Gregory M. Bump

Paroxetine versus nortriptyline in the continuation and maintenance treatment of depression in the elderly.

Elderly depressed patients are vulnerable to recurrence of depression and benefit from long‐term antidepressant therapy. Physicians increasingly use selective serotonin re‐uptake inhibitors (SSRIs) as maintenance therapy, although in the absence of data showing that SSRIs are as efficacious as tricyclic antidepressants (TCAs) in the prevention of depression relapse and recurrence. Our objective was to evaluate, in an open trial, the efficacy of paroxetine versus nortriptyline for preventing recurrence of depression in the elderly. Elderly patients with major depression were randomly assigned in a double‐blinded fashion to receive either paroxetine or nortriptyline for the acute treatment of depression. Patients who did not respond or tolerate their assigned medications were crossed over openly to the comparator agent. Patients whose depression remitted continued antidepressant medication (paroxetine n = 38; nortriptyline n = 21) during an open 18‐month follow‐up study. We examined the rates of and times to relapse and to termination of treatment for any reason. Paroxetine (PX) and nortriptyline (NT) patients had similar rates of relapse (16% vs. 10%, respectively) and time to relapse (60.3 weeks vs. 58.8 weeks, respectively) over 18 months. A lower burden of residual depressive symptoms and side effects during continuation and maintenance treatment was evident in nortriptyline‐treated patients. Paroxetine and nortriptyline demonstrated similar efficacy in relapse and recurrence prevention in elderly depressed patients over an 18‐month period. Depression and Anxiety 13:38–44, 2001.

Resident Sign-Out and Patient Hand-Offs: Opportunities for Improvement

Background: Inpatient care is characterized by multiple transitions of patient care responsibilities. In most residency programs trainees manage transitions via verbal, written, or combined methods of communication termed “sign-out.” Often sign-out occurs without standardization or supervision. Purpose: The purpose was to assess daily sign-out with a goal of identifying aspects of this process most in need of improvement. Methods: This was a prospective, observational cohort study of interns’ sign-out conducted by industrial engineering students. Daily sign-out was analyzed for inclusion of multiple criteria and scored on organization (on a scale of 0–4) based on how effectively written information was conveyed. Results: We observed 124 unique verbal and written sign-outs. We found that 99% of sign-outs included a general hospital course. Sign-outs were well organized with a mean of 3.1, though substantial variation was noted (SD = 0.8). Directions for anticipated patient events were included in only 42% of sign-outs. Do Not Resuscitate (DNR) or advanced directive discussions were reported in only 11% of sign-outs. Only 50% of successive daily sign-outs were updated. Conclusions: We found variability in the content and organization of interns’ sign-out, possibly reflecting a lack of instruction and supervision. Standardization of sign-out content, and education on good sign-out skills are increasingly important as patient hand-offs become more frequent.

Accelerating response in geriatric depression: A pilot study combining sleep deprivation and paroxetine

Elderly depressed patients often require an average of 12 weeks of pharmacotherapy before attaining remission. The delay between treatment initiation and remission may decrease compliance and prolongs suffering; hence, interventions that decrease the time to onset of antidepressant activity are needed. Our objective was to evaluate, in an open trial, the use of one night of total sleep deprivation combined with paroxetine to accelerate antidepressant response in elderly patients. Thirteen elderly patients with major depression were sleep‐deprived for one night and started paroxetine on the night of recovery sleep. Patients were followed for twelve weeks, and clinical improvement was rated using the 17‐item Hamilton Depression Rating Scale and a version of the Hamilton modified for sleep deprivation studies. 8/13 (62%) patients experienced significant improvement of depressive symptoms by 2 weeks. Within 12 weeks 11/13 (85%) patients responded to the combination of sleep deprivation and paroxetine. Median response time was 2 weeks. Clinical response at 12 weeks was correlated with changes in Sleep Deprivation Depression Rating Scale Scores between baseline and recovery sleep. In an open trial, the combined use of total sleep deprivation and paroxetine appears to be an effective method for speeding the onset of clinical antidepressant activity in geriatric depression and for improving early recognition of non‐response. Depression and Anxiety 6:113–118, 1997.

Overcoming Patient Barriers to Discussing Physician Hand Hygiene: Do Patients Prefer Electronic Reminders to Other Methods?

BACKGROUND Despite agreement that handwashing decreases hospital-acquired infections (HAIs), physician hand hygiene remains suboptimal. Interventions to empower patients to discuss handwashing have had variable success. OBJECTIVE To understand patient perceived barriers to discussing physician hand hygiene and to determine whether patients prefer electronic alerts over printed information as an intervention to discuss physician handwashing. DESIGN Cross-sectional study of 250 medical/surgical patients at an academic medical center. RESULTS Ninety-six percent of patients had heard of HAIs. Ninety-six percent of patients thought it was important for physicians to clean their hands before touching anything in a patients room. The majority of patients (78%) believed patients should remind physicians to clean their hands. Thirty-two percent of patients observed physician hand hygiene noncompliance. In multivariate analysis, predictors of not speaking up regarding physician hand hygiene included never having worked in health care (odds ratio [OR], 2.8 [95% confidence interval (CI), 1.5-5.1]), not observing a physician clean hands before touching the patient (OR, 2.4 [95% CI, 1.3-4.4]), and not thinking patients should have to remind physicians to clean hands (OR, 5.5 [95% CI, 2.4-12.7]). Ninety-three percent of patients favored electronic device reminders over printed information as an intervention to encourage patients to discuss hand hygiene with their doctors. CONCLUSIONS The strongest predictor of not challenging a doctor to clean their hands was not believing it was the patients role to do so. Patients prefer electronic device reminders to printed information as an aid in overcoming barriers to discussing hand hygiene with physicians.

Faculty member review and feedback using a sign-out checklist: improving intern written sign-out.

Purpose Although residents commonly perform patient care sign-out during training, faculty do not frequently supervise or evaluate sign-out. The authors designed a sign-out checklist, and they investigated whether use of the checklist, paired with faculty member review and feedback, would improve interns’ written sign-out. Method In a randomized, controlled design in 2011, the authors compared the sign-out content and the overall sign-out summary scores of interns who received twice-monthly faculty member sign-out evaluation with those of interns who received the standard sign-out instruction. A sign-out checklist, which the authors developed on the basis of internal needs assessment and published sign-out recommendations, guided the evaluation of written sign-out content and sign-out organization as well as the twice-monthly, face-to-face evaluation that the interns in the intervention group received. Results Using the sign-out checklist and receiving feedback from a faculty member led to statistically significant improvements in interns’ sign-out. Through regression analysis, the authors calculated a 23% difference in the sign-out content (P = .005) and a 2.2-point difference in the overall summary score (on a 9-point scale, P = .009) between the interns who received sign-out feedback and those who did not. The content and quality of the intervention group’s sign-outs improved, whereas the content and quality of the control group’s worsened. Conclusions A sign-out checklist paired with twice-monthly, face-to-face feedback from a faculty member led to improvements in the content and quality of interns’ written sign-out.

How Complete Is the Evidence for Thromboembolism Prophylaxis in General Medicine Patients? A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES Guidelines recommend pharmacologic prophylaxis for hospitalized medical patients at increased risk of thromboembolism. Despite recommendations, multiple studies demonstrate underutilization. Factors contributing to underutilization include uncertainty that prophylaxis reduces clinically relevant events, as well as questions about the best form of prophylaxis. We sought to determine whether prophylaxis decreases clinically significant events and to answer whether unfractionated heparin (UFH) or low molecular weight heparin (LMWH) is either more effective or safer. DATA SOURCES The MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched through June 2008. Relevant bibliographies and conference proceedings were reviewed and LMWH manufacturers were contacted. STUDY SELECTION Randomized trials comparing UFH or LMWH to control, as well as head-to-head comparisons of UFH to LMWH in general medicine patients. DATA EXTRACTION AND ANALYSIS End points of deep venous thrombosis (DVT), proximal or symptomatic DVT, pulmonary embolism, mortality, bleeding, and thrombocytopenia were extracted from individual trials. Pooled relative risks were calculated using random effects modeling. RESULTS We identified 8 trials comparing prophylaxis to control, and 6 trials comparing UFH to LMWH. Prophylaxis reduced DVT (relative risk [RR] = 0.55; 95% confidence interval [CI]: 0.36-0.92), proximal DVT (RR = 0.46; 95% CI: 0.31-0.69), and pulmonary embolism (RR = 0.70; 95% CI: 0.53-0.93). Prophylaxis increased the risk of any bleeding (RR = 1.54; 95% CI: 1.15-2.06) but not major bleeding. Across trials comparing LMWH to UFH, there were no differences for any outcome. CONCLUSIONS Among medical patients, pharmacologic prophylaxis reduced the risk of thromboembolism without increasing risk of major bleeding. The current literature does not demonstrate superior efficacy of UFH or LMWH.

Head CT Scan Overuse in Frequently Admitted Medical Patients

BACKGROUND Patients frequently admitted to medical services undergo extensive computed tomography (CT) imaging. Some of this imaging may be unnecessary, and in particular, head CT scans may be over-used in this patient population. We describe the frequency of abnormal head CT scans in patients with multiple medical hospitalizations. METHODS We retrospectively reviewed all CT scans done in 130 patients with 7 or more admissions to medical services between January 1 and December 31, 2011 within an integrated health care system. We calculated the number of CT scans, anatomic site of imaging, and source of ordering (emergency department, inpatient floor). We scored all head CT scans on a 0-4 scale based on the severity of radiographic findings. Higher scores signified more clinically important findings. RESULTS There were 795 CT scans performed in total, with a mean of 6.7 (± SD 5.8) CT scans per patient. Abdominal/pelvis (39%), chest (30%), and head (22%) CT scans were the most frequently obtained. The mean number of head CT scans performed was 2.9 (SD ± 4.2). Inpatient floors were the major site of CT scan ordering (53.7%). Of 172 head CT scans, only 4% had clinically significant findings (scores of 3 or 4). CONCLUSIONS Patients with frequent medical admissions are medically complex and undergo multiple CT scans in a year. The vast majority of head CT scans lack clinically significant findings and should be ordered less frequently. Interdisciplinary measures should be advocated by hospitalists, emergency departments, and radiologists to decrease unnecessary imaging in this population.

Implementing Faculty Evaluation of Written Sign-Out

Purpose: Recently the Accreditation Council for Graduate Medical Education mandated decreased shift duration for intern physicians to no more than 16 hours. Such work-hour restrictions are likely to increase patient care hand-offs. It is well accepted that sign-out (i.e., hand-off) processes are error prone and lack standardization. Moreover, many residency programs do not evaluate sign-out. We designed and tested whether a sign-out evaluation process could be implemented to improve written sign-out. Method: Based on observed sign-out deficiencies at our institution we adapted a simple curriculum incorporating the SIGNOUT mnemonic, which we paired with weekly faculty member evaluation and feedback on sign-out using a structured sign-out evaluation tool. Later in the week, written sign-out was independently scored by 2-blinded senior resident reviewers who compared the inclusion of sign-out content, organization, and readability. Results: Compared to baseline data in 128 written sign-outs, the pairing of a 1-page curriculum with weekly faculty member evaluation of written sign-out improved the inclusion of advanced directives from 38% to 69% (p < .001) and anticipatory guidance from a mean score of 1.8 (SD = 1.2) to 2.3 (SD = 1.5) on a 5-point scale ( p = .01) in 177 written sign-outs. Readability and organization were unchanged. Conclusions: A simple curriculum paired with structured faculty evaluation and feedback can improve some parameters of sign-out. Structured evaluative sign-out tools may be useful to improve and teach sign-out skills.

Platypnea-Orthodeoxia, An Uncommon Presentation of Patent Foramen Ovale

The platypnea-orthodeoxia syndrome is a rare clinical presentation. The differential diagnosis is short and includes cardiac, hepatic, and pulmonary causes, with right-to-left intracardiac shunt being the most common. A secondary process is usually present in conjunction with an intracardiac shunt in order for platypnea and orthodeoxia to develop. We present a 63-year-old man in whom the platypnea-orthodeoxia syndrome was associated with a patent foramen ovale and symptoms were manifested by the subacute development of pulmonary arterial hypertension mediated by pulmonary tumor emboli. On postmortem examination, the patient had an underlying poorly differentiated lung adenocarcinoma. This case provides a concise review of the platypnea-orthodeoxia syndrome and pulmonary tumor emboli and stresses the importance of looking for a secondary process in conjunction with an intracardiac shunt in establishing the underlying diagnosis.

Simple and Complex

A 44-year-old man presented to the emergency department with chest pain that had started 1 hour earlier and had awakened him from sleep. The pain was severe, substernal, burning, radiating to the left arm, and accompanied by nausea and nonbilious, nonbloody vomiting. For the past month he had experienced intermittent chest pain of a similar character but less intense. The pain was not related to exertion and lasted for hours to days at a time. Antacids and omeprazole had provided temporary relief. He reported no dyspnea, lower-extremity edema, immobility, fever, cough, or trauma. Conditions that should be ruled out first are the lethal causes of chest pain: acute coronary syndromes, pulmonary embolism, aortic dissection, pneumothorax, pericardial tamponade, and mediastinitis. Of these conditions, an acute coronary syndrome is the most likely, based on the chest pain as described and the presence of similar but less intense episodes over the previous month. Nausea and vomiting may occur with acute coronary syndromes but are nonspecific. Other causes of chest pain such as gastroesophageal reflux or musculoskeletal disorders are also possible. The patient’s medical history was unremarkable, but he had not seen a physician for years. Medications included omeprazole and antacids as needed. He reported that he did not use tobacco, alcohol, or illicit drugs. He was employed as a physician. There was no family history of premature coronary artery disease. On physical examination, he was afebrile; the blood pressure was 133/83 mm Hg (approximately the same in both arms), the heart rate 61 beats per minute, and the oxygen saturation 97% while he was breathing ambient air. He appeared to be in considerable distress, clutching his chest. He was thin. The trachea was midline. Cardiac examination revealed a regular rhythm without extra heart sounds, no jugular venous distention, and no lower-extremity edema. Breath sounds were normal in both lungs. Chest palpation did not produce pain. The abdomen was soft and nontender, with normal bowel sounds. There was no organomegaly or lymphadenopathy. Examination of the skin was unremarkable.