The vitamin d dose response in obesity.

OBJECTIVE: The prevalence of vitamin D inadequacy is high in obese individuals. Determining the response of serum 25-hydroxyvitamin D (25[OH]D) to vitamin D3 supplementation in obese and nonobese individuals may lead to concurrent recommendations for optimal vitamin D intake in these populations. The objective of this study was to determine the dose response of vitamin D3 in subjects with a body mass index ≥35 kg/m2. METHODS: Randomized, double-blind, placebo-controlled study. This study is an extension of our previous study of vitamin D dosing in healthy adults. After an assessment of baseline 25(OH)D levels, participants were randomized to a vitamin D supplementation arm (100 µg daily if baseline 25[OH]D was <50 nmol/L, or 50 µg daily if baseline 25[OH]D was ≥50 nmol/L) or placebo arm. Subjects with baseline 25(OH)D level ≥80 nmol/L were excluded from the study. Two months following randomization, a repeat 25(OH)D measurement was done. RESULTS: Final analysis included 25 subjects (14 placebo, 11 active). At 2 months, serum 25(OH)D concentration increased to a mean of 75 nmol/L in the active group. Mean slope (i.e., vitamin D3 response), defined as 25(OH) D change/baseline dose, was 0.398 nmol/L/µg/day. CONCLUSION: The dose response of vitamin D3 (slope) in obese subjects was significantly lower (P<.03) at 0.398 nmol/L/µg/day compared to the slope in the previous study of healthy subjects (0.66 nmol/L/µg/day). These results suggest that obese individuals may require 40% higher vitamin D intake than nonobese individuals to attain the same serum 25(OH)D concentration.

Role of alvimopan (entereg) in gastrointestinal recovery and hospital length of stay after bowel resection.

PURPOSE: Postoperative ileus (POI) can delay gastrointestinal (GI) recovery after bowel resection. Alvimopan (Entereg), a peripherally acting mu-opioid receptor antagonist, is thought to favorably reduce various outcome measures such as the length of stay (LOS) and time from surgery to hospital discharge following partial-bowel, large-bowel, or small-bowel resection surgery with primary anastomosis. We undertook a study to compare these outcome measures in alvimopan-treated patients undergoing laparoscopic or open-bowel resection against a control group. We also sought to determine whether any other factors-Diagnosis-Related Group (DRG) status, complications, inflammatory bowel disease, type of surgery, age, sex, intestinal cancer, diverticular disease, number of chronic conditions, and operative time-were predictive of a more favorable (shorter) time to GI recovery. METHODS: Patients' charts were retrospectively reviewed at a large 591-bed teaching hospital in suburban New York City between June and August 2010. We applied descriptive statistics for five outcome variables to compare alvimopan-treated patients with non-users. The main outcome variable was the time from surgery to hospital discharge. Secondary outcome variables were the time to pass gas, time to a liquid diet, time to a solid diet, and total LOS. We compared the outcome variables for three groups of DRG codes (329, the most complicated cases; 330, intermediate; and 331, least complicated) to determine which variables influenced these outcome measures. Multivariate analysis with stepwise multiple linear regression analysis was performed to determine independent predictors of shorter times of outcome variables. RESULTS: Of 80 patients, 43 received alvimopan (53.75%), and 37 (46.25%) did not. The female-to-male ratio was about 50:50 (56.25% vs. 43.75%). The mean age (standard deviation) was 66.0 (14.9) years (range, 30-92 years). In the multivariate analysis (adjusted for demographics, DRG status, type of surgery, complications, comorbidities, and operative time), for all of our outcome variables (except for time to a liquid diet), patients receiving alvimopan had shorter times to GI recovery (about 25% less) than controls did (p < 0.05). DRG status, complications, inflammatory bowel disease, type of surgery, and age were also significantly predictive of one or more outcome variables, whereas sex, intestinal cancer, diverticular disease, the number of chronic conditions, and operative time were not predictive of any outcomes. CONCLUSION: GI recovery times were generally shorter for alvimopan-treated patients than for those who did not receive the study drug (P < 0.05). Alvimopan improved quality of life and reduced the cost of surgical care. This medication was considered to be a good choice for the perioperative management of patients requiring segmental bowel resection with primary anastomosis.

The appendix may protect against Clostridium difficile recurrence.

BACKGROUND & AIMS: Several risk factors have been identified for the development of recurrent Clostridium difficile infection (CDI) that alter host immunity and disrupt colonic flora. Although the function of the appendix has been debated, its active, gut-associated lymphoid tissue and biofilm production indicate potential roles in recovery from initial CDI and protection against recurrent CDI. We investigated whether the presence or absence of an appendix is associated with CDI recurrence. METHODS: We reviewed the medical records of adult inpatients with CDI who were admitted to a tertiary-care teaching hospital from 2005 to 2007 to identify those with and without an appendix. The primary dependent variable for statistical analysis was CDI recurrence. RESULTS: In a multivariate analysis of 11 clinical variables, the presence of an appendix was associated inversely with CDI recurrence (P < .0001; adjusted relative risk, .398). Age older than 60 years also was associated with CDI recurrence (P = .0280; adjusted relative risk, 2.44). CONCLUSIONS: The presence of an appendix has a significant and independent, inverse association with CDI recurrence, but this finding requires validation in a prospective study. Assessing the presence or absence of an appendix might be useful in predicting CDI recurrence.

Post-carotid endarterectomy hyperperfusion syndrome-is it predictable by lack of cerebral reserve?

BACKGROUND: Cerebral hyperperfusion syndrome (HS) is presumed to be because of an increase in postendarterectomy flow in patients with fixed cerebral vascular reserve. Severe headache is thought to be an early sign of possible HS. An increase in partial pressure CO2 (pCO2) is known to cause cerebral vasodilatation and is used to evaluate the presence of cerebral reserve. METHODS: A total of 45 patients undergoing carotid endarterectomy had internal carotid artery flow measured with a transonic flow probe as follows: F1, immediately after full dissection of the internal carotid artery; F2, after 30 seconds of breath holding; and F3, after restoration of flow. ΔF2-F1 and ΔF3-F2 were also evaluated. A 10% increase between F2 and F1 indicated normal cerebral reserve and between F3 and F2 indicated increased postoperative flow. Age, gender, medical comorbidities, indication for carotid endarterectomy, intraoperative cerebral oximetry values, and percentage of bilateral carotid stenosis were recorded. All patients were contacted after discharge about the presence of postoperative headache or other suggestions of HS. Fisher's exact test was used for categorical predictors and the rank-sum test for continuous predictors. RESULTS: Seven (16%) patients (group A) developed postoperative headache and 38 (group B) did not. No patient developed HS. No variables were associated with postoperative headache except for female gender (p = 0.005). There were no statistically significant differences in F1, F2, F3, and ΔF (F2-F1 or F3-F2) between groups A and B (there was no descriptively significant ΔF2-F1 in 17 patients). Only one of the nine patients who had no change between F2 and F1, who had a significant increase in F3, and who was thought to be at higher risk for HS developed a postoperative headache. CONCLUSIONS: Lack of cerebral reserve is common in patients undergoing endarterectomy. If headache is an early sign of hyperperfusion, it does not seem to be predicted by lack of cerebral reserve and an increase in postendarterectomy flow.

Femoral-popliteal bypass with endoscopically harvested saphenous vein in patients with TASC D disease of the superficial femoral artery.

BACKGROUND: This study evaluated patients undergoing femoropopliteal bypasses using endoscopically harvested vein to treat Trans-Atlantic Inter-Society Consensus (TASC) stage D lesions. Primary patency and primary assisted patency were evaluated, as were perioperative morbidity and mortality and hospital length of stay (LOS). Results for this minimally invasive alternative to femoropopliteal bypass with conventional open vein harvesting were analyzed. METHODS: A retrospective analysis was performed on patients who underwent femoral-popliteal bypass with endoscopic saphenous vein harvest and angiographic TASC D anatomy. Postoperative duplex exams were evaluated, and the study end points of graft thrombosis or the development of a high-grade stenosis prompting reintervention were sought. Patient demographics, morbidity, mortality, and hospital LOS were analyzed. RESULTS: Twenty-seven patients meeting our inclusion criteria underwent surgery between June 2002 and June 2007. Indications for surgery in these patients were claudication (n=10), gangrene or ulceration (n=9), and ischemic rest pain (n=8). Fifty-two percent of the patients were male, 50% had cardiac disease, 65% had hypertension, 54% were diabetic, and 65% had a significant smoking history. Median LOS was 2.5 days in claudicants, 3.0 days in patients with rest pain, and 7.0 days in patients with gangrene or ulceration (p<0.05). Kaplan-Meier primary patency and primary assisted patency rates were 73.2% and 80.8% at 1 year, respectively; and these rates were maintained for 70 months. The only perioperative complication was a superficial wound infection, and two patients died during follow-up from causes unrelated to the surgery. CONCLUSION: Femoropopliteal bypass using endoscopic vein harvest is a durable reconstructive vascular procedure which can be performed with minimal postoperative morbidity, short LOS, and satisfactory long-term patency.

Fetal fibronectin testing in patients with short cervix in the midtrimester: can it identify optimal candidates for ultrasound-indicated cerclage?

OBJECTIVE: The objective of the study was to determine the relationship between fetal fibronectin (fFN) testing prior to ultrasound-indicated cerclage and obstetric outcome. STUDY DESIGN: Singleton pregnancies between 18 and 24 weeks' gestation with an ultrasound-diagnosed short cervix (< 25 mm) and funneling (> 25%) of the chorioamniotic membranes into the endocervical canal were analyzed. The fFN testing was performed and patients were randomized to cerclage or no-cerclage. Groups were stratified by fFN result. Cerclage patients were compared with no-cerclage patients. The primary outcome was delivery prior to 35 weeks' gestation. RESULTS: Spontaneous preterm birth prior to 35 weeks' gestation occurred in 15 (44.1%) fFN-positive-cerclage patients and 16 (55.2%) fFN-positive no-cerclage patients (P = .45). Similarly, it occurred in 16 (17.8%) fFN-negative cerclage patients and 11 (17%) fFN-no-cerclage patients (P = .99). CONCLUSION: fFN did not identify optimal candidates for cerclage. However, fFN testing before an ultrasound-indicated cerclage aids in counseling patients, anticipating the outcome of pregnancies complicated by cervical shortening.

Do geriatricians practice what they preach?: geriatricians' personal establishment of advance directives.

Previous research has been conducted regarding preferences of physicians for life-sustaining treatments for themselves, but there is a dearth of data on personal use of advance directives (ADs) by geriatricians specifically. Using a phone survey, we contacted all graduates of the geriatric fellowship program to assess their personal use of advance directives and their personal preferences for life-sustaining treatment. Of the 124 living graduates of the Parker Jewish Institute for Health Care and Rehabilitation, 70 agreed to participate. One third of respondents had established ADs for themselves, with higher rates in women than men (p = .054). Older geriatricians were significantly more likely to have advance directives (exact trend test yields, p < .0001). In general, respondents did not inform their health care providers about their desires for end-of-life care. This study revealed that the majority of fellowship-trained geriatricians did not formally establish advance directives for themselves. Further research is needed to determine whether physicians who establish advance directives for themselves are more likely to encourage their patients to do so.

Endoscopic ultrasound guided fine-needle aspiration: What variables influence diagnostic yield?

BACKGROUND: Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) plays an important role in the diagnosis of various lesions. We sought to determine factors that influence the diagnostic yield of EUS-FNA, specifically, the presence of a cytopathologist, FNA site, and the endoscopist's skill. METHODS: The data on cytopathologist's availability, duration of procedure, number of passes made, and diagnostic material for cell block (CB) preparation was collected over an 18 months period. RESULTS: 230 specimens (218 patients) were obtained from pancreas (114), lymph node (64), submucosal lesions of the gastrointestinal tract (27), liver (8), and miscellaneous (17) sites. The results were classified as informative (77.8%) and non-informative (NI) (22.2%). The NI rate was significantly high, when a cytopathologist was absent (P = .0008). As the likelihood of cytopathologist's presence increased from 35.8% to 82.9%, the CB quality increased (P < .0001). In the absence of a cytopathologist, the likelihood of NI result increased more than 2-fold (P = .03) and of an inadequate CB increased 3-fold (P < .0001). The more experienced endoscopist "C" (compared to the less experienced "A + B") was less likely to get inadequate material (40.5% vs. 66.3%) (P = .0001). CONCLUSION: The diagnostic yield of EUS-FNA is significantly related to the presence of an on-site cytopathologist and endoscopist's skill in procuring diagnostic material.

Optimal vitamin D status and serum parathyroid hormone concentrations in African American women.

BACKGROUND: Optimal vitamin D status for the prevention of osteoporosis has been inferred from examinations of the serum 25-hydroxyvitamin D [25(OH)D] concentration below which there is an increase in serum parathyroid hormone (PTH). OBJECTIVE: The objectives of the study were to ascertain whether a threshold for serum 25(OH)D exists below which serum PTH increases and whether persons with 25(OH)D above this threshold have lower rates of bone loss than do persons with 25(OH)D below the threshold. DESIGN: The relation of serum 25(OH)D to serum PTH was analyzed in 208 African American women studied longitudinally for 3 y. These healthy women in midlife were randomly assigned to receive placebo or 800 IU vitamin D3/d; after 2 y, the vitamin D3 supplementation was increased to 2000 IU/d. Both groups received calcium supplements to ensure an adequate calcium intake. A systematic literature review found a wide range of threshold values in part due to varied calcium intake. RESULTS: A Loess plot suggested a breakpoint between 40 and 50 nmol/L for serum 25(OH)D. A line-line model was fitted to the data, and it showed a spline knot at 44 nmol/L. A heuristic approach verified that PTH does not decline as rapidly when the serum concentration of 25(OH)D is >40 nmol/L as when it is <40 nmol/L. We found no significant difference in rates of bone loss between persons with 25(OH)D concentrations above and below 40 nmol/L. CONCLUSION: Although a threshold for 25(OH)D can be identified, we suggest that it should not be used to recommend optimal vitamin D status.

Reference range for serum parathyroid hormone.

OBJECTIVE: To determine whether the reference range for parathyroid hormone (PTH) should be lowered (from 65 pg/mL to a proposed value of 46 pg/mL) with use of the Allegro radioimmunometric assay. METHODS: We examined the reference range for PTH, adjusted for serum 25-hydroxyvitamin D (25-OHD), in 503 healthy African American and white women, who were 20 to 80 years old. We also analyzed other factors that are thought to influence PTH levels. RESULTS: Univariate predictors of PTH were identified, and a multivariate model was developed with use of the variables and PTH. Serum PTH was significantly higher in black study subjects than in white study subjects (P<0.02). Increasing PTH was also significantly correlated with increasing body mass index, age, and serum creatinine and with decreasing dietary calcium intake and serum 25-OHD levels. A stepwise multiple linear regression analysis yielded the following predictors of PTH: body mass index (R2=9.4%), age (R2=1.0%), and serum 25-OHD (R2=0.8%). In our study population, many PTH values were above the proposed new upper limit of 46 pg/mL. CONCLUSION: The upper limit of the reference range for serum PTH should not be changed. Factors to be considered in analysis of serum PTH values in the upper reference range in patients with normocalcemia include obesity, race, 25-OHD levels, advanced age, serum creatinine, and dietary calcium intake.

Open aneurysm repair in elderly patients not candidates for endovascular repair (EVAR): Comparison with patients undergoing EVAR or preferential open repair.

The authors reviewed a 2-year experience with abdominal aortic aneurysm (AAA) repair to determine if patients who were excluded from endovascular aneurysm repair (EVAR) because of anatomic criteria (Group III) represented a higher risk for subsequent open aneurysm repair than either patients undergoing EVAR (Group II) or those patients who preferentially underwent open repair (Group I). Between January 2001 and December 2003, 107 patients underwent AAA repair. Open repair was recommended in patients <70 years of age and without significant comorbidities (Group I). There were 35 patients in Group I; 72 patients were evaluated for EVAR; 29 patients underwent EVAR (Group II), and 43 were excluded and underwent open repair (Group III). Exclusion criteria were those recommended by the graft manufacturers. Patients in Group I were significantly younger than those in Groups II and III (p < 0.0001). Gender, incidence of diabetes, and hypertension were similar in all groups. Patients in Group III had a greater incidence of coronary artery disease (CAD) than those in Groups I and II, trending toward statistical significance (p = 0.06). Aneurysm size in Group II was statistically smaller than in Group I or III. Group III had significantly more complications (25.6% vs 5.7% and 6.9%) than either Group I or II (p < 0.015). Cardiac complications were similar in all groups. Three patients in Group III required prolonged intubation and 3 in Group III developed renal insufficiency. A history of CAD was predictive of complications (21.8% vs 5.8%, p < 0.024), as was inclusion in Group III. There were 2 deaths in this series, both in Group III. Length of stay was significantly less in Group II (4.17 +/-2.36 days) than in Group I (6.57 +/-1.84 days) or Group III (12.30 +/-9.82 days) (p = 0.0001). Open aneurysm repair can be safely performed in younger good-risk patients (Group I) with results equivalent to EVAR (Group II) but with slightly longer length of stay (LOS). In older patients with suitable anatomy EVAR can be performed with minimal morbidity and short LOS. Older patients not suitable for EVAR (Group III) constitute a higher risk group of patients because of increased incidence of CAD and the need for more complex repairs. However, the mortality rate in this group was only 4.6%.

Prevalence and Description of Palliative Care in US Nursing Homes: A Descriptive Study.

OBJECTIVE: To describe rates and policies in U.S. Nursing Homes (NH) related to palliative care, comfort care, and hospice care based on a nationwide survey of directors of nursing. MEASUREMENTS: A national survey was distributed online and was completed by 316 directors of nursing of NHs (11% response rate). The directors of nursing were asked about availability and policies in their facilities. Specifically, questions were related to policies, referral patterns, discussion about such care, and types of medical conditions qualifying for such services. RESULTS: Hospice is significantly more available than palliative or comfort care programs; also, for-profit facilities, compared to non-profits, are significantly more likely to have palliative care programs and medical directors for palliative care. Social workers and nurses were most likely to suggest palliative type programs. Only 42% of facilities with palliative program provide consultation by a palliative certified physician. Residents with non-healing pressure ulcers, frequent hospitalizations, or severe/uncontrolled pain or non-pain symptoms were less likely to be referred. CONCLUSIONS: There is limited availability of palliative type programs in NH facilities and underutilization in those NH with programs.

Sex in Nursing Homes: A Survey of Nursing Home Policies Governing Resident Sexual Activity.

OBJECTIVE: To identify nursing home (NH) standards related to sexual activity and sexual relationships for residents through a nationwide survey of directors of nursing (DONs). METHODS: A national survey was distributed online and was completed by 366 DONs of skilled nursing facilities. The DONs answered questions concerning policies and experiences related to sexual activities of their residents including types of resident sexual activity they have encountered, perceptions about residents with dementia engaging in sexual activity, and policies pertaining to sexual activity including masturbation. RESULTS: The results of the survey demonstrated that the vast majority (71.2%) indicated that there had been issues regarding residents' sexual activities in their facilities with over one-half (58%) of the DONs reporting situations of resident with resident sexual activity and 60% with situations of resident masturbation. More than one-half (56.6%) require a family or designated representative to approve sexual activity for a cognitively impaired resident. For a cognitively intact resident, 12.4% of facilities still require family or designated representative to approve sexual activity. However, despite the prevalence of sexual activity, the majority of NHs (63.4%) actually do not have policies dealing with resident sexual activity. Of the NHs with policies, 58.6% have written policies in place, with 11.2% requiring a physician order to allow sexual activity and 9.5% requiring a physician order to restrict sexual activity. CONCLUSIONS: Issues related to sexual activity in NH residents are quite prevalent, however, the rates of policies related to sexual activity are low and the policies and restrictions are not uniform. Our study suggests nursing homes should have a clear policy addressing resident sexual activity. It would be beneficial for such a policy to be communicated to residents and their families as part of an admission package instead of waiting for sexual interest to be noticed. This would enable residents to engage in sexual activity with understanding and support rather than hiding.

Total body phosphorus in healthy women and ethnic variations.

Total body phosphorus (TBP) levels were measured in 90 black and 143 white healthy women to determine ethnic differences. The measurements were performed by in vivo delayed gamma neutron activation (DGNA) analysis at Brookhaven National Laboratory (BNL). Mean value of TBP in whites was 10.4% lower as compared with the black women (mean TBP in white women 401.4 +/- 57.5 g v. 447.7 +/- 57.7 g in black women). Both subgroups have a decrease in TBP with age with a rapid phase after the onset of menopause, which corresponds to bone loss. The decrease in TBP is similar in both ethnic groups with black women losing -1.59 g/yr (-0.33%/yr) and white women losing -2.08 g/yr (-0.45%/yr).

Cerebral oximetry monitoring during carotid endarterectomy: effect of carotid clamping and shunting.

Cerebral oximetry is a simple method of measuring regional cerebral oxygen saturation (rSO(2)). One promising application is its use during carotid endarterectomy (CEA) to help minimize the risk of perioperative stroke. The authors used the INVOS-4100 cerebral oximeter at several steps during CEA to measure the effect of carotid clamping and shunting on rSO(2). The authors prospectively evaluated 42 consecutive CEAs in 40 patients. All had CEA under general anesthesia with the routine use of a Javid shunt. The INVOS-4100 oximeter was used to measure rSO(2) before clamping (t1), after clamping but before shunting (t2), 5 minutes after shunt insertion (t3), and after patch closure with reestablished flow (t4). The Wilcoxon signed-rank and rank-sum tests were used for analysis. Clamping of the internal carotid artery (t1 vs t2) resulted in a drop of ipsilateral rSO(2) by -12.3% (p < 0.001). Shunt insertion (t2 vs t3) increased rSO(2) by 10.9% (p < 0.001). Contralateral rSO(2) for the same time periods was insignificant. Patients with preoperative neurologic symptoms had a greater decrease in rSO(2) after clamping (-18.4%) compared with a decrease of -10.4% in asymptomatic patients (p = 0.037). Cerebral oximetry monitoring is simple and inexpensive. The study showed statistically significant changes in rSO(2) as a result of clamping and shunting of the carotid artery. Symptomatic patients had a greater drop in rSO(2).

Chest radiography in supporting the diagnosis of asthma in children with persistent cough.

OBJECTIVE: To establish whether chest radiographic findings suggestive of lower airway obstruction (LAO) disease support the diagnosis of asthma in pediatric patients with persistent cough in an outpatient setting. METHODS: 180 patient charts were reviewed. The patients were children aged 1 to 18 years referred over a 3-year period to a pediatric pulmonary subspecialty clinic for evaluation of cough lasting ≥ 4 weeks. Chest radiographic images obtained after the initial evaluation of 90 patients diagnosed with cough-variant asthma and 90 patients diagnosed with persistent cough from nonasthma origins were compared with radiologic findings of a control group consisting of patients with a positive tuberculin skin test and no respiratory symptoms. Increased peribronchial markings/peribronchial cuffing and hyperinflation were considered radiographically suggestive findings of LAO disease. RESULTS: Children diagnosed with cough-variant asthma at the initial evaluation had higher rates of chest radiographic findings suggestive of LAO disease (30.00%) than children with persistent cough from other causes (17.80%) or those with a positive tuberculin skin test and no respiratory symptoms (8.16%) (overall P value = 0.0063). They also had higher rates of spirometry abnormalities suggestive of an LAO defect. Children with chest radiographic findings suggestive of LAO disease were found to be younger than those with normal chest radiographic findings (5.0 ± 2.7 years vs 8.6 ± 4.7 years; P < 0.0001). CONCLUSION: This study suggests that chest radiographic findings indicative of an LAO in correlation with the clinical presentation can support the diagnostic suspicion of asthma, especially in younger children unable to perform spirometry.

Antipsychotic drug use since the FDA black box warning: survey of nursing home policies.

OBJECTIVES: To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA. DESIGN/SETTING/PARTICIPANTS: A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications. MEASUREMENTS/RESULTS: The most commonly reported intervention to manage symptoms in residents with dementia since the black box warning was to lower doses of antipsychotics. Over half of facilities report obtaining more frequent psychiatry/psychology consults. One-hundred seven facilities have a policy regarding informing family members of residents about the black box warning. Most facilities (63.6%) with a policy require family to sign consent. In the NH setting, the presence or absence of a policy did not correlate with the reported change in use of antipsychotics or types of alternative interventions. CONCLUSION: Notably, a large number of NH facilities have policies regarding informed consent on the use of antipsychotics. However, in our study, the rate of use of antipsychotics did not change in many facilities since the black box warning. In addition, having a policy did not correlate with decreased antipsychotic use or with use of alternate agents or nonpharmacologic methods to address symptoms. The results of this survey suggest that NH administrators should worry less about the legal exposure of using antipsychotics and focus on actions that result in improved patient care.

Improving uniformity of care for colorectal cancers through National Quality Forum quality indicators at a Commission on Cancer-accredited community based teaching hospital.

The National Cancer Data Base (NCDB) provides feedback on adherence to National Quality Forum (NQF)-endorsed measures to promote best outcomes in colorectal cancer. We examined the care delivered to patients with colorectal cancer at our institution and developed a protocol to enhance nodal retrieval and to ensure that patients with fewer than 12 nodes are considered for adjuvant chemotherapy. Few patients met the NQF criteria for adjuvant radiation. A protocol was developed to address this issue, and this provides a model for use in a multidisciplinary effort to improve adherence to measures associated with best outcomes in colorectal cancer.

Evaluation of housestaff knowledge and perception of competence in palliative symptom management.

PURPOSE: The Accreditation Council for Graduate Medical Education requires that internal medicine (IM) core curricula include end-of-life care and pain management concepts and that fellows in hematology/oncology, pulmonary/critical care, and geriatrics should receive formal instruction and clinical experience in palliative and end-of-life care. We aimed to assess the effectiveness of current teaching methods for housestaff in these fields. METHOD: All of the IM residents, geriatric medicine fellows, hematology/oncology fellows, and pulmonary/critical care fellows from four regional graduate medical education sites were asked to participate in an online survey at the beginning and end of the 2008-2009 academic year. We evaluated seven domains of knowledge of palliative care and pain management with a self-assessment of competence in these areas. We also asked participants to describe their current curriculum and training in palliative medicine. RESULTS: There were 326 e-mailed survey invitations. There were 180 responses for the start-year survey and 102 responses for the end-year survey. All sites were represented in the responses. The only learners to significantly improve their palliative knowledge during a year of training were PGY-1s and PGY-4s. The majority of housestaff surveyed report that their current palliative medicine training is inadequate. The vast majority (84.6%) said a dedicated palliative medicine rotation would be "useful" or "very useful." CONCLUSIONS: Housestaff recognize their lack of experience and training in palliative medicine and are interested in many teaching venues to improve their skills. A more focused curriculum in palliative and end-of-life care is required at both resident and subspecialty fellowship levels.

Rapid influenza A testing for novel H1N1: point-of-care performance.

OBJECTIVES: The 2009 outbreak of novel influenza A H1N1 reached a pandemic status on June 11, 2009. Early detection is a key factor for management and infection-control practices. Recent studies have suggested a difference in performance of rapid influenza kits for influenza A H1N1. Our goal was to evaluate the performance of the QuickVue influenza A+B test (Quidel Corp., San Diego, CA) in an emergency department setting and determine the most current epidemiologic trends in our community. METHODS: Results from 1137 samples for influenza A collected between April 8, 2009 and June 30, 2009 were retrospectively reviewed. Results of QuickVue influenza A+B test were compared with R-Mix viral culture and DFA results. Age distribution and hospitalization rates by age group were analyzed to further delineate the epidemiology of influenza A in a suburban hospital. RESULTS: The sensitivity of the rapid test was 77%, the specificity was 85%, the positive predictive value was 74%, and the negative predictive value was 87%. We found a similar age distribution for positive influenza tests and admissions when compared with the national Centers for Disease Control and Prevention data. CONCLUSIONS: The QuickVue influenza A+B test is a sensitive assay for the novel H1N1 strain of influenza. In our hospital, the group with highest risk of hospital admission was patients aged < 25 years.