Pamela Charney

Hypertension in Women: What is Really Known?: The Women's Caucus, Working Group on Women's Health of the Society of General Internal Medicine

PURPOSE To determine whether there is sufficient information in the medical literature to guide appropriate treatment of hypertensive women. DATA IDENTIFICATION Epidemiologic surveys of hypertension, clinical trials of antihypertensive therapy, and studies of selected adverse effects of antihypertensive agents were identified through a computerized search using MEDLINE and by identifying all studies cited in current medical textbooks as supporting evidence for the guidelines for the treatment of hypertensive individuals. All epidemiologic studies selected were cross-sectional or longitudinal, multicenter, population-based surveys. All clinical trials were large, randomized studies comparing one or more antihypertensive agents with a placebo or nonplacebo control group. Epidemiologic studies and clinical trials were reviewed to assess the quantity and quality of information available regarding important aspects of hypertension in women. Data pertaining to epidemiology, natural history, results of treatment, and two significant side effects of antihypertensive treatment were examined. RESULTS OF DATA ANALYSIS The prevalence of hypertension is greater in black women than in black men and is about equal in white women and men. Because women outnumber men in the population, there are more hypertensive women than men. The attributable risk percent (the proportion of end points that could be eliminated by removing hypertension) for cardiovascular complications of hypertension is higher for women than men. Clinical trials show clear benefit of therapy for black women but no clear benefit for white women; some studies suggest that treatment of white women is harmful. Lipid profiles and their relation to ischemic heart disease differ for women and men; there is currently no information on the effects of antihypertensive agents on serum lipids in women. Few data have been published on the frequency of sexual dysfunction in treated hypertensive women. CONCLUSIONS Hypertension in women and its related cardiovascular outcomes are a major public health problem. Clinical trials of antihypertensive therapy do not fully support current guidelines for the treatment of hypertensive women. Research concerning adverse effects of antihypertensive agents has largely excluded women from consideration; further studies are required to guide appropriate treatment.

Use of Multidisciplinary Rounds to Simultaneously Improve Quality Outcomes, Enhance Resident Education, and Shorten Length of Stay

BACKGROUNDHospital-based clinicians and educators face a difficult challenge trying to simultaneously improve measurable quality, educate residents in line with ACGME core competencies, while also attending to fiscal concerns such as hospital length of stay (LOS).OBJECTIVEThe purpose of this study was to determine the effect of multidisciplinary rounds (MDR) on quality core measure performance, resident education, and hospital length of stay.DESIGNPre and post observational study assessing the impact of MDR during its first year of implementation.SETTINGThe Norwalk Hospital is a 328-bed, university-affiliated community teaching hospital in an urban setting with a total of 44 Internal Medicine residents.METHODSJoint Commission on Accreditation of Healthcare Organizations (JCAHO) core measure performance was obtained on a monthly basis for selected heart failure (CHF), pneumonia, and acute myocardial infarction (AMI) measures addressed on the general medical service. Resident knowledge and attitudes about MDR were determined by an anonymous questionnaire. LOS and monthly core measure performance rates were adjusted for patient characteristics and secular trends using linear spline logistic regression modeling.RESULTSInstitution of MDR was associated with a significant improvement in quality core measure performance in targeted areas of CHF from 65% to 76% (p < .001), AMI from 89% to 96% (p = .004), pneumonia from 27% to 70% (p < .001), and all combined from 59% to 78% (p < .001). Adjusted overall monthly performance rates also improved during MDR (odds ratio [OR] 1.09, CI 1.06–1.12, p < .001). Residents reported substantial improvements in core measure knowledge, systems-based care, and communication after institution of MDR (p < .001). Residents also agreed that MDR improved efficiency, delivery of evidence-based care, and relationships with involved disciplines. Adjusted average LOS decreased 0.5 (95% CI 0.1–0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5–0.7) days for all medicine DRGs (p < .001).CONCLUSIONSResident-centered MDR is an effective process using no additional resources that simultaneously improves quality of care while enhancing resident education and is associated with shortened length of stay.

The positive impact of initiation of hospitalist clinician educators

OBJECTIVE: Although hospitalists have been shown to improve both financial and educational outcomes, their ability to manage dual roles as clinicians and educators has been infrequently demonstrated, particularly in the community setting where large numbers of residents train. We evaluated the impact of hospitalists on financial and educational outcomes at a mid-sized community teaching hospital 1 year after implementation.DESIGN: Two hospitalist clinician educators (HCEs) were hired to provide inpatient medical care while participating in resident education. Length of stay and cost per case data were calculated for all patients admitted to the hospitalist service during their first year and compared with patients admitted to private physicians. The hospitalists’ top 11 discharge diagnoses were individually assessed. For the same time period, categorical medicine residents (N=36) were given an anonymous written survey to assess the HCEs’ impact on resident education and service.RESULTS: Resource consumption: length of stay was reduced by 20.8% and total cost per case was reduced by 18.4% comparing the HCEs with community-based physicians. Reductions in both length of stay and cost per case were noted for 8 of the 11 most common discharge diagnoses. Resident survey: over 75% of residents responded, with all noting improvement in the quality of attending rounds, bedside teaching, and the overall inpatient experience. Residents’ roles as teachers and team leaders were largely unchanged.CONCLUSION: Hospitalist clinician educators as inpatient teaching attendings effectively reduce length of stay and resource utilization while improving resident education at community-based teaching hospitals.

Preventing cardiovascular disease in diabetes and glucose intolerance: evidence and implications for care.

With the increased attention being given to cardiovascular risk factor reduction, the opportunity exists to substantially decrease the largest cause of mortality in diabetic patients. The concept that type 2 diabetes and CVD are linked via a common etiologic pathway (metabolic syndrome) has substantial ramifications for the care of individual patients. Many of the metabolic abnormalities that contribute to both glycemic disorders and CVD are interrelated. For example, hyperinsulinemia and insulin resistance coupled with abdominal obesity further worsens HTN and hyperlipidemia. Likewise, the procoagulant state and endothelial dysfunction increase with worsening glycemic control. Specific interventions include tobacco cessation, a food management and physical activity plan, choice of antidiabetic agent (such as metformin), and use of ACE inhibitors for hypertension and microalbuminuria (Table 5). Programs to enhance cardiovascular risk factor reduction as part of the comprehensive evaluation and management of diabetic patients have been described [95,99]. One community-based program provided free screening to diabetic patients with randomization to either annotated result reports provided to the patient and their physician or results provided by a project nurse (either face-to-face or over the phone). Greater improvements in mean glycohemoglobin, cholesterol, and blood pressure were noted with verbal presentation of results [99]. Recent data from the Centers for Disease Control and Prevention Diabetes Cost-effectiveness Group support the idea that interventions to decrease CVD in diabetics are economically beneficial. Intensive management of hypertension, glycemic control, and hyperlipidemia each improved health outcomes. Hypertension control reduced costs. Although intensive treatment of glucose and hyperlipidemia increased costs, the increase was comparable to that of other frequently used health care interventions [100]. Further directions include further exploration of the implications and management of metabolic syndrome as it relates to CVD prevention. Interventions such as exercise, which can impact on all outcomes, require special attention. Efforts by physicians, health systems, and society are necessary to increase physical activity for individuals of all ages. It makes clinical sense that the recommendations for prevention of CVD in diabetics described in this article may also benefit patients with prediabetes (fasting glucose 110-125 mg/dl), but this remains to be definitively shown.

Nutrition screening vs nutrition assessment: how do they differ?

Interest in nutrition screening has increased rapidly due to regulatory requirements as well as the known adverse impact of nutrition deficits on outcomes of hospitalization. Screening programs now in use in acute care are often complex and difficult to administer. Current interest in evaluation of all aspects of healthcare using evidence-based methods requires that nutrition screening programs be thoroughly evaluated. Clinicians attempting to evaluate evidence in support of different methods to identify patients who might have nutrition problems are often confronted with research that blurs the distinction between screening and assessment. Therefore, before identifying methods to conduct nutrition screening, it is necessary to have a thorough understanding of the difference between screening and assessment. A review of terms, definitions, and programs for screening in other areas of healthcare will provide some guidance to the clinician faced with development, implementation, and monitoring of nutrition screening programs. This facilitates development of nutrition assessment programs so that patients who have a nutrition screen are assessed in a timely fashion and receive appropriate nutrition interventions.

Nutrition Assessment in the 1990s: Where Are We Now?

This review addresses some of the challenges confronting the modern nutrition support clinician in developing protocols for nutrition assessment. While it is generally agreed upon that patients who are malnourished are at greater risk for development of complications during hospitalization, there is no consensus on the best method for assessment of nutritional status. Assessment parameters currently available include clinical, biochemical, anthropometric, and functional tests designed to evaluate nutrition status as well as estimate body composition. As some of these parameters are expensive or not practical for routine clinical use, they should be evaluated carefully when a nutrition assessment protocol is designed.

Update in Women's Health

INTRODUCTION The aim of this clinical update is to summarize articles and guidelines published in the last year with the potential to change current clinical practice as it relates to women’s health.

Stigmatization of Substance Use Disorders Among Internal Medicine Residents

ABSTRACT Background: Evidence suggests that some physicians harbor negative attitudes towards patients with substance use disorders (SUDs). The study sought to (1) measure internal medicine residents’ attitudes towards patients with SUDs and other conditions; (2) determine whether demographic factors influence regard for patients with SUDs; and (3) assess the efficacy of a 10-hour addiction medicine course for improving attitudes among a subset of residents. Methods: A prospective cohort study of 128 internal medicine residents at an academic medical center in New York City. Scores from the validated Medical Condition Regard Scale (MCRS) were used to assess attitude towards patients with alcoholism, dependence on narcotic pain medication, heartburn, and pneumonia. Demographic variables included gender, postgraduate training year, and prior addiction education. Results: Mean baseline MCRS scores were lower (less regard) for patients with alcoholism (41.4) and dependence on narcotic pain medication (35.3) than for patients with pneumonia (54.5) and heartburn (48.9) (P < .0001). Scores did not differ based upon gender, prior hours of addiction education, or year of training. After the course, MCRS scores marginally increased for patients with alcoholism (mean increased by 0.16, P = .04 [95% confidence interval, CI: 0.004–0.324]) and dependence on narcotic pain medication (mean increased by 0.09, P = .10 [95% CI: 0.02–0.22]). Conclusions: Internal medicine residents demonstrate less regard for patients with SUDs. Participation in a course in addiction medicine was associated with modest attitude improvement; however, other efforts may be necessary to ensure that patients with potentially stigmatized conditions receive optimal care.

Management of blood glucose and diabetes in the critically ill patient receiving enteral feeding.

Diabetes mellitus causes profound alterations in nutrient metabolism, leading to long-term systemic complications, particularly in individuals with poorly controlled disease. Nutrition support clinicians need to be aware of the effect of acute illness on stress-induced and established diabetes mellitus and the appropriate management strategies. Because enteral feeding is a vital component of critical care for many patients with diabetes mellitus, it is important to develop techniques to best manage metabolic control during enteral feeding. This article will review mechanics of blood glucose regulation, evaluation of energy sources for patients with diabetes mellitus, selection of enteral formulas and infusion routes, and glycemic control in patients receiving tube feeding. At this point, it is appropriate to use a standard formula to initiate feedings in most patients with blood glucose abnormalities. Close monitoring and judicious use of insulin are key in maintaining glucose control and avoiding complications.

Gender, ethnicity, and genes in cardiovascular disease. Part 2: implications for pharmacotherapy.

Women are underrepresented in clinical trials. Lower doses of beta-blockers are required for Southeast Asians. ACE and ARBs are teratogenic in the second trimester. Torsades de Pointes is more common in women related to a longer QT-interval. Lower dose OCPs decrease the risk of MI, stroke and thrombosis. HRTs are not effective for CAD prevention.