Supplements Are Not a Synonym for Safe: Suspected Liver Injury From Ashwagandha.

Background: As patients look more to alternative herbal and dietary supplements to boost energy and mood, reports are increasing of unintended adverse effects, particularly to the liver. Case Presentation: We report a case of a 48-year-old man with a history of severe alcohol use disorder who presented to the emergency department with a cholestatic pattern of liver injury in the setting of alcohol and use of a testosterone-boosting supplement containing ashwagandha. Conclusions: Drug-induced liver damage should be considered in patients with alcohol use disorder who present with a cholestatic pattern of liver injury. Although many natural substances are well tolerated, others can have unanticipated and harmful adverse effects and drug interactions. Future research should identify not only potentially harmful substances, but also which patients may be at greatest risk.

The Association of Medical Preoperative Evaluation Using Clinical Video Telehealth With Hospital Length of Stay: Descriptive Analysis.

BACKGROUND: Preoperative medical evaluation serves to identify risk factors and optimize patients before surgery. Providing a telehealth option in the perioperative setting has played a significant role in reducing barriers to quality perioperative health care. OBJECTIVE: We aimed to evaluate how telemedicine preoperative evaluations using Clinical Video Telehealth (CVT) impact hospital length of stay. METHODS: We performed a retrospective chart review between 2016 and 2017 of adult patients who underwent evaluations in our hospitalist-run preoperative medicine clinic. Patients seen in our preoperative CVT program were compared to patients seen in person to evaluate the association of visit type (preoperative CVT versus in-person evaluation) with hospital length of stay, defined as hospital stay from postoperative day 0 to discharge. There were 62 patients included in this retrospective study. RESULTS: The adjusted incidence rate ratio (IRR) for hospital length of stay was significantly shorter in patients who underwent preoperative CVT compared to an in-person visit (IRR 0.52, 95% CI 0.29-0.92, P=.02). CONCLUSIONS: After adjusting for age and comorbidities, we show that preoperative telemedicine in the perioperative setting is associated with a shorter hospital length of stay compared to in-person visits. This suggests that telemedicine can play a viable role in this clinical setting.

Difluoroethane Inhalant Abuse, Skeletal Fluorosis, and Withdrawal.

Prolonged or excessive use of the central nervous system depressant difluoroethane, which is an easily acquired and inexpensive volatile substance that can be inhaled recreationally, is associated with toxicity, and abrupt cessation can induce withdrawal.

Long-Term Experience With a Mandatory Clinical Decision Rule and Mandatory d-Dimer in the Evaluation of Suspected Pulmonary Embolism.

PURPOSE: This study evaluated the long-term effectiveness of mandatory assignment of both a clinical decision rule (CDR) and highly sensitive d-dimer in the evaluation of patients with suspected pulmonary embolism (PE). MATERIALS AND METHODS: Institutional guidelines with a CDR and highly sensitive d-dimer were embedded in an order entry menu with mandatory assignment of key components before ordering a CT pulmonary angiogram (CTPA). Data were retrospectively extracted from the electronic health record. RESULTS: This was a retrospective review of 1,003 CTPA studies (905 patients, 845 male and 60 female patients, age 63.7 ± 13.5 years). CTPAs were positive for PE in 170 studies (17%), representing an average yield of 15% (year [average]; 2007 [15%], 2008 [18%], 2009 [15%], 2010 [15%], 2011 [17%], 2012 [15%], 2013 [23%]). The increased yield represented efforts of mandatory order entry assignments, educational sessions, and clinical champions. Different d-dimer thresholds with or without age adjustments in combination with the CDR identified about 10% of patients who may have been managed without CTPA. CONCLUSION: Mandatory assignment of a CDR and highly sensitive d-dimer clinical decision pathway can be successfully incorporated into an order entry menu and produce a sustained increase in CTPA yield of patients with suspected PE.

Perioperative processes and outcomes after implementation of a hospitalist-run preoperative clinic.

BACKGROUND: A structured, medical preoperative evaluation may positively impact the perioperative course of medically complex patients. Hospitalists are in a unique position to assist in preoperative evaluations, given their expertise with inpatient medicine and postoperative surgical consultation. OBJECTIVE: To evaluate specific outcomes after addition of a Hospitalist-run, medical Preoperative clinic to the standard Anesthesia preoperative evaluation. DESIGN, SETTING, PATIENTS: A pre/post retrospective, comparative review of outcomes of 5223 noncardiac surgical patients at a tertiary care Veterans Administration (VA) medical center. RESULTS: Length of stay was reduced for inpatients with an American Society of Anesthesia (ASA) score of 3 or higher (P < 0.0001). There was a trend towards a reduction in same-day, medically avoidable surgical cancellations (8.5% vs 4.9%, P = 0.065). More perioperative beta blockers were used (P < 0.0001) and more stress tests were ordered (P = 0.012). Inpatient mortality rates were reduced (1.27% vs 0.36%, P = 0.0158). CONCLUSION: A structured medical preoperative evaluation may benefit medically complex patients and improve perioperative processes and outcomes.

Does a clinical decision rule using D-dimer level improve the yield of pulmonary CT angiography?

OBJECTIVE: The objective of our study was to evaluate the impact of incorporating a mandatory clinical decision rule and selective d-dimer use on the yield of pulmonary CT angiography (CTA). MATERIALS AND METHODS: Guidelines incorporating a clinical decision rule (Wells score: range, 0-12.5) and a highly sensitive d-dimer assay as decision points were placed into a computerized order entry menu. From December 2006 through November 2008, 261 pulmonary CTA examinations of 238 men and 14 women (mean age ± SD, 65 ± 12 years; range, 31-92 years) were performed. Eight patients underwent more than one pulmonary CTA examination. Charts were reviewed. The results of pulmonary CTA, the clinical decision rule, and d-dimer level (if obtained) were analyzed with the Student t test, chi-square test, or other comparisons using statistical software (MedCalc, version 11.0). RESULTS: Of the pulmonary CTA examinations, 16.5% (43/261) were positive for pulmonary embolism (PE) compared with 3.1% (6/196) during the previous 2 years. The mean clinical decision rule score and mean d-dimer level were 5.5 ± 2.4 (SD) and 4956 ± 2892 ng/mL, respectively, for those with PE compared with 4.5 ± 2.1 and 2398 ± 2100 ng/mL for those without PE (both, p < 0.01). The negative predictive value of a clinical decision rule score of 4 or less and d-dimer level of less than 1000 ng/mL was 1.0. A clinical decision rule of greater than 4 and a higher d-dimer level were better predictors for PE, especially a d-dimer level of greater than 3000 ng/mL (odds ratio = 6.69; 95% CI = 2.72-16.43). CONCLUSION: Guidelines combining a clinical decision rule with d-dimer level significantly improved the utilization of pulmonary CTA and positive yield for PE.

The top 10 infectious disease pitfalls that hospitalists can avoid.

Infectious diseases are commonly encountered by hospitalists in their day-to-day care of patients. Challenges involved in caring for patients with infectious diseases include choosing the correct antibiotic, treating patients with a penicillin allergy, interpreting blood cultures, and caring for patients with human immunodeficiency virus (HIV). The evidence-based pearls in this article will help hospitalists avoid common pitfalls in the recognition and treatment of such disorders and guide their decision about when to consult an infectious diseases specialist.

Evaluating and minimizing cardiac risk in surgical patients.

Cardiovascular complications are a major cause of postoperative morbidity and mortality. Proper assessment of risk and subsequent interventions can help diminish these complications. Assessing the patient's risk is based on the type of surgery performed and on individual patient characteristics. The latter can be established with a thorough history and physical, laboratory testing, risk indices, and cardiology studies.

Evaluation of a Web-based education and counseling pilot program for older heart failure patients.

Web-based communication has been reported as a feasible management tool for heart failure (HF) patients and has also been documented to positively impact quality of life (QOL). The feasibility and effectiveness of a Web-based educational and HF management program among older HF patients (60 years and older), however, have not been previously explored. Therefore, a prospective study was conducted. QOL (physical and mental health) and perceived control (PC) scores of 40 participants were measured (baseline and 3 months) and retrospectively compared with an age- and sex-matched control group of 40 patients receiving HF care as usual. Between-group differences over time were statistically significant in the QOL mental health component and PC scores. The authors' findings demonstrate the beneficial effects of a Web-based program on QOL and PC in older patients with HF. This approach may be potentially beneficial in delivering educational and behavioral support to this high-risk group in ways that are affordable and accessible.

The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs.

OBJECTIVE: To compare nurse practitioner/physician management of hospital care, multidisciplinary team-based planning, expedited discharge, and assessment after discharge to usual management. BACKGROUND: In the context of managed care, the goal of academic medical centers is to provide quality care at the lowest cost and minimize length of stay (LOS) while not compromising quality. METHODS: Comparative, 2-group, quasiexperimental design was used; 1,207 general medicine patients (n=581 in the experimental group and n=626 in the control group) were enrolled. The control unit provided usual care. The care management in the experimental unit had 3 different components: an advanced practice nurse who followed the patients during hospitalization and 30 days after discharge, a hospitalist medical director and another hospitalist, and daily multidisciplinary rounds. LOS, hospital costs, mortality, and readmission 4 months after discharge were measured. RESULTS: Average LOS was significantly lower for patients in the experimental group than the control group (5 vs. 6 days, P<.0001). The "backfill profit" to the hospital was US$1591 per patient in the experimental group (SE, US$639). There were no significant group differences in mortality or readmissions. CONCLUSIONS: Collaborative physician/nurse practitioner multidisciplinary care management of hospitalized medical patients reduced LOS and improved hospital profit without altering readmissions or mortality.

An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model.

OBJECTIVE: Hospitals adapt to changing market conditions by exploring new care models that allow them to maintain high quality while containing costs. The authors examined the net cost savings associated with care management by teams of physicians and nurse practitioners, along with daily multidisciplinary rounds and postdischarge patient follow-up. METHODS: One thousand two hundred and seven general medicine inpatients in an academic medical center were randomized to the intervention versus usual care. Intervention costs were compared to the difference in nonintervention costs, estimated by comparing changes between preadmission and postadmission in regression-adjusted costs for intervention versus usual care patients. Intervention costs were calculated by assigning hourly costs to the time spent by different providers on the intervention. Patient costs during the index hospital stay were estimated from administrative records and during the 4-month follow-up by weighting self-reported utilization by unit costs. RESULTS: Intervention costs were $1187 per patient and associated with a significant $3331 reduction in nonintervention costs. About $1947 of the savings were realized during the initial hospital stay, with the remainder attributable to reductions in postdischarge service use. After adjustment for possible attrition bias, a reasonable estimate of the cost offset was $2165, for a net cost savings of $978 per patient. Because health outcomes were comparable for the 2 groups, the intervention was cost-effective. CONCLUSIONS: Wider adoption of multidisciplinary interventions in similar settings might be considered. The savings previously reported with hospitalist models may also be achievable with other models that focus on efficient inpatient care and appropriate postdischarge care.

Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses.

BACKGROUND: Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients' satisfaction and quality of care. OBJECTIVE: To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit. METHODS: During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit; nurses, biannually. RESULTS: Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P < .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P < .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P = .006). Nurses in both groups reported similar levels of communication (P = .59) and collaboration (P = .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P < .001). CONCLUSIONS: The multidisciplinary intervention resulted in better communication and collaboration among the participants.