Archive for June 2010

Initiation of dialysis can be delayed until symptoms develop

In this large trial of patients with end stage kidney disease, patients were randomized to initiation of dialysis at a GFR of 10-14 or GFR of 5-7. Mean time to dialysis initiation was 1.8 months versus 7.4 months, but there was no difference between the groups (after a median of 3.6 years) in death or adverse events (including complications of dialysis). Dialysis initiation can be delayed until the development of symptoms (abstract)

Quality of care for dying inpatients

In this retrospective cohort of almost 500 patients who died in the hospital, researchers found over half of them were admitted with an end-stage disease, and 15% died during CPR. In assessing 16 quality indicators to assess the quality of the dying experience, they found almost 1/3 of patients did not receive recommended care for applicable indicators. This quality assessment can identify areas of needed improvement for palliative symptom management in patient dying in the hospital setting (abstract)

Diagnostic adverse errors are often preventable and fatal

In this large retrospective analysis of diagnostic adverse errors, researchers found diagnostic adverse errors accounted for only 6% of all adverse errors, but 83% of these were judged as preventable, and 29% were judged to contribute to death. The primary causes were found to be problems with physician knowledge or information transfer. Continued training in building on clinical knowledge base, and training in how to transfer clinical information may reduce the incidence and mortality of diagnostic adverse errors (abstract)

Echo to predict peri-operative cardiac events

In this prospective cohort 1005 patients scheduled for elective vascular surgery, all had an echo performed. Of all the patients, 21% had asymptomatic diastolic dysfunction, and 19% had asymptomatic systolic dysfunction. After multivariate adjustment, LV dysfunction independently predicted risk of 30 day cardiovascular events (OR 2.3 and 1.8 for systolic and diastolic dysfunction, respectively) and long term cardiovascular mortality (HR 4.6 and 3.0 for systolic and diastolic dysfunction, respectively) in patients undergoing open vascular surgery. Although the authors recommend routine pre-operative echo for patients undergoing vascular surgery, as of now it is unclear what interventions would be performed to reduce the risk of events (abstract)

Beta blockers probably safe in cocaine associated chest pain

Beta blockers have long thought to be contraindicated in patients with cocaine-associated chest pain. In this retrospective single center analysis of 331 patients with chest pain and cocaine-positive drug screens, almost half received a beta blocker. There was no significant differences in EKG changes or troponin levels between those that did and did not receive a beta blocker, but those discharged on a beta blocker had significantly lower long term cardiovascular mortality. Use of beta blockers appears to be safe in patients with cocaine-associated chest pain, and may actually improve long term mortality (abstract)