Journal of hospital medicine最新文献

Varicella Zoster virus (VZV) is the etiologic agent responsible for varicella and herpes zoster (shingles). Nonimmune children and adults acutely infected with VZV typically experience a vesicular and pruritic rash that progresses from the face and trunk and generalizes to the extremities, accompanied by an oral enanthem along with symptoms of fever and malaise. Later, the virus may reactivate from dormancy in the dorsal root ganglia, leading to a stereotypical, unilateral, painful, vesicular rash limited to one or two dermatomes. While either pattern of infection is usually self-limited in healthy children, more severe complications including death may occur among immunocompromised, pregnant, or adult patients. VZV vaccines have greatly reduced morbidity and mortality since their introduction more than 30 years ago. Hospitalists should be prepared to recognize and treat patients with VZV infection, particularly in an era of increasing vaccine hesitancy.

Violence in hospitals poses a vexing and increasingly urgent problem. At Cooper University Hospital, we recently developed the therapeutic violence mitigation (TVM) initiative. Innovations in TVM include the use of technology, automated text notifications, and tailored care plans for patients at risk for violence. Pilot results show substantial decreases in violent events for patients receiving TVM interventions.

A 58-year-old man with acute myeloid leukemia developed five distinct new fingernail changes after chemotherapy. These include onycholysis, palpable transverse depressions across his fingernails, diffuse melanonychia, transverse, nonblanching white bands, and thin white transverse lines all caused by his chemotherapy regimen. It is uncommon to find all five of these physical exam findings simultaneously. We describe the underlying pathophysiology for hospital-based clinicians and highlight their transient course.

Patients in the hospital frequently have multiple chronic conditions in addition to their acute illnesses. Inpatient providers may feel pressured to adjust outpatient medication regimens in response to acute variations in labs or vital signs during hospitalization, or in an attempt to optimize long-term disease control. However, this practice should generally be deferred to the outpatient setting, as the effective management of chronic conditions requires longitudinal care and should take place during periods of homeostasis. In select circumstances and for certain high-risk patients, stepwise modifications to chronic disease medications may be considered during hospitalization, but this should always be coordinated with the primary care provider.

Care coordination is integral during posthospital transitions. The Centers for Medicare & Medicaid Services (CMS) has sought to promote post-hospitalization care coordination through population-based alternative payment models (APMs) and transitional care management (TCM) services. Both can be associated with benefits, but data are lacking about their overlap. Using 2018–2019 100% Medicare claims, we compared characteristics and quantified overlap across APM and TCM groups. Of 7,034,244 beneficiaries and 11,148,266 discharges, 41.6% were APM-aligned and 14.5% involved TCM. TCM services were received in 19.7% of APM-aligned discharges; among discharges involving TCM, 56.7% occurred among APM-aligned beneficiaries. Relative to non-APM beneficiaries, APM-aligned beneficiaries receiving TCM were less likely to be from historically underserved populations, suggesting potential health disparity concerns. This early descriptive analysis offers novel evidence about TCM and APMs as major national policy investments, highlighting the need for future work on overlap and its effects on care coordination and patient outcomes.

We developed a Best Practice Advisory (BPA) to encourage switching from intravenous (IV) to oral (PO) formulations of antimicrobials with equal efficacy, to decrease costs and IV usage. We conducted a prospective study analyzing our BPA's effect on prescribing practices of antimicrobials in the inpatient setting of Stanford Hospital in Palo Alto, CA, over a 22-month period. Our BPA achieved a 1526/6585 (23.2%) acceptance rate and led to decreased use of IV antimicrobials, with substantial direct cost savings of at least $66,976. Future efforts will focus on expanding our BPA to non-antimicrobials given ongoing IV fluid shortages.