In 2000, the Institute of Medicine published an oft-cited report, "To Err Is Human: Building a Safer Health System – A Report of The Committee on Quality of Health Care in America." The report estimated that up to 98,000 patients die from preventable medical errors each year.

Many of us can remember the boot camp–like conditions of residency: working incredibly long shifts that made every part of our bodies (and brains) cry out for rest – even a 10-minute nap could bring much-needed relief.

I remember sometimes working 48- to 72-hour shifts, between my regular residency responsibilities and moonlighting in the VA emergency room. That seems like a lifetime ago, a lifetime I would not want to relive.

While we may have been trained to believe we can perform at our peak despite sleep deprivation, in reality many of us made mistakes, whether great or small, as a result of our highly stressed, sleep-deprived state. And if we are honest with ourselves, we would not want to be a patient who is cared for by any doctor whose mental facilities have been impaired due to lack of sleep. Finally, wisdom defeated pride and custom, and residents’ shifts have been limited, which was a true victory for patients and residents alike.

Subsequently, it was acknowledged that nurses also made errors when working in suboptimal conditions. A study in the New England Journal of Medicine found a significant association between low staffing and patient mortality ("Nurse Staffing and Inpatient Hospital Mortality," N. Engl. J. Med. 2011;364:1037-45).

Truth be told, we already knew that nurses and inexperienced resident physicians make mistakes when overwhelmed and overworked, but what about seasoned hospitalists? What about us? Do we honestly believe we are somehow immune to making medical errors because of years of experience?

A piece in the Jan. 28 edition of JAMA – "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists" – sheds light on how we really feel. The survey assessed hospitalists’ perceptions of the association between their workload and patient safety and quality-of-care measures during daytime shifts. The respondents’ average age was 38 years, median time in practice was 6 years, and median annual compensation was $180,000 (doi: 10.1001/jamainternmed.2013.1864).

Important study findings include the following:

• Forty percent of respondents reported that at least once per month, their census exceeded safe levels, and 36% of these noted they experienced unsafe levels multiple times per week.

• Fifteen patients per shift was the magic number that would optimize patient safety, regardless of any assistance doctors received, and that was assuming their shift was a purely clinical shift.

• More than 20% of hospitalists believe their average workload likely contributed to patient transfers, patient suffering, or even the death of patients. That was the most sobering finding of the study.

This study has profound implications for patient safety, and less importantly, patient satisfaction. The potential for unnecessary suffering, excessive medical costs, and unnecessary death is staggering. The actual number of physicians who are willing to admit their limitations is likely far lower than the actual number who experience these adverse effects, even if they are oblivious to their understandable limitations.

When the pager is going off incessantly while you are answering another call, and nurses are lined up to ask you questions about their patients, and, of course, you have a patient or two in the ER who need your attention, it is easy to get sidetracked. To err is human.

The bottom line is patients are the bottom line. They depend on us to provide safe, compassionate, high-quality health care. They literally entrust their lives to us, and we must honor that trust by speaking up if we feel like their safety is in jeopardy, and work with hospitalist directors and hospital administrators to create an environment in which patient safety is valued above all.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

In 2000, the Institute of Medicine published an oft-cited report, "To Err Is Human: Building a Safer Health System – A Report of The Committee on Quality of Health Care in America." The report estimated that up to 98,000 patients die from preventable medical errors each year.

Many of us can remember the boot camp–like conditions of residency: working incredibly long shifts that made every part of our bodies (and brains) cry out for rest – even a 10-minute nap could bring much-needed relief.

I remember sometimes working 48- to 72-hour shifts, between my regular residency responsibilities and moonlighting in the VA emergency room. That seems like a lifetime ago, a lifetime I would not want to relive.

While we may have been trained to believe we can perform at our peak despite sleep deprivation, in reality many of us made mistakes, whether great or small, as a result of our highly stressed, sleep-deprived state. And if we are honest with ourselves, we would not want to be a patient who is cared for by any doctor whose mental facilities have been impaired due to lack of sleep. Finally, wisdom defeated pride and custom, and residents’ shifts have been limited, which was a true victory for patients and residents alike.

Subsequently, it was acknowledged that nurses also made errors when working in suboptimal conditions. A study in the New England Journal of Medicine found a significant association between low staffing and patient mortality ("Nurse Staffing and Inpatient Hospital Mortality," N. Engl. J. Med. 2011;364:1037-45).

Truth be told, we already knew that nurses and inexperienced resident physicians make mistakes when overwhelmed and overworked, but what about seasoned hospitalists? What about us? Do we honestly believe we are somehow immune to making medical errors because of years of experience?

A piece in the Jan. 28 edition of JAMA – "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists" – sheds light on how we really feel. The survey assessed hospitalists’ perceptions of the association between their workload and patient safety and quality-of-care measures during daytime shifts. The respondents’ average age was 38 years, median time in practice was 6 years, and median annual compensation was $180,000 (doi: 10.1001/jamainternmed.2013.1864).

Important study findings include the following:

• Forty percent of respondents reported that at least once per month, their census exceeded safe levels, and 36% of these noted they experienced unsafe levels multiple times per week.

• Fifteen patients per shift was the magic number that would optimize patient safety, regardless of any assistance doctors received, and that was assuming their shift was a purely clinical shift.

• More than 20% of hospitalists believe their average workload likely contributed to patient transfers, patient suffering, or even the death of patients. That was the most sobering finding of the study.

This study has profound implications for patient safety, and less importantly, patient satisfaction. The potential for unnecessary suffering, excessive medical costs, and unnecessary death is staggering. The actual number of physicians who are willing to admit their limitations is likely far lower than the actual number who experience these adverse effects, even if they are oblivious to their understandable limitations.

When the pager is going off incessantly while you are answering another call, and nurses are lined up to ask you questions about their patients, and, of course, you have a patient or two in the ER who need your attention, it is easy to get sidetracked. To err is human.

The bottom line is patients are the bottom line. They depend on us to provide safe, compassionate, high-quality health care. They literally entrust their lives to us, and we must honor that trust by speaking up if we feel like their safety is in jeopardy, and work with hospitalist directors and hospital administrators to create an environment in which patient safety is valued above all.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

In 2000, the Institute of Medicine published an oft-cited report, "To Err Is Human: Building a Safer Health System – A Report of The Committee on Quality of Health Care in America." The report estimated that up to 98,000 patients die from preventable medical errors each year.

Many of us can remember the boot camp–like conditions of residency: working incredibly long shifts that made every part of our bodies (and brains) cry out for rest – even a 10-minute nap could bring much-needed relief.

I remember sometimes working 48- to 72-hour shifts, between my regular residency responsibilities and moonlighting in the VA emergency room. That seems like a lifetime ago, a lifetime I would not want to relive.

While we may have been trained to believe we can perform at our peak despite sleep deprivation, in reality many of us made mistakes, whether great or small, as a result of our highly stressed, sleep-deprived state. And if we are honest with ourselves, we would not want to be a patient who is cared for by any doctor whose mental facilities have been impaired due to lack of sleep. Finally, wisdom defeated pride and custom, and residents’ shifts have been limited, which was a true victory for patients and residents alike.

Subsequently, it was acknowledged that nurses also made errors when working in suboptimal conditions. A study in the New England Journal of Medicine found a significant association between low staffing and patient mortality ("Nurse Staffing and Inpatient Hospital Mortality," N. Engl. J. Med. 2011;364:1037-45).

Truth be told, we already knew that nurses and inexperienced resident physicians make mistakes when overwhelmed and overworked, but what about seasoned hospitalists? What about us? Do we honestly believe we are somehow immune to making medical errors because of years of experience?

A piece in the Jan. 28 edition of JAMA – "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists" – sheds light on how we really feel. The survey assessed hospitalists’ perceptions of the association between their workload and patient safety and quality-of-care measures during daytime shifts. The respondents’ average age was 38 years, median time in practice was 6 years, and median annual compensation was $180,000 (doi: 10.1001/jamainternmed.2013.1864).

Important study findings include the following:

• Forty percent of respondents reported that at least once per month, their census exceeded safe levels, and 36% of these noted they experienced unsafe levels multiple times per week.

• Fifteen patients per shift was the magic number that would optimize patient safety, regardless of any assistance doctors received, and that was assuming their shift was a purely clinical shift.

• More than 20% of hospitalists believe their average workload likely contributed to patient transfers, patient suffering, or even the death of patients. That was the most sobering finding of the study.

This study has profound implications for patient safety, and less importantly, patient satisfaction. The potential for unnecessary suffering, excessive medical costs, and unnecessary death is staggering. The actual number of physicians who are willing to admit their limitations is likely far lower than the actual number who experience these adverse effects, even if they are oblivious to their understandable limitations.

When the pager is going off incessantly while you are answering another call, and nurses are lined up to ask you questions about their patients, and, of course, you have a patient or two in the ER who need your attention, it is easy to get sidetracked. To err is human.

The bottom line is patients are the bottom line. They depend on us to provide safe, compassionate, high-quality health care. They literally entrust their lives to us, and we must honor that trust by speaking up if we feel like their safety is in jeopardy, and work with hospitalist directors and hospital administrators to create an environment in which patient safety is valued above all.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

ANSWER


The radiograph demonstrates lateral dislocation of the patella, with no evidence of an acute fracture of any surrounding bones. The patella was easily reduced in the emergency department, and the patient was placed in a knee immobilizer. Orthopedic consultation was obtained.

ANSWER


The radiograph demonstrates lateral dislocation of the patella, with no evidence of an acute fracture of any surrounding bones. The patella was easily reduced in the emergency department, and the patient was placed in a knee immobilizer. Orthopedic consultation was obtained.

ANSWER


The radiograph demonstrates lateral dislocation of the patella, with no evidence of an acute fracture of any surrounding bones. The patella was easily reduced in the emergency department, and the patient was placed in a knee immobilizer. Orthopedic consultation was obtained.

ANSWER


The correct interpretation includes marked sinus bradycardia with a first-degree atrioventricular (AV) block, left anterior fascicular block, and evidence of an anteroseptal MI. Marked sinus bradycardia is evidenced by a heart rate significantly less than 60 beats/min (in this case, almost half the rate). A first-degree AV block is apparent by the presence of a PR interval > 200 ms. The presence of a left anterior fascicular block (or left anterior hemiblock) includes a left-axis deviation between –45° and –90°, small Q waves with tall R waves in leads I and aVL, small R waves with deep S waves in leads II, III, and aVF, and a normal or slightly prolonged QRS duration. Finally, an anteroseptal MI is evident from the presence of deep S waves in leads V1 to V3.

The patient was directly admitted to the cardiology service for definitive workup and treatment.    

ANSWER


The correct interpretation includes marked sinus bradycardia with a first-degree atrioventricular (AV) block, left anterior fascicular block, and evidence of an anteroseptal MI. Marked sinus bradycardia is evidenced by a heart rate significantly less than 60 beats/min (in this case, almost half the rate). A first-degree AV block is apparent by the presence of a PR interval > 200 ms. The presence of a left anterior fascicular block (or left anterior hemiblock) includes a left-axis deviation between –45° and –90°, small Q waves with tall R waves in leads I and aVL, small R waves with deep S waves in leads II, III, and aVF, and a normal or slightly prolonged QRS duration. Finally, an anteroseptal MI is evident from the presence of deep S waves in leads V1 to V3.

The patient was directly admitted to the cardiology service for definitive workup and treatment.    

ANSWER


The correct interpretation includes marked sinus bradycardia with a first-degree atrioventricular (AV) block, left anterior fascicular block, and evidence of an anteroseptal MI. Marked sinus bradycardia is evidenced by a heart rate significantly less than 60 beats/min (in this case, almost half the rate). A first-degree AV block is apparent by the presence of a PR interval > 200 ms. The presence of a left anterior fascicular block (or left anterior hemiblock) includes a left-axis deviation between –45° and –90°, small Q waves with tall R waves in leads I and aVL, small R waves with deep S waves in leads II, III, and aVF, and a normal or slightly prolonged QRS duration. Finally, an anteroseptal MI is evident from the presence of deep S waves in leads V1 to V3.

The patient was directly admitted to the cardiology service for definitive workup and treatment.    

ANSWER


The correct answer is juvenile plantar dermatosis (JPD; choice “b”). It is a condition related to having thin, dry, hyperreactive skin exposed to friction, wetting and drying, and constant exposure to the nonpermeable surfaces of shoes.
Pitted keratolysis (choice “a”) is a condition caused by sweating and increased warmth. The plantar keratin is broken down with the help of bacteria that overgrow in affected areas; this eventuates in focal loss of keratin in arcuate patterns. It is quite unlikely to occur prior to puberty.

Tinea pedis (choice “c”) is dermatophytosis, or fungal infection of the foot. It is also unusual prior to puberty, unlikely to present in the manner seen in this case, and likely to have responded at least partially to antifungal creams.
Psoriasis (choice “d”) seldom presents with fissuring, would not be confined to weight-bearing surfaces, and would probably have involved other areas, such as the scalp, elbows, knees, or nails.

DISCUSSION


JPD, also known as juvenile plantar dermatitis, is found almost exclusively on the weight-bearing surfaces of the feet of children ages 4 to 8—mostly boys, for whom this represents a manifestation of the atopic diathesis. Seen mostly in the summer, it is thought to be triggered by friction, wetting and drying, and shoe selection (ie, plastic rather than leather soles).

Affected children not only have dry, sensitive skin; their skin is actually thin and fragile as well. Plastic or other synthetic shoe surfaces worn in the summertime are thought to contribute to the friction, heat, and sweating necessary to produce these changes.

As in this case, JPD is often mistaken for tinea pedis but has nothing to do with infection of any kind. Tinea pedis is uncommon in children this young, and it would present in completely different ways, such as between the toes (especially the fourth and fifth) or with blisters on the instep.
Psoriasis, though not unknown in this age-group, does not resemble JPD clinically at all. When suspected, the diagnosis of psoriasis can be corroborated by finding it elsewhere (eg, through a positive family history or biopsy).

Pitted keratolyis is common enough, but is seen in older teens and men whose feet are prone to sweat a great deal. The choice of shoes and occupation are often crucial factors in its development. The clinical hallmark is arcuate whitish maceration on weight-bearing surfaces, which are often malodorous as well.

TREATMENT


The first treatment for JPD is education of parents and patients, reassuring them about the relatively benign nature of the problem. Moisturizing frequently with petrolatum-based moisturizers is necessary for prevention, but changing the type of shoes worn is the most effective step to take; it is also the most difficult, since children this age favor cheap, plastic flip-flops or shoes in the summer.

For the fissures, spraying on a flexible spray bandage can be helpful in protecting them and allowing them to heal. With significant inflammation, the use of mild steroid ointments, such as hydrocortisone 2.5%, can help. But by far, the best relief comes with the change in season and the choice of shoe (leather-soled).

ANSWER


The correct answer is juvenile plantar dermatosis (JPD; choice “b”). It is a condition related to having thin, dry, hyperreactive skin exposed to friction, wetting and drying, and constant exposure to the nonpermeable surfaces of shoes.
Pitted keratolysis (choice “a”) is a condition caused by sweating and increased warmth. The plantar keratin is broken down with the help of bacteria that overgrow in affected areas; this eventuates in focal loss of keratin in arcuate patterns. It is quite unlikely to occur prior to puberty.

Tinea pedis (choice “c”) is dermatophytosis, or fungal infection of the foot. It is also unusual prior to puberty, unlikely to present in the manner seen in this case, and likely to have responded at least partially to antifungal creams.
Psoriasis (choice “d”) seldom presents with fissuring, would not be confined to weight-bearing surfaces, and would probably have involved other areas, such as the scalp, elbows, knees, or nails.

DISCUSSION


JPD, also known as juvenile plantar dermatitis, is found almost exclusively on the weight-bearing surfaces of the feet of children ages 4 to 8—mostly boys, for whom this represents a manifestation of the atopic diathesis. Seen mostly in the summer, it is thought to be triggered by friction, wetting and drying, and shoe selection (ie, plastic rather than leather soles).

Affected children not only have dry, sensitive skin; their skin is actually thin and fragile as well. Plastic or other synthetic shoe surfaces worn in the summertime are thought to contribute to the friction, heat, and sweating necessary to produce these changes.

As in this case, JPD is often mistaken for tinea pedis but has nothing to do with infection of any kind. Tinea pedis is uncommon in children this young, and it would present in completely different ways, such as between the toes (especially the fourth and fifth) or with blisters on the instep.
Psoriasis, though not unknown in this age-group, does not resemble JPD clinically at all. When suspected, the diagnosis of psoriasis can be corroborated by finding it elsewhere (eg, through a positive family history or biopsy).

Pitted keratolyis is common enough, but is seen in older teens and men whose feet are prone to sweat a great deal. The choice of shoes and occupation are often crucial factors in its development. The clinical hallmark is arcuate whitish maceration on weight-bearing surfaces, which are often malodorous as well.

TREATMENT


The first treatment for JPD is education of parents and patients, reassuring them about the relatively benign nature of the problem. Moisturizing frequently with petrolatum-based moisturizers is necessary for prevention, but changing the type of shoes worn is the most effective step to take; it is also the most difficult, since children this age favor cheap, plastic flip-flops or shoes in the summer.

For the fissures, spraying on a flexible spray bandage can be helpful in protecting them and allowing them to heal. With significant inflammation, the use of mild steroid ointments, such as hydrocortisone 2.5%, can help. But by far, the best relief comes with the change in season and the choice of shoe (leather-soled).

ANSWER


The correct answer is juvenile plantar dermatosis (JPD; choice “b”). It is a condition related to having thin, dry, hyperreactive skin exposed to friction, wetting and drying, and constant exposure to the nonpermeable surfaces of shoes.
Pitted keratolysis (choice “a”) is a condition caused by sweating and increased warmth. The plantar keratin is broken down with the help of bacteria that overgrow in affected areas; this eventuates in focal loss of keratin in arcuate patterns. It is quite unlikely to occur prior to puberty.

Tinea pedis (choice “c”) is dermatophytosis, or fungal infection of the foot. It is also unusual prior to puberty, unlikely to present in the manner seen in this case, and likely to have responded at least partially to antifungal creams.
Psoriasis (choice “d”) seldom presents with fissuring, would not be confined to weight-bearing surfaces, and would probably have involved other areas, such as the scalp, elbows, knees, or nails.

DISCUSSION


JPD, also known as juvenile plantar dermatitis, is found almost exclusively on the weight-bearing surfaces of the feet of children ages 4 to 8—mostly boys, for whom this represents a manifestation of the atopic diathesis. Seen mostly in the summer, it is thought to be triggered by friction, wetting and drying, and shoe selection (ie, plastic rather than leather soles).

Affected children not only have dry, sensitive skin; their skin is actually thin and fragile as well. Plastic or other synthetic shoe surfaces worn in the summertime are thought to contribute to the friction, heat, and sweating necessary to produce these changes.

As in this case, JPD is often mistaken for tinea pedis but has nothing to do with infection of any kind. Tinea pedis is uncommon in children this young, and it would present in completely different ways, such as between the toes (especially the fourth and fifth) or with blisters on the instep.
Psoriasis, though not unknown in this age-group, does not resemble JPD clinically at all. When suspected, the diagnosis of psoriasis can be corroborated by finding it elsewhere (eg, through a positive family history or biopsy).

Pitted keratolyis is common enough, but is seen in older teens and men whose feet are prone to sweat a great deal. The choice of shoes and occupation are often crucial factors in its development. The clinical hallmark is arcuate whitish maceration on weight-bearing surfaces, which are often malodorous as well.

TREATMENT


The first treatment for JPD is education of parents and patients, reassuring them about the relatively benign nature of the problem. Moisturizing frequently with petrolatum-based moisturizers is necessary for prevention, but changing the type of shoes worn is the most effective step to take; it is also the most difficult, since children this age favor cheap, plastic flip-flops or shoes in the summer.

For the fissures, spraying on a flexible spray bandage can be helpful in protecting them and allowing them to heal. With significant inflammation, the use of mild steroid ointments, such as hydrocortisone 2.5%, can help. But by far, the best relief comes with the change in season and the choice of shoe (leather-soled).

A new strain of norovirus, identified last March in Australia, has swept through the United States, causing more than half of the 2012 outbreaks.

GII.4 Sydney is implicated in 53% of the outbreaks that occurred from September to December, Leslie Barclay and her colleagues reported in the Jan. 24 issue of the Morbidity and Mortality Weekly Report (2013;62:55).

The other outbreaks were caused by 10 different GI and GII genotypes, including GII.4 New Orleans, said Ms. Barclay of the National Calicivirus Laboratory at the Centers for Disease Control and Prevention, and her coauthors. However, she noted, the GII.4 Sydney virus appears to have replaced the New Orleans strain as the predominant pathogen.

GII.4 Sydney was implicated in 19% of the September norovirus outbreaks; 46% of the October outbreaks; and 58% of outbreaks in both November and December, Ms. Barclay and her coinvestigators said.

The report noted that 51% of the outbreaks were direct, person-to-person transmission; 20% were foodborne; and 1% waterborne. For the other outbreaks, the mode of transmission remains unknown.

The sudden appearance of a new norovirus strain isn’t unusual or unexpected, Dr. Aron J. Hall said in an interview.

"This group of viruses is constantly evolving. New strains develop all the time," said Dr. Hall, an epidemiologist with CDC’s Division of Viral Diseases. "This is following the same pattern we’ve seen for the past 10 years, with a new strain evolving every 2-3 years."

Since the norovirus season doesn’t normally peak until January, it’s too soon to say whether GII.4 Sydney is more virulent, either in the number or severity of cases it causes.

"Every time a new strain emerges, there’s a potential for increased disease activity, numbers of outbreaks, and severity. But sometimes they simply replace the predominant strain with no increases. We have to wait until we’ve tallied all the numbers before we can get an assessment of this season’s magnitude and impact," he said.

GII.4 Sydney was first identified in Australia, and rapidly moved to Japan, the Netherlands, and the United Kingdom, according to a Jan. 4 report (Eurosurv. 2013;18:1)

In early December and late November, the ProMed disease reporting system reported a 64% increase in confirmed norovirus lab reports in England and Wales, and increased deaths in elderly Japanese patients. Molecular assays pinpointed the cause as the new variant of norovirus, the Eurosurveillance researchers noted.

The virus is highly transmissible; exposure to as few as 18 viral particles can cause illness, according to a presentation by Jan Vinjé, Ph.D., head of the National Calicivirus Laboratory. And since about 30% of cases are asymptomatic, the transmission rate can be extremely high.

"These are the two characteristics that explain why norovirus is such a serious public health challenge," Dr. Hall said. "It takes a very tiny amount of exposure to make someone sick, and someone who is sick is shedding billions of viral particles. They can shed virus without any symptoms, so they don’t know they have it and there’s no way to advise them about how to avoid spreading it."

The illness is characterized by vomiting and/or diarrhea with abdominal cramps and low-grade fever. Most patients recover within 12-72 hours, but about 10% need hospitalization and fluid therapy. Severe illness and/or death are most common among the elderly and people with chronic illnesses.

The United States sees about 21 million cases annually; 800 will result in death. A norovirus outbreak can overwhelm local medical resources; the virus causes nearly 2 million outpatient visits and 400,000 emergency department visits each year. The combined annual cost reaches $2 billion, according to the CDC.

As federal employees, Dr. Hall and Ms. Barclay have no financial disclosures.

A new strain of norovirus, identified last March in Australia, has swept through the United States, causing more than half of the 2012 outbreaks.

GII.4 Sydney is implicated in 53% of the outbreaks that occurred from September to December, Leslie Barclay and her colleagues reported in the Jan. 24 issue of the Morbidity and Mortality Weekly Report (2013;62:55).

The other outbreaks were caused by 10 different GI and GII genotypes, including GII.4 New Orleans, said Ms. Barclay of the National Calicivirus Laboratory at the Centers for Disease Control and Prevention, and her coauthors. However, she noted, the GII.4 Sydney virus appears to have replaced the New Orleans strain as the predominant pathogen.

GII.4 Sydney was implicated in 19% of the September norovirus outbreaks; 46% of the October outbreaks; and 58% of outbreaks in both November and December, Ms. Barclay and her coinvestigators said.

The report noted that 51% of the outbreaks were direct, person-to-person transmission; 20% were foodborne; and 1% waterborne. For the other outbreaks, the mode of transmission remains unknown.

The sudden appearance of a new norovirus strain isn’t unusual or unexpected, Dr. Aron J. Hall said in an interview.

"This group of viruses is constantly evolving. New strains develop all the time," said Dr. Hall, an epidemiologist with CDC’s Division of Viral Diseases. "This is following the same pattern we’ve seen for the past 10 years, with a new strain evolving every 2-3 years."

Since the norovirus season doesn’t normally peak until January, it’s too soon to say whether GII.4 Sydney is more virulent, either in the number or severity of cases it causes.

"Every time a new strain emerges, there’s a potential for increased disease activity, numbers of outbreaks, and severity. But sometimes they simply replace the predominant strain with no increases. We have to wait until we’ve tallied all the numbers before we can get an assessment of this season’s magnitude and impact," he said.

GII.4 Sydney was first identified in Australia, and rapidly moved to Japan, the Netherlands, and the United Kingdom, according to a Jan. 4 report (Eurosurv. 2013;18:1)

In early December and late November, the ProMed disease reporting system reported a 64% increase in confirmed norovirus lab reports in England and Wales, and increased deaths in elderly Japanese patients. Molecular assays pinpointed the cause as the new variant of norovirus, the Eurosurveillance researchers noted.

The virus is highly transmissible; exposure to as few as 18 viral particles can cause illness, according to a presentation by Jan Vinjé, Ph.D., head of the National Calicivirus Laboratory. And since about 30% of cases are asymptomatic, the transmission rate can be extremely high.

"These are the two characteristics that explain why norovirus is such a serious public health challenge," Dr. Hall said. "It takes a very tiny amount of exposure to make someone sick, and someone who is sick is shedding billions of viral particles. They can shed virus without any symptoms, so they don’t know they have it and there’s no way to advise them about how to avoid spreading it."

The illness is characterized by vomiting and/or diarrhea with abdominal cramps and low-grade fever. Most patients recover within 12-72 hours, but about 10% need hospitalization and fluid therapy. Severe illness and/or death are most common among the elderly and people with chronic illnesses.

The United States sees about 21 million cases annually; 800 will result in death. A norovirus outbreak can overwhelm local medical resources; the virus causes nearly 2 million outpatient visits and 400,000 emergency department visits each year. The combined annual cost reaches $2 billion, according to the CDC.

As federal employees, Dr. Hall and Ms. Barclay have no financial disclosures.

A new strain of norovirus, identified last March in Australia, has swept through the United States, causing more than half of the 2012 outbreaks.

GII.4 Sydney is implicated in 53% of the outbreaks that occurred from September to December, Leslie Barclay and her colleagues reported in the Jan. 24 issue of the Morbidity and Mortality Weekly Report (2013;62:55).

The other outbreaks were caused by 10 different GI and GII genotypes, including GII.4 New Orleans, said Ms. Barclay of the National Calicivirus Laboratory at the Centers for Disease Control and Prevention, and her coauthors. However, she noted, the GII.4 Sydney virus appears to have replaced the New Orleans strain as the predominant pathogen.

GII.4 Sydney was implicated in 19% of the September norovirus outbreaks; 46% of the October outbreaks; and 58% of outbreaks in both November and December, Ms. Barclay and her coinvestigators said.

The report noted that 51% of the outbreaks were direct, person-to-person transmission; 20% were foodborne; and 1% waterborne. For the other outbreaks, the mode of transmission remains unknown.

The sudden appearance of a new norovirus strain isn’t unusual or unexpected, Dr. Aron J. Hall said in an interview.

"This group of viruses is constantly evolving. New strains develop all the time," said Dr. Hall, an epidemiologist with CDC’s Division of Viral Diseases. "This is following the same pattern we’ve seen for the past 10 years, with a new strain evolving every 2-3 years."

Since the norovirus season doesn’t normally peak until January, it’s too soon to say whether GII.4 Sydney is more virulent, either in the number or severity of cases it causes.

"Every time a new strain emerges, there’s a potential for increased disease activity, numbers of outbreaks, and severity. But sometimes they simply replace the predominant strain with no increases. We have to wait until we’ve tallied all the numbers before we can get an assessment of this season’s magnitude and impact," he said.

GII.4 Sydney was first identified in Australia, and rapidly moved to Japan, the Netherlands, and the United Kingdom, according to a Jan. 4 report (Eurosurv. 2013;18:1)

In early December and late November, the ProMed disease reporting system reported a 64% increase in confirmed norovirus lab reports in England and Wales, and increased deaths in elderly Japanese patients. Molecular assays pinpointed the cause as the new variant of norovirus, the Eurosurveillance researchers noted.

The virus is highly transmissible; exposure to as few as 18 viral particles can cause illness, according to a presentation by Jan Vinjé, Ph.D., head of the National Calicivirus Laboratory. And since about 30% of cases are asymptomatic, the transmission rate can be extremely high.

"These are the two characteristics that explain why norovirus is such a serious public health challenge," Dr. Hall said. "It takes a very tiny amount of exposure to make someone sick, and someone who is sick is shedding billions of viral particles. They can shed virus without any symptoms, so they don’t know they have it and there’s no way to advise them about how to avoid spreading it."

The illness is characterized by vomiting and/or diarrhea with abdominal cramps and low-grade fever. Most patients recover within 12-72 hours, but about 10% need hospitalization and fluid therapy. Severe illness and/or death are most common among the elderly and people with chronic illnesses.

The United States sees about 21 million cases annually; 800 will result in death. A norovirus outbreak can overwhelm local medical resources; the virus causes nearly 2 million outpatient visits and 400,000 emergency department visits each year. The combined annual cost reaches $2 billion, according to the CDC.

As federal employees, Dr. Hall and Ms. Barclay have no financial disclosures.

SAN FRANCISCO – Surgically removing residual gastrointestinal stromal tumors in patients who respond to imatinib therapy significantly increased time to tumor progression to 88 months, compared with 43 months using imatinib alone, based on findings from a retrospective study of 134 patients.

After controlling for the effects of other risk factors, the surgery decreased threefold the likelihood of disease progression and decreased fivefold the risk of death, Dr. Seong Joon Park reported in a press briefing sponsored by the American Society of Clinical Oncology (ASCO). The press conference was held in advance of at a meeting on gastrointestinal cancers sponsored by ASCO and three other cancer organizations.

The findings support the widely adopted practice of removing residual tumors in these patients, despite the retrospective and observational design of the study, Dr. Park said. A prospective European study of similar design to this one terminated early due to poor patient enrollment. "It’s really hard to conduct a prospective study of this design," said Dr. Park of Asan Medical Center, Seoul, South Korea.

He and his associates reviewed the records of patients who showed at least 6 months of disease stabilization or response to imatinib (Gleevec) treatment, 92 of whom got the drug treatment alone and 42 of whom underwent surgery to remove residual tumors after a median of 19 months of imatinib therapy. The imatinib therapy was restarted after surgery. Median follow-up for the cohort as a whole was 59 months.

"This treatment strategy is worth trying as a clinical practice if the medical center is large enough to have an experienced multidisciplinary team and to have low morbidity and mortality associated with surgery," he said.

Each year, approximately 5,000 new cases of gastrointestinal stromal tumors are diagnosed in the United States, most often in the stomach and small intestine, though they can occur anywhere in or near the GI tract. Imatinib typically is first-line therapy, and 80%-85% of patients will respond to the treatment, he said. A majority of patients who respond to imatinib will have residual tumors, however, which are believed to contribute to the development of drug resistance, leading to the hypothesis that removing the residual tumors would improve survival.

In general, one-third of patients are candidates for surgical removal of residual lesions, depending on the tumor size and other tumor and patient characteristics, Dr. Park said.

The two patient groups in the study were similar except that the surgery group was significantly younger (51 vs. 58 years) and was less likely to have metastases in the peritoneum (41% in the surgery group vs. 61% in the control group).

As it is an aggressive and difficult treatment, surgery is more likely to be considered and recommended to younger patients who have a good performance status and, thus, less likely to be recommended in patients with multiple peritoneal metastases.

Factors associated with longer progression-free and overall survival included surgery and having an initial tumor size less than 150 mm, multivariate analyses showed. Female sex and having the KIT exon 11 mutation also were associated with longer progression-free survival. The researchers used propensity scores and inverse-probability-weighting adjustments to account for the effects of factors other than surgery.

The gastrointestinal cancers meeting, where Dr. Park will present the results, is cosponsored by ASCO, the American Gastroenterological Association Institute, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Dr. Park reported having no financial disclosures.

On Twitter @sherryboschert

SAN FRANCISCO – Surgically removing residual gastrointestinal stromal tumors in patients who respond to imatinib therapy significantly increased time to tumor progression to 88 months, compared with 43 months using imatinib alone, based on findings from a retrospective study of 134 patients.

After controlling for the effects of other risk factors, the surgery decreased threefold the likelihood of disease progression and decreased fivefold the risk of death, Dr. Seong Joon Park reported in a press briefing sponsored by the American Society of Clinical Oncology (ASCO). The press conference was held in advance of at a meeting on gastrointestinal cancers sponsored by ASCO and three other cancer organizations.

The findings support the widely adopted practice of removing residual tumors in these patients, despite the retrospective and observational design of the study, Dr. Park said. A prospective European study of similar design to this one terminated early due to poor patient enrollment. "It’s really hard to conduct a prospective study of this design," said Dr. Park of Asan Medical Center, Seoul, South Korea.

He and his associates reviewed the records of patients who showed at least 6 months of disease stabilization or response to imatinib (Gleevec) treatment, 92 of whom got the drug treatment alone and 42 of whom underwent surgery to remove residual tumors after a median of 19 months of imatinib therapy. The imatinib therapy was restarted after surgery. Median follow-up for the cohort as a whole was 59 months.

"This treatment strategy is worth trying as a clinical practice if the medical center is large enough to have an experienced multidisciplinary team and to have low morbidity and mortality associated with surgery," he said.

Each year, approximately 5,000 new cases of gastrointestinal stromal tumors are diagnosed in the United States, most often in the stomach and small intestine, though they can occur anywhere in or near the GI tract. Imatinib typically is first-line therapy, and 80%-85% of patients will respond to the treatment, he said. A majority of patients who respond to imatinib will have residual tumors, however, which are believed to contribute to the development of drug resistance, leading to the hypothesis that removing the residual tumors would improve survival.

In general, one-third of patients are candidates for surgical removal of residual lesions, depending on the tumor size and other tumor and patient characteristics, Dr. Park said.

The two patient groups in the study were similar except that the surgery group was significantly younger (51 vs. 58 years) and was less likely to have metastases in the peritoneum (41% in the surgery group vs. 61% in the control group).

As it is an aggressive and difficult treatment, surgery is more likely to be considered and recommended to younger patients who have a good performance status and, thus, less likely to be recommended in patients with multiple peritoneal metastases.

Factors associated with longer progression-free and overall survival included surgery and having an initial tumor size less than 150 mm, multivariate analyses showed. Female sex and having the KIT exon 11 mutation also were associated with longer progression-free survival. The researchers used propensity scores and inverse-probability-weighting adjustments to account for the effects of factors other than surgery.

The gastrointestinal cancers meeting, where Dr. Park will present the results, is cosponsored by ASCO, the American Gastroenterological Association Institute, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Dr. Park reported having no financial disclosures.

On Twitter @sherryboschert

SAN FRANCISCO – Surgically removing residual gastrointestinal stromal tumors in patients who respond to imatinib therapy significantly increased time to tumor progression to 88 months, compared with 43 months using imatinib alone, based on findings from a retrospective study of 134 patients.

After controlling for the effects of other risk factors, the surgery decreased threefold the likelihood of disease progression and decreased fivefold the risk of death, Dr. Seong Joon Park reported in a press briefing sponsored by the American Society of Clinical Oncology (ASCO). The press conference was held in advance of at a meeting on gastrointestinal cancers sponsored by ASCO and three other cancer organizations.

The findings support the widely adopted practice of removing residual tumors in these patients, despite the retrospective and observational design of the study, Dr. Park said. A prospective European study of similar design to this one terminated early due to poor patient enrollment. "It’s really hard to conduct a prospective study of this design," said Dr. Park of Asan Medical Center, Seoul, South Korea.

He and his associates reviewed the records of patients who showed at least 6 months of disease stabilization or response to imatinib (Gleevec) treatment, 92 of whom got the drug treatment alone and 42 of whom underwent surgery to remove residual tumors after a median of 19 months of imatinib therapy. The imatinib therapy was restarted after surgery. Median follow-up for the cohort as a whole was 59 months.

"This treatment strategy is worth trying as a clinical practice if the medical center is large enough to have an experienced multidisciplinary team and to have low morbidity and mortality associated with surgery," he said.

Each year, approximately 5,000 new cases of gastrointestinal stromal tumors are diagnosed in the United States, most often in the stomach and small intestine, though they can occur anywhere in or near the GI tract. Imatinib typically is first-line therapy, and 80%-85% of patients will respond to the treatment, he said. A majority of patients who respond to imatinib will have residual tumors, however, which are believed to contribute to the development of drug resistance, leading to the hypothesis that removing the residual tumors would improve survival.

In general, one-third of patients are candidates for surgical removal of residual lesions, depending on the tumor size and other tumor and patient characteristics, Dr. Park said.

The two patient groups in the study were similar except that the surgery group was significantly younger (51 vs. 58 years) and was less likely to have metastases in the peritoneum (41% in the surgery group vs. 61% in the control group).

As it is an aggressive and difficult treatment, surgery is more likely to be considered and recommended to younger patients who have a good performance status and, thus, less likely to be recommended in patients with multiple peritoneal metastases.

Factors associated with longer progression-free and overall survival included surgery and having an initial tumor size less than 150 mm, multivariate analyses showed. Female sex and having the KIT exon 11 mutation also were associated with longer progression-free survival. The researchers used propensity scores and inverse-probability-weighting adjustments to account for the effects of factors other than surgery.

The gastrointestinal cancers meeting, where Dr. Park will present the results, is cosponsored by ASCO, the American Gastroenterological Association Institute, the American Society for Radiation Oncology, and the Society of Surgical Oncology.

Dr. Park reported having no financial disclosures.

On Twitter @sherryboschert

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at [email protected].

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at [email protected].

When tragedies like the Aurora, Colo., and Newtown, Conn., shootings occur, we wonder whether people can ever overcome their grief and find a way to move on with their lives. Froma Walsh, Ph.D., a leading authority on family resilience, has developed an approach that can be used to strengthen families and communities that have suffered such tragedies.

Dr. Walsh is the codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.

Resilience originally was described as individual resilience. Dr. Walsh, who has broadened that concept, provides us with important steps to understand how to help heal families and communities that suffer from unimaginable trauma and loss.

Individual resilience

Beginning in the 1960s, British psychiatrist Sir Michael Rutter studied youth from inner-city London and on the Isle of Wight. Even though they experienced many risk factors, 25% of the children had a good outcome. The children who showed individual resilience had the following characteristics: an easy temperament; female; a positive school climate; self-mastery; self-efficacy; planning skills; and a warm, close, personal relationship with an adult.

From 1955 to 1985, American researchers Emmy E. Werner, Ph.D., and Ruth S. Smith, Ph.D., studied a high-risk population of children in Hawaii and found that 36% showed individual resilience, despite their risk factors. Resilient personal characteristics found in this study were similar: being female, socially responsible, adaptable, tolerant, achievement oriented, a good communicator, and having good self-esteem as well as a caring environment inside and outside the family.

Acquiring resilient qualities

After traumatic events happen, how do people cope? How does the coping process result in growth? We are all familiar with the saying: "What doesn’t break you makes you stronger." This is resilience. How can we help families and communities become stronger?

Family resilience

Dr. Walsh developed the concept of family resilience and a practice framework, identifying key family processes that clinicians can target to strengthen family resilience. She is quick to point out that resilience does not lie in specific characteristics, but rather in family processes that promote resilience. These family processes include a family belief system that pulls family members together and forward, the ability to have hope, a spiritual or value orientation to draw meaning and new purpose out of a tragedy, being able to organize family life to meet challenges, reaching out to extended kin and community networks, collaborative problem solving, and clear communication between members.

Her article, "Traumatic loss and major disasters: strengthening family and community resilience," identifies ways that professionals can help families cope with traumatic loss (Fam. Process 2007;46:207-27). She identifies nine aspects of family life as being key factors in families being able to cope well with traumatic loss:.

• Making meaning of traumatic loss experience. Families ask "Why us?" Families need to make sense of their experiences in a way that allows them to live on. "New meaning" highlights the strengths of the survivors and shows a "new way" of relating to the world and to others. As psychiatrists, we can support the family in finding their own meaning, by helping them examine their beliefs about blame, responsibility, or negligence; and helping them come to terms with accountability and limits of control in the situation.

• Hope. Families need to regain hope in their future possibilities. How does this family want to continue and what does this family want to become? Although they cannot change what has happened, we can support their efforts to "master the possible" by promoting active agency in doing all they can as they move forward.

• Transcendence and spirituality. Families can use their personal values and faith communities for support and to help with forgiveness. Honoring those who died with memorials, anniversary remembrances, and celebrations of milestones in recovery will facilitate healing and growth. These rituals help affirm social values of goodness and compassion. "Recovery is a journey of the heart and spirit, bringing survivors back to the fullness of life," Dr. Walsh wrote in her article.

• Flexibility and stability. Flexibility allows adaptation in the family and allows it to stabilize. Families need to buffer the upheaval and restore security, reliability, and continuity in daily routines. They might need to construct a "new normal" in their lives.

• Connectedness. Each family member has her own adaptation to loss, but family members need to remain mutually supportive. If relationships have prior unresolved conflicts, distress can be worse. Family therapy can prove helpful.

• Extended kin and social resources. Reach out to friends, neighbors, health care providers, clergy and congregational support, school teachers and counselors, employers and coworkers, and neighborhood or community organizations. Multifamily community support groups can help families exchange information, share painful memories and feelings, provide mutual support, and encourage hope and efforts for recovery.

• Clear, consistent information. Families often need help to clarify facts and circumstances of traumatic events and to help their children understand, as age appropriate.

• Emotional sharing and support. Families and the community will experience a wide range of feelings. It is important to allow painful or unacceptable feelings to be expressed and supported, even when differences are viewed as threatening, to avoid the risk of future somatic and emotional disturbance, destructive behavior, or substance abuse. Journals and artwork are helpful, especially with children.

• Collaborative problem solving. Family and communities can coordinate collaborative efforts to promote recovery and resilience. Learning from their experience, they can take steps proactively to prevent future tragedies. One mother who lost a child in the Newtown massacre said she wanted her family and her community to be defined not by their tragedy and suffering, but by the way they are responding, by galvanizing action to stop gun violence.

Community resilience

Community resilience is promoted by Dr. Judith Landau and Jack Saul, Ph.D. in a book edited by Dr. Walsh and Monica McGoldrick, Ph.D., called "Living Beyond Loss: Death in the Family" (see list of further reading below). Community members can create a support system that connects individuals and families. Community support provides a highly connected and reality based understanding. Ongoing support groups can respond accurately to the community needs. Perhaps the community might create a neighborhood resource center or a public space to gather, a witness project, or a community website. Such interventions can have a long-lasting positive impact on the community and the families.

Professional resilience

Compassion fatigue can occur when witnessing trauma and in experiencing ongoing distress. Mental health professionals cannot heal all wounds, but we can create a safe haven for family and community members to share pain and their seeking a new path.

Kaethe Weingarten, Ph.D., has developed a compassionate witnessing project aimed at helping professionals understand the importance of "witnessing" suffering and struggle. She encourages professionals to become aware of their own responses to witnessing trauma and to develop tools to cope with the effects of witnessing trauma.

A family resilience approach is a very positive and constructive way that we can use to teach families how to make sense of what has happened and how to move forward, as difficult as that may currently seem to be.

Further reading:

Here is a list of additional reading you can do to help patients who are facing unimaginable loss:

• "Common Shock: Witnessing Violence Every Day," (New York: Dutton, 2003)

• "Family Resilience: A Framework for Clinical Practice," (Family Process 2003;42:1-18)

• "Living Beyond Loss: Death in the Family," (New York: Norton, 2004, 2nd ed.).

• "Resilience Concepts and Findings: Implications for Family Therapy," (J. Family Therapy 1999;21:119-44).

• "Strengthening Family Resilience," (New York: Guilford Press, 2006)

 Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. E-mail Dr. Heru at [email protected].

The Food and Drug Administration has approved a new paclitaxel-eluting stent indciated for the treatment of peripheral artery disease.

The Zilver PTX Drug-Eluting Peripheral Stent, which is manufactured by Cook Medical of Bloomington, Ind., is the first drug-eluting stent to win approval for this indication.

Courtesy Dr. Fabrizio Fanelli / Copyright COOK Medical 

The approval was based on findings from both a randomized controlled trial and on a registry study, which together comprised more than 1,200 patients.

According to an FDA press statement, the studies indicate that treatment with the stent "is at least as safe as treatment with percutaneous transluminal angioplasty (PTA) and significantly more effective."

The randomized trial included a total of 479 patients who had a single stenotic lesion less than 140 mm in one or both of the femoropopliteal arteries.

The patients were randomized to the paclitaxel-eluting stent or to PTA. If the transluminal procedure failed, then the patients received either the paclitaxel-eluting stent or a bare-metal stent.

After 12 months, 83% of the arteries treated with the drug-eluting stent were still open, compared with 33% of those in the PTA group.

In those patients who had the stent placed after a failed PTA, 90% of arteries were open, compared with 73% in those who got the bare-metal stent.

In October 2011, the FDA's Circulatory System Devices Panel voted 11 to 0 that the benefits of the Zilver PTX stent outweighed its risks as a treatment for patients with symptomatic atherosclerotic stenosis of the femoropopliteal arteries on the basis of that trial.

This past October, the 3-year results of the study were presented at the Vascular Interventional Advances 2012 meeting in Las Vegas. The results showed that there was a 70.7% primary patency seen for the paclitaxel-eluting stent, compared with 49.1% for PTA and bare-metal stents.

The registry study followed 767 patients for 24 months. These patients had a maximum of four stents placed; the stents could be utilized to treat a single lesion or to treat multiple lesions.

At 12 months, the fracture rate was 1.5%; fractures were not associated with any clinical problems. The rate of stent thrombosis was 2.8% at 12 months and 3.5% at 24 months.

"The clinical study demonstrated that the [the paclitaxel-eluting stent] is more effective than the use of balloon angioplasty for the treatment of symptomatic peripheral artery disease in above-the-knee femoropopliteal artery," Christy Foreman, director of the Office of Device Evaluation at the FDA's Center for Devices and Radiological Health, said in the statement.

"This approval expands the treatment options for patients suffering from symptomatic peripheral artery disease," she added.

In both studies, the most common major adverse event was restenosis requiring additional treatment to reestablish adequate flow in the artery. 

The device is contraindicated in patients with stenoses that cannot be dilated to permit passage of the catheter or proper placement of the stent.

It is also contraindicated in patients who cannot receive recommended drug therapy due to bleeding disorders, or women who are pregnant, breastfeeding, or planning to become pregnant in the next 5 years.

The FDA will now require the manufacturer to conduct a 5-year postapproval study of 900 patients to further evaluate the stent's safety and efficacy.

[email protected]

The Food and Drug Administration has approved a new paclitaxel-eluting stent indciated for the treatment of peripheral artery disease.

The Zilver PTX Drug-Eluting Peripheral Stent, which is manufactured by Cook Medical of Bloomington, Ind., is the first drug-eluting stent to win approval for this indication.

Courtesy Dr. Fabrizio Fanelli / Copyright COOK Medical 

The approval was based on findings from both a randomized controlled trial and on a registry study, which together comprised more than 1,200 patients.

According to an FDA press statement, the studies indicate that treatment with the stent "is at least as safe as treatment with percutaneous transluminal angioplasty (PTA) and significantly more effective."

The randomized trial included a total of 479 patients who had a single stenotic lesion less than 140 mm in one or both of the femoropopliteal arteries.

The patients were randomized to the paclitaxel-eluting stent or to PTA. If the transluminal procedure failed, then the patients received either the paclitaxel-eluting stent or a bare-metal stent.

After 12 months, 83% of the arteries treated with the drug-eluting stent were still open, compared with 33% of those in the PTA group.

In those patients who had the stent placed after a failed PTA, 90% of arteries were open, compared with 73% in those who got the bare-metal stent.

In October 2011, the FDA's Circulatory System Devices Panel voted 11 to 0 that the benefits of the Zilver PTX stent outweighed its risks as a treatment for patients with symptomatic atherosclerotic stenosis of the femoropopliteal arteries on the basis of that trial.

This past October, the 3-year results of the study were presented at the Vascular Interventional Advances 2012 meeting in Las Vegas. The results showed that there was a 70.7% primary patency seen for the paclitaxel-eluting stent, compared with 49.1% for PTA and bare-metal stents.

The registry study followed 767 patients for 24 months. These patients had a maximum of four stents placed; the stents could be utilized to treat a single lesion or to treat multiple lesions.

At 12 months, the fracture rate was 1.5%; fractures were not associated with any clinical problems. The rate of stent thrombosis was 2.8% at 12 months and 3.5% at 24 months.

"The clinical study demonstrated that the [the paclitaxel-eluting stent] is more effective than the use of balloon angioplasty for the treatment of symptomatic peripheral artery disease in above-the-knee femoropopliteal artery," Christy Foreman, director of the Office of Device Evaluation at the FDA's Center for Devices and Radiological Health, said in the statement.

"This approval expands the treatment options for patients suffering from symptomatic peripheral artery disease," she added.

In both studies, the most common major adverse event was restenosis requiring additional treatment to reestablish adequate flow in the artery. 

The device is contraindicated in patients with stenoses that cannot be dilated to permit passage of the catheter or proper placement of the stent.

It is also contraindicated in patients who cannot receive recommended drug therapy due to bleeding disorders, or women who are pregnant, breastfeeding, or planning to become pregnant in the next 5 years.

The FDA will now require the manufacturer to conduct a 5-year postapproval study of 900 patients to further evaluate the stent's safety and efficacy.

[email protected]

The Food and Drug Administration has approved a new paclitaxel-eluting stent indciated for the treatment of peripheral artery disease.

The Zilver PTX Drug-Eluting Peripheral Stent, which is manufactured by Cook Medical of Bloomington, Ind., is the first drug-eluting stent to win approval for this indication.

Courtesy Dr. Fabrizio Fanelli / Copyright COOK Medical 

The approval was based on findings from both a randomized controlled trial and on a registry study, which together comprised more than 1,200 patients.

According to an FDA press statement, the studies indicate that treatment with the stent "is at least as safe as treatment with percutaneous transluminal angioplasty (PTA) and significantly more effective."

The randomized trial included a total of 479 patients who had a single stenotic lesion less than 140 mm in one or both of the femoropopliteal arteries.

The patients were randomized to the paclitaxel-eluting stent or to PTA. If the transluminal procedure failed, then the patients received either the paclitaxel-eluting stent or a bare-metal stent.

After 12 months, 83% of the arteries treated with the drug-eluting stent were still open, compared with 33% of those in the PTA group.

In those patients who had the stent placed after a failed PTA, 90% of arteries were open, compared with 73% in those who got the bare-metal stent.

In October 2011, the FDA's Circulatory System Devices Panel voted 11 to 0 that the benefits of the Zilver PTX stent outweighed its risks as a treatment for patients with symptomatic atherosclerotic stenosis of the femoropopliteal arteries on the basis of that trial.

This past October, the 3-year results of the study were presented at the Vascular Interventional Advances 2012 meeting in Las Vegas. The results showed that there was a 70.7% primary patency seen for the paclitaxel-eluting stent, compared with 49.1% for PTA and bare-metal stents.

The registry study followed 767 patients for 24 months. These patients had a maximum of four stents placed; the stents could be utilized to treat a single lesion or to treat multiple lesions.

At 12 months, the fracture rate was 1.5%; fractures were not associated with any clinical problems. The rate of stent thrombosis was 2.8% at 12 months and 3.5% at 24 months.

"The clinical study demonstrated that the [the paclitaxel-eluting stent] is more effective than the use of balloon angioplasty for the treatment of symptomatic peripheral artery disease in above-the-knee femoropopliteal artery," Christy Foreman, director of the Office of Device Evaluation at the FDA's Center for Devices and Radiological Health, said in the statement.

"This approval expands the treatment options for patients suffering from symptomatic peripheral artery disease," she added.

In both studies, the most common major adverse event was restenosis requiring additional treatment to reestablish adequate flow in the artery. 

The device is contraindicated in patients with stenoses that cannot be dilated to permit passage of the catheter or proper placement of the stent.

It is also contraindicated in patients who cannot receive recommended drug therapy due to bleeding disorders, or women who are pregnant, breastfeeding, or planning to become pregnant in the next 5 years.

The FDA will now require the manufacturer to conduct a 5-year postapproval study of 900 patients to further evaluate the stent's safety and efficacy.

[email protected]

Most of us struggle to be proficient in that fine art of balancing high-quality, cost-effective medical care, patient and family satisfaction, and length of stay. One, or even two, of these without the other, just won’t cut muster these days, and with the CMS Hospital Readmissions Reduction Program, the pressure is on to cut readmissions within 30 days of discharge, or else! (Section 3025 of the Affordable Care Act requires the CMS to reduce payments to acute care hospitals with excessive readmission rates as of Oct. 1, 2012.)

Realistically, we all know that even if we provide the best medical care possible, there will always be patients with chronic, end-stage disease whom we will never "fix." The best we can do is optimize the quality of their lives until they die or are readmitted and the cycle begins again. But there may be much more we as hospitalists can do to optimize the overall care of our patients to improve their outcomes, and save our hospitals a great deal of money at the same time.

"Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk" an article published Jan. 10 in the New England Journal of Medicine, gives excellent insight into underappreciated factors that result in readmission to the hospital (N. Engl. J. Med. 2013;368:100-2). Approximately one-fifth of Medicare patients admitted to a hospital require readmission within 30 days, surprisingly often for conditions completely unrelated to the original reason for admission. For instance, among patients initially admitted for heart failure, only 37% of readmissions within 30 days were for worsening heart failure. Likewise, after a hospitalization for a COPD exacerbation, only 36% of readmissions within 30 days were for another exacerbation.

Regardless of the original reason for admission, common causes of readmission include infection, gastrointestinal conditions, metabolic derangements, mental illness, trauma, heart failure, COPD, and pneumonia. And, despite what would seem intuitive, the severity of the initial illness did not help predict which patients would require readmission.

Sleep deprivation is a major contributor to postdischarge morbidity. Polysomnographic studies have demonstrated a reduction in REM sleep and an increase in non-REM sleep in hospitalized patients. Sleep deprivation is known to adversely impact immune function, cardiac risk, and even the coagulation cascade, in addition to the more obvious things such as mental function, ability to ambulate safely, and emotional well-being.

Inadequate nutrition is another culprit. Between being NPO for procedures, which are commonly rescheduled, feeling too sick (or too groggy) to eat, and the increased catabolic demands of many acute illnesses, the pendulum often swings far away from a homeostasis into a potentially dangerous zone, despite how the patient may look at first glance. Some potential consequences of poor nutrition include impaired wound healing, increased infection risk, and decreased cardiac and respiratory function.

Other factors, such as uncontrolled pain, a host of new medications – with myriad side effects – and deconditioning from lying in bed for prolonged periods also play key roles in setting patients up for a potentially debilitating vulnerability that often results in yet another acute illness requiring hospitalization not long after their initial discharge.

We ought to start thinking about discharge planning when we first admit patients. Based on this article, we need to include innovative ways to decrease the posthospital syndrome. There are some simple things we can do: Optimize pain control, get them out of bed as soon as possible, and create an environment to facilitate peaceful sleep. For example, we can easily minimize interruptions during early morning hours for vital sign checks and blood draws in stable patients. (Do we really need routine follow-up lab to be drawn at 6 a.m. in every patient?)

We should all think about our workflow and what we can do differently to minimize the physiologic vulnerability of our patients at discharge so they can be safely discharged (and stay discharged).

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. 

Most of us struggle to be proficient in that fine art of balancing high-quality, cost-effective medical care, patient and family satisfaction, and length of stay. One, or even two, of these without the other, just won’t cut muster these days, and with the CMS Hospital Readmissions Reduction Program, the pressure is on to cut readmissions within 30 days of discharge, or else! (Section 3025 of the Affordable Care Act requires the CMS to reduce payments to acute care hospitals with excessive readmission rates as of Oct. 1, 2012.)

Realistically, we all know that even if we provide the best medical care possible, there will always be patients with chronic, end-stage disease whom we will never "fix." The best we can do is optimize the quality of their lives until they die or are readmitted and the cycle begins again. But there may be much more we as hospitalists can do to optimize the overall care of our patients to improve their outcomes, and save our hospitals a great deal of money at the same time.

"Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk" an article published Jan. 10 in the New England Journal of Medicine, gives excellent insight into underappreciated factors that result in readmission to the hospital (N. Engl. J. Med. 2013;368:100-2). Approximately one-fifth of Medicare patients admitted to a hospital require readmission within 30 days, surprisingly often for conditions completely unrelated to the original reason for admission. For instance, among patients initially admitted for heart failure, only 37% of readmissions within 30 days were for worsening heart failure. Likewise, after a hospitalization for a COPD exacerbation, only 36% of readmissions within 30 days were for another exacerbation.

Regardless of the original reason for admission, common causes of readmission include infection, gastrointestinal conditions, metabolic derangements, mental illness, trauma, heart failure, COPD, and pneumonia. And, despite what would seem intuitive, the severity of the initial illness did not help predict which patients would require readmission.

Sleep deprivation is a major contributor to postdischarge morbidity. Polysomnographic studies have demonstrated a reduction in REM sleep and an increase in non-REM sleep in hospitalized patients. Sleep deprivation is known to adversely impact immune function, cardiac risk, and even the coagulation cascade, in addition to the more obvious things such as mental function, ability to ambulate safely, and emotional well-being.

Inadequate nutrition is another culprit. Between being NPO for procedures, which are commonly rescheduled, feeling too sick (or too groggy) to eat, and the increased catabolic demands of many acute illnesses, the pendulum often swings far away from a homeostasis into a potentially dangerous zone, despite how the patient may look at first glance. Some potential consequences of poor nutrition include impaired wound healing, increased infection risk, and decreased cardiac and respiratory function.

Other factors, such as uncontrolled pain, a host of new medications – with myriad side effects – and deconditioning from lying in bed for prolonged periods also play key roles in setting patients up for a potentially debilitating vulnerability that often results in yet another acute illness requiring hospitalization not long after their initial discharge.

We ought to start thinking about discharge planning when we first admit patients. Based on this article, we need to include innovative ways to decrease the posthospital syndrome. There are some simple things we can do: Optimize pain control, get them out of bed as soon as possible, and create an environment to facilitate peaceful sleep. For example, we can easily minimize interruptions during early morning hours for vital sign checks and blood draws in stable patients. (Do we really need routine follow-up lab to be drawn at 6 a.m. in every patient?)

We should all think about our workflow and what we can do differently to minimize the physiologic vulnerability of our patients at discharge so they can be safely discharged (and stay discharged).

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care. 

Most of us struggle to be proficient in that fine art of balancing high-quality, cost-effective medical care, patient and family satisfaction, and length of stay. One, or even two, of these without the other, just won’t cut muster these days, and with the CMS Hospital Readmissions Reduction Program, the pressure is on to cut readmissions within 30 days of discharge, or else! (Section 3025 of the Affordable Care Act requires the CMS to reduce payments to acute care hospitals with excessive readmission rates as of Oct. 1, 2012.)

Realistically, we all know that even if we provide the best medical care possible, there will always be patients with chronic, end-stage disease whom we will never "fix." The best we can do is optimize the quality of their lives until they die or are readmitted and the cycle begins again. But there may be much more we as hospitalists can do to optimize the overall care of our patients to improve their outcomes, and save our hospitals a great deal of money at the same time.

"Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk" an article published Jan. 10 in the New England Journal of Medicine, gives excellent insight into underappreciated factors that result in readmission to the hospital (N. Engl. J. Med. 2013;368:100-2). Approximately one-fifth of Medicare patients admitted to a hospital require readmission within 30 days, surprisingly often for conditions completely unrelated to the original reason for admission. For instance, among patients initially admitted for heart failure, only 37% of readmissions within 30 days were for worsening heart failure. Likewise, after a hospitalization for a COPD exacerbation, only 36% of readmissions within 30 days were for another exacerbation.

Regardless of the original reason for admission, common causes of readmission include infection, gastrointestinal conditions, metabolic derangements, mental illness, trauma, heart failure, COPD, and pneumonia. And, despite what would seem intuitive, the severity of the initial illness did not help predict which patients would require readmission.

Sleep deprivation is a major contributor to postdischarge morbidity. Polysomnographic studies have demonstrated a reduction in REM sleep and an increase in non-REM sleep in hospitalized patients. Sleep deprivation is known to adversely impact immune function, cardiac risk, and even the coagulation cascade, in addition to the more obvious things such as mental function, ability to ambulate safely, and emotional well-being.

Inadequate nutrition is another culprit. Between being NPO for procedures, which are commonly rescheduled, feeling too sick (or too groggy) to eat, and the increased catabolic demands of many acute illnesses, the pendulum often swings far away from a homeostasis into a potentially dangerous zone, despite how the patient may look at first glance. Some potential consequences of poor nutrition include impaired wound healing, increased infection risk, and decreased cardiac and respiratory function.

Other factors, such as uncontrolled pain, a host of new medications – with myriad side effects – and deconditioning from lying in bed for prolonged periods also play key roles in setting patients up for a potentially debilitating vulnerability that often results in yet another acute illness requiring hospitalization not long after their initial discharge.

We ought to start thinking about discharge planning when we first admit patients. Based on this article, we need to include innovative ways to decrease the posthospital syndrome. There are some simple things we can do: Optimize pain control, get them out of bed as soon as possible, and create an environment to facilitate peaceful sleep. For example, we can easily minimize interruptions during early morning hours for vital sign checks and blood draws in stable patients. (Do we really need routine follow-up lab to be drawn at 6 a.m. in every patient?)

We should all think about our workflow and what we can do differently to minimize the physiologic vulnerability of our patients at discharge so they can be safely discharged (and stay discharged).

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.