Patient’s View: 10 Things I’d Like to Tell My Doctor, But Don’t


In response to the slideshow MedPage Today posted Monday, “10 Things Doctors Wish They Could Tell Their Patients, But Don’t,” we received the following reply from a patient’s perspective. The author is Marilyn Geiger, of Greenwich, Conn., who holds a law degree from Columbia University but describes herself primarily as a mother and grandmother with “no experience in medicine other than as a patient.”

1. My time is valuable, too. Stop overbooking, and at least give me the courtesy of an apology when you are running late.

2. If you find that patients are being rude to your office staff, try sending in a shill patient so that you can see how staff interacts with patients when you’re out of earshot.

3. Please don’t make me call the office three times before you call in a refill for that antihypertensive/proton pump inhibitor/levothyroxine that I’ve been on for years.

4. Your nurse has long fingernails, and I wonder if her hands are really clean.

5. I know electronic health records are the new thing, but it would be nice if you looked up from your computer once or twice while I am describing my symptoms.

6. Walk the talk. Don’t tell me to lose weight when you can barely button your white coat these days. Don’t you think I notice?

7. Yes, I know the drug rep is pretty, but it’s not fair to make me wait so that you can enjoy her attentions for a while longer.

8. If the phone menu at your office requires that I press more than two buttons to get where I need to be, it should be redesigned.

9. I am human. I am scared. What is routine to you is earth-shattering to me. I know that’s hard to understand after all your years in practice, but it’s true.

10. I appreciate you. If I didn’t, I would never make a second appointment.

Hospital Room Lighting May Worsen Your Mood and Pain.


Story at-a-glance

  • Hospital patients are exposed to insufficient levels of light, disrupting both their circadian rhythms and sleep cycles
  • Light-deprived patients had fragmented and low levels of sleep, and those with the lowest exposures to light during the day reported more depressed mood and fatigue
  • Inadequate bright-light exposure has a far-reaching impact on your most critical bodily functions, including your ability to heal
  • Exposure to night-time light may also hinder the production of the hormone melatonin, which is very important for immune health
  • If you or a loved one is confined to a hospital room, move to areas with brighter natural light as much as possible, or bring in some full-spectrum light bulbs, and wear an eye mask at night to block night-time artificial light exposures

Hopefully you have never spent much time in a hospital, but if you have you likely experienced frequent disruptions to your sleep.

Aside from the beeping machines and nightly checks from hospital staff, your room was probably dimly lit with artificial light both day and night — a major impediment to proper sleep and well-being.

As a new study in the Journal of Advanced Nursing1 revealed, the lighting in many hospital rooms may be so bad that it actually worsens patients’ sleep, mood and pain levels.

Hospital-Room Lighting May Lead to Disrupted Sleep Cycles, Increased Pain and Fatigue

The study found that, on average, hospital patients in the study were exposed to about 105 lux (a measure of light emission) daily. This is a very low level of light; for comparison, an office would generally provide about 500 lux and being outdoors on a sunny day could provide 100,000 lux.2

The rooms were so dimly lit that many hospital patients had trouble sleeping. Your body requires a minimum of 1,500 lux for 15 minutes a day just to maintain a normal sleep-wake cycle, but ideally it should be closer to 4,000 for healthful sleep.3

Not surprisingly, the researchers found that the patients’ sleep time was “fragmented and low,” with most averaging just four hours of sleep a night.

Those with the lowest exposures to light during the day also reported more depressed mood and fatigue than those exposed to more light. The researchers noted:4 “Low light exposure significantly predicted fatigue and total mood disturbance.”

Why You Need Exposure to Bright Light During the Day

When full-spectrum light enters your eyes, it not only goes to your visual centers enabling you to see, it also goes to your brain’s hypothalamus where it affects your entire body.

Your hypothalamus controls body temperature, hunger and thirst, water balance and blood pressure. Additionally, it controls your body’s master gland, the pituitary, which secretes many essential hormones, including those that influence your mood.

Exposure to full-spectrum lighting is actually one effective therapy used for treating depression, infection, and much more – so it’s not surprising that hospital patients deprived of such exposures had poorer moods and fatigue.

Studies have also shown that poor lighting in the workplace triggers headaches, stress, fatigue and strained watery eyes, not to mention inferior work production.

Conversely, companies that have switched to full-spectrum lights report improved employee morale, greater productivity, reduced errors and decreased absenteeism. Some experts even believe that “malillumination” is to light what malnutrition is to food.

In a hospital setting, this has serious ramifications, as patients are already under profound stress due to illness and may be further stressed by a lack of natural bright light.

Your ‘body clock’ is also housed in tiny centers located in your hypothalamus, controlling your body’s circadian rhythm. This light-sensitive rhythm is dependent on Mother Nature, with its natural cycles of light and darkness, to function optimally.

Consequently, anything that disrupts these rhythms, like inadequate sunlight exposure to your body (including your eyes), has a far-reaching impact on your body’s ability to function and, certainly, also on its ability to heal.

Nighttime Light Exposure is Also Detrimental

While the featured study didn’t focus specifically on hospital patients’ nighttime light exposures, they’re likely to be significant. Most hospital room doors remain ajar all night, allowing artificial light from the hall to flood the room. There are also lights on medical equipment and monitors, and if your room is not private you may also be exposed to light from a roommates’ television or bathroom trips.

This is important because just as your body requires bright-light exposure during the day, it requires pitch-blackness at night to function optimally – which is all the more critical in the case of a hospital stay when bodily self-healing is most needed.

When you turn on a light at night, you immediately send your brain misinformation about the light-dark cycle. The only thing your brain interprets light to be is day. Believing daytime has arrived, your biological clock instructs your pineal gland to immediately cease its production of the hormone melatonin – a significant blow to your health, especially if you’re ill, as melatonin produces a number of health benefits in terms of your immune system. It’s a powerful antioxidant and free radical scavenger that helps combat inflammation.

In fact, melatonin is so integral to your immune system that a lack of it causes your thymus gland, a critically important part of your immune system, to atrophy.5 In addition, melatonin helps you fall asleep and bestows a feeling of overall comfort and well being, and it has proven to have an impressive array of anti-cancer benefits.6 So unnaturally suppressing this essential hormone is the last thing that a recovering hospital patient needs.

If a Loved One is In the Hospital, Let the Daylight Shine In

The best way to get exposure to healthy full-spectrum light is to do it the way nature intended, by going out in the sun with your bare skin – and ‘bare’ eyes — exposed on a regular basis. If you or a loved one is confined to a hospital room, however, the next best option is to move to areas with brighter natural light as much as possible, or alternatively bring in some full-spectrum light bulbs.

At night, the opposite holds true. You should turn off lights as much as possible, keep the door closed and close the blinds on the window. Wearing an eye mask is another simple trick that can help to keep unwanted light exposures to a minimum if you’re spending the night in a hospital. Taken together, these are simple ways to boost mood and improve sleep and fatigue levels among hospitalized patients.

The Other Major Risk of Spending Time in a Hospital

No matter how important it is, poor lighting may be the least of your worries if you find yourself hospitalized, as once you’re hospitalized you’re immediately at risk for medical errors, which is actually a leading cause of death in the US. According to the most recent research7 into the cost of medical mistakes in terms of lives lost, 210,000 Americans are killed by preventable hospital errors each year.

When deaths related to diagnostic errors, errors of omission, and failure to follow guidelines are included, the number skyrockets to an estimated 440,000 preventable hospital deaths each year!

One of the best safeguards is to have someone there with you. Dr. Andrew Saul has written an entire book on the issue of safeguarding your health while hospitalized. Frequently, you’re going to be relatively debilitated, especially post-op when you’re under the influence of anesthesia, and you won’t have the opportunity to see clearly the types of processes that are going on.

For every medication given in the hospital, ask, “What is this medication? What is it for? What’s the dose?” Take notes. Ask questions. Building a relationship with the nurses can go a long way. Also, when they realize they’re going to be questioned, they’re more likely to go through that extra step of due diligence to make sure they’re getting it right—that’s human nature. Of course, knowing how to prevent disease so you can avoid hospitals in the first place is clearly your best bet. One of the best strategies on that end is to optimize your diet. You can get up to speed on that by reviewing my comprehensive Nutrition Plan.

It’s Important for Virtually Everyone to Optimize Light Exposure: 5 Top Tips

Getting back to the issue of lighting, this isn’t only an issue for hospital patients. Virtually everyone requires exposure to bright light during the day and darkness at night for optimal health. Toward that end, here are my top tips to optimize your light exposure on a daily (and nightly) basis:

1.    Get some sun in the morning, if possible. Your circadian system needs bright light to reset itself. Ten to 15 minutes of morning sunlight will send a strong message to your internal clock that day has arrived, making it less likely to be confused by weaker light signals during the night. More sunlight exposure is required as you age.

2.    Make sure you get BRIGHT sun exposure regularly. Remember, your pineal gland produces melatonin roughly in approximation to the contrast of bright sun exposure in the day and complete darkness at night. If you work indoors, make a point to get outdoors during your breaks.

3.    Avoid watching TV or using your computer in the evening, at least an hour or so before going to bed.These devices emit blue light, which tricks your brain into thinking it’s still daytime. Normally your brain starts secreting melatonin between 9 and 10 pm, and these devices emit light that may stifle that process.

4.    Sleep in complete darkness, or as close to it as possible. Even the slightest bit of light in your bedroom can disrupt your biological clock and your pineal gland’s melatonin production. This means that even the tiny glow from your clock radio could be interfering with your sleep, so cover your alarm clock up at night or get rid of it altogether. You may want to cover your windows with drapes or blackout shades, or wear an eye mask while you sleep.

5.    Install a low-wattage yellow, orange or red light bulb if you need a source of light for navigation at night.Light in these bandwidths does not shut down melatonin production in the way that white and blue bandwidth light does. Salt lamps are handy for this purpose.

 

 

 

 

New Recommendations for Hypertension Management Released.


New recommendations published online in the Journal of the American Medical AssociationExternal Link aim to provide guidance on the management of patients with hypertension. More specifically, the recommendations focus on when medication should be started in patients, the best choices for medications to begin treatment; and communicating achievable blood pressure goals to patients.

“Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults,” the report authors note.

The report, written by panel members appointed to the Eighth Joint National Committee, notes there is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg. However, given insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, the panel recommends a BP of less than 140/90 mm Hg for those groups. “The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years,” the report notes.

In general, the report authors note that the 140/90 mm Hg definition from Joint National Committee 7 “remains reasonable” and recommend that lifestyle interventions be used for everyone with blood pressures in this range. “For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized,” they said. “These lifestyle treatments have the potential to improve BP control and even reduce medication needs.”

Also in the report, the authors note there is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. Additionally, there is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes.

Moving forward, the authors point out that an algorithm included as part of the recommendations will facilitate implementation and be useful to busy clinicians. They also suggest that “the strong evidence base of this report be used to inform quality measures for the treatment of patients with hypertension.”

Practice guidelines are traditionally promulgated by the government or by learned medical professional societies. The JAMA paper is a report of a group experts in the field of hypertension, but it does not carry the endorsement of any organized body. Moving forward, these recommendations will be taken into account in the coming year as the ACC/AHA Task Force on Practice Guidelines moves forward with developing the collaborative model to update the national hypertension guidelines in partnership with the National Heart, Lung, and Blood Institute (NHLBI). According to the ACC and the American Heart Association (AHA), once a writing group is appointed, there will be an extensive science and evidence review process, followed by draft recommendations that will undergo a peer and stakeholder review. Once the review process is complete, the ACC/AHA and partnering organizations will publish the guidelines in 2015 for clinicians to follow as the national standard for hypertension prevention and treatment.

The ACC, AHA and the Centers for Disease Control and Prevention released a scientific advisory on the effective approach to hypertension in November that encourages use of enhanced, evidence-based, blood pressure treatment systems for providers, including standardization of protocols and algorithms, incentives for improved performance based on achieving and maintaining patients at blood pressure goals, and technology-facilitated clinical decision support and feedback.

Early Specialty Palliative Care — Translating Data in Oncology into Practice.


Palliative care suffers from an identity problem. Seventy percent of Americans describe themselves as “not at all knowledgeable” about palliative care, and most health care professionals believe it is synonymous with end-of-life care.1 This perception is not far from current medical practice, because specialty palliative care — administered by clinicians with expertise in palliative medicine — is predominantly offered through hospice care or inpatient consultation only after life-prolonging treatment has failed. Limiting specialty palliative care to those enrolled in hospice or admitted to the hospital ignores the majority of patients facing a serious illness, such as advanced cancer, who have physical and psychological symptoms throughout their disease. To ensure that patients receive the best care throughout their disease trajectory, we believe that palliative care should be initiated alongside standard medical care for patients with serious illnesses.

For palliative care to be used appropriately, clinicians, patients, and the general public must understand the fundamental differences between palliative care and hospice care. The Medicare hospice benefit provides hospice care exclusively to patients who are willing to forgo curative treatments and who have a physician-estimated life expectancy of 6 months or less.2 In contrast, palliative care is not limited by a physician’s estimate of life expectancy or a patient’s preference for curative medication or procedures. According to a field-tested definition developed by the Center to Advance Palliative Care and the American Cancer Society, “Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.”1 Several clinical trials have shown benefits of early specialty palliative care in patients with advanced cancer.3 The effect of early specialty palliative care in other patient populations is less well studied, but there are data suggesting a beneficial role in patients with multiple sclerosis4 and congestive heart failure.5,6

Although there are salient differences between hospice care and palliative care, notably the limitations on prognosis and use of curative therapies with hospice care, most palliative care is currently provided at the end of life. This perceived association between palliative care and end-of-life care has led to a marginalization of palliative care.1 Debates over “death panels,” physician-assisted suicide, and reimbursement for advance care planning have made policymakers reluctant to devote resources to initiatives perceived to be associated with “death and dying.” For example, National Institutes of Health allocations for research focused on palliative care remain far behind funding for procedure-oriented specialties.7 The practice and policy behind palliative care must be considered independently from end-of-life care. Palliative care should no longer be reserved exclusively for those who have exhausted options for life-prolonging therapies .Traditional versus Early Palliative Care.).

We present three separate cases — clinical, economic, and political — focused predominantly on data in patients with advanced cancer to show the value of earlier specialty palliative care. We then use these data to propose initial priorities for clinicians and policymakers to achieve early integration of palliative care across all populations with serious illness.

THE CLINICAL CASE

Several randomized studies involving patients with advanced cancer show that integrating specialty palliative care with standard oncology care leads to significant improvements in quality of life and care and possibly survival .Randomized Trials of Early Specialty Palliative Care Interventions in Patients with Cancer.).6,9-12 Patients with advanced cancer who receive palliative care consultations early in the course of their disease report better symptom control than those not receiving consultations.11,12 Several prospective trials have also shown that early palliative care improves patients’ quality of life.10-12 For example, patients with metastatic lung cancer who receive outpatient palliative care from the time of diagnosis and throughout the course of their illness report better quality of life and lower rates of depression than do controls.11,13

Initiating palliative care upon diagnosis of advanced cancer also improves patients’ understanding of their prognosis.14 Patients with serious illness often feel that their doctors do not provide all available information about their illness and treatment options.1 These information gaps can lead patients to misunderstand their treatment goals. For example, recent studies show that the majority of patients with metastatic cancer incorrectly report that their cancer can be cured with chemotherapy or radiation.15,16 Palliative care clinicians can remedy this situation by helping patients develop a more accurate assessment of their prognosis.14Improved prognostic understanding may explain why patients with advanced cancer who receive early palliative care consultations are less likely to receive chemotherapy near the end of life than are controls.14,17

THE ECONOMIC CASE

Cost savings are never the primary intent of providing palliative care to patients with serious illnesses, for whom ensuring the best quality of life and care is paramount. Nevertheless, it is necessary to consider the financial consequences of serious illness, because 10% of the sickest Medicare beneficiaries account for nearly 60% of total program spending.18 The growing cost of hospital care is the main driver of the spending growth observed for seriously ill patients.19 Fortunately, the quality improvements offered by early specialty palliative care may also lead to lower total spending on inpatient health care.20Hospitals with specialty palliative care services have decreased lengths of stay, admissions to the intensive care unit, and pharmacy and laboratory expenses.9,21-23 One study estimated that inpatient palliative care consultations are associated with more than $2,500 in net cost savings per patient admission.23

Similarly, outpatient palliative care services have been estimated to reduce overall treatment costs for seriously ill patients by up to 33% per patient.6 Early outpatient palliative care achieves these savings by decreasing the need for acute care services, leading to fewer hospital admissions and emergency department visits.11,24 The site of death may be another mediator of savings, because patients receiving early specialized palliative care are more likely to forgo costly inpatient care at the end of life than are other patients.6 Outpatient palliative care may thus lower health care spending by reducing patients’ need for hospital and acute care. The goal of early palliative care, both in and out of the hospital, is to provide a better quality of life; cost savings through reduced resource use are an epiphenomenon of this better care.

THE POLITICAL CASE

These data show that earlier specialized palliative care services meet the “triple aim” of better health, improved care, and lower cost.25 Despite such positive outcomes, legislative efforts to support the delivery of palliative care have lagged behind clinical interest. High-profile and controversial legal cases, such as those of Terry Schiavo and Dr. Jack Kevorkian, have heightened public sensitivity about medical care perceived to hasten death. Similarly, the inflammatory language surrounding “death panels” that surfaced during the Affordable Care Act debate left legislators wary of addressing policies perceived as promoting end-of-life care.

However, policy momentum is now building, bolstered by evidence establishing the quality-of-life benefit of palliative care for patients with advanced cancer. Federal legislative proposals, including the Patient Centered Quality Care for Life Act and the Palliative Care and Hospice Education and Training Act, have built bipartisan support for federal and state legislation that addresses palliative care research, the palliative care workforce, and barriers to accessing care. These efforts foreshadow more legislative initiatives that prioritize quality of life and survivorship.

Although legislation is a key step toward changing policy regarding palliative care, the main impediment remains a matter of messaging. Reframing the policy and professional discussion around palliative care as a means to improve quality of life without decreasing survival is essential to make this advocacy agenda more politically tenable. More than 90% of Americans react favorably to a definition of palliative care that emphasizes it as “an extra layer of support” that is appropriate at “any stage in a serious illness.”1 Advocacy groups, practitioners, and researchers should use this language consistently to advance this effort to integrate palliative care earlier in illness.

SOLUTIONS TO MAKE THE TRANSITION

Although data to date support the use of early specialty palliative care for patients with advanced cancer, the clinical and economic benefits are likely to apply to other patient populations. Randomized trials of early palliative care have shown benefit for patients with chronic obstructive pulmonary disease, congestive heart failure, and multiple sclerosis.4,6,9 Further investigation of the role of early specialty palliative care in patients with other serious illnesses is clearly warranted. In addition, all clinicians caring for patients with serious illness, not just palliative care specialists, must be capable of practicing “primary palliative care,” which includes managing illness- and treatment-related symptoms to improve quality of life and assessing treatment preferences and prognostic understanding.26

Incentive Changes

To reinforce the practice of early palliative care for all serious illnesses, hospitals, insurance providers, and the government would need to provide practice and payment incentives for clinicians. Medicare reimbursement for clinicians to counsel patients about their goals and options for care throughout their illness is necessary to encourage and reinforce early palliative care. Unfortunately, congressional efforts to reimburse for this service have been unsuccessful. Hospital administrators have also identified several barriers to implementing consultative specialty palliative care teams, including limited institutional budgets, poor reimbursement, and few trained staff.27 Although public awareness of the clinical benefits of palliative care may itself drive hospital-level integration, increased reimbursement would most strongly convince hospitals and physicians to integrate primary and specialty palliative care into routine practice.

More broadly, reimbursement structures should encourage coordinated medical care that aligns treatments with patients’ goals. Health care systems that provide structured palliative care services in coordination with disease-centered treatment have enjoyed tremendous success. The Aetna Compassionate Care Program of early nurse-managed palliative care and advanced care planning alongside usual care has decreased hospital lengths of stay and admissions while decreasing costs at the end of life by 22%.28,29 The success of such initiatives should convince Medicare and commercial insurers to reimburse for palliative care services regardless of prognosis and treatment goals.

Educational Reform

Dedicated clinical exposure to seriously ill patients, in combination with structured didactic teaching, improves medical students’ attitudes toward palliative care.30 A study based on survey data from 1998 through 2006 from the Association of American Medical Colleges showed greater student exposure to palliative care training over the past decade.31 However, current curricula generally focus exclusively on care at the end of life. Instead, we believe that health professional schools should establish content areas in palliative care during the preclinical and clinical years and train students in managing symptoms, providing psychosocial support, and discussing prognosis and treatment preferences for all seriously ill patients. Furthermore, lawmakers should adjust the current cap on training positions in graduate medical education and increase funding for fellowship programs in palliative care to expand the palliative care workforce.

Expanding Hospital-Based Palliative Care Teams

Integrated palliative care requires patients to have access to palliative care services in the inpatient and outpatient settings, across both the acute and chronic phases of disease. Although hospital-based palliative care teams improve quality of care while reducing inpatient costs, their prevalence varies considerably according to geographic region and is quite low in some locations. Among adult-care hospitals with 50 or more beds, the statewide prevalence of inpatient palliative care teams ranges from 20 to 100% across the United States.32 Small, for-profit, and public hospitals are far less likely to have palliative care teams than large and nonprofit institutions.22 Hospital leaders should ensure that all hospitals have access to integrated palliative care services within the next decade. Data suggest that this trend has already begun: more than half of administrators at major cancer centers plan to increase palliative care professional recruitment in the short term.27 The American Hospital Association and Center to Advance Palliative Care have released guidelines advocating the use of specialist palliative care services for the management of complex conditions in inpatient settings.33 These efforts, coupled with strong external incentives such as Medicare Conditions of Participation and Joint Commission accreditation requirements, will reinforce hospital penetration of palliative care.

CONCLUSIONS

Early provision of specialty palliative care improves quality of life, lowers spending, and helps clarify treatment preferences and goals of care for patients with advanced cancer. However, widespread integration of palliative care with standard medical treatment remains unrealized, and more evidence is needed to show the potential gains of early palliative care in other populations. This will require improved public and professional awareness of the benefits of palliative care and coordinated action from advocacy groups, health professionals, educators, and policymakers. Patients who access earlier specialty palliative care have better clinical outcomes at potentially lower costs — a compelling message for providers, policymakers, and the general public.

Source: NEJM

 

 

One fifth of drips ‘are dangerous’


Nurse attending to drip

A fifth of patients on an intravenous drip develop complications because they are given the wrong levels of fluid, according to a review of guidance in England and Wales.

Too much fluid can cause heart failure and too little leads to kidney problems.

The National Institute for Health and Care Excellence (NICE) said doctors and nurses needed better drip training.

Patients’ groups said the scale of the problem was “staggering”.

Thousands of people each year need a drip in hospital. But NICE warns that staff are putting lives in danger due to a lack of education in managing intravenous drips.

It has developed new guidelines for the NHS in England and Wales.

Dr Mike Stroud, a gastroenterology consultant at Southampton University Hospitals NHS Trust, who developed the guidelines, said: “Doctors and other health professionals are not well educated in terms of what a patient needs and that is astonishing really.

“This needs to change.”

Drip chief

Hospitals will also be expected to appoint an “intravenous fluid champion” and patients’ drips will need to be managed and monitored more closely.

Katie Scales, a consultant nurse at Imperial College Healthcare NHS Trust, said: “The majority of patients who receive intravenous fluids do so without complications but this is not the case for every patient.

“This NICE guideline is an important lever for improvement and may ultimately help to save lives.”

Katherine Murphy, the chief executive of the Patients’ Association, said the guidelines were “very welcome” due to the “staggering” figure of one in five patients developing complications.

“It’s essential that all staff receive support and training in the administration of IV fluids and hospitals should ensure time is dedicated to this,” she added.

Dr Mike Durkin, director of patient safety at NHS England, said: “I welcome this new guidance.

“Hospitals across the country need to ensure that the recommendations are implemented as routine practice so that the clinical effectiveness of infusion fluids are maximised and any risks are minimised.”

Instead of the ER: Paramedics making house calls to chronic patients.


Emergency rooms — which can cost patients thousands of dollars each visit — have become the primary source of medical care for the uninsured and people with chronic illnesses.

A Minnesota health care provider is testing a new program in the hopes of reducing ER admissions and keeping people healthier: they’re sending paramedics on house calls to some of the area’s sickest patients who might otherwise end up in the ER.

The need for such out-of-the-box solutions is clear. In the last year, one in five Americans went to the ER at least once for an estimated 130 million visits. The cost of all those ER visits is staggering, considering that the price for treating some of the most common conditions can range from an average of $750 all the way up to $73,000.

“We don’t screen for insurance at the door,” said Dr. Joey Duren, an emergency physician with North Memorial Healthcare System in Minnesota. “So in our country now, a big thing is that the emergency department is a safety net for people who don’t have insurance.”

Patients with chronic conditions like asthma and diabetes can spiral out of control without regular monitoring and land in the ER multiple times in a single year. The number of repeat patients is often staggering; some of whom visit dozens of times each month, according to North Memorial’s chief medical officer, Dr. Kevin Croston.

“What’s really the biggest cost in health care are the chronic conditions where there are readmissions to the emergency department,” Duren said. “We realized we needed to create care that stopped that.”

That’s where house calls from the community paramedics came in. Since the program began last October paramedics have made more than 1,000 home visits, at a fraction of the cost for a trip to the ER. Although North Memorial doesn’t have data yet on the savings, officials believe the program will help reduce admissions.

“The role of this community paramedic is helping people get on top of their chronic disease processes so they aren’t getting so sick that they need to come to us in the emergency department,” Duren explained. “We’re controlling their diseases so they can be handled in an outpatient setting versus having to come here or be admitted to the hospital for multiple days because they’ve gotten so far behind in their insulin for their diabetes or their COPD has gotten out of control.”

Chris Anderson is among the first group of paramedics who were specially trained to make house calls. He quickly recognized the value of those home visits.

“It’s when you get to spend more time with [patients], you get to find out what’s going on, what’s truly bothering them, what they need the most help with,” Anderson said.

The house calls have been a life-saver for folks like 65-year-old Victoria Denbleyker, who suffers from multiple, hard-to-manage chronic conditions, like diabetes, congestive heart failure, and rheumatoid arthritis—problems that used to routinely send her to the ER.

With doctors, Denbleyker said, “you don’t have that much time to really talk to them, even if you get the maximum amount of time, which is half an hour. Sometimes there are too many things going on. “

Without consistent monitoring, Denbleyker’s condition can rapidly descend into the danger zone.

“My system can change in a heartbeat,” she said. “I never know what is coming next. So the fact that they know what is going on with me means a lot.”

The Minnesota project started last October. To figure out which patients might benefit from the program, the hospital searched for anyone who had used the ER nine or more times in a year.

Nine was “the number we had to land on for our own survival mode,” said North Memorial’s Croston.

Think that’s a lot?

“We’ve had some patients that were here 23 times in a month,” he said.

Croston said, “readmission rates are down for us as a health system, and that’s largely due to the fact that we’re intervening once they leave the hospital or once they leave the emergency department.”

Barb Andrews, who runs the program, says it’s a new way of thinking about health care.

“It gives us, as paramedics, an opportunity to be proactive rather than reactive,” she said. “The community paramedics empower [patients] to be able to manage their own health better in the home.”

And ultimately, she said, that can “keep them out of the hospital, keep them out of the nursing home.”

Nurse reveals the top 5 regrets people make on their deathbed.


For many years I worked in palliative care. My patients were those who had gone home to die. Some incredibly special times were shared. I was with them for the last three to twelve weeks of their lives. People grow a lot when they are faced with their own mortality..

stihl-deathbed-scene

I learnt never to underestimate someone’s capacity for growth. Some changes were phenomenal. Each experienced a variety of emotions, as expected, denial, fear, anger, remorse, more denial and eventually acceptance. Every single patient found their peace before they departed though, every one of them.

When questioned about any regrets they had or anything they would do differently, common themes surfaced again and again. Here are the most common five:

1. I wish I’d had the courage to live a life true to myself, not the life others expected of me.
This was the most common regret of all. When people realize that their life is almost over and look back clearly on it, it is easy to see how many dreams have gone unfulfilled. Most people had not honoured even a half of their dreams and had to die knowing that it was due to choices they had made, or not made.

It is very important to try and honour at least some of your dreams along the way. From the moment that you lose your health, it is too late. Health brings a freedom very few realise, until they no longer have it.

2. I wish I didn’t work so hard.
This came from every male patient that I nursed. They missed their children’s youth and their partner’s companionship. Women also spoke of this regret. But as most were from an older generation, many of the female patients had not been breadwinners. All of the men I nursed deeply regretted spending so much of their lives on the treadmill of a work existence.

By simplifying your lifestyle and making conscious choices along the way, it is possible to not need the income that you think you do. And by creating more space in your life, you become happier and more open to new opportunities, ones more suited to your new lifestyle.

3. I wish I’d had the courage to express my feelings.
Many people suppressed their feelings in order to keep peace with others. As a result, they settled for a mediocre existence and never became who they were truly capable of becoming. Manydeveloped illnesses relating to the bitterness and resentment they carried as a result.

We cannot control the reactions of others. However, although people may initially react when you change the way you are by speaking honestly, in the end it raises the relationship to a whole new and healthier level. Either that or it releases the unhealthy relationship from your life. Either way,you win.

4. I wish I had stayed in touch with my friends.
Often they would not truly realise the full benefits of old friends until their dying weeks and it was not always possible to track them down. Many had become so caught up in their own lives that they had let golden friendships slip by over the years. There were many deep regrets about not giving friendships the time and effort that they deserved. Everyone misses their friends when they are dying.

It is common for anyone in a busy lifestyle to let friendships slip. But when you are faced with your approaching death, the physical details of life fall away. People do want to get their financial affairs in order if possible. But it is not money or status that holds the true importance for them. They want to get things in order more for the benefit of those they love. Usually though, they are too ill and weary to ever manage this task. It is all comes down to love and relationships in the end. That is all that remains in the final weeks, love and relationships.

5. I wish that I had let myself be happier.
This is a surprisingly common one. Many did not realise until the end that happiness is a choice. They had stayed stuck in old patterns and habits. The so-called ‘comfort’ of familiarity overflowed into their emotions, as well as their physical lives. Fear of change had them pretending to others, and to their selves, that they were content. When deep within, they longed to laugh properly and have silliness in their life again. When you are on your deathbed, what  others think of you is a long way from your mind. How wonderful to be able to let go and smile again, long before you are dying..

Life is a choice. It is YOUR life. Choose consciously, choose wisely, choose honestly. Choose happine

 

Home Test for Pharyngitis May Reduce Unneeded Strep Cultures.


A patient-driven approach to streptococcal pharyngitis diagnosis using a new home test score might save on unnecessary physician visits, cultures, and treatment, according to a retrospective cohort study published online November 4 in the Annals of Internal Medicine. However, some experts are skeptical of the home score algorithm and of its potential cost-savings.

“Globally, group A streptococcal (GAS) pharyngitis affects hundreds of millions of persons each year,” write Andrew M. Fine, MD, MPH, from the Division of Emergency Medicine-Main 1, Boston Children’s Hospital in Massachusetts, and colleagues. “In the United States, more than 12 million persons make outpatient visits for pharyngitis; however, clinicians cannot differentiate GAS pharyngitis from other causes of acute pharyngitis (for example, viral) on the basis of a physical examination of the oropharynx.”

Most cases of sore throat are viral, rather than bacterial, and therefore are self-limiting and transient even without antibiotic treatment. To classify risk for GAS pharyngitis and guide management of adults with acute pharyngitis, the American College of Physicians and Centers for Disease Control and Prevention recommend use of clinical scores to identify low-risk patients. According to consensus guidelines, such patients should not be tested or treated for GAS pharyngitis.

The goal of this study was to help patients decide when to visit a clinician for evaluation of sore throat. The study sample consisted of 71,776 patients at least 15 years of age who were evaluated for pharyngitis from September 2006 to December 2008 at one of a national chain of retail health clinics.

Using information from patient-reported clinical variables, as well as local incidence of GAS pharyngitis, the investigators created a score and compared it with the Centor score and other traditional scores, using information from clinicians’ assessments. Clinical variables in the new score were fever, absence of cough, and age.

The investigators estimated outcomes if patients who were at least 15 years of age with sore throat did not visit a clinician when the new score indicated less than 10% likelihood of GAS pharyngitis, compared with being managed by clinicians following guidelines using the Centor score. The researchers suggest that following this strategy would avoid 230,000 clinician visits in the United States each year, and that 8500 patients with GAS pharyngitis who would have received antibiotics under clinician management would not receive antibiotics.

A limitation of this approach is current lack of availability of real-time information about the local incidence of GAS pharyngitis, which is needed to calculate the new score. Study limitations include retrospective design and reliance on self-report of symptoms.

“A patient-driven approach to pharyngitis diagnosis that uses this new score could save hundreds of thousands of visits annually by identifying patients at home who are unlikely to require testing or treatment,” the authors write.

Experts Question Limitations and Cost-Savings of the New Score

In an accompanying editorial, Edward L. Kaplan, MD, MMC, from the Department of Pediatrics, University of Minnesota Medical School in Minneapolis, warns of limitations of the new home score. These include overly broad age range, as GAS pharyngitis is rare in persons older than 50 years, and the assumption that GAS pharyngitis has even prevalence across communities.

Dr. Kaplan recommends stratification by age categories and notes that uncomplicated GAS pharyngitis has not been reportable to health departments for several decades in most states, making incidence difficult to determine. Other limitations include failure to account for potential effects of the decisions made by the multiple clinicians from more than 70 clinics attended by patients in this sample, and lack of differentiation of true GAS infection from upper respiratory tract “carriers” among adults.

“Until we have a proven cost-effective vaccine to protect against Streptococcus pyogenes, we cannot expect the magnitude of this medical and public health issue to decrease,” Dr. Kaplan writes. “Even if a cost-effective vaccine is developed, how it may affect true infections and the carrier state in children may be entirely different in adults. Fine and colleagues have proposed an interim approach, but there are surely others.”

In a second editorial, Robert M. Centor, MD, from the University of Alabama at Birmingham in Huntsville, questions the potential cost-savings if the new score were widely used. Alternative strategies to improve treatment and reduce costs include clinical assessment that eliminates testing for patients at low risk, as well as the use of generic antibiotics for those with GAS pharyngitis. He also warns that all guidelines and recommendations for GAS pharyngitis apply only to patients who have had symptoms for fewer than 3 days.

“If symptoms persist or worsen, then the patient no longer has acute pharyngitis; therefore, we should use a different diagnostic and therapeutic approach,” he writes.

Other questions posed by Dr. Centor include whether patients would actually download and use such a test before deciding whether to seek medical care for sore throat and why many physicians, clinics, and emergency departments do not follow published guidelines recommending against antibiotic use for patients with low probability of GAS pharyngitis.

“Although the goals [of this study] are admirable, the approach does not seem practical or cost-saving,” Dr. Centor concludes. “We have more practical strategies for decreasing costs for patients with sore throat.

Vedolizumab as Induction and Maintenance Therapy for Crohn’s Disease.


BACKGROUND

The efficacy of vedolizumab, an α4β7 integrin antibody, in Crohn’s disease is unknown.

METHODS

In an integrated study with separate induction and maintenance trials, we assessed intravenous vedolizumab therapy (300 mg) in adults with active Crohn’s disease. In the induction trial, 368 patients were randomly assigned to receive vedolizumab or placebo at weeks 0 and 2 (cohort 1), and 747 patients received open-label vedolizumab at weeks 0 and 2 (cohort 2); disease status was assessed at week 6. In the maintenance trial, 461 patients who had had a response to vedolizumab were randomly assigned to receive placebo or vedolizumab every 8 or 4 weeks until week 52.

RESULTS

At week 6, a total of 14.5% of the patients in cohort 1 who received vedolizumab and 6.8% who received placebo were in clinical remission (i.e., had a score on the Crohn’s Disease Activity Index [CDAI] of ≤150, with scores ranging from 0 to approximately 600 and higher scores indicating greater disease activity) (P=0.02); a total of 31.4% and 25.7% of the patients, respectively, had a CDAI-100 response (≥100-point decrease in the CDAI score) (P=0.23). Among patients in cohorts 1 and 2 who had a response to induction therapy, 39.0% and 36.4% of those assigned to vedolizumab every 8 weeks and every 4 weeks, respectively, were in clinical remission at week 52, as compared with 21.6% assigned to placebo (P<0.001 and P=0.004 for the two vedolizumab groups, respectively, vs. placebo). Antibodies against vedolizumab developed in 4.0% of the patients. Nasopharyngitis occurred more frequently, and headache and abdominal pain less frequently, in patients receiving vedolizumab than in patients receiving placebo. Vedolizumab, as compared with placebo, was associated with a higher rate of serious adverse events (24.4% vs. 15.3%), infections (44.1% vs. 40.2%), and serious infections (5.5% vs. 3.0%).

CONCLUSIONS

Vedolizumab-treated patients with active Crohn’s disease were more likely than patients receiving placebo to have a remission, but not a CDAI-100 response, at week 6; patients with a response to induction therapy who continued to receive vedolizumab (rather than switching to placebo) were more likely to be in remission at week 52. Adverse events were more common with vedolizumab.

Source: NEJM

Phase II study of dovitinib in patients with metastatic and/or unresectable gastrointestinal stromal tumours after failure of imatinib and sunitinib.


This prospective, phase II trial evaluated the efficacy and safety of dovitinib in patients with metastatic and/or unresectable gastrointestinal stromal tumours (GISTs) after failure of at least imatinib and sunitinib.

methods:

Patients received oral dovitinib, 500mg once daily, for 5 consecutive days, followed by a 2-day rest, every 28 days. The primary endpoint was disease control rate (DCR; objective response+stable disease (SD)) at 24 weeks, assessed by computed tomography (CT) scan according to RECIST v1.0. Metabolic response was evaluated by positron emission tomography (PET)–CT scans performed at baseline and after 4 weeks of treatment.

results:

Between September 2011 and April 2012, 30 patients were enroled. DCR at 24 weeks by RECIST v1.0 was 13% and one patient (3%) had a partial response. Based on the European Organization for Research and Treatment of Cancer PET response criteria, four patients (13%) had a metabolic partial response after 4 weeks of treatment. At a median follow-up of 8.3 months (range, 6.3–12.2 months), median progression-free survival (PFS) was 3.6 months (95% confidence interval (CI), 3.5–3.7 months) and median overall survival was 9.7 months (95% CI, 6.0–13.4 months). Metabolic progressive disease at Week 4 was significantly associated with shorter PFS (P=0.03). Grade 3/4 adverse events included asthenia (20%), neutropenia (13%), thrombocytopenia (10%), and hypertriglyceridaemia (10%). Most toxicities were manageable by dose modification.

conclusion:

Dovitinib showed modest antitumour activity with manageable toxicities in heavily pretreated patients with advanced GISTs.

Source: BJC