Early Detection and Intervention for Patients with Delirium Admitted to the Department of Internal Medicine: Lessons from a Pilot Initiative

Introduction: Older patients who arrive to the emergency room with delirium have a worse prognosis than others. Early detection and treatment of this problem has been shown to improve outcome. We have launched a project at our hospital to improve the care of patients who arrive delirious to the medical emergency room. The present article describes lessons that can be learned from this pilot initiative. Methods: All patients older than 70 years admitted to the department of internal medicine were screened for delirium in the emergency room using the 4AT screening tool. Data of patients with a 4AT score ≥5 (or with incomplete score) were transferred to the geriatric unit of the hospital. On the ward, the presence of delirium was confirmed by a geriatric nurse that validated that the patient could walk with support and ordered mobilization and physiotherapy (M&P). Results: Over the 2 and a half years (10 quarters) allocated for the pilot project, 1,078 medical patients with delirium were included in this survey. In 59.3%, the diagnosis of delirium could be confirmed only after admission. Due to budgetary constraints, only 54.7% received the allocated specific intervention – early M&P. Since it was decided that randomization was not appropriate for our initiative, we found that patients who received M&P had lower (better) 4AT scores on admission, and lower mortality. No significant difference was found between the patients who received M&P and the others in length of hospitalization and discharge to nursing homes. Retrospective comparison of the two groups did not enable to determine whether M&P was given to the patients for whom it was most effective. Conclusions: It is often not possible to verify in the emergency room that the cognitive decline is indeed new, that is, is due to delirium, and measures must be taken to verify this point as soon as possible after admission. Due to numerous constraints, the availability of early M&P is often insufficient. Whenever resources are scarce and randomization is avoided, adequate criteria should be found for allocating existing dedicated staff to patients for whom early mobilization is likely to be most beneficial.

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Prevention of Venous Thromboembolism in Internal Medicine with Unfractionated or Low-molecular-weight Heparins: A Meta-analysis of Randomised Clinical Trials

Thrombosis and Haemostasis ◽

10.1055/s-0037-1613749 ◽

2000 ◽

Vol 83 (01) ◽

pp. 14-19 ◽

Cited By ~ 255

Author(s):

Silvy Laporte-Simitsidis ◽

Bernard Tardy ◽

Michel Cucherat ◽

Andréa Buchmüller ◽

Daphné Juillard-Delsart ◽

...

Keyword(s):

Internal Medicine ◽

Molecular Weight ◽

Venous Thromboembolism ◽

Meta Analysis ◽

Low Molecular Weight ◽

Medical Patients ◽

Randomised Trials ◽

Low Molecular Weight Heparins ◽

Significant Difference ◽

Venous Thromboembolic

SummaryThe prevention of venous thromboembolic disease is less studied in medical patients than in surgery.We performed a meta-analysis of randomised trials studying prophylactic unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) in internal medicine, excluding acute myocardial infarction or ischaemic stroke. Deepvein thrombosis (DVT) systematically detected at the end of the treatment period, clinical pulmonary embolism (PE), death and major bleeding were recorded.Seven trials comparing a prophylactic heparin treatment to a control (15,095 patients) were selected. A significant decrease in DVT and in clinical PE were observed with heparins as compared to control (risk reductions = 56% and 58% respectively, p <0.001 in both cases), without significant difference in the incidence of major bleedings or deaths. Nine trials comparing LMWH to UFH (4,669 patients) were also included. No significant effect was observed on either DVT, clinical PE or mortality. However LMWH reduced by 52% the risk of major haemorrhage (p = 0.049).This meta-analysis, based on the pooling of data available for several heparins, shows that heparins are beneficial in the prevention of venous thromboembolism in internal medicine.

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The The Effectiveness of Early Mobilization Time on Balance and Functional Ability after Ischemic Stroke

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2019.269 ◽

2019 ◽

Vol 7 (7) ◽

pp. 1088-1092

Author(s):

Umi Budi Rahayu ◽

Samekto Wibowo ◽

Ismail Setyopranoto

Keyword(s):

Randomized Controlled Trial ◽

Ischemic Stroke ◽

Functional Ability ◽

Controlled Trial ◽

Early Mobilization ◽

Berg Balance Scale ◽

Early Mobilisation ◽

Inclusion Criteria ◽

Randomized Controlled ◽

Significant Difference

BACKGROUND: Early mobilisation (EM) after-ischemic stroke is a motor learning intervention aimed to restore nerve cells and to improve balance and functional ability. Unfortunately, the study of when this intervention began has not been widely studied. AIM: On this study was compared the effect of EM started at 24 hours and 48 hours after an ischemic stroke on balance and functional ability. MATERIAL AND METHODS: Randomized controlled trial involving 40 patients on 2 groups meeting predefined inclusion criteria. The levels of balance were measured using the Berg Balance Scale, and the functional ability was measured using the Barthel Index, at 5th and 7th day. RESULTS: A significant difference was observed in both balance (p = 0.038) and functional ability (p = 0.021) obtained on the 7th day of assessment between both groups. A significant difference on the 5th day was observed only in the functional ability (p = 0.002) and not in the balance (p = 0.147), between the groups. CONCLUSION: EM started at 24 hours after the ischemic stroke has been found to have a better impact on balance and functional ability compared to that at 48 hours.

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Examining the impact of mental disease on type 2 diabetes outcomes: results from the EpiChron Cohort

European Journal of Public Health ◽

10.1093/eurpub/ckaa165.819 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

I Guerrero Fernández de Alba ◽

A Gimeno-Miguel ◽

B Poblador Plou ◽

K Bliek Bueno ◽

J Carmona Pirez ◽

...

Keyword(s):

Type 2 Diabetes ◽

Substance Abuse ◽

Early Detection ◽

Health Outcomes ◽

Emergency Room ◽

Mental Disease ◽

Emergency Room Visits ◽

Mental Diseases ◽

The Impact

Abstract Background Type 2 diabetes mellitus (T2D) is often accompanied by other chronic diseases, including mental diseases (MD). This work aimed at studying MD prevalence in T2D patients and analyse its impact on T2D health outcomes. Methods Retrospective, observational study of individuals of the EpiChron Cohort aged 18 and over with prevalent T2D at baseline (2011) in Aragón, Spain (n = 63,365). Participants were categorized by the existence or absence of MD, defined as the presence of depression, anxiety, schizophrenia or substance abuse. MD prevalence was calculated, and a logistic regression model was performed to analyse the likelihood of the four studied health outcomes (4-year all-cause mortality, all-cause hospitalization, T2D-hospitalization, and emergency room visits) based on the presence of each type of MD, after adjusting by age, sex and number of comorbidities. Results Mental diseases were observed in 19% of T2D patients, with depression being the most frequent condition, especially in women (20.7% vs. 7.57%). Mortality risk was significantly higher in patients with MD (odds ratio -OR- 1.24; 95% confidence interval -CI- 1.16-1.31), especially in those with substance abuse (OR 2.18; 95% CI 1.84-2.57) and schizophrenia (OR 1.82; 95% CI 1.50-2.21). The presence of MD also increased the risk of T2D-hospitalization (OR 1.51; 95% CI 1.18-1.93), emergency room visits (OR 1.26; 95% CI 1.21-1.32) and all-cause hospitalization (OR 1.16; 95% CI 1.10-1.23). Conclusions The high prevalence of MD among T2D patients, and its association with health outcomes, underscores the importance of providing integrated, person-centred care and early detection of comorbid mental diseases in T2D patients to improve disease management and health outcomes. Key messages Comprehensive care of T2D should include specific strategies for prevention, early detection, and management of comorbidities, especially mental disorders, in order to reduce their impact on health. Substance abuse was the mental disease with the highest risk of T2D-hospitalization, emergency room visits and all-cause hospitalization.

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Speech Methodologies in Cleft Palate Assessment: A Pilot Project to Compare Two Phonetically Different Sentence Sets

Journal of Clinical Speech and Language Studies ◽

10.3233/acs-2013-20106 ◽

2013 ◽

Vol 20 (1) ◽

pp. 49-72

Author(s):

Jennie Smith ◽

Tim Pring ◽

Debbie Sell

Keyword(s):

Cleft Palate ◽

Pilot Project ◽

Wilcoxon Test ◽

Consecutive Series ◽

Video Recordings ◽

Significant Difference ◽

The Difference ◽

Audio Video ◽

Age Range ◽

The Impact

Objective: To investigate the impact of the phonetic content of two sentence sets on speech outcomes, specifically the effects of nasal phonemes. Method: Audio-video recordings of a consecutive series of 15 participants (age range 4–22 years), with cleft palate (syndromic or non-syndromic), with and without velopharyngeal dysfunction were taken. Participants repeated Sentence Set 1 (with nasals across sentences) and Sentence Set 2 (without nasals except the three nasal target sentences) during a routine speech recording. Two experienced Specialist Speech and Language Therapists, blinded to the study’s purpose, analyzed participants’ speech using the Cleft Audit Protocol for Speech-Augmented (CAPS-A). On day 1, recordings included Sentence Set 1. On day 2, 23 days later, recordings included Sentence Set 2. Main results: The difference between Sentence Set 1 and Sentence Set 2 ‘total scores’ (sum of scores on all CAPS-A parameters) was significant. The Pearson Product Moment showed high correlation. A Wilcoxon test revealed a significant difference between Sets 1 and 2 on the hypernasality parameter, and this alone accounted for the significant difference in total scores. Conclusion: The inclusion or exclusion of nasal consonants in the sentence set significantly affected perceptual ratings of hypernasality but none of the other CAPS-A parameters, highlighting the need for further investigation into perceptual nasality ratings.

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Enhancing Competency in Professionalism: Targeting Resident Advance Directive Education

Journal of Graduate Medical Education ◽

10.4300/jgme-d-10-00003.1 ◽

2010 ◽

Vol 2 (2) ◽

pp. 278-282 ◽

Cited By ~ 4

Author(s):

Colleen Y. Colbert ◽

Curtis Mirkes ◽

Paul E. Ogden ◽

Mary Elizabeth Herring ◽

Christian Cable ◽

...

Keyword(s):

Internal Medicine ◽

Medical School ◽

Advance Directives ◽

Advance Directive ◽

Residency Program ◽

Health Science ◽

Science Center ◽

Sufficient Knowledge ◽

Significant Difference ◽

School Curricula

Abstract Background Education about advance directives typically is incorporated into medical school curricula and is not commonly offered in residency. Residents' experiences with advance directives are generally random, nonstandardized, and difficult to assess. In 2008, an advance directive curriculum was developed by the Scott & White/Texas A&M University System Health Science Center College of Medicine (S&W/Texas A&M) internal medicine residency program and the hospital's legal department. A pilot study examining residents' attitudes and experiences regarding advance directives was carried out at 2 medical schools. Methods In 2009, 59 internal medicine and family medicine residents (postgraduate year 2–3 [PGY-2, 3]) completed questionnaires at S&W/Texas A&M (n = 32) and The University of Texas Medical School at Houston (n = 27) during a validation study of knowledge about advance directives. The questionnaire contained Likert-response items assessing attitudes and practices surrounding advance directives. Our analysis included descriptive statistics and analysis of variance (ANOVA) to compare responses across categories. Results While 53% of residents agreed/strongly agreed they had “sufficient knowledge of advance directives, given my years of training,” 47% disagreed/strongly disagreed with that statement. Most (93%) agreed/strongly agreed that “didactic sessions on advance directives should be offered by my hospital, residency program, or medical school.” A test of responses across residency years with ANOVA showed a significant difference between ratings by PGY-2 and PGY-3 residents on 3 items: “Advance directives should only be discussed with patients over 60,” “I have sufficient knowledge of advance directives, given my years of training,” and “I believe my experience with advance directives is adequate for the situations I routinely encounter.” Conclusion Our study highlighted the continuing need for advance directive resident curricula. Medical school curricula alone do not appear to be sufficient for residents' needs in this area.

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Knowledge, Attitude, and Practice Related to Malaria Diagnosis among Healthcare Workers in Hospitals: A Cross-Sectional Survey

Journal of Tropical Medicine ◽

10.1155/2019/1414079 ◽

2019 ◽

Vol 2019 ◽

pp. 1-9

Author(s):

Kwuntida Uthaisar Kotepui ◽

Manas Kotepui ◽

Chuchard Punsawad

Keyword(s):

Early Detection ◽

Healthcare Workers ◽

Malaria Diagnosis ◽

Medical Emergency ◽

Medical Laboratory ◽

P Value ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Attitude And Practice ◽

Knowledge Attitude And Practice

Malaria is a potential medical emergency and should be treated immediately because delays in diagnosis and treatment are the leading causes of death in many countries. This study aimed to assess the knowledge, attitude, and practice related to malaria diagnosis for early detection among healthcare workers in the laboratories of hospitals in Thailand. The design of the study was a descriptive cross-sectional study carried out between January 2016 and March 2017 at 11 hospitals in Thailand. The interviewees included any scientists who were currently working in a medical laboratory. Mean scores for knowledge, attitude, and practice for each healthcare group were calculated and compared between groups. Data analysis was performed using the SPSS version 11.5 software package (SPSS Inc., Chicago, IL, USA). Among a total of 118 healthcare workers, most of the healthcare workers had fair to good knowledge, attitude, and practice related to malaria detection. Among the various positions of healthcare workers, medical technologists possessed a greater knowledge on malaria detection than medical technician assistants or laboratory assistants (X2 = 9.822, d.f. = 2, and P value=0.007). This study infers that knowledge, attitude, and practice related to malaria detection among healthcare workers in laboratories were adequate. However, some points of knowledge and practice must be updated. There is a very urgent need to update knowledge on malaria, especially about the number of Plasmodium species causing relapse in malaria patients. In addition, there is an urgent need to update the practice related to malaria detection, especially about the staining process for early detection of malaria.

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A Circulating Exosome RNA Signature Is a Potential Diagnostic Marker for Pancreatic Cancer, a Systematic Study

Cancers ◽

10.3390/cancers13112565 ◽

2021 ◽

Vol 13 (11) ◽

pp. 2565

Author(s):

Yixing Wu ◽

Hongmei Zeng ◽

Qing Yu ◽

Huatian Huang ◽

Beatrice Fervers ◽

...

Keyword(s):

Pancreatic Cancer ◽

Chronic Pancreatitis ◽

Early Detection ◽

Validation Dataset ◽

Healthy Controls ◽

Rna Seq ◽

Healthy Individuals ◽

Kras Mutations ◽

Significant Difference ◽

Rna Signature

Several exosome proteins, miRNAs and KRAS mutations have been investigated in the hope of carrying out the early detection of pancreatic cancer with high sensitivity and specificity, but they have proven to be insufficient. Exosome RNAs, however, have not been extensively evaluated in the diagnosis of pancreatic cancer. The purpose of this study was to investigate the potential of circulating exosome RNAs in pancreatic cancer detection. By retrieving RNA-seq data from publicly accessed databases, differential expression and random-effects meta-analyses were performed. The results showed that pancreatic cancer had a distinct circulating exosome RNA signature in healthy individuals, and that the top 10 candidate exosome RNAs could distinguish patients from healthy individuals with an area under the curve (AUC) of 1.0. Three (HIST2H2AA3, LUZP6 and HLA-DRA) of the 10 genes in exosomes had similar differential patterns to those in tumor tissues based on RNA-seq data. In the validation dataset, the levels of these three genes in exosomes displayed good performance in distinguishing cancer from both chronic pancreatitis (AUC = 0.815) and healthy controls (AUC = 0.8558), whereas a slight difference existed between chronic pancreatitis and healthy controls (AUC = 0.586). Of the three genes, the level of HIST2H2AA3 was positively associated with KRAS status. However, there was no significant difference in the levels of the three genes across the disease stages (stages I–IV). These findings indicate that circulating exosome RNAs have a potential early detection value in pancreatic cancer, and that a distinct exosome RNA signature exists in distinguishing pancreatic cancer from healthy individuals.

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Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

Journal of Medical Education and Curricular Development ◽

10.1177/2382120521996368 ◽

2021 ◽

Vol 8 ◽

pp. 238212052199636

Author(s):

Jeffrey Chidester ◽

Rebecca Vigen ◽

Sandeep R Das

Keyword(s):

Internal Medicine ◽

Graduate Education ◽

Parametric Analysis ◽

Cost Of Care ◽

Patient Centered ◽

Internal Medicine Residents ◽

Significant Difference ◽

Centered Care ◽

Barrier To Care ◽

Out Of Pocket Costs

Background: Out-of-pocket costs are a serious barrier to care and drive suboptimal medical therapy. Understanding of these costs can lead to care oriented around the limits they generate. Despite this, there is minimal attention paid to these costs in post-graduate education. Objective: To define a potential knowledge gap regarding costs experienced by patients by surveying Internal Medicine residents at our large academic institution. Methods: We surveyed Internal Medicine residents in spring 2019 about knowledge and practices surrounding patient out-of-pocket costs. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better.” Non-parametric analysis was used to test differences between outpatients and inpatients and by year of training. Results: Of 159 residents, 109 (67%) responded. Familiarity with patient insurance status was moderate or better in 85%. Reported understanding of costs associated with medications, testing, and clinic visits was less common. Respondents had higher familiarity with out-of-pocket costs for clinic patients compared with inpatients. Knowledge of cost of care was not an often-considered factor in decision making. There was no significant difference in response by year of training. Conclusion: Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care.

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Detection of Hydroxychloroquine Retinal Toxicity by Automated Perimetry in 60 Rheumatoid Arthritis Patients with Normal Fundoscopic Findings

Global Journal of Health Science ◽

10.5539/gjhs.v8n3p59 ◽

2015 ◽

Vol 8 (3) ◽

pp. 59 ◽

Cited By ~ 2

Author(s):

Qader Motarjemizadeh ◽

Naser Samadi Aidenloo ◽

Mohammad Abbaszadeh

Keyword(s):

Rheumatoid Arthritis ◽

Early Detection ◽

Anterior Segment ◽

Field Testing ◽

Retinal Toxicity ◽

Screening Tests ◽

Automated Perimetry ◽

Cross Sectional ◽

Dry Eyes ◽

Significant Difference

Hydroxychloroquine (HCQ) is an antimalarial drug used extensively in treatment of autoimmune diseases such as rheumatoid arthritis. Retinal toxicity is the most important side effects of this drug. Even after the drug is discontinued, retinal degeneration from HCQ can continue to progress. Consequently, multiple ophthalmic screening tests have been developed to detect early retinopathy. The aim of the current study was to evaluate the value of central 2-10 perimetry method in early detection of retinal toxicity. This prospective cross-sectional investigation was carried out on 60 rheumatoid arthritis patients, who had been receiving HCQ for at least 6 months and still were on their medication (HCQ intake) at the time of enrollment. An ophthalmologist examined participants using direct and indirect ophthalmoscopy. Visual field testing with automated perimetry technique (central 2-10 perimetry with red target) was performed on all included subjects twice in 6 months interval: The first one at the time of enrollment and the second one 6 months later. Males and females did not show any significant difference in terms of age, duration of therapy, daily and cumulative HCQ dose, anterior or posterior segment abnormalities, hypertension, body mass index, and best corrected visual acuity. Anterior segment was abnormal in 9 individuals including 3 subjects with macular pigmentary changes, 4 individuals with cataract and 2 cases with dry eyes. Moreover, 12 subjects had retinal pigmented epithelium (RPE) in their posterior segments. After 6 months, depressive changes appeared in 12 subjects. Additionally, HCQ therapy worsened significantly the perimetric results of 5 (55.6%) patients with abnormal anterior segment. A same trend was observed in perimetric results of 6 (50.0%) subjects with abnormal posterior segments (P=0.009). The daily dose of HCQ (P=0.035) as well as the cumulative dose of hydroxychloroquine (P=0.021) displayed statistically significant associations with perimetric results. Central 2-10 perimetry is a useful method for early detection of HCQ retinal toxicity, but more comprehensive studies, with larger sample size, longer-term follow-up and more precise techniques are mandatory to confirm HCQ retinal toxicity.

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The Effect of Sonophoresis on Topical Anesthesia: A Pilot Project

Anesthesia Progress ◽

10.2344/0003-3006-60.2.37 ◽

2013 ◽

Vol 60 (2) ◽

pp. 37-41 ◽

Cited By ~ 1

Author(s):

Joseph L. Packer ◽

Barry Krall ◽

Ali Makki ◽

Mahmoud Torabinejad

Keyword(s):

Stratum Corneum ◽

Pain Perception ◽

Pilot Project ◽

Control Device ◽

Topical Anesthesia ◽

Needle Puncture ◽

Topical Anesthetic ◽

Novel Device ◽

Needle Penetration ◽

Significant Difference

Abstract The dental anesthesia sonophoresis device (DASD) is a novel device that is intended to reduce the discomfort associated with intraoral mucosa needle puncture. The DASD produces ultrasonic energy that provides a sonophoretic effect on the oral mucosa, generating microchannels through the lipids between the keratinized cells that make up the stratum corneum. Once the topical anesthetic has permeated the stratum corneum, it quickly diffuses through the soft tissue, desensitizing the nerve endings and reducing the perception of pain caused by needle penetration. The aim of this study is to evaluate whether topical anesthesia applied using the DASD will reduce the discomfort of the needle puncture when compared to the control device. A split-mouth model, using 50 healthy subjects with puncture site at the maxillary canine vestibule, was used for this study. Subjects received a needle puncture on both sides of the mouth. Prior to the needle puncture, there was randomized application of 5% lidocaine with the DASD and a control device. Subjects rated their discomfort after needle punctures utilizing the visual analog scale pain scoring system. There was no statistically significant difference in the pain perception using the DASD versus the control device.

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