HCA healthcare journal of medicine最新文献

Description This letter is submitted in response to the letter to the editor regarding the authors' article "Exercise Is a Vital Sign."

Background: Limited information exists on the characteristics of older adults admitted with delirium at risk of poor hospital outcomes. This study aims to identify risk factors present on admission that are associated with hospital mortality and length of stay (LOS) among older adults admitted with delirium.

Methods: This is a retrospective study of 5598 patients 65 years of age or older who were admitted to acute care units at 8 community hospitals with an International Statistical Classification of Diseases, Tenth Revision code of delirium.

Results: Multivariate regression analyses revealed that in-hospital mortality increase was associated with increased age, Asian race, various medical comorbidities, abnormal agitation-sedation score, abnormal blood urea nitrogen level, intensive care unit admission, and opioid use. Increased LOS was associated with male sex, Asian race, Black race, Medicaid insurance, chronic lung disease, renal disease, and antipsychotic use.

Conclusion: This study identified a subgroup with specific demographic and clinical characteristics associated with an increased risk of hospital mortality and increased LOS among older patients admitted with delirium. This subgroup would likely benefit from targeted interventions that may address potential health care inequalities among older adults with delirium.

Description The term "vital sign" has been attached to at least 83 conditions, symptoms, or phenomena in the literature to highlight their role and importance in overall health and well-being. This has created considerable confusion and overlapping terms in the medical literature. The 4 time-honored vital signs include temperature, pulse, blood pressure, and respiration. Two other measurements, blood oxygen saturation, and capnography (end-tidal CO2) are considered the fifth and sixth vital signs, respectively. The authors argue that exercise should be named a vital sign, and several authors have designated it as the fifth vital sign. However, not all symptoms or phenomena, such as exercise, are essential for life. This article traces the origins of the term "vital sign," reports on the various conditions named the fifth through eighth vital signs, and proposes an objective definition that describes the requirements for designating something as a vital sign.

Description We detail 2 cases of cutaneous horn, also referred to as cornu cutaneum, which is a hard-compacted linear outgrowth of keratin that projects above the skin. We present these images to increase awareness for all medical specialties who may see a patient with this skin lesion.

Background: Total knee arthroplasty in younger patients presents a heightened risk of postoperative complications and implant failures compared to older populations, particularly in those with posttraumatic arthritis. These challenges necessitate careful consideration and specialized approaches to optimize the outcomes in this patient demographic.

Case presentation: A 43-year-old man presented with left knee pain resulting from a traumatic lawn mower injury, causing an intraarticular distal femur, at the age of 6. The injury led to a limb-length discrepancy for which he underwent 2 limb-lengthening procedures in his early 20s. Radiographs demonstrated advanced posttraumatic osteoarthritis, and the patient elected to proceed with surgical intervention. Intraoperatively, significant deficiencies of the medial femur and anterodistal femur were noted, making cement, a bone graft, or a combination of both, less viable options. He underwent a left total knee arthroplasty, with the utilization of a femoral metaphyseal sleeve, due to severe bone loss in the distal femur. Postoperatively, the patient progressed well and returned to his activities of daily living, and, at about 3 months, had a pain-free left knee, without a disturbance of his prior limb-length discrepancy.

Conclusion: This is a rare case of a metaphyseal sleeve being used in a younger patient, revealing the potential for this procedure to be used in cases of primary total knee arthroplasty in patients with posttraumatic osteoarthritis.

Background: Medical decision-making in indigent patients with baseline cognitive deficits and lack of supportive resources is a difficult problem that reveals many ethical issues. Performing high-level medical procedures (eg, invasive surgery, chemotherapy, radiation therapy) on these patients without supportive resources brings into question the efficacy and necessity of treatment if it places the patient at higher risk of additional complications and mortality.

Case presentation: In this article, we present a case of a 62-year-old indigent man with a long history of encephalopathy secondary to alcohol abuse, presenting with an aggressive head and neck cancer impacting his quality of life.

Conclusion: Determining a patient's cognition level, capacity, and ability to give informed consent can be challenging as all these factors can be ever-changing in patients with baseline cognitive deficits. In this report, we examine the complexities involved in deciding not to offer advanced treatment to a patient who has decreased cognitive function and lacks social and financial resources due to his experiencing homelessness.

Description The goal of this article is to discuss 1 of the questions in the Accreditation Council for Graduate Medical Education Resident/Fellow Survey, which assesses the fear of retaliation in a program. To better understand the needs of residents and facilitate the reporting of concerns, programs must evaluate and educate residents on the difference between remediation and retaliation.

Introduction: Clostridioides difficile infection (CDI) is a significant cause of antibiotic-associated diarrhea and colitis, ranging from mild to severe and potentially life-threatening conditions, like fulminant colitis with toxic megacolon and bowel perforation. The 2021 guidelines from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) recommend vancomycin and metronidazole for fulminant CDI (FCDI), with consideration of rectal vancomycin for cases with ileus. Fidaxomicin, though preferred for initial and recurrent CDI treatment, is not the first line for FCDI due to limited evidence. Fidaxomicin has a narrow spectrum of activity only targeting C difficile and spares the normal intestinal microbiota, which may contribute to its favorable outcomes.

Case presentation: Our case study involves a 79-year-old man with worsening symptoms post-amoxicillin/clavulanic acid use. Diagnosed with septic shock from C difficile and toxic megacolon, the patient started on oral vancomycin and metronidazole, followed by rectal vancomycin, per guidelines, also requiring vasopressors and renal replacement therapy. Despite initial treatment, his condition deteriorated, after which he underwent a sub-total colectomy without improvement. He was eventually started on rectal fidaxomicin and loperamide, resulting in rapid improvement. This case introduces rectal fidaxomicin as a novel approach for FCDI treatment with unique preparation and administration methods.

Conclusion: An extensive review of the literature found only a few instances of rectal fidaxomicin use for FCDI, suggesting its novelty and rarity. The successful outcome prompts further studies to validate its efficacy and its possible inclusion in future treatment guidelines. In summary, this case underscores the complexity of FCDI management and highlights the potential of rectal fidaxomicin as a salvage therapy. Further research is warranted to elucidate its role in treating FCDI and incorporating it into clinical practice guidelines.

Background: Research is a core component of health profession training programs, but few efficient training resources exist that provide introductory research training that is brief, freely accessible, and supportive of learners with varying levels of research experience.

Methods: We set out to create the Mountain Area Health Education Center (MAHEC) Research Certificate program to support Graduate Medical Education (GME) residents and other learners. We initially explored existing curricula used to instruct medical and doctor of pharmacy students in order to identify foundational research topics to include in our introductory research program. We were guided by stakeholders to create a curriculum for interdisciplinary learners that avoided costs to the user, kept learning sessions under 30 minutes, could be fully completed online, and could be incorporated into larger research courses. We created 8 modules by vetting freely available online resources or produced original content if existing resources were deemed inadequate. Additionally, we developed our evaluation processes.

Results: The MAHEC Research Certificate Curriculum was implemented, and several GME programs, and other educational programs, incorporated the modules into their research curriculum. Preliminary results demonstrate that learner confidence on all 8 research topics improved after module completion. Overall, participants were highly satisfied with the curriculum and were likely to recommend the modules to peers.

Conclusion: This research curriculum fills a need for a free, brief, accessible, and asynchronous online research training program for learners. The curriculum can be used to supplement existing research didactic training in professional programs, to support researchers reviewing specific research topics, and/or to introduce research concepts to inexperienced researchers, all of whom can receive an automatically generated certificate of completion.

Background: Surgical management of kidney stones in pregnancy can be a serious problem for both mother and fetus.

Case presentation: A 20-year-old woman with a second trimester pregnancy presented to the emergency room with renal calculi. She required surgical intervention and a left nephrostomy tube after consultation with urology. Five weeks later, her tube was solidified in place unbeknownst to her care team. She required several surgeries, dealt with encrustation remnants, infections, radiation exposure, persistent infection requiring antibiotic management, and, ultimately, an early delivery at 37 weeks.

Conclusion: At the time of writing, this was the first case to describe a stent encrustation remnant in pregnancy. This case illustrates the need for timely follow-up after interventional radiology procedures and the potential complications a pregnant patient can encounter with surgical interventions, such as a nephrostomy tube. This case highlights stone challenges that obstetricians, internists, urologists, and radiologists should be aware of when managing the most common nonobstetrical cause of admission in pregnancy.