Kah Poh Loh

From hospital to community: Use of antipsychotics in hospitalized elders

Antipsychotic (AP) medications are often used in the hospitalized geriatric population for the treatment of delirium. Because of adverse events associated with APs, efforts have been made to reduce their use in hospitalized elders, but it is not clear if these recommendations have been widely adopted. We studied the use of APs in a cohort of hospitalized elders to better understand why APs are started and how often they are continued on discharge.

Paraneoplastic autoimmune hemolytic anemia in ovarian cancer: a marker of disease activity

Autoimmune hemolytic anemia (AIHA) is a rare paraneoplastic syndrome associated with ovarian malignancies. We report a case of a 77 year-old female with metastatic ovarian carcinoma who presented with worsening anemia from her baseline, and was found to have a warm autoimmune hemolytic anemia. We performed a literature review and analyzed all 10 cases (including our patient) that have been reported to date, and incorporated the clinical presentation, histology and stage of underlying malignancies, types, treatment, prognosis and mechanisms of AIHA in ovarian carcinoma.

Elderly‐Onset Neuromyelitis Optica Spectrum Disorders

To the Editor: Neuromyelitis optica (NMO), also known as Devic disease, is a demyelinating disorder of the central nervous system primarily affecting the spinal cord and optic nerve. Since the discovery of the NMO-immunoglobulin (Ig)G antibody or aquaporin-4 antibody, it has been discovered that there are different variants of NMO, classified as NMO spectrum disorders (NMOSDs). A case of elderly-onset NMOSD is reported.

Long-term outcomes of elders discharged on antipsychotics

BACKGROUND Despite limited evidence of efficacy, antipsychotics (APs) are commonly used to treat delirium. There has been little research on the long-term outcomes of patients who are started on APs in the hospital. METHODS Using a previously described retrospective cohort of 300 elders (≥65 years old) who were newly prescribed APs while hospitalized between October 1, 2012 and September 31, 2013, we examined the 1-year outcomes of patients alive at the time of discharge. We examined number of readmissions, reasons for readmission, duration of AP therapy, use of other sedating medications, and incidence of readmission. We used the National Death Index to describe 1-year mortality and then created a multivariable model to identify predictors of 1-year mortality. RESULTS The 260 patients discharged alive from their index admissions had a 1-year mortality rate of 29% (75/260). Of the 146/260 patients discharged on APs, 60 (41%) patients experienced at least 1 readmission. At the time of first readmission, 65% of patients were still taking the same APs on which they had been discharged. Eighteen patients received new APs during the readmission hospitalizations. Predictors of death at 1 year included discharge to postacute facilities after index admission (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.10-4.73, P = 0.03) and QT interval prolongation >500 ms during index admission (OR: 3.41; 95% CI: 1.34-8.67, P = 0.01). CONCLUSIONS Initiating an AP in the hospital is likely to result in long-term use of these medications. Patients who received an AP during a hospitalization were at high risk of death in the following year. Journal of Hospital Medicine 2016;11:550-555.

Healthcare Professionals' Perceptions and Knowledge of the USPSTF Guidelines on Breast Self-Examination.

Objectives In 2009, the US Preventive Services Task Force (USPSTF) published revised guidelines for breast cancer screening, which recommended against teaching breast self-examination (BSE). The objective of this study was to assess providers’ perceptions and knowledge regarding these updated guidelines. Methods A cross-sectional survey study was administered to 205 attending and resident physicians, nurse practitioners, physician’s assistants, and registered nurses working in five medical and gynecological practices affiliated with a large academic teaching hospital in western Massachusetts. The survey solicited demographic data and inquired about practitioners’ perceptions and knowledge of the revised guidelines. Results Fewer than half (41.1%) of respondents correctly identified the new USPSTF guidelines for BSE. Among those who stated they were aware of guidelines, only 37.1% adhered to them. Overall, 70% report that they teach patients to perform BSE. Teaching BSE was associated with female sex (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.11–6.29), a belief that BSE reduces morbidity and mortality (OR 2.91, 95% CI 1.08–7.81), and internal medicine residency (OR 0.18, 95% CI 0.06–0.59). Conclusions Knowledge of the 2009 USPSTF guidelines is suboptimal and greater efforts should be made to educate healthcare professionals about them.

Internal Medicine Hospitalists’ Perceived Barriers and Recommendations for Optimizing Secondary Prevention of Osteoporotic Hip Fractures

Objectives Osteoporosis is a major public health concern affecting an estimated 10 million people in the United States. To the best of our knowledge, no qualitative study has explored barriers perceived by medicine hospitalists to secondary prevention of osteoporotic hip fractures. We aimed to describe these perceived barriers and recommendations regarding how to optimize secondary prevention of osteoporotic hip fracture. Methods In-depth, semistructured interviews were performed with 15 internal medicine hospitalists in a tertiary-care referral medical center. The interviews were analyzed with directed content analysis. Results Internal medicine hospitalists consider secondary osteoporotic hip fracture prevention as the responsibility of outpatient physicians. Identified barriers were stratified based on themes including physicians’ perception, patients’ characteristics, risks and benefits of osteoporosis treatment, healthcare delivery system, and patient care transition from the inpatient to the outpatient setting. Some of the recommendations include building an integrated system that involves a multidisciplinary team such as the fracture liaison service, initiating a change to the hospital policy to facilitate inpatient care and management of osteoporosis, and creating a smooth patient care transition to the outpatient setting. Conclusions Our study highlighted how internal medicine hospitalists perceive their role in the secondary prevention of osteoporotic hip fractures and what they perceive as barriers to initiating preventive measures in the hospital. Inconsistency in patient care transition and the fragmented nature of the existing healthcare system were identified as major barriers. A fracture liaison service could remove some of these barriers.

An unusual cause of delirium and debility: refractory hypercalcemia in a man with b-cell prolymphocytic leukemia

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Thrombosis in a bleeding disorder: case of thromboembolism in factor VII deficiency

Congenital factor VII deficiency (FVIID) is a rare disorder with a wide range of bleeding manifestations. The disorder does not protect patients against occurrence of thrombosis, and deep vein thrombosis can occur in the setting of surgery and recombinant factor VIIa replacement.

Nonconvulsive Status Epilepticus: Master of Disguise

rectal cancer can spread by lymphatic and hematogenous dissemination, as well as through contiguous and transperitoneal routes. Approximately 20% of individuals with colorectal cancer have distant metastatic disease at the time of presentation, the most common metastatic sites being regional lymph nodes, liver, lungs, and peritoneum but rarely in the bones. Although infrequent, there are several reports in literature of colorectal cancer diffusely involving bone marrow, in the case of primary presentation or even infectious complications of unknown underlying disease (e.g., paravertebral abscess). In the course of neoplastic diseases, back pain is frequently associated with marked abnormalities of blood count and coagulation, such as disseminated intravascular coagulation. A substantial proportion of deaths in older persons with colorectal cancer may be attributed to comorbidity, especially congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease, but in this case, the cause of death was a fungal infection. Candida species can be life threatening in elderly people, in particular when they are immunocompromised, and rank fourth among the most common nosocomial pathogens. Low back pain is extremely frequent in people referred to the hospital, and contrary to common belief, it does not always derive from a benign cause. Thus, the large number of individuals presenting for this symptom may be misdiagnosed. Although infrequent, the hypothesis of spinal bone marrow involvement could also be taken into consideration in elderly adults with severe back pain.