Ochsner Journal最新文献

Background: Pulmonary arterial hypertension (PAH) is a rare and fatal disease. While many treatment options have been shown to improve quality of life, exercise tolerance, and hemodynamics in PAH, survival remains poor, in part due to the advanced stage at which patients present to PAH specialists.

Methods: This perspective paper explores challenges related to the timing of referral, diagnosis, and initiation of therapy.

Results: Multiple factors account for the delay in referral, including fallacies in physician education, commercial influence resulting in inappropriate prescribing practices, and barriers in access to care.

Conclusion: Improving physician education, encouraging the prescription of PAH medications to be done predominantly by PAH specialists, overcoming barriers to care, and promoting screening for PAH will help ensure early referral, diagnosis, and treatment.

Background: Imiquimod is a topical cream approved by the US Food and Drug Administration for treatment of superficial basal cell carcinoma, actinic keratosis, and genital-perianal warts. Its successful use in patients with persistently positive margins of melanoma in situ (MIS) after surgical excision has been previously reported.

Case report: A 75-year-old female presented with a primary melanoma that was removed through an elliptical excision with 1 cm margins. Pathology revealed 3 involved margins with residual MIS without an invasive component. After a second operation removed an additional 1 cm margin, pathology revealed 2 positive margins with residual MIS. Rather than undergoing a third excision, the patient decided to pursue a nonsurgical approach with topical imiquimod, and at the 4-month follow-up examination, the incision was completely healed with no clinical evidence of tumor recurrence.

Conclusion: A nonsurgical approach with 5% topical imiquimod cream applied along the incision was utilized. In specific patient populations, the use of imiquimod is a reasonable alternative approach for the management of persistently positive MIS margins. Long-term follow-up is necessary to assess for evidence of recurrence and the ultimate success of this nonsurgical approach.

Background: Hospital-associated disability is the loss of the ability to complete one activity of daily living (ADL), with this decline occurring between the onset of acute illness and discharge from the hospital. Approximately 30% of patients who are >70 years old and admitted to hospitals are discharged with an ADL disability. Comprehensive geriatric assessment (CGA) models use a multidimensional, interdisciplinary process of diagnosis and treatment with the goal of improving outcomes and decreasing lengths of stay.

Methods: A retrospective clinical audit of Ipswich Hospital's medical records included patients for random selection who were >75 years of age and had an acute admission to the Older Person Evaluation Review and Assessment (OPERA) or general medicine (GM) service from July 2012 to December 2012. Data were collected for the entire admission period on length of stay, comorbidities, allied health visits, functional ability, and delirium and dementia at admission.

Results: Of the 267 patients evaluated, 133 were admitted to the OPERA service, and 134 were admitted to the GM service. Patients admitted to the OPERA service were significantly more ill than patients admitted to the GM service as measured by the Charlson Comorbidity Index scores (6.53 ± 1.83 vs 6.02 ± 1.96, respectively, P=0.02), Katz Index of Independence in ADL scores (3.77 ± 2.22 vs 4.72 ± 2.00, respectively, P<0.001), presence of delirium at admission (28% vs 15%, respectively, P=0.02), and presence of dementia at admission (42% vs 21%, respectively, P=0.002). However, patients in both groups had a mean acute length of stay of 4 days (P=0.33), the readmission rate was <20% for both groups (P=0.33), and the mortality rate for each group was similar (3%).

Conclusion: By showing that patients admitted to the OPERA service were more ill than patients admitted to the GM service but health outcomes were maintained, researchers hope to justify the need for such CGA models. Additional goals include garnering support for the maintenance and growth of CGA models; decreasing mortality, cost, and readmission rates; and improving the quality of life for older patients.