Medicine

To explore the effects of cancer on psychosocial aspects of Pakistani patients and their families, assessing the need for interventions to improve their quality of life. A prospective, Cross-sectional study was performed on 200 patients visiting the oncology outpatient facility of AKUH from December 2010 to May 2011 through an interview. Responses were recorded on pre-designed questionnaires including FACT-G QOL (Functional Assessment of Cancer Therapy-General Quality Of Life) component. Out of the 200 patients 52 (26%) were males and 148 (74%) were females. Mean age was 51.8 +/- 14.2 years. Breast cancer accounted for the commonest cancer in females 116 (58%) and lung in males 30 (15%), 100 (50%) patients were currently undergoing chemotherapy. In all 148 (74%) patients were well aware of their diagnosis and were able to cope better and 142 (71%) were well supported by families (majority being financially stable). Major financial impact was found in 42 (21%) cases. Religious/spirit...

Delirium is a multifactorial entity, and its understanding continues to evolve. Delirium has been associated with increased morbidity, mortality, length of stay, and cost for hospitalized patients, especially for patients in the intensive care unit (ICU). Recent literature on delirium focuses on specific pharmacologic risk factors and pharmacologic interventions to minimize course and severity of delirium. While medication management clearly plays a role in delirium management, there are a variety of nonpharmacologic interventions, pharmacologic minimization strategies, and protocols that have been recently described. A PubMed search was performed to review the evidence for nonpharmacologic management, pharmacologic minimization strategies, and prevention of delirium for patients in the ICU. Recent approaches were condensed into 10 actionable steps to manage delirium and minimize medications for ICU patients and are presented in this review.

An outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2, initially in December 2019 at Wuhan, China, subsequently spread around the world. We describe a case series of COVID-19 patients treated at our academic medical center with focus on cytokine storm and potential therapeutic role of tocilizumab. A 59-year-old female admitted for shortness of breath (SOB), productive cough, fever, and nausea in the setting of COVID-19 pneumonia. Oxygen saturation was 81% necessitating supplemental oxygen. She was transferred to intensive care unit (ICU) for worsening hypoxia; intubated and received tocilizumab following which her oxygen requirements improved. A 52-year-old female admitted from an outside hospital with SOB, intubated for worsening hypoxia, in the setting of COVID-19 pneumonia. She received tocilizumab 400 mg intravenous for 2 doses on ICU admission, with clinical improvement. A 56-year-old female hospitalized with worsening SOB,...

B Conclusions: b SPT and SPM need to be in consideration not just as a possible complication of severe COVID-19 disease but also an indicator of poor prognosis. Spontaneous pneumothorax (SPT) and pneumo-mediastinum (SPM) is generally a complication of blunt trauma or intrinsic lung diseases such as Asthma or Bronchiolitis Obliterans, seen as a direct complication of air leaking into surrounding closed structures from either the pulmonary system or esophagus. Adding onto this, patients developing these complications have documented worsened morbidity and mortality. [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Amiodarone is a class III antiarrhythmic drug with a structure comparable to thyroid hormone and 37% iodine content by weight. In addition to direct drug cytotoxicity on thyroid cells, amiodarone deiodination in the body releases an excessive amount of iodine, which can impair thyroid function and cause hypothyroidism or thyrotoxicosis, including thyroid storm in susceptible individuals. In this report, we discuss the case of a 52-year-old woman who experienced a thyroid storm after being treated with amiodarone, eventually leading to her death.

Background: Nonadherence to asthma medications is associated with increased emergencydepartment visits and hospitalizations. If adherence is to be improved, first-fill adherence is thefirst goal to meet after the physician and patient have decided to begin treatment. Little is knownabout first-fill adherence with asthma medications and the factors for no-fill.Objective: The goal of the study was to examine the proportion of patients who fill a new pre-scription for an asthma medication and analyze characteristics associated with this first-fill.Methods: This retrospective cohort study linked electronic health records with pharmacy claims.The cohort was comprised of 2023 patients aged 18 years or older who sought care from theGeisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthmamedication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescriptionfilled by the patient within 30 days of the prescription order date. Covariates examined included factors related to thepatient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office vis-its, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy co-pay amount. A logistic-regression model was used to determine covariates associated with first-fill.Results: The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with acopay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients pre-scribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).Conclusions: Several factors associated with failing to fill an initial prescription for asthma can be addressed throughsimple interventions: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary med-ications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreas-ing copay may improve adherence and, therefore, asthma control. [AHDB. 2009;2(4):174-180

Objectives: We used an interviewer-administered questionnaire to investigate workplace exacerbation of asthma symptoms (WEAS) among low-income, minority, working asthmatics admitted Bellevue Hospital Center in New York City from 2001 to 2002. We hypothesized that a high prevalence of WEAS would be found in this population among all jobs held and a subset of individual occupational classifications.

Measurements and Main Results: Of 301 subjects, 51% reported WEAS in their current or most recent job; 71% reported WEAS in any job. Prevalences (95% confidence intervals) of WEAS in common job classifications were 61% (49-73%) in janitorial jobs, 50% (33-67%) in garment and textile manufacturing jobs, and 38% (23-55%) in construction jobs.

Conclusion: WEAS is prevalent in this urban minority population.

Objective Bayesian and frequentist approaches to statistical modelling in epidemiology are often pitted against each other as if they represented diametrically opposing philosophies. However, both approaches have a role to play in clinical epidemiology and the evaluation of clinical practice.

Methods Here I present an overview of the philosophical underpinnings of the Bayesian and frequentist approaches, showing that each model has its place depending on the philosophical and evaluative needs of the user.

Results If the user's approach to a clinical problem places an emphasis on identifying causal relationships, a frequentist approach might be best suited. On the other hand, if the user takes an approach in which estimating a priori probabilities is appropriate, a Bayesian approach might be more appropriate. One could imagine both approaches used for the same study.

Conclusions Bayesian and frequentist approaches are complementary tools in the clinical evaluator's toolkit.

Background Physicians can adhere to the principles of professionalism by practicing high-quality, evidence-based care and advocating for just and cost-effective distribution of finite clinical resources. To promote these principles, the National Physicians Alliance (NPA) initiated a project titled "Promoting Good Stewardship in Clinical Practice" that aimed to develop a list of the top 5 activities in family medicine, internal medicine,
and pediatrics where the quality of care could be improved.

Methods Working groups of NPA members in each of the 3 primary care specialties agreed that an ideal activity would be one that was common in primary care practice, that was strongly supported by the evidence, and that would lead to significant health benefits and reduce risks, harms, and costs. A modification of nominal group process was used to generate a preliminary list of activities. A first round of field testing was conducted with 83 primary care physicians, and a second round of field testing with an additional 172 physicians.

Results The first round of field testing resulted in 1 activity being deleted from the family medicine list. Support for the remaining activities was strong. The second round of field testing showed strong support for all activities. The family medicine and internal medicine groups independently selected 3 activities that were the same, so the final lists reflect 12 unique activities that could improve clinical care.

Conclusions Physician panels in the primary care specialties of family medicine, internal medicine, and pediatrics identified common clinical activities that could lead to higher quality care and better use of finite clinical resources. Field testing showed support among physicians for the evidence supporting the activities, the potential positive impact on medical care quality and cost, and the ease with which the activities could be performed. We recommend that these "Top 5" lists of activities be implemented in primary care practice across the United States.

Dr Finestone inquires whether the generation of the "Top 5" lists by the Good Stewardship working groups is better characterized as a subject of quality performance rather than professionalism. Our characterization of the effort as professionalism arises from the Physician Charter, in which the definition of professionalism rests, in part, on the principle of social justice. The charter ethically commits physicians to work toward "the wise and cost-effective management of limited clinical resources."1

The ethical principle of justice requires that everyone be treated fairly. Professionalism requires that resources be used wisely. Both assure that resources are allocated in the fairest and most effective manner. Making wise clinical decisions and being good stewards of clinical resources creates a health system that provides the best care to the most people.

Guyatt and colleagues (1) group financial conflicts of interest with intellectual conflicts of interest. I find this puzzling. Financial conflicts of interest are of concern because they do not coincide with and are not accountable to research or clinical aims. But “intellectual conflicts of interest,” according to Guyatt and colleagues, are to be found in persons with substantive knowledge, engagement, or research investment in the question at issue (indeed, according to the authors' view, they themselves would be disqualified from primary authorship of any future expert guideline on intellectual conflicts of interest). But those are precisely the people whose opinions I want to hear.