Delirium.

Delirium is an acute and fluctuating disorder characterized by a disturbance in attention and cognition. Delirium is underdiagnosed by clinicians, but there are excellent diagnostic tools using history and physical examination that can assist clinicians in making the diagnosis in multiple settings (ie, CAM, CAM-ICU, 3D-CAM, bCAM, 4AT, and UB-CAM). Delirium is caused by underlying medical conditions and is often multifactorial, so a full diagnosis requires a careful assessment for a wide range of underlying conditions. Physical examination has not been well studied in this regard, but still can provide useful clues to the clinician.

Effects of race and ethnicity on the incidence of venous thromboembolism.

Although there is strong evidence that the prevalence of venous thrombo-embolism (VTE) varies significantly among different ethnic/racial groups, the genetic, physiologic and/or clinical basis for these differences remain largely undefined. African-American patients have a significantly higher rate of incident VTE, particularly following exposure to a provoking risk factor such as surgery, medical illness, trauma, etc. In addition, African-Americans are more likely to be diagnosed with pulmonary embolism (PE) than deep-vein thrombosis (DVT) compared to Caucasian and other racial groups. On the other extreme, Asians/Pacific Islanders have a 70% lower prevalence of VTE and this is true for both idiopathic VTE and provoked, or 'secondary', VTE. Hispanics have a significantly lower prevalence of VTE compared to Caucasians, but higher than Asians/Pacific Islanders. The incidence of recurrent VTE varies depending on gender, type of thromboembolic event and race. Further research is needed in order to determine the fundamental differences between racial/ethnic groups that explain the observed differences in the prevalence of VTE. Race/ethnicity should be considered an important factor in the risk-stratification of patients with suspected VTE or patients at some risk for developing VTE.

The effects of race/ethnicity and sex on the risk of venous thromboembolism.

PURPOSE OF THE REVIEW: Recently, studies on large diverse populations have described important ethnic/racial differences in venous thromboembolism incidence, and sex has been reported as an important predictor of recurrence. We review the influence of race/ethnicity and sex on venous thromboembolism, concentrating on articles from 2005 to 2007. RECENT FINDINGS: Most studies found that women have a 40-400% lower risk of recurrent venous thromboembolism than men. Studies of ethnicity/race on risk provide strong evidence that African-American patients are the highest risk group for first-time venous thromboembolism, while Hispanic patients' risk is about half that of Caucasians. African-Americans and Hispanics have a higher risk of recurrence than Caucasians, but sex and the type of index venous thromboembolism event seem to play a role in this risk. Asian/Pacific Islanders have a markedly lower risk of first-time and cancer-associated venous thromboembolism. There is little difference in incidence in African-Americans, Hispanics, and Caucasians diagnosed with cancer. Sex does not seem to be associated with risk in cancer patients. SUMMARY: Sex and race/ethnicity are important factors in the risk of first-time and recurrent venous thromboembolism and need to be included as risk assessment and diagnostic prediction tools are developed or updated.

The many faces of error disclosure: a common set of elements and a definition.

BACKGROUND: Patients want to know when errors happen in their care. Professional associations, ethicists, and patient safety experts endorse disclosure of medical error to patients. Surveys of physicians show that they believe harmful errors should be disclosed to patients, yet errors are often not disclosed. OBJECTIVE: To understand the discrepancy between patients' expectations and physicians' behavior concerning error disclosure. DESIGN, SETTING, AND PARTICIPANTS: We conducted focus groups to determine what constitutes disclosure of medical error. Twenty focus groups, 4 at each of 5 academic centers, included 204 hospital administrators, physicians, residents, and nurses. APPROACH: Qualitative analysis of the focus group transcripts with attention to examples of error disclosure by clinicians and hospital administrators. RESULTS: Clinicians and administrators considered various forms of communication about errors to be error disclosure. Six elements of disclosure identified from focus group transcripts characterized disclosures ranging from Full disclosure (including admission of a mistake, discussion of the error, and a link from the error to harm) to Partial disclosures, which included deferral, misleading statements, and inadequate information to "connect the dots." Descriptions involving nondisclosure of harmful errors were uncommon. CONCLUSIONS: Error disclosure may mean different things to clinicians than it does to patients. The various forms of communication deemed error disclosure by clinicians may explain the discrepancy between error disclosure beliefs and behaviors. We suggest a definition of error disclosure to inform practical policies and interventions.

Visualizing the future: technology competency development in clinical medicine, and implications for medical education.

OBJECTIVE: In this article, the authors ask three questions. First, what will physicians need to know in order to be effective in the future? Second, what role will technology play in achieving that high level of effectiveness? Third, what specific skill sets will physicians need to master in order to become effective? METHOD: Through three case vignettes describing past, present, and potential future medical practices, the authors identify trends in major medical, technological and cultural shifts that will shape medical education and practice. RESULTS: From these cases, the authors generate a series of technology-related competencies and skill sets that physicians will need to remain leaders in the delivery of medical care. Physicians will choose how they will be end-users of technology, technology developers, and/or the interface between users and developers. These choices will guide the types of skills each physician will need to acquire. Finally, the authors explore the implications of these trends for medical educators, including the competencies that will be required of educators as they develop the medical curriculum. CONCLUSIONS: Examining historical and social trends, including how users adopt current and emerging technologies, allows us to anticipate changes in the practice of medicine. By considering market pressures, global trends and emerging technologies, medical educators and practicing physicians may prepare themselves for the changes likely to occur in the medical curriculum and in the marketplace.

Electronic medical records and their impact on resident and medical student education.

OBJECTIVE: Electronic medical records (EMRs) are becoming prevalent and integral tools for residents and medical students. EMRs can integrate point-of-service information delivery within the context of patient care. Though it may be an educational tool, little is known about how EMR technology is currently used for medical learners. METHOD: The authors reviewed the available published literature about the impact of EMRs on learners, including learners' attitudes about EMRs, educational uses of EMRs, and the potential effects of EMRs on learners' daily work. RESULTS: Research on EMRs for education is in its infancy. The authors found fewer than 50 articles with evidence on their use in medical education. The applications to education included point-of-care knowledge delivery, computerized clinical decision support systems, profiling of learner experiences, and daily workflow management. The evidence was mainly derived from single institution studies and occasionally across disciplines. CONCLUSIONS: EMRs have great potential as an educational tool, but thus far, strong data to support their use for this are lacking. As the usage of EMRs rises, educators must continue to study how best to use technology as an educational tool and as a tool to improve the daily work of residents and medical students.

Age as a risk factor for venous thromboembolism after major surgery.

PURPOSE OF REVIEW: Postoperative deep venous thrombosis and pulmonary embolism are serious and potentially life-threatening complications that frequently occur after major surgery. Most guidelines for thromboprophylaxis use advancing age as a key component to estimate thromboembolic risk. The reported effect of age on postoperative venous thromboembolism varies widely, making it unclear whether age alone is a significant risk factor. This article reviews the recent literature on the effect of age on the incidence of postoperative venous thromboembolism. RECENT FINDINGS: Between 2003 and 2005, several cohort studies assessed the risk factors for postoperative venous thromboembolism, showing a variable effect of age on its incidence in the 2- to 3-month period after major surgery. Studies also revealed a significant difference in the effect of age on the incidence of venous thromboembolism depending on the type of surgery. Obesity, postoperative immobilization, the use of thromboprophylaxis, the nature of the surgery, and underlying comorbid conditions such as heart failure seem to have a greater influence on the risk of venous thromboembolism than does age. SUMMARY: The variation in the effect of age on postoperative venous thromboembolism likely depends on whether or not other comorbid conditions or age-related changes in functional status are considered as risk factors. When these other risk factors are taken into account, the effect of advanced age decreases. More research is needed to develop validated venous thromboembolism risk-prediction tools for specific types of surgery. By use of this information, the intensity and duration of postoperative thromboprophylaxis can be tailored to the level of risk, not just age alone.

Strategies to reduce medication errors in ambulatory practice.

Medication errors generally refer to mistakes made in the processes of ordering, transcribing, dispensing, administering or monitoring of pharmaceutical agents used in clinical practice. The Institute of Medicine report, To Err Is Human: Building a Safer Health System, has helped raise public awareness surrounding the issue of patient safety within our hospitals. A number of legislative and regulatory steps have resulted in hospital authorities putting in place various systems to allow for error reporting and prevention. Medication errors are being closely scrutinized as part of these hospital-based efforts. Most Americans, however, receive their healthcare in the ambulatory primary care setting. Primary care physicians are involved in the writing of several million prescriptions annually. The steps underway in our hospitals to reduce medication errors should occur concurrently with steps to increase awareness of this problem in the out-patient setting. This article provides an overview of strategies that can be adopted by primary care physicians to decrease medication errors in ambulatory practice.