Publications

Abstract

Background: Care transitions are commonplace for ill older adults, but no studies to our knowledge have examined the occurrence of iatrogenic harm from medication changes during patient transfer. Objectives: To identify medication changes during transfer between hospital and nursing home and adverse drug events (ADEs) caused by these changes. Methods: Participants were residents of 4 nursing homes in the New York City metropolitan area admitted to 2 academic hospitals. Nursing home and hospital medical records were reviewed to identify changes in medication regimens between sites. Medications were matched and compared regarding dosage, route, and frequency of administration. Two physician investigators used structured implicit review to identify ADEs attributable to transfer-related medication changes. Results: During a total of 122 admissions, the mean numbers of medications altered during transfer from nursing home to hospital and hospital to nursing home were 3.1 and 1.4, respectively (P<.001 for comparison). Most changes in drug use were discontinuations, followed by dose changes and class substitutions. Of 71 bidirectional transfers that were reviewed by 2 physician investigators, ADEs attributable to medication changes occurred during 14 (20%). The overall risk of ADE per drug alteration (n = 320) was 4.4% (95% confidence interval, 2.5%-7.4%). Although most medication changes (8/14) implicated in causing ADEs occurred in the hospital, most ADEs (12/14) occurred in the nursing home after nursing home readmission. Conclusions: Medication changes are common during transfer between hospital and nursing home and are a cause of ADEs. Research is needed on interinstitutional patient care and systems interventions designed to prevent ADEs.

Abstract

The objective of this article is to study a barrier for breastfeeding women working full-time outside the home: breast milk expression in the workplace. Data are from a large corporation that provides employee benefits. Mothers express breast milk about twice a day when infants are 4 months old (x = 2.2 ± 0.8) and 6 months old (x = 1.9 ± 0.6), with a significant decline in frequency (P < .05 comparing the 2 age groups. Most mothers spend 1 hour or less expressing breast milk when infants are 3 (82%) or 6 months old (96%), with a significant difference (P < .05) between the 2 age groups. Mothers of younger infants were no more likely to work fewer days per week than were mothers of older infants. Most women can express breast milk for 3- and 6-month-old infants in less than an hour, distributed in about 2 separate portions, in an employment environment supportive of breastfeeding.

Abstract

OBJECTIVE - To assess the prevalence and clinical predictors of silent myocardial ischemia in asymptomatic patients with type 2 diabetes and to test the effectiveness of current American Diabetes Association screening guidelines. RESEARCH DESIGN AND METHODS - In the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study, 1,123 patients with type 2 diabetes, aged 50-75 years, with no known or suspected coronary artery disease, were randomly assigned to either stress testing and 5-year clinical follow-up or to follow-up only. The prevalence of ischemia in 522 patients randomized to stress testing was assessed by adenosine technetium-99m sestamibi single-photon emission-computed tomography myocardial perfusion imaging. RESULTS - A total of 113 patients (22%) had silent ischemia, including 83 with regional myocardial perfusion abnormalities and 30 with normal perfusion but other abnormalities (i.e., adenosine-induced ST-segment depression, ventricular dilation, or rest ventricular dysfunction). Moderate or large perfusion defects were present in 33 patients. The strongest predictors for abnormal tests were abnormal Valsalva (odds ratio [OR] 5.6), male sex (2.5), and diabetes duration (5.2). Other traditional cardiac risk factors or inflammatory and prothrombotic markers were not predictive. Ischemic adenosine-induced ST-segment depression with normal perfusion (n = 21) was associated with women (OR 3.4). Selecting only patients who met American Diabetes Association guidelines would have failed to identify 41% of patients with silent ischemia. CONCLUSIONS - Silent myocardial ischemia occurs in greater than one in five asymptomatic patients with type 2 diabetes. Traditional and emerging cardiac risk factors were not associated with abnormal stress tests, although cardiac autonomic dysfunction was a strong predictor of ischemia.

Abstract

We demonstrate a model for categorical data that parallels the MIMIC model for continuous data. The model is equivalent to a latent class model with observed covariates; further, it includes simple handling of missing data. The model is used on data from a large-scale study of HIV that had both biological measures of infection and self-report (missing on some cases). The model allows the determination of sensitivity and specificity of each measure, and an assessment of how well true HIV status can be predicted from characteristics of the individuals in the study.

Abstract

This article addresses significant challenges in the delivery of critical care services in hospitals including the need for partnerships between service and education, the need to strengthen interdisciplinary teams, and educational challenges in preparing critical care nurses at both the specialist and generalist levels. Each of these challenges has a direct impact on the quality-of-care outcomes for critical care patients.