When you assess a patient with a swollen joint, limited range of motion, and/or pain, consider a diagnosis of juvenile idiopathic arthritis.

Start with a detailed history and physical examination. Questions to ask include: How long have the symptoms been present? Was the onset acute or gradual? What is its severity? Ask the patient to rate the severity of pain. Use a 0-10 rating scale in older children and a faces scale in younger kids. Remember that not all children with oligoarticular juvenile idiopathic arthritis (JIA) experience pain.

Is there interference with school or any other activities? Are the symptoms improving or getting worse?

Also inquire about diurnal variation: Are symptoms more problematic in the morning or evening? Stiffness in the morning or following prolonged inactivity is a classic sign of arthritis in children as well as in adults. Also, what medications or other strategies has the patient tried, and how successful where they?

Inquire about associated symptoms. Fever, cutaneous eruption, weight loss, abdominal pain, diarrhea, and behavioral or visual changes are examples. Ocular inflammation is a common feature of some of the subtypes of juvenile arthritis.

Ask the patient or family about a history of trauma to rule out a fracture or significant intraarticular injury. Keep in mind that even chronic swelling of a joint sometimes may be an orthopedic issue.

One diagnosis you don’t want to miss is malignancy. You think automatically about arthritis when a child presents with joint pain, but all pediatric rheumatologists see a few children each year who turn out to have cancer instead. So be sure that pain truly is localized to the joint, and it’s not bone pain which may reflect the presence of leukemia, lymphoma, or another malignancy.

Remember arthritis is not always the primary disorder. During the initial evaluation you might see a child with inflammation of two of three joints. If you don’t ask about recurrent abdominal pain and/or low-grade fever, you may miss the fact that their arthritis is part of inflammatory bowel disease. If you have any questions about the primary vs. secondary nature of a child’s arthritis, refer the patient to a pediatric rheumatologist for further evaluation. The differential diagnosis for juvenile idiopathic arthritis (now the preferred name replacing "juvenile rheumatoid arthritis") can be lengthy.

Once a diagnosis of JIA is confirmed, a pediatric rheumatologist is best qualified to oversee ongoing care of the patient. Compared with 20 years ago, there are now a great many new agents specifically tailored to treat JIA (particularly biologics), and these medications require that those familiar with dosing schedules and side effects direct their administration. A medication that works well for one subtype of JIA may not work as well for another.

Physical and occupational therapists are critical for a successful approach to children with chronic arthritis. Their involvement helps to maintain range of motion, muscle strength, and endurance while preventing joint contractures and abnormalities of bone growth. The overall goal is to "mainstream" children back to their usual activities. However, if they participated in rugby, ice hockey, or tackle football, we will try to steer these patients to activities with a lower potential for direct trauma. We don’t want a child to be isolated from their peers.

It also is important not to overtest children with suspected arthritis. Laboratory testing is indicated if you strongly suspect an inflammatory process rather than for a child with vague aches and pains. Appropriate initial assays often include a complete blood count, urinalysis, sedimentation rate, and measurement of the C-reactive protein.

Tests such as an ANA (antinuclear antibody) and rheumatoid factor should be reserved for those children with symptoms and signs more likely to be associated with an inflammatory condition. These tests may be misleading with frequent false-positive results that cause undue anxiety for the patient and their family.

For more information on when to refer your patient, see the American College of Rheumatology’s 2010 Guidelines for the Referral of Children and Adolescents to Pediatric Rheumatologists.

Dr. Goldsmith is professor of pediatrics at Drexel University and chief of the rheumatology section at St. Christopher’s Hospital for Children, both in Philadelphia. Dr. Goldsmith said that he has no relevant financial disclosures.

This column, "Subspecialist Consult," appears regularly in Pediatric News, a publication of Elsevier.

When you assess a patient with a swollen joint, limited range of motion, and/or pain, consider a diagnosis of juvenile idiopathic arthritis.

Start with a detailed history and physical examination. Questions to ask include: How long have the symptoms been present? Was the onset acute or gradual? What is its severity? Ask the patient to rate the severity of pain. Use a 0-10 rating scale in older children and a faces scale in younger kids. Remember that not all children with oligoarticular juvenile idiopathic arthritis (JIA) experience pain.

Is there interference with school or any other activities? Are the symptoms improving or getting worse?

Also inquire about diurnal variation: Are symptoms more problematic in the morning or evening? Stiffness in the morning or following prolonged inactivity is a classic sign of arthritis in children as well as in adults. Also, what medications or other strategies has the patient tried, and how successful where they?

Inquire about associated symptoms. Fever, cutaneous eruption, weight loss, abdominal pain, diarrhea, and behavioral or visual changes are examples. Ocular inflammation is a common feature of some of the subtypes of juvenile arthritis.

Ask the patient or family about a history of trauma to rule out a fracture or significant intraarticular injury. Keep in mind that even chronic swelling of a joint sometimes may be an orthopedic issue.

One diagnosis you don’t want to miss is malignancy. You think automatically about arthritis when a child presents with joint pain, but all pediatric rheumatologists see a few children each year who turn out to have cancer instead. So be sure that pain truly is localized to the joint, and it’s not bone pain which may reflect the presence of leukemia, lymphoma, or another malignancy.

Remember arthritis is not always the primary disorder. During the initial evaluation you might see a child with inflammation of two of three joints. If you don’t ask about recurrent abdominal pain and/or low-grade fever, you may miss the fact that their arthritis is part of inflammatory bowel disease. If you have any questions about the primary vs. secondary nature of a child’s arthritis, refer the patient to a pediatric rheumatologist for further evaluation. The differential diagnosis for juvenile idiopathic arthritis (now the preferred name replacing "juvenile rheumatoid arthritis") can be lengthy.

Once a diagnosis of JIA is confirmed, a pediatric rheumatologist is best qualified to oversee ongoing care of the patient. Compared with 20 years ago, there are now a great many new agents specifically tailored to treat JIA (particularly biologics), and these medications require that those familiar with dosing schedules and side effects direct their administration. A medication that works well for one subtype of JIA may not work as well for another.

Physical and occupational therapists are critical for a successful approach to children with chronic arthritis. Their involvement helps to maintain range of motion, muscle strength, and endurance while preventing joint contractures and abnormalities of bone growth. The overall goal is to "mainstream" children back to their usual activities. However, if they participated in rugby, ice hockey, or tackle football, we will try to steer these patients to activities with a lower potential for direct trauma. We don’t want a child to be isolated from their peers.

It also is important not to overtest children with suspected arthritis. Laboratory testing is indicated if you strongly suspect an inflammatory process rather than for a child with vague aches and pains. Appropriate initial assays often include a complete blood count, urinalysis, sedimentation rate, and measurement of the C-reactive protein.

Tests such as an ANA (antinuclear antibody) and rheumatoid factor should be reserved for those children with symptoms and signs more likely to be associated with an inflammatory condition. These tests may be misleading with frequent false-positive results that cause undue anxiety for the patient and their family.

For more information on when to refer your patient, see the American College of Rheumatology’s 2010 Guidelines for the Referral of Children and Adolescents to Pediatric Rheumatologists.

Dr. Goldsmith is professor of pediatrics at Drexel University and chief of the rheumatology section at St. Christopher’s Hospital for Children, both in Philadelphia. Dr. Goldsmith said that he has no relevant financial disclosures.

This column, "Subspecialist Consult," appears regularly in Pediatric News, a publication of Elsevier.

When you assess a patient with a swollen joint, limited range of motion, and/or pain, consider a diagnosis of juvenile idiopathic arthritis.

Start with a detailed history and physical examination. Questions to ask include: How long have the symptoms been present? Was the onset acute or gradual? What is its severity? Ask the patient to rate the severity of pain. Use a 0-10 rating scale in older children and a faces scale in younger kids. Remember that not all children with oligoarticular juvenile idiopathic arthritis (JIA) experience pain.

Is there interference with school or any other activities? Are the symptoms improving or getting worse?

Also inquire about diurnal variation: Are symptoms more problematic in the morning or evening? Stiffness in the morning or following prolonged inactivity is a classic sign of arthritis in children as well as in adults. Also, what medications or other strategies has the patient tried, and how successful where they?

Inquire about associated symptoms. Fever, cutaneous eruption, weight loss, abdominal pain, diarrhea, and behavioral or visual changes are examples. Ocular inflammation is a common feature of some of the subtypes of juvenile arthritis.

Ask the patient or family about a history of trauma to rule out a fracture or significant intraarticular injury. Keep in mind that even chronic swelling of a joint sometimes may be an orthopedic issue.

One diagnosis you don’t want to miss is malignancy. You think automatically about arthritis when a child presents with joint pain, but all pediatric rheumatologists see a few children each year who turn out to have cancer instead. So be sure that pain truly is localized to the joint, and it’s not bone pain which may reflect the presence of leukemia, lymphoma, or another malignancy.

Remember arthritis is not always the primary disorder. During the initial evaluation you might see a child with inflammation of two of three joints. If you don’t ask about recurrent abdominal pain and/or low-grade fever, you may miss the fact that their arthritis is part of inflammatory bowel disease. If you have any questions about the primary vs. secondary nature of a child’s arthritis, refer the patient to a pediatric rheumatologist for further evaluation. The differential diagnosis for juvenile idiopathic arthritis (now the preferred name replacing "juvenile rheumatoid arthritis") can be lengthy.

Once a diagnosis of JIA is confirmed, a pediatric rheumatologist is best qualified to oversee ongoing care of the patient. Compared with 20 years ago, there are now a great many new agents specifically tailored to treat JIA (particularly biologics), and these medications require that those familiar with dosing schedules and side effects direct their administration. A medication that works well for one subtype of JIA may not work as well for another.

Physical and occupational therapists are critical for a successful approach to children with chronic arthritis. Their involvement helps to maintain range of motion, muscle strength, and endurance while preventing joint contractures and abnormalities of bone growth. The overall goal is to "mainstream" children back to their usual activities. However, if they participated in rugby, ice hockey, or tackle football, we will try to steer these patients to activities with a lower potential for direct trauma. We don’t want a child to be isolated from their peers.

It also is important not to overtest children with suspected arthritis. Laboratory testing is indicated if you strongly suspect an inflammatory process rather than for a child with vague aches and pains. Appropriate initial assays often include a complete blood count, urinalysis, sedimentation rate, and measurement of the C-reactive protein.

Tests such as an ANA (antinuclear antibody) and rheumatoid factor should be reserved for those children with symptoms and signs more likely to be associated with an inflammatory condition. These tests may be misleading with frequent false-positive results that cause undue anxiety for the patient and their family.

For more information on when to refer your patient, see the American College of Rheumatology’s 2010 Guidelines for the Referral of Children and Adolescents to Pediatric Rheumatologists.

Dr. Goldsmith is professor of pediatrics at Drexel University and chief of the rheumatology section at St. Christopher’s Hospital for Children, both in Philadelphia. Dr. Goldsmith said that he has no relevant financial disclosures.

This column, "Subspecialist Consult," appears regularly in Pediatric News, a publication of Elsevier.

The Centers for Medicare & Medicaid Services (CMS) on Aug. 23 introduced the Bundled Payments for Care Improvement Initiative, developed as part of the payment bundling provision of the Affordable Care Act (ACA). CMS has invited providers to apply to help test and develop four different models of bundling payments, which allow for great flexibility in selecting conditions, developing the care delivery structure, and determining how payments will be allocated among participating providers.

SHM learned last week that the Center for Medicare & Medicaid Innovation (CMMI) will accept nonbinding letters of intent for Model 1 of the program through Oct. 6. CMMI extended the deadline, originally set for Sept. 22, to give institutions and providers more time. Once institutions submit their letters of intent, the deadline to submit a formal application is Nov. 18.

The deadline for letters of intent for Models 2-4 remains Nov. 4, according to CMMI. The application deadline for those three models is March 15, 2012.

Felix Aguirre, MD, SFHM, vice president of medical affairs for North Hollywood, Calif.-based IPC: The Hospitalist Co., says HM group leaders should continue to monitor the process, but how involved they get depends on their individual situations and their relationship with an institution. “If you’re a private group, there’s a lot of weight on you to try to convince an acute-care facility to go down this risk-bearing road,” he says.

Dr. Aguirre says CMMI’s first three models are all “retrospective,” meaning hospitals and/or providers will be paid fees for service, and once episodic care is completed, as defined by each of the models, reconciliation will be made—and there is the real risk of having to pay back funds to CMS. In Model 4, the lone “prospective” setup, there is a single bundled payment up front “and you live and die by that money,” Dr. Aguirre says. “If it costs you a lot more to provide the service, it’s a true risk arrangement where you take a loss. Of course, if you have reduced costs by providing services a little more efficiently and you’ve saved a few dollars, you get to remain with those dollars.”

Dr. Aguirre also notes that of the four current models, Model 3 is the only one available directly to individual providers or HM groups as a risk-bearing entity, and only for post-acute-care services.

CMMI is expected to introduce at least a few more models in the coming months.

For more about CMS' bundling initiatives, visit our website.

The Centers for Medicare & Medicaid Services (CMS) on Aug. 23 introduced the Bundled Payments for Care Improvement Initiative, developed as part of the payment bundling provision of the Affordable Care Act (ACA). CMS has invited providers to apply to help test and develop four different models of bundling payments, which allow for great flexibility in selecting conditions, developing the care delivery structure, and determining how payments will be allocated among participating providers.

SHM learned last week that the Center for Medicare & Medicaid Innovation (CMMI) will accept nonbinding letters of intent for Model 1 of the program through Oct. 6. CMMI extended the deadline, originally set for Sept. 22, to give institutions and providers more time. Once institutions submit their letters of intent, the deadline to submit a formal application is Nov. 18.

The deadline for letters of intent for Models 2-4 remains Nov. 4, according to CMMI. The application deadline for those three models is March 15, 2012.

Felix Aguirre, MD, SFHM, vice president of medical affairs for North Hollywood, Calif.-based IPC: The Hospitalist Co., says HM group leaders should continue to monitor the process, but how involved they get depends on their individual situations and their relationship with an institution. “If you’re a private group, there’s a lot of weight on you to try to convince an acute-care facility to go down this risk-bearing road,” he says.

Dr. Aguirre says CMMI’s first three models are all “retrospective,” meaning hospitals and/or providers will be paid fees for service, and once episodic care is completed, as defined by each of the models, reconciliation will be made—and there is the real risk of having to pay back funds to CMS. In Model 4, the lone “prospective” setup, there is a single bundled payment up front “and you live and die by that money,” Dr. Aguirre says. “If it costs you a lot more to provide the service, it’s a true risk arrangement where you take a loss. Of course, if you have reduced costs by providing services a little more efficiently and you’ve saved a few dollars, you get to remain with those dollars.”

Dr. Aguirre also notes that of the four current models, Model 3 is the only one available directly to individual providers or HM groups as a risk-bearing entity, and only for post-acute-care services.

CMMI is expected to introduce at least a few more models in the coming months.

For more about CMS' bundling initiatives, visit our website.

The Centers for Medicare & Medicaid Services (CMS) on Aug. 23 introduced the Bundled Payments for Care Improvement Initiative, developed as part of the payment bundling provision of the Affordable Care Act (ACA). CMS has invited providers to apply to help test and develop four different models of bundling payments, which allow for great flexibility in selecting conditions, developing the care delivery structure, and determining how payments will be allocated among participating providers.

SHM learned last week that the Center for Medicare & Medicaid Innovation (CMMI) will accept nonbinding letters of intent for Model 1 of the program through Oct. 6. CMMI extended the deadline, originally set for Sept. 22, to give institutions and providers more time. Once institutions submit their letters of intent, the deadline to submit a formal application is Nov. 18.

The deadline for letters of intent for Models 2-4 remains Nov. 4, according to CMMI. The application deadline for those three models is March 15, 2012.

Felix Aguirre, MD, SFHM, vice president of medical affairs for North Hollywood, Calif.-based IPC: The Hospitalist Co., says HM group leaders should continue to monitor the process, but how involved they get depends on their individual situations and their relationship with an institution. “If you’re a private group, there’s a lot of weight on you to try to convince an acute-care facility to go down this risk-bearing road,” he says.

Dr. Aguirre says CMMI’s first three models are all “retrospective,” meaning hospitals and/or providers will be paid fees for service, and once episodic care is completed, as defined by each of the models, reconciliation will be made—and there is the real risk of having to pay back funds to CMS. In Model 4, the lone “prospective” setup, there is a single bundled payment up front “and you live and die by that money,” Dr. Aguirre says. “If it costs you a lot more to provide the service, it’s a true risk arrangement where you take a loss. Of course, if you have reduced costs by providing services a little more efficiently and you’ve saved a few dollars, you get to remain with those dollars.”

Dr. Aguirre also notes that of the four current models, Model 3 is the only one available directly to individual providers or HM groups as a risk-bearing entity, and only for post-acute-care services.

CMMI is expected to introduce at least a few more models in the coming months.

For more about CMS' bundling initiatives, visit our website.

An FDA advisory panel has recommended the approval of rivaroxaban (Xarelto) for stroke prevention in patients with non-valvular atrial fibrillation, but the panelists raised questions about the methodology of the trial that compared the drug to the gold standard, warfarin (Coumadin).

A final decision on the drug is expected in November.

Rivaroxaban has been developed as a once-a-day oral medication that prevents clotting by inhibiting factor Xa, a key component in the generation of thrombin. It is one medication in a line of drugs trying to position themselves to replace warfarin, which has many contraindications and requires frequent blood draws for monitoring; the new drugs would not require frequent blood draws.

Panelists questioned whether ROCKET-AF—the trial that compared rivaroxaban to warfarin—was sufficient to show noninferiority, as only 55% of the patients on warfarin had international normalized ratio (INR) levels needed for stroke prevention.

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says that rivaroxaban “will be an option for AF, but probably not my first choice.”

Another oral warfarin alternative—dabigatran, which inhibits thrombin—is already available, he notes. And dabigatran was found to be superior to warfarin, while rivaroxaban was only found to be noninferior. But Dr. Jenkins also notes that dabigatran and rivaroxaban have not been compared head-to-head.

“The low percent of therapeutic INRs in ROCKET-AF does concern me,” Dr. Jenkins adds, “but we have to remember that the patients who will benefit the most from these medications are the ones with difficult-to-control INRs anyway.”

He also explains that patients now doing well on warfarin don’t have a “great reason” to boost their costs by trying another drug.

An FDA advisory panel has recommended the approval of rivaroxaban (Xarelto) for stroke prevention in patients with non-valvular atrial fibrillation, but the panelists raised questions about the methodology of the trial that compared the drug to the gold standard, warfarin (Coumadin).

A final decision on the drug is expected in November.

Rivaroxaban has been developed as a once-a-day oral medication that prevents clotting by inhibiting factor Xa, a key component in the generation of thrombin. It is one medication in a line of drugs trying to position themselves to replace warfarin, which has many contraindications and requires frequent blood draws for monitoring; the new drugs would not require frequent blood draws.

Panelists questioned whether ROCKET-AF—the trial that compared rivaroxaban to warfarin—was sufficient to show noninferiority, as only 55% of the patients on warfarin had international normalized ratio (INR) levels needed for stroke prevention.

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says that rivaroxaban “will be an option for AF, but probably not my first choice.”

Another oral warfarin alternative—dabigatran, which inhibits thrombin—is already available, he notes. And dabigatran was found to be superior to warfarin, while rivaroxaban was only found to be noninferior. But Dr. Jenkins also notes that dabigatran and rivaroxaban have not been compared head-to-head.

“The low percent of therapeutic INRs in ROCKET-AF does concern me,” Dr. Jenkins adds, “but we have to remember that the patients who will benefit the most from these medications are the ones with difficult-to-control INRs anyway.”

He also explains that patients now doing well on warfarin don’t have a “great reason” to boost their costs by trying another drug.

An FDA advisory panel has recommended the approval of rivaroxaban (Xarelto) for stroke prevention in patients with non-valvular atrial fibrillation, but the panelists raised questions about the methodology of the trial that compared the drug to the gold standard, warfarin (Coumadin).

A final decision on the drug is expected in November.

Rivaroxaban has been developed as a once-a-day oral medication that prevents clotting by inhibiting factor Xa, a key component in the generation of thrombin. It is one medication in a line of drugs trying to position themselves to replace warfarin, which has many contraindications and requires frequent blood draws for monitoring; the new drugs would not require frequent blood draws.

Panelists questioned whether ROCKET-AF—the trial that compared rivaroxaban to warfarin—was sufficient to show noninferiority, as only 55% of the patients on warfarin had international normalized ratio (INR) levels needed for stroke prevention.

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says that rivaroxaban “will be an option for AF, but probably not my first choice.”

Another oral warfarin alternative—dabigatran, which inhibits thrombin—is already available, he notes. And dabigatran was found to be superior to warfarin, while rivaroxaban was only found to be noninferior. But Dr. Jenkins also notes that dabigatran and rivaroxaban have not been compared head-to-head.

“The low percent of therapeutic INRs in ROCKET-AF does concern me,” Dr. Jenkins adds, “but we have to remember that the patients who will benefit the most from these medications are the ones with difficult-to-control INRs anyway.”

He also explains that patients now doing well on warfarin don’t have a “great reason” to boost their costs by trying another drug.

LISBON – Although microcirculation in cardiac surgery patients is impaired during the first few hours of admission to the intensive care unit, the degree of impairment was not great enough to affect the accuracy of continuous glucose monitors in a prospective, observational study of 60 patients.

Hyperglycemia, hypoglycemia, and glucose hypervariability are all associated with increased mortality in critically ill patients following cardiac surgery. Continuous glucose monitoring (CGM) is a potential alternative to frequent, time-consuming fingerstick glucose measurements, and can provide more information about glucose trends. However, the accuracy of these systems in critically ill patients has been uncertain, said Dr. J. Hans DeVries, an endocrinologist at the University of Amsterdam.

Now, "these results support CGM use in cardiac surgery patients, with quite good sensor accuracy in patients with a low severity of illness," he said at the annual meeting of the European Association for the Study of Diabetes (EASD).

The patients had a mean age of 65 years, and 48 of the 60 were male. Nearly a third (27%) had diabetes. Thirty-two (53%) of the patients were undergoing only coronary artery bypass surgery, 16 (27%) were having just valve surgery, and 12 (20%) had both procedures. Their APACHE score predicting mortality was low, 0.01. Total ICU stay was 23 hours. Hemodynamic parameters were fairly good, with a microcirculatory function index of 2.8 (out of 3.0). The proportion of perfused vessels was high, 0.97. However, the patients’ peripheral temperature was low, 32.8 °C.

Two sensors – the Medtronic Guardian REAL-Time and the Abbott FreeStyle Navigator – were placed subcutaneously in the abdominal wall of each patient prior to surgery. The Navigator performed slightly better than did the Guardian. Microcirculation was measured by microvascular flow index (MFI), perfused vessel density (PVD), and proportion of perfused vessels (PPV) using sublingual sidestream dark-field (SDF) imaging; and tissue oxygenation (StO₂) was obtained with near-infrared spectroscopy.

While StO₂ and PVD were impaired in the first hours after surgery, at no point were any microcirculatory parameters significantly associated with sensor accuracy. For the Navigator CGM, lower peripheral temperature and higher APACHE IV scores were significantly associated with decreased sensor accuracy (P values of .003 and less than .001, respectively). For the Guardian, lower peripheral temperature was significantly associated with decreased sensor accuracy (P = .048).

"Further studies are needed to assess the influence of microcirculation on sensor accuracy in more severely ill patients, such as those with sepsis," Dr. DeVries concluded.

The study was supported by the EASD’s European Foundation for the Study of Diabetes. Dr. DeVries has received research support from, and is on the speakers’ bureau for Dexcom, Abbott, and Medtronic.

LISBON – Although microcirculation in cardiac surgery patients is impaired during the first few hours of admission to the intensive care unit, the degree of impairment was not great enough to affect the accuracy of continuous glucose monitors in a prospective, observational study of 60 patients.

Hyperglycemia, hypoglycemia, and glucose hypervariability are all associated with increased mortality in critically ill patients following cardiac surgery. Continuous glucose monitoring (CGM) is a potential alternative to frequent, time-consuming fingerstick glucose measurements, and can provide more information about glucose trends. However, the accuracy of these systems in critically ill patients has been uncertain, said Dr. J. Hans DeVries, an endocrinologist at the University of Amsterdam.

Now, "these results support CGM use in cardiac surgery patients, with quite good sensor accuracy in patients with a low severity of illness," he said at the annual meeting of the European Association for the Study of Diabetes (EASD).

The patients had a mean age of 65 years, and 48 of the 60 were male. Nearly a third (27%) had diabetes. Thirty-two (53%) of the patients were undergoing only coronary artery bypass surgery, 16 (27%) were having just valve surgery, and 12 (20%) had both procedures. Their APACHE score predicting mortality was low, 0.01. Total ICU stay was 23 hours. Hemodynamic parameters were fairly good, with a microcirculatory function index of 2.8 (out of 3.0). The proportion of perfused vessels was high, 0.97. However, the patients’ peripheral temperature was low, 32.8 °C.

Two sensors – the Medtronic Guardian REAL-Time and the Abbott FreeStyle Navigator – were placed subcutaneously in the abdominal wall of each patient prior to surgery. The Navigator performed slightly better than did the Guardian. Microcirculation was measured by microvascular flow index (MFI), perfused vessel density (PVD), and proportion of perfused vessels (PPV) using sublingual sidestream dark-field (SDF) imaging; and tissue oxygenation (StO₂) was obtained with near-infrared spectroscopy.

While StO₂ and PVD were impaired in the first hours after surgery, at no point were any microcirculatory parameters significantly associated with sensor accuracy. For the Navigator CGM, lower peripheral temperature and higher APACHE IV scores were significantly associated with decreased sensor accuracy (P values of .003 and less than .001, respectively). For the Guardian, lower peripheral temperature was significantly associated with decreased sensor accuracy (P = .048).

"Further studies are needed to assess the influence of microcirculation on sensor accuracy in more severely ill patients, such as those with sepsis," Dr. DeVries concluded.

The study was supported by the EASD’s European Foundation for the Study of Diabetes. Dr. DeVries has received research support from, and is on the speakers’ bureau for Dexcom, Abbott, and Medtronic.

LISBON – Although microcirculation in cardiac surgery patients is impaired during the first few hours of admission to the intensive care unit, the degree of impairment was not great enough to affect the accuracy of continuous glucose monitors in a prospective, observational study of 60 patients.

Hyperglycemia, hypoglycemia, and glucose hypervariability are all associated with increased mortality in critically ill patients following cardiac surgery. Continuous glucose monitoring (CGM) is a potential alternative to frequent, time-consuming fingerstick glucose measurements, and can provide more information about glucose trends. However, the accuracy of these systems in critically ill patients has been uncertain, said Dr. J. Hans DeVries, an endocrinologist at the University of Amsterdam.

Now, "these results support CGM use in cardiac surgery patients, with quite good sensor accuracy in patients with a low severity of illness," he said at the annual meeting of the European Association for the Study of Diabetes (EASD).

The patients had a mean age of 65 years, and 48 of the 60 were male. Nearly a third (27%) had diabetes. Thirty-two (53%) of the patients were undergoing only coronary artery bypass surgery, 16 (27%) were having just valve surgery, and 12 (20%) had both procedures. Their APACHE score predicting mortality was low, 0.01. Total ICU stay was 23 hours. Hemodynamic parameters were fairly good, with a microcirculatory function index of 2.8 (out of 3.0). The proportion of perfused vessels was high, 0.97. However, the patients’ peripheral temperature was low, 32.8 °C.

Two sensors – the Medtronic Guardian REAL-Time and the Abbott FreeStyle Navigator – were placed subcutaneously in the abdominal wall of each patient prior to surgery. The Navigator performed slightly better than did the Guardian. Microcirculation was measured by microvascular flow index (MFI), perfused vessel density (PVD), and proportion of perfused vessels (PPV) using sublingual sidestream dark-field (SDF) imaging; and tissue oxygenation (StO₂) was obtained with near-infrared spectroscopy.

While StO₂ and PVD were impaired in the first hours after surgery, at no point were any microcirculatory parameters significantly associated with sensor accuracy. For the Navigator CGM, lower peripheral temperature and higher APACHE IV scores were significantly associated with decreased sensor accuracy (P values of .003 and less than .001, respectively). For the Guardian, lower peripheral temperature was significantly associated with decreased sensor accuracy (P = .048).

"Further studies are needed to assess the influence of microcirculation on sensor accuracy in more severely ill patients, such as those with sepsis," Dr. DeVries concluded.

The study was supported by the EASD’s European Foundation for the Study of Diabetes. Dr. DeVries has received research support from, and is on the speakers’ bureau for Dexcom, Abbott, and Medtronic.

Approximately 95% of visits related to medication poisoning in children younger than 5 years are caused by self-ingestion, based on data from nearly 500,000 emergency visits during 2001-2008, according to a study published online Sept. 16 in the Journal of Pediatrics.

"If we are to make progress in reducing childhood injury from pharmaceutical poisoning, we need to better understand the epidemic," said Dr. G. Randall Bond of the University of Cincinnati and colleagues.

The researchers reviewed case information from 453,599 children aged 5 years and younger who visited emergency departments due to possible medication poisoning via ingestion of a single product. Data were taken from the American Association of Poison Control Centers’ National Poison Data System, an electronic database of all calls to the organization’s member centers (J. Pediatr. 2011 Sept. 16 [doi:10.1016/j.jpeds.2011.07.042]).

©PhotoDisk

Of the self-ingested poisonings, prescription products accounted for the largest percentage of ED visits (55%), hospital admissions (76%), and significant injuries (71%).

Opioid analgesics had the greatest increase in impact on health care resources during the study period – ED visits increased by 101%, injury rates increased by 92%, and hospital admission rates increased by 86%.

The findings were limited by the self-reported nature of the cases, but they support data from previous studies on the increasing numbers of emergency department visits by young children due to medication poisoning, Dr. Bond and his coauthors said. "The most likely explanation for these observations is a rise in the number of medications in the environment of small children," they noted.

These medications may be more accessible to children in the home because the number of opioid analgesic prescriptions has increased, according to data from the U.S. Drug Enforcement Administration’s database, the researchers noted.

When it comes to preventing medication poisonings, "the results of this study suggest that focus should shift to self-ingestion and prescription products," the researchers said. "The largest potential benefits would come from a shift in attention to packaging design changes that reduce the quantity a child could quickly and easily access in a self-ingestion episode," they added.

Of 90 unintentional deaths recorded in the database, 66 were ingestion related. Of these, opioid analgesic and cough medicines accounted for the most deaths (20).

Another recent study by Dr. Gary M. Vilke of the University of California, San Diego and colleagues provided a breakdown of more than 40,000 paramedic transport calls related to poisonings in children younger than 5 years between 2000 and 2007 (J. Emerg. Med. 2011;41:265-9).

In this retrospective study, more than half of the poisonings were due to ingestion of prescription or over-the-counter medications (56%). In addition, medications made up a majority of the poisonings in each age group: less than 1 year (40%), 1 year (46%), 2 years (66%), 3 years (68%), and 4 years (60%). The researchers also noted that 10% of the poisonings were caused by cosmetics. This study was limited by the use of a preexisting database and the inclusion only of cases in which poisoning was the chief complaint.

However, the findings reinforce the need for better education about the poisoning potential of household medications, as shown in the study by Dr. Bond and colleagues.

None of the researchers in either study had any financial conflicts to disclose.

Approximately 95% of visits related to medication poisoning in children younger than 5 years are caused by self-ingestion, based on data from nearly 500,000 emergency visits during 2001-2008, according to a study published online Sept. 16 in the Journal of Pediatrics.

"If we are to make progress in reducing childhood injury from pharmaceutical poisoning, we need to better understand the epidemic," said Dr. G. Randall Bond of the University of Cincinnati and colleagues.

The researchers reviewed case information from 453,599 children aged 5 years and younger who visited emergency departments due to possible medication poisoning via ingestion of a single product. Data were taken from the American Association of Poison Control Centers’ National Poison Data System, an electronic database of all calls to the organization’s member centers (J. Pediatr. 2011 Sept. 16 [doi:10.1016/j.jpeds.2011.07.042]).

©PhotoDisk

Of the self-ingested poisonings, prescription products accounted for the largest percentage of ED visits (55%), hospital admissions (76%), and significant injuries (71%).

Opioid analgesics had the greatest increase in impact on health care resources during the study period – ED visits increased by 101%, injury rates increased by 92%, and hospital admission rates increased by 86%.

The findings were limited by the self-reported nature of the cases, but they support data from previous studies on the increasing numbers of emergency department visits by young children due to medication poisoning, Dr. Bond and his coauthors said. "The most likely explanation for these observations is a rise in the number of medications in the environment of small children," they noted.

These medications may be more accessible to children in the home because the number of opioid analgesic prescriptions has increased, according to data from the U.S. Drug Enforcement Administration’s database, the researchers noted.

When it comes to preventing medication poisonings, "the results of this study suggest that focus should shift to self-ingestion and prescription products," the researchers said. "The largest potential benefits would come from a shift in attention to packaging design changes that reduce the quantity a child could quickly and easily access in a self-ingestion episode," they added.

Of 90 unintentional deaths recorded in the database, 66 were ingestion related. Of these, opioid analgesic and cough medicines accounted for the most deaths (20).

Another recent study by Dr. Gary M. Vilke of the University of California, San Diego and colleagues provided a breakdown of more than 40,000 paramedic transport calls related to poisonings in children younger than 5 years between 2000 and 2007 (J. Emerg. Med. 2011;41:265-9).

In this retrospective study, more than half of the poisonings were due to ingestion of prescription or over-the-counter medications (56%). In addition, medications made up a majority of the poisonings in each age group: less than 1 year (40%), 1 year (46%), 2 years (66%), 3 years (68%), and 4 years (60%). The researchers also noted that 10% of the poisonings were caused by cosmetics. This study was limited by the use of a preexisting database and the inclusion only of cases in which poisoning was the chief complaint.

However, the findings reinforce the need for better education about the poisoning potential of household medications, as shown in the study by Dr. Bond and colleagues.

None of the researchers in either study had any financial conflicts to disclose.

Approximately 95% of visits related to medication poisoning in children younger than 5 years are caused by self-ingestion, based on data from nearly 500,000 emergency visits during 2001-2008, according to a study published online Sept. 16 in the Journal of Pediatrics.

"If we are to make progress in reducing childhood injury from pharmaceutical poisoning, we need to better understand the epidemic," said Dr. G. Randall Bond of the University of Cincinnati and colleagues.

The researchers reviewed case information from 453,599 children aged 5 years and younger who visited emergency departments due to possible medication poisoning via ingestion of a single product. Data were taken from the American Association of Poison Control Centers’ National Poison Data System, an electronic database of all calls to the organization’s member centers (J. Pediatr. 2011 Sept. 16 [doi:10.1016/j.jpeds.2011.07.042]).

©PhotoDisk

Of the self-ingested poisonings, prescription products accounted for the largest percentage of ED visits (55%), hospital admissions (76%), and significant injuries (71%).

Opioid analgesics had the greatest increase in impact on health care resources during the study period – ED visits increased by 101%, injury rates increased by 92%, and hospital admission rates increased by 86%.

The findings were limited by the self-reported nature of the cases, but they support data from previous studies on the increasing numbers of emergency department visits by young children due to medication poisoning, Dr. Bond and his coauthors said. "The most likely explanation for these observations is a rise in the number of medications in the environment of small children," they noted.

These medications may be more accessible to children in the home because the number of opioid analgesic prescriptions has increased, according to data from the U.S. Drug Enforcement Administration’s database, the researchers noted.

When it comes to preventing medication poisonings, "the results of this study suggest that focus should shift to self-ingestion and prescription products," the researchers said. "The largest potential benefits would come from a shift in attention to packaging design changes that reduce the quantity a child could quickly and easily access in a self-ingestion episode," they added.

Of 90 unintentional deaths recorded in the database, 66 were ingestion related. Of these, opioid analgesic and cough medicines accounted for the most deaths (20).

Another recent study by Dr. Gary M. Vilke of the University of California, San Diego and colleagues provided a breakdown of more than 40,000 paramedic transport calls related to poisonings in children younger than 5 years between 2000 and 2007 (J. Emerg. Med. 2011;41:265-9).

In this retrospective study, more than half of the poisonings were due to ingestion of prescription or over-the-counter medications (56%). In addition, medications made up a majority of the poisonings in each age group: less than 1 year (40%), 1 year (46%), 2 years (66%), 3 years (68%), and 4 years (60%). The researchers also noted that 10% of the poisonings were caused by cosmetics. This study was limited by the use of a preexisting database and the inclusion only of cases in which poisoning was the chief complaint.

However, the findings reinforce the need for better education about the poisoning potential of household medications, as shown in the study by Dr. Bond and colleagues.

None of the researchers in either study had any financial conflicts to disclose.

A U.S. District Court judge has granted a preliminary injunction that stops Florida from enforcing a new law barring physicians from asking their patients about firearms ownership, saying that the law may be unconstitutional and has a good chance of being overturned.

The injunction, granted Sept. 14 by Judge Marcia Cooke, immediately prevents the state from pursuing disciplinary action against physicians who inquire about firearms in the home and counsel on firearms-injury prevention.

The decision won praise from the American Academy of Pediatrics, which has fought the law.

"The AAP is pleased the court recognized the confidential nature of the physician-patient relationship and the critical importance of this counseling, which is a cornerstone of pediatric care," Dr. O. Marion Burton, AAP president, said in a statement. "Today’s court victory ensures that important conversations about firearm safety can continue to take place between doctors and patients."

The Florida law, passed last spring and signed by Gov. Rick Scott (R) in June, forbids licensed health care practitioners from asking about gun ownership unless the practitioner believes "in good faith" that the information is relevant to patients’ and family members’ medical care or safety. Under the law, physicians and other health care practitioners also cannot record information on firearms in patients’ medical records.

Violators of the law could be subject to state medical board disciplinary action and sanctions.

The Florida chapters of the AAP, the American College of Physicians, and the American Academy of Family Physicians, along with six individual Florida physicians, filed suit in June against the law, saying it substantially curtails their First Amendment rights to exchange information with patients about gun safety. The judge agreed.

"Plaintiffs state that, as a result of the law, they are no longer (i) asking patients about firearm ownership, (ii) following up on routine questions regarding firearm ownership, (iii) providing patient intake questionnaires that include questions about firearms, or (iv) orally counseling patients about firearm safety," Judge Cooke wrote in her injunction.

Proponents of the Florida law have argued that it represents a Second Amendment issue involving the right to bear arms. However, Judge Cooke disagreed, calling it a First Amendment – or freedom of speech – issue instead.

"A practitioner who counsels a patient on firearm safety, even when entirely irrelevant to medical care or safety, does not affect nor interfere with the patient’s right to continue to own, possess, or use firearms," she wrote.

A U.S. District Court judge has granted a preliminary injunction that stops Florida from enforcing a new law barring physicians from asking their patients about firearms ownership, saying that the law may be unconstitutional and has a good chance of being overturned.

The injunction, granted Sept. 14 by Judge Marcia Cooke, immediately prevents the state from pursuing disciplinary action against physicians who inquire about firearms in the home and counsel on firearms-injury prevention.

The decision won praise from the American Academy of Pediatrics, which has fought the law.

"The AAP is pleased the court recognized the confidential nature of the physician-patient relationship and the critical importance of this counseling, which is a cornerstone of pediatric care," Dr. O. Marion Burton, AAP president, said in a statement. "Today’s court victory ensures that important conversations about firearm safety can continue to take place between doctors and patients."

The Florida law, passed last spring and signed by Gov. Rick Scott (R) in June, forbids licensed health care practitioners from asking about gun ownership unless the practitioner believes "in good faith" that the information is relevant to patients’ and family members’ medical care or safety. Under the law, physicians and other health care practitioners also cannot record information on firearms in patients’ medical records.

Violators of the law could be subject to state medical board disciplinary action and sanctions.

The Florida chapters of the AAP, the American College of Physicians, and the American Academy of Family Physicians, along with six individual Florida physicians, filed suit in June against the law, saying it substantially curtails their First Amendment rights to exchange information with patients about gun safety. The judge agreed.

"Plaintiffs state that, as a result of the law, they are no longer (i) asking patients about firearm ownership, (ii) following up on routine questions regarding firearm ownership, (iii) providing patient intake questionnaires that include questions about firearms, or (iv) orally counseling patients about firearm safety," Judge Cooke wrote in her injunction.

Proponents of the Florida law have argued that it represents a Second Amendment issue involving the right to bear arms. However, Judge Cooke disagreed, calling it a First Amendment – or freedom of speech – issue instead.

"A practitioner who counsels a patient on firearm safety, even when entirely irrelevant to medical care or safety, does not affect nor interfere with the patient’s right to continue to own, possess, or use firearms," she wrote.

A U.S. District Court judge has granted a preliminary injunction that stops Florida from enforcing a new law barring physicians from asking their patients about firearms ownership, saying that the law may be unconstitutional and has a good chance of being overturned.

The injunction, granted Sept. 14 by Judge Marcia Cooke, immediately prevents the state from pursuing disciplinary action against physicians who inquire about firearms in the home and counsel on firearms-injury prevention.

The decision won praise from the American Academy of Pediatrics, which has fought the law.

"The AAP is pleased the court recognized the confidential nature of the physician-patient relationship and the critical importance of this counseling, which is a cornerstone of pediatric care," Dr. O. Marion Burton, AAP president, said in a statement. "Today’s court victory ensures that important conversations about firearm safety can continue to take place between doctors and patients."

The Florida law, passed last spring and signed by Gov. Rick Scott (R) in June, forbids licensed health care practitioners from asking about gun ownership unless the practitioner believes "in good faith" that the information is relevant to patients’ and family members’ medical care or safety. Under the law, physicians and other health care practitioners also cannot record information on firearms in patients’ medical records.

Violators of the law could be subject to state medical board disciplinary action and sanctions.

The Florida chapters of the AAP, the American College of Physicians, and the American Academy of Family Physicians, along with six individual Florida physicians, filed suit in June against the law, saying it substantially curtails their First Amendment rights to exchange information with patients about gun safety. The judge agreed.

"Plaintiffs state that, as a result of the law, they are no longer (i) asking patients about firearm ownership, (ii) following up on routine questions regarding firearm ownership, (iii) providing patient intake questionnaires that include questions about firearms, or (iv) orally counseling patients about firearm safety," Judge Cooke wrote in her injunction.

Proponents of the Florida law have argued that it represents a Second Amendment issue involving the right to bear arms. However, Judge Cooke disagreed, calling it a First Amendment – or freedom of speech – issue instead.

"A practitioner who counsels a patient on firearm safety, even when entirely irrelevant to medical care or safety, does not affect nor interfere with the patient’s right to continue to own, possess, or use firearms," she wrote.

Listen to Dr. Farber

With our aging population, the challenges of meeting the unique needs of frail elderly patients will continue to mount. In the current issue of the Journal of Hospital Medicine, authors from Mount Sinai Medical Center in New York City report on their adaptation of the acute care for the elderly, or ACE, approach.¹ They found that by bringing geriatrics-focused, team-based care to the patient (instead of locating the patient only in the ACE unit), they were able to reduce costs by an average of $4,943 per patient.

And, beginning in year two of the study, when the team incorporated hospitalists into their model, the ACE team decreased length of stay (LOS) by 1.6 days per patient.

From ACE to MACE

Since the mid-1990s, studies have shown that the ACE unit model can be effective in meeting the unique needs of frail, elderly patients. But even at institutions where these geriatric-focused units have been established, hospitals might not have enough dedicated beds for every elderly patient.

“A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital,” says lead author Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile ACE Service at Mount Sinai.

Dr. Farber and his colleagues began their mobile ACE (MACE) approach in 2007. Their retrospective cohort study compared outcomes of 8,094 hospitalized elderly patients cared for in the traditional ACE, the general medical service, or the MACE over a three-year period. To compare ACE and MACE patient outcomes, they limited their study sample to patients who already had been seen as part of their outpatient geriatrics service. Besides the shorter LOS, the MACE model also realized a net savings of $2,081 in direct hospital costs, $9,37 in nursing costs, and $223 in pharmacy costs in year two.

The MACE team, comprised of a geriatrician-hospitalist, geriatric medicine fellow, social worker, and nurse coordinator, met daily or twice a day. The nurse coordinator identified and resolved complex family and living situations, and daily check-ins with the patients’ caregivers or family members ensured that care plans and discharge plans were clearly understood before the patient left the hospital, Dr. Farber explains.

A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital.

                                                                                                              —Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine, director, Mobile ACE Service, Mount Sinai Medical Center, New York City

Gathering pre-hospitalization history is facilitated by the linkage of the hospital’s electronic health record with that of the Mount Sinai outpatient geriatrics practice and the hospital’s affiliated nursing home. Dr. Farber admits the integrated system confers an advantage to the geriatrics service. But community-based hospitalists can increase their odds of having accurate pre-hospitalization information by concerted outreach to referral sources in their community, he says.

Commenting on the study’s results, Heidi Wald, MD, MSPH, associate professor of medicine in the division of healthcare policy research at the University of Colorado Denver School of Medicine, notes that “hospitalists are great at providing efficient care, and geriatricians are good at preserving function and mitigating harm, so it was only logical that hybrids of the two models might achieve both sets of aims.”

One model that she and her UC Denver colleagues have studied utilizes “geriatricized” hospitalists (through focused geriatrics and CME programs), which allows the physicians to feel comfortable managing the unique needs of these patients. She says that functional outcomes warrant attention in the next generation of studies in this area.

Dr. Farber’s colleague, William Hung, MD, is analyzing the data of a prospective, longitudinal study focusing on functional status and post-hospitalization follow-up.

Gretchen Henkel is a freelance writer based in southern California.

Reference

1. Farber JI, Korc-Grodzicki B, Du Q, Leipzig, RM, Siu, AL. Operational and quality outcomes of a mobile acute care for the elderly service. J Hosp Med. 2011;6(6):358-363.

Listen to Dr. Farber

With our aging population, the challenges of meeting the unique needs of frail elderly patients will continue to mount. In the current issue of the Journal of Hospital Medicine, authors from Mount Sinai Medical Center in New York City report on their adaptation of the acute care for the elderly, or ACE, approach.¹ They found that by bringing geriatrics-focused, team-based care to the patient (instead of locating the patient only in the ACE unit), they were able to reduce costs by an average of $4,943 per patient.

And, beginning in year two of the study, when the team incorporated hospitalists into their model, the ACE team decreased length of stay (LOS) by 1.6 days per patient.

From ACE to MACE

Since the mid-1990s, studies have shown that the ACE unit model can be effective in meeting the unique needs of frail, elderly patients. But even at institutions where these geriatric-focused units have been established, hospitals might not have enough dedicated beds for every elderly patient.

“A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital,” says lead author Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile ACE Service at Mount Sinai.

Dr. Farber and his colleagues began their mobile ACE (MACE) approach in 2007. Their retrospective cohort study compared outcomes of 8,094 hospitalized elderly patients cared for in the traditional ACE, the general medical service, or the MACE over a three-year period. To compare ACE and MACE patient outcomes, they limited their study sample to patients who already had been seen as part of their outpatient geriatrics service. Besides the shorter LOS, the MACE model also realized a net savings of $2,081 in direct hospital costs, $9,37 in nursing costs, and $223 in pharmacy costs in year two.

The MACE team, comprised of a geriatrician-hospitalist, geriatric medicine fellow, social worker, and nurse coordinator, met daily or twice a day. The nurse coordinator identified and resolved complex family and living situations, and daily check-ins with the patients’ caregivers or family members ensured that care plans and discharge plans were clearly understood before the patient left the hospital, Dr. Farber explains.

A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital.

                                                                                                              —Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine, director, Mobile ACE Service, Mount Sinai Medical Center, New York City

Gathering pre-hospitalization history is facilitated by the linkage of the hospital’s electronic health record with that of the Mount Sinai outpatient geriatrics practice and the hospital’s affiliated nursing home. Dr. Farber admits the integrated system confers an advantage to the geriatrics service. But community-based hospitalists can increase their odds of having accurate pre-hospitalization information by concerted outreach to referral sources in their community, he says.

Commenting on the study’s results, Heidi Wald, MD, MSPH, associate professor of medicine in the division of healthcare policy research at the University of Colorado Denver School of Medicine, notes that “hospitalists are great at providing efficient care, and geriatricians are good at preserving function and mitigating harm, so it was only logical that hybrids of the two models might achieve both sets of aims.”

One model that she and her UC Denver colleagues have studied utilizes “geriatricized” hospitalists (through focused geriatrics and CME programs), which allows the physicians to feel comfortable managing the unique needs of these patients. She says that functional outcomes warrant attention in the next generation of studies in this area.

Dr. Farber’s colleague, William Hung, MD, is analyzing the data of a prospective, longitudinal study focusing on functional status and post-hospitalization follow-up.

Gretchen Henkel is a freelance writer based in southern California.

Reference

1. Farber JI, Korc-Grodzicki B, Du Q, Leipzig, RM, Siu, AL. Operational and quality outcomes of a mobile acute care for the elderly service. J Hosp Med. 2011;6(6):358-363.

Listen to Dr. Farber

With our aging population, the challenges of meeting the unique needs of frail elderly patients will continue to mount. In the current issue of the Journal of Hospital Medicine, authors from Mount Sinai Medical Center in New York City report on their adaptation of the acute care for the elderly, or ACE, approach.¹ They found that by bringing geriatrics-focused, team-based care to the patient (instead of locating the patient only in the ACE unit), they were able to reduce costs by an average of $4,943 per patient.

And, beginning in year two of the study, when the team incorporated hospitalists into their model, the ACE team decreased length of stay (LOS) by 1.6 days per patient.

From ACE to MACE

Since the mid-1990s, studies have shown that the ACE unit model can be effective in meeting the unique needs of frail, elderly patients. But even at institutions where these geriatric-focused units have been established, hospitals might not have enough dedicated beds for every elderly patient.

“A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital,” says lead author Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine and director of the Mobile ACE Service at Mount Sinai.

Dr. Farber and his colleagues began their mobile ACE (MACE) approach in 2007. Their retrospective cohort study compared outcomes of 8,094 hospitalized elderly patients cared for in the traditional ACE, the general medical service, or the MACE over a three-year period. To compare ACE and MACE patient outcomes, they limited their study sample to patients who already had been seen as part of their outpatient geriatrics service. Besides the shorter LOS, the MACE model also realized a net savings of $2,081 in direct hospital costs, $9,37 in nursing costs, and $223 in pharmacy costs in year two.

The MACE team, comprised of a geriatrician-hospitalist, geriatric medicine fellow, social worker, and nurse coordinator, met daily or twice a day. The nurse coordinator identified and resolved complex family and living situations, and daily check-ins with the patients’ caregivers or family members ensured that care plans and discharge plans were clearly understood before the patient left the hospital, Dr. Farber explains.

A geographically based unit is difficult to accomplish when you have high occupancy rates in the hospital.

                                                                                                              —Jeffrey Farber, MD, assistant professor of geriatrics and palliative medicine, director, Mobile ACE Service, Mount Sinai Medical Center, New York City

Gathering pre-hospitalization history is facilitated by the linkage of the hospital’s electronic health record with that of the Mount Sinai outpatient geriatrics practice and the hospital’s affiliated nursing home. Dr. Farber admits the integrated system confers an advantage to the geriatrics service. But community-based hospitalists can increase their odds of having accurate pre-hospitalization information by concerted outreach to referral sources in their community, he says.

Commenting on the study’s results, Heidi Wald, MD, MSPH, associate professor of medicine in the division of healthcare policy research at the University of Colorado Denver School of Medicine, notes that “hospitalists are great at providing efficient care, and geriatricians are good at preserving function and mitigating harm, so it was only logical that hybrids of the two models might achieve both sets of aims.”

One model that she and her UC Denver colleagues have studied utilizes “geriatricized” hospitalists (through focused geriatrics and CME programs), which allows the physicians to feel comfortable managing the unique needs of these patients. She says that functional outcomes warrant attention in the next generation of studies in this area.

Dr. Farber’s colleague, William Hung, MD, is analyzing the data of a prospective, longitudinal study focusing on functional status and post-hospitalization follow-up.

Gretchen Henkel is a freelance writer based in southern California.

Reference

1. Farber JI, Korc-Grodzicki B, Du Q, Leipzig, RM, Siu, AL. Operational and quality outcomes of a mobile acute care for the elderly service. J Hosp Med. 2011;6(6):358-363.

Hospitalist Andrea Peterson, MD, of Norwalk Hospital in Norwalk, Conn., whose job involves educating hospitalized patients about their personal health, has found an additional channel for teaching health concepts: She cohosts "Health Talk," a half-hour local cable television show in Fairfield County.

Dr. Peterson, who started working at Norwalk in 2002 as the hospital's fourth hospitalist, cohosts "Health Talk" with the hospital's vice president and chief medical officer, Eric Mazur, MD. She first appeared on the show as a guest, discussing subjects of professional interest, such as end-of-life care, ethics, patient safety, and spirituality in medicine, then served later as fill-in host before becoming the permanent cohost.

"It's really fun. It's totally different than my day job," she says. "It can also be fatiguing—you have to be bright and energetic on a sustained basis."

Conversations on the air are different than interactions with patients, as the dead space of TV can be deadly, she says. "I had to learn, with the help of a media coach, to start asking the next question while the person is finishing the previous answer. But I've gotten to interact with colleagues in totally different ways and to meet patients with inspiring stories," she says.

The program tapes four shows one day a month. Each program is broadcast several times over the course of a week. Interview subjects are both doctors and patients, and most of the interactions are unscripted.

"Both Eric and I feel it is very important to have topics and discussions that are real and meaningful to people's health, bread-and-butter issues like diabetes, colon-cancer screening, strokes and MI, and medication safety," Dr. Peterson says. "We continually do smoking education. We're always telling people: Talk to your family about what's important to you. Appoint a healthcare surrogate. These are the same messages I give to my patients in the hospital," she says.

Think you may be interesting in hosting your own patient education program? Click here for a list of community and public access TV sites.

Hospitalist Andrea Peterson, MD, of Norwalk Hospital in Norwalk, Conn., whose job involves educating hospitalized patients about their personal health, has found an additional channel for teaching health concepts: She cohosts "Health Talk," a half-hour local cable television show in Fairfield County.

Dr. Peterson, who started working at Norwalk in 2002 as the hospital's fourth hospitalist, cohosts "Health Talk" with the hospital's vice president and chief medical officer, Eric Mazur, MD. She first appeared on the show as a guest, discussing subjects of professional interest, such as end-of-life care, ethics, patient safety, and spirituality in medicine, then served later as fill-in host before becoming the permanent cohost.

"It's really fun. It's totally different than my day job," she says. "It can also be fatiguing—you have to be bright and energetic on a sustained basis."

Conversations on the air are different than interactions with patients, as the dead space of TV can be deadly, she says. "I had to learn, with the help of a media coach, to start asking the next question while the person is finishing the previous answer. But I've gotten to interact with colleagues in totally different ways and to meet patients with inspiring stories," she says.

The program tapes four shows one day a month. Each program is broadcast several times over the course of a week. Interview subjects are both doctors and patients, and most of the interactions are unscripted.

"Both Eric and I feel it is very important to have topics and discussions that are real and meaningful to people's health, bread-and-butter issues like diabetes, colon-cancer screening, strokes and MI, and medication safety," Dr. Peterson says. "We continually do smoking education. We're always telling people: Talk to your family about what's important to you. Appoint a healthcare surrogate. These are the same messages I give to my patients in the hospital," she says.

Think you may be interesting in hosting your own patient education program? Click here for a list of community and public access TV sites.

Hospitalist Andrea Peterson, MD, of Norwalk Hospital in Norwalk, Conn., whose job involves educating hospitalized patients about their personal health, has found an additional channel for teaching health concepts: She cohosts "Health Talk," a half-hour local cable television show in Fairfield County.

Dr. Peterson, who started working at Norwalk in 2002 as the hospital's fourth hospitalist, cohosts "Health Talk" with the hospital's vice president and chief medical officer, Eric Mazur, MD. She first appeared on the show as a guest, discussing subjects of professional interest, such as end-of-life care, ethics, patient safety, and spirituality in medicine, then served later as fill-in host before becoming the permanent cohost.

"It's really fun. It's totally different than my day job," she says. "It can also be fatiguing—you have to be bright and energetic on a sustained basis."

Conversations on the air are different than interactions with patients, as the dead space of TV can be deadly, she says. "I had to learn, with the help of a media coach, to start asking the next question while the person is finishing the previous answer. But I've gotten to interact with colleagues in totally different ways and to meet patients with inspiring stories," she says.

The program tapes four shows one day a month. Each program is broadcast several times over the course of a week. Interview subjects are both doctors and patients, and most of the interactions are unscripted.

"Both Eric and I feel it is very important to have topics and discussions that are real and meaningful to people's health, bread-and-butter issues like diabetes, colon-cancer screening, strokes and MI, and medication safety," Dr. Peterson says. "We continually do smoking education. We're always telling people: Talk to your family about what's important to you. Appoint a healthcare surrogate. These are the same messages I give to my patients in the hospital," she says.

Think you may be interesting in hosting your own patient education program? Click here for a list of community and public access TV sites.

Clinical question: Is transcatheter aortic-valve replacement comparable to surgical valve replacement in high-operative-risk patients?

Background: In the randomized Placement of Aortic Transcatheter Valves (PARTNER) trial, patients who were not surgical candidates underwent transcatheter aortic-valve replacement, resulting in reduced symptoms and 20% improvement in one-year survival rates. Transcatheter valve replacement has not been compared to surgical replacement in high-operative-risk patients who remain candidates for surgical replacement.

Study design: Randomized controlled trial powered for noninferiority.

Setting: Twenty-five centers in the U.S., Canada, and Germany.

Synopsis: Six-hundred ninety-nine high-operative-risk patients with severe aortic stenosis were randomized to undergo transcatheter aortic-valve replacement or surgical replacement. In the intention-to-treat analysis, all-cause mortality rates were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (P=0.07) and 24.2% vs. 26.8% at one year (P=0.44). Rates of major stroke were 3.8% in the transcatheter group compared with 2.1% in the surgical group at 30 days (P=0.20) and 5.1% vs. 2.4% at one year (P=0.07).

The transcatheter group had a significantly higher rate of major vascular complications, but had lower rates of major bleeding and new onset-atrial fibrillation. At one year, improvement in cardiac symptoms and the six-minute-walk distance were not significantly different in the two groups.

Bottom line: In high-operative-risk patients with severe aortic stenosis, transcatheter and surgical aortic-valve replacement had similar mortality at 30 days and one year, but there were a few significant differences in periprocedural risks.

Citation: Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187-2198.

For more physician reviews of HM-related literature, visit our website.

Clinical question: Is transcatheter aortic-valve replacement comparable to surgical valve replacement in high-operative-risk patients?

Background: In the randomized Placement of Aortic Transcatheter Valves (PARTNER) trial, patients who were not surgical candidates underwent transcatheter aortic-valve replacement, resulting in reduced symptoms and 20% improvement in one-year survival rates. Transcatheter valve replacement has not been compared to surgical replacement in high-operative-risk patients who remain candidates for surgical replacement.

Study design: Randomized controlled trial powered for noninferiority.

Setting: Twenty-five centers in the U.S., Canada, and Germany.

Synopsis: Six-hundred ninety-nine high-operative-risk patients with severe aortic stenosis were randomized to undergo transcatheter aortic-valve replacement or surgical replacement. In the intention-to-treat analysis, all-cause mortality rates were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (P=0.07) and 24.2% vs. 26.8% at one year (P=0.44). Rates of major stroke were 3.8% in the transcatheter group compared with 2.1% in the surgical group at 30 days (P=0.20) and 5.1% vs. 2.4% at one year (P=0.07).

The transcatheter group had a significantly higher rate of major vascular complications, but had lower rates of major bleeding and new onset-atrial fibrillation. At one year, improvement in cardiac symptoms and the six-minute-walk distance were not significantly different in the two groups.

Bottom line: In high-operative-risk patients with severe aortic stenosis, transcatheter and surgical aortic-valve replacement had similar mortality at 30 days and one year, but there were a few significant differences in periprocedural risks.

Citation: Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187-2198.

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Clinical question: Is transcatheter aortic-valve replacement comparable to surgical valve replacement in high-operative-risk patients?

Background: In the randomized Placement of Aortic Transcatheter Valves (PARTNER) trial, patients who were not surgical candidates underwent transcatheter aortic-valve replacement, resulting in reduced symptoms and 20% improvement in one-year survival rates. Transcatheter valve replacement has not been compared to surgical replacement in high-operative-risk patients who remain candidates for surgical replacement.

Study design: Randomized controlled trial powered for noninferiority.

Setting: Twenty-five centers in the U.S., Canada, and Germany.

Synopsis: Six-hundred ninety-nine high-operative-risk patients with severe aortic stenosis were randomized to undergo transcatheter aortic-valve replacement or surgical replacement. In the intention-to-treat analysis, all-cause mortality rates were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (P=0.07) and 24.2% vs. 26.8% at one year (P=0.44). Rates of major stroke were 3.8% in the transcatheter group compared with 2.1% in the surgical group at 30 days (P=0.20) and 5.1% vs. 2.4% at one year (P=0.07).

The transcatheter group had a significantly higher rate of major vascular complications, but had lower rates of major bleeding and new onset-atrial fibrillation. At one year, improvement in cardiac symptoms and the six-minute-walk distance were not significantly different in the two groups.

Bottom line: In high-operative-risk patients with severe aortic stenosis, transcatheter and surgical aortic-valve replacement had similar mortality at 30 days and one year, but there were a few significant differences in periprocedural risks.

Citation: Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187-2198.

For more physician reviews of HM-related literature, visit our website.