate, and illiteracy rate were significantly associated with physical, mental, and overall health and mortality among the elderly in China. We also found that air pollution increased the odds of disability in activities of daily living (ADLs), cognitive impairment, and health deficits; more rainfall was protective, reducing the odds of ADL disability and cognitive impairment; low seasonal temperatures increased the odds of ADL disability and mortality; high seasonal temperatures increased the odds of cognitive impairment and deficits; and living in hilly areas decreased the odds of ADL disability and health deficits.Conclusions. Efforts to reduce pollution and improve socioeconomic conditions could significantly improve elderly health and survival.China''s continued rapid economic growth¹ has been coupled with significant environmental degradation. For example, approximately 40% of China''s land is affected by soil erosion and deforestation.^2,3 Rapid economic growth and significant environmental degradation are also occurring in many other developing countries.^4,5 Hence, although socioeconomic development may improve population health and survival, related environmental degradation may have an opposite effect in China and elsewhere.The population of China, as in all developed and many other developing countries, is aging because of substantial declines in both fertility and mortality. The number of persons aged 65 years and older in China is forecast to increase dramatically from 87 million in 2000 (6.7% of the population), to 243–252 million in 2030 (16.5%–17.0%), and then to 352–398 million in 2050 (24.1%–26.4%), with the ranges reflecting uncertainty about changes in mortality in the next few decades.⁶ Population aging is occurring 3.3 to 4.4 times as quickly in China and other developing countries as it is in Europe.⁷Previous studies identified significant associations of community socioeconomic conditions and physical environment (such as degree of air pollution, average temperature, yearly rainfall, and geographic topography) with health and mortality.^8,9 Elderly persons are especially sensitive to their physical and social surroundings and may be more vulnerable than younger adults to the negative effects of environmental degradation on health and survival.^10–12 Consequently, the concurrent rapid population aging and environmental degradation in China and other developing countries are likely to impair the quality of life of elderly people and their families. Furthermore, developing countries lag behind developed countries in both socioeconomic welfare and environmental protection; with little preparation, the challenges of coping with an aging society that China faces are more serious than those in developed countries. Estimates of the associations of environmental factors with elderly health and survival are therefore vital for the formulation of policies for sustainable development and public health in developing countries. The elderly are among the groups most susceptible to the adverse effects of community socioeconomic problems and environmental pollution; research is needed in this population to identify the most crucial issues as targets of policy remedies.¹²The current literature concerning the associations of community conditions with elderly health and mortality has major limitations. First, few longitudinal studies at the nationwide and population level have measured the actual environmental exposures of individual older persons.¹² Most previous research collected and analyzed community and individual data from 1 or a few municipalities^10,13 or used aggregated data only.^14,15 Second, almost all of the published studies focused on elderly persons younger than age 85 years because they lacked a sufficiently large subsample to adequately represent the oldest old, a subpopulation that is growing twice as fast as the overall elderly population (aged 65 years or older).¹⁶ Third, previous work mostly focused on the developed countries; published analyses of data from developing countries, including China, are rare.¹⁷ In developed countries, the socioeconomic conditions may differ less between different communities than they do in developing countries; this lack of variability may limit the statistical power of analyses of the associations of community environment with elderly health and mortality.Elderly health outcomes are generally believed to be affected by social and behavioral factors at the individual level, socioeconomic and physical environmental factors at the community level, and genetic factors at the molecular level, as well as the complex interactions among all of these.¹⁸ We assessed the impact of community socioeconomic and physical environmental factors on health and survival among the elderly, adjusting for individual social and behavior factors such as age, gender, childhood conditions, and adulthood socioeconomic status (SES). We also conducted statistical analyses of the potential interactions between community- and individual-level factors. Genotype data were not available, but we used random-effects modeling to account for unobserved heterogeneity.We analyzed data from a large, prospective, nationally representative cohort of the Chinese elderly, including a large subsample of the oldest old and a compatible subsample of the younger old, to test the hypothesis that community socioeconomic conditions, air pollution, and the physical environment in China are associated with elderly health and survival. Community conditions varied tremendously in the 866 counties and cities in our sample, providing a good opportunity to investigate the impact of environmental factors on health and mortality among the elderly.     

Radiographic viewing conditions at Johannesburg Hospital

Purpose

To measure the luminance level of X-ray viewing boxes and ambient lighting levels in reporting rooms as a quality assurance procedure, and to compare the results with those recommended by the Directorate of Radiation Control, South Africa (DRC), European Commission (EC) and Nordic Radiation Protection Co-operation (NORDIC).

Materials and Methods

All the viewing boxes housed at the Divisions of Radiation Oncology and Radiology of Johannesburg Hospital had their luminance levels measured using a calibrated photometer. In addition the room’s ambient light was measured using a photometer.

Results

The mean average luminance was 1026.75 ± 548.65 cd m^-2 and 3284.38 ± 327.91 cd m^-2 at the Division of Radiology and Division of Radiation Oncology respectively. The Division of Radiation Oncology had an average viewing box uniformity of 7.14% compared to 27.32% at the Division of Radiology. The average ambient lighting was found to be 66.30 lux and 66.43 lux at the Division of Radiation Oncology and Division of Radiology respectively.

Conclusion

The radiograph viewing conditions in Johannesburg variably comply with guidelines. This study underscores the need to implement quality control and quality assurance standards in radiographic image viewing.     

Emergency Department Discharge Diagnosis and Adverse Health Outcomes in Older Adults

OBJECTIVES: To determine the relationship between the reason for an emergency department (ED) visit and subsequent risk of adverse health outcomes in older adults discharged from the ED.
DESIGN: Secondary analysis of data from the Medicare Current Beneficiary Survey.
SETTING: ED.
PARTICIPANTS: One thousand eight hundred fifty-one community-dwelling Medicare fee-for-service enrollees aged 65 and older discharged from the ED between January 2000 and September 2002.
MEASUREMENTS: Independent variables were ED discharge diagnosis groups: injury or musculoskeletal (MSK) (e.g., fracture, open wound), chronic condition (e.g., chronic obstructive pulmonary disorder, heart failure), infection, non-MSK symptom (e.g., chest pain, abdominal pain), and unclassified. Adverse health outcomes were hospitalization or death within 30 days of the index ED visit.
RESULTS: Injury or MSK was the largest ED diagnosis group (31.4%), followed by non-MSK symptom (22.2%), chronic condition (20.9%), and infection (7.8%); 338 (17.8%) had ED discharge diagnoses that were unclassified. In adjusted analyses, a discharge diagnosis of injury or MSK condition was associated with lower risk of subsequent adverse health outcomes (hazard ratio (HR)=0.69, 95% confidence interval (CI)=0.50–0.96) than for all other diagnosis groups. Patients seen in the ED for chronic conditions were at greater risk of adverse outcomes (HR=1.86, 95% CI=1.37–2.52) than all others. There were no significant differences in risk between patients with infections, those with non-MSK symptoms, and the unclassified group.
CONCLUSION: Adverse health outcomes were common in older patients with an ED discharge diagnosis classified as a chronic condition. ED discharge diagnosis may improve risk assessment and inform the development of targeted interventions to reduce adverse health outcomes in older adults discharged from the ED.