Barrett T. Kitch

Hypovitaminosis D in Medical Inpatients

BACKGROUND Vitamin D deficiency is a major risk factor for bone loss and fracture. Although hypovitaminosis D has been detected frequently in elderly and housebound people, the prevalence of vitamin D deficiency among patients hospitalized on a general medical service is unknown. METHODS We assessed vitamin D intake, ultraviolet-light exposure, and risk factors for hypovitaminosis D and measured serum 25-hydroxyvitamin D, parathyroid hormone, and ionized calcium in 290 consecutive patients on a general medical ward. RESULTS A total of 164 patients (57 percent) were considered vitamin D-deficient (serum concentration of 25-hydroxyvitamin D, < or = 15 ng per milliliter), of whom 65 (22 percent) were considered severely vitamin D-deficient (serum concentration of 25-hydroxyvitamin D, <8 ng per milliliter). Serum 25-hydroxyvitamin D concentrations were related inversely to parathyroid hormone concentrations. Lower vitamin D intake, less exposure to ultraviolet light, anticonvulsant-drug therapy, renal dialysis, nephrotic syndrome, hypertension, diabetes mellitus, winter season, higher serum concentrations of parathyroid hormone and alkaline phosphatase, and lower serum concentrations of ionized calcium and albumin were significant univariate predictors of hypovitaminosis D. Sixty-nine percent of the patients who consumed less than the recommended daily allowance of vitamin D and 43 percent of the patients with vitamin D intakes above the recommended daily allowance were vitamin D-deficient. Inadequate vitamin D intake, winter season, and housebound status were independent predictors of hypovitaminosis D in a multivariate model. In a subgroup of 77 patients less than 65 years of age without known risk factors for hypovitaminosis D, the prevalence of vitamin D deficiency was 42 percent. CONCLUSIONS Hypovitaminosis D is common in general medical inpatients, including those with vitamin D intakes exceeding the recommended daily allowance and those without apparent risk factors for vitamin D deficiency.

axl, a transforming gene isolated from primary human myeloid leukemia cells, encodes a novel receptor tyrosine kinase.

Using a sensitive transfection-tumorigenicity assay, we have isolated a novel transforming gene from the DNA of two patients with chronic myelogenous leukemia. Sequence analysis indicates that the product of this gene, axl, is a receptor tyrosine kinase. Overexpression of axl cDNA in NIH 3T3 cells induces neoplastic transformation with the concomitant appearance of a 140-kDa axl tyrosine-phosphorylated protein. Expression of axl cDNA in the baculovirus system results in the expression of the appropriate recombinant protein that is recognized by antiphosphotyrosine antibodies, confirming that the axl protein is a tyrosine kinase. The juxtaposition of fibronectin type III and immunoglobulinlike repeats in the extracellular domain, as well as distinct amino acid sequences in the kinase domain, indicate that the axl protein represents a novel subclass of receptor tyrosine kinases.

Handoffs causing patient harm: a survey of medical and surgical house staff.

BACKGROUND Communication lapses at the time of patient handoffs are believed to be common, and yet the frequency with which patients are harmed as a result of problematic handoffs is unknown. Resident physicians were surveyed about their handoffpractices and the frequency with which they perceive problems with handoffs lead to patient harm. METHODS A survey was conducted in 2006 of all resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) concerning the quality and effects of handoffs during their most recent inpatient rotations. Surveys were sent to 238 eligible residents; 161 responses were obtained (response rate, 67.6%). RESULTS Fifty-nine percent of residents reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12% reported that this harm had been major. Overall quality of handoffs was reported to be fair or poor by 31% of residents. A minority of residents (26%) reported that handoffs usually or always took place in a quiet setting, and 37% reported that one or more interruptions during the receipt of handoffs occurred either most of the time or always. DISCUSSION Although handoffs have long been recognized as potentially hazardous, further scrutiny of handoffs has followed recent reports that handoffs are often marked by missing, incomplete, or inaccurate information and are associated with adverse events. In this study, reports of harm to patients from problematic handoffs were common among residents in internal medicine and general surgery. Many best-practice recommendations for handoffs are not observed, although the extent to which improvement of these practices could reduce patient harm is not known. MGH has recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs, for its house staff and clinical leadership.

Assessing Patient Safety Culture: A Review and Synthesis of the Measurement Tools

Context: Interest in the measurement of organizational culture that supports patient safety has grown among health care providers. Objective: To review available quantitative instruments for the assessment of patient safety culture. Methods: Surveys were identified through a systematic review, which included a MEDLINE and internet search, expert input, and review of references from relevant articles. For each instrument, we examined target populations, number of questions, safety dimensions covered, reliability and validity testing, and ease of use. Results: Our review yielded 13 instruments, covering a total of 23 individual dimensions of patient safety grouped into the broad categories of management/supervision, risk, work pressure, competence, rules, and miscellaneous. The instruments varied substantially in content (number of dimensions addressed), emphasis, and length. Although most of the surveys have substantial face validity, limited validation of the instruments by comparison with qualitative measures of patient safety culture, such as in-depth interviews or observation, has been done, and few data exist on their ability to predict other existing patient safety outcomes or indicators. Questions about how best to analyze and interpret the results remain. Conclusions: The desire to address safety culture in the hope of improving patient safety will continue to motivate researchers and managers to make use of safety culture surveys. Choice of instruments will depend on the intended use, the target population, reliability, validity, and other considerations. An awareness of the differences between the instruments and their collective limitations should facilitate this endeavor.

The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters’ Wake Up and Breathe Collaborative

RATIONALE The CDC introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs. OBJECTIVES To assess the preventability of VAEs. METHODS We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance among 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining eight units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, Sequential Organ Failure Assessment score, and comorbidity index. MEASUREMENTS AND MAIN RESULTS We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator day but significant decreases in VAE risk per episode of mechanical ventilation (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.42-0.97) and infection-related ventilator-associated complications (OR, 0.35; 95% CI, 0.17-0.71) but not pneumonias (OR, 0.51; 95% CI, 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates. CONCLUSIONS Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registered with www.clinicaltrials.gov (NCT 01583413).

Late onset asthma: epidemiology, diagnosis and treatment.

Asthma is common among older persons, affecting approximately 4 to 8% of those above the age of 65 years. Despite its prevalence, late onset asthma may be misdiagnosed and inadequately treated, with important negative consequences for the patient’s health. The histopathology of late onset disease appears to be similar to that of asthma in general, with persistent airway inflammation a characteristic feature. It is less clear, however, that allergic exposure and sensitisation play the same role in the development of disease in adults as they do in children. Atopy is less common among those with late onset asthma, and the prevalence of elevated immunoglobulin E levels is lower among those aged over 55 years of age than younger patients. Occupational asthma is an aetiological consideration unique to adult onset disease, with important implications for treatment.The differential diagnosis for cough, wheeze, and dyspnoea in the elderly is broad, and includes chronic obstructive bronchitis, bronchiectasis, congestive heart failure, lung cancer with endobronchial lesion and vocal cord dysfunction.Keys to accurate diagnosis include a good history and physical examination, the demonstration of reversible airways obstruction on pulmonary function tests and a favorable response to treatment. Inhaled corticosteroid therapy is recommended for patients with persistent disease, and careful instruction in the use of metered-dose inhalers is particularly important for the elderly.

Patient safety climate in hospitals: act locally on variation across units.

BACKGROUND An appreciation of how human factors affect patient safety has led to development of safety climate surveys and recommendations that hospitals regularly assess safety attitudes among caregivers. A better understanding of variation in patient safety climate across units within hospitals would facilitate internal efforts to improve safety climate. A study was conducted to assess the extent and nature of variation in safety climate across units within an academic medical center. METHODS The Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety was administered in 2008 to all nurses and attending physicians (N=4283) in a 900-bed acute care hospital (overall response rate, 69% [n=2961]). Responses were analyzed from the 2,163 physicians and nurses (73% of respondents) who could be assigned to one specific clinical unit. Results were examined for 57 units, categorized into six types. RESULTS Ratings of various safety climate domains differed markedly across the 57 units, with the percentage reporting a safety grade of excellent ranging from 0% to 50%. The overall percentage of positive ratings was lower for the operating and emergency unit types than for inpatient medical and other clinical units. Even within the six unit types, substantial variation across individual units was evident. Unlike previous findings, physicians reported more negative ratings than nurses for some safety climate dimensions. CONCLUSIONS Safety climate may vary markedly within hospitals. Assessments of safety climate and educational and other interventions should anticipate considerable variation across units within individual hospitals. Furthermore, clinicians at individual hospitals may offer different relative perceptions of the safety climate than their professional peers at other hospitals.

Trends in Mortality and Medical Spending in Patients Hospitalized for Community-Acquired Pneumonia: 1993 – 2005

Background:Community-acquired pneumonia (CAP) is the most common infectious cause of death in the United States. To understand the effect of efforts to improve quality and efficiency of care in CAP, we examined the trends in mortality and costs among hospitalized CAP patients. Methods:Using the National Inpatient Sample between 1993 and 2005, we studied 569,524 CAP admissions. The primary outcome was mortality at discharge. We used logistic regression to evaluate the mortality trend, adjusting for age, gender, and comorbidities. To account for the effect of early discharge practices, we also compared daily mortality rates and performed a Cox proportional hazards model. We used a generalized linear model to analyze trends in hospitalization costs, which were derived using cost-to-charge ratios. Results:Over time, length of stay declined, while more patients were discharged to other facilities. The frequency of many comorbidities increased. Age/gender-adjusted mortality decreased from 8.9% to 4.1% (P < 0.001). In multivariable analysis, the mortality risk declined through 2005 (odds ratio, 0.50; 95% confidence interval, 0.48–0.53), compared with the reference year 1993. The daily mortality rates demonstrated that most of the mortality reduction occurred early during hospitalization. After adjusting for early discharge practices, the risk of mortality still declined through 2005 (hazard ratio, 0.74; 95% confidence interval, 0.70–0.78). Median hospitalization costs exhibited a moderate reduction over time, mostly because of reduced length of stay. Conclusions:Mortality among patients hospitalized for CAP has declined. Lower in-hospital mortality at a reduced cost suggests that pneumonia is a case of improved productivity in health care.

A novel approach to defining the relationship between lung function and symptom status in asthma

We present a novel approach to estimating functional relationships between forced expiratory volume in 1 second (FEV(1)) and asthma-related symptoms on a population-wide basis. We used asthma-related clinical trials that reported estimates of mean lung function (measured as FEV(1) percent predicted) and symptoms (symptom score or percentage of symptom days or nighttime awakenings). Using average baseline values from each study in weighted linear regression analyses, we found a negative association between lung function and symptom score (P < 0.001) and the percentage of nighttime awakenings (P = 0.18), but no association between lung function and symptom days. We also found consistent relationships between the mean changes in lung function and symptoms at follow-up within the studies. Functional relationships between FEV(1) percent predicted and asthma-related symptoms can be useful for inferring the effect on the symptoms of a population associated with overall improvements in lung function.

In vitro activity of orally administered antimicrobial agents against Haemophilus influenzae recovered from children monitored longitudinally in a group day-care center.

To determine whether the prevalence of resistance to commonly used oral antimicrobial agents varied over time, we compared the in vitro susceptibilities of 217 strains of Haemophilus influenzae recovered from nasopharyngeal secretions of children in a day-care center studied longitudinally between 1979 and 1987. The overall rate of beta-lactamase production in these strains was 18%, with rates of 57% in type b isolates (n = 21) and 14% in non-type b isolates (n = 196). The percentages of isolates for which MICs were less than or equal to 1.0 micrograms/ml for amoxicillin alone, amoxicillin in combination with clavulanic acid, and cefuroxime alone were 82, 92, and 93%, respectively. The percentage of strains for which cefaclor MICs were less than or equal to 1.0 micrograms/ml was only 0.5%. Isolates for which chloramphenicol MICs were greater than 2.0 micrograms/ml or for which trimethoprim-sulfamethoxazole MICs were greater than 0.5/9.5 micrograms/ml were uncommon: 1 and less than 1%, respectively. High concentrations of erythromycin alone and in combination with sulfisoxazole were required to inhibit the majority of test strains; there was no evidence of erythromycin-sulfisoxazole synergy. In vitro susceptibility to commonly used oral antimicrobial agents remained at a constant level when H. influenzae isolates collected from children in a day-care center during 1979 through 1983 were compared with strains collected during 1984 through 1987.