Perioperative Management of the Liver Transplant Recipient.

Perioperative management of the liver transplant recipient is a team effort that requires close collaboration between intensivist, surgeon, anesthesiologist, hepatologist, nephrologist, other specialists, and hospital staff before and after surgery. Transplant viability must be reassessed regularly and particularly with each donor organ. Regular discussions with patient and family facilitate realistic determinations of goals based on patient aspirations and clinical realities. Early attention to hemodynamics with optimal resuscitation and judicious vasopressor support, respiratory care designed to minimize iatrogenic injury, and early renal support is key. Preoperative and postoperative nutritional support and physical rehabilitation should remain a focus.

Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs.

Categorical internal medicine (IM) residency training has historically effectively prepared graduates to manage the medical needs of acutely ill adults. The development of the field of hospital medicine, however, has resulted in hospitalists filling clinical niches that have been traditionally ignored or underemphasized in categorical IM training. Furthermore, hospitalists are increasingly leading inpatient safety, quality and efficiency initiatives that require understanding of hospital systems, multidisciplinary care and inpatient quality assessment and performance improvement. Taken in this context, many graduating IM residents are under-prepared to practice as effective hospitalists. In this paper, we outline the rationale for targeted training in hospital medicine and discuss the content and methods for delivering this training.

Characterizing Hospitalist Practice and Perceptions of Critical Care Delivery.

BACKGROUND: Intensivist shortages have led to increasing hospitalist involvement in critical care delivery. OBJECTIVE: To characterize the practice of hospitalists practicing in the intensive care unit (ICU) setting. DESIGN: Survey of hospital medicine physicians. SETTING: This survey was conducted as a needs assessment for the ongoing efforts of the Critical Care Task Force of the Society of Hospital Medicine Education Committee. PARTICIPANTS: Hospitalists in the United States. INTERVENTION: An iteratively developed, 25-item, webbased survey. MEASUREMENTS: Results were compiled from all respondents then analyzed in subgroups. Various items were examined for correlations. RESULTS: A total of 425 hospitalists completed the survey. Three hundred and twenty-five (77%) provided critical care services, and 280 (66%) served as primary physicians in the ICU. Hospitalists were significantly more likely to serve as primary physicians in rural ICUs (85% of rural respondents vs 62% of nonrural; P < .001 for association). Half of the rural hospitalists who were primary physicians for ICU patients felt obliged to practice beyond their scope, and 90% at least occasionally perceived that they had insufficient support from board-certified intensivists. Among respondents serving as primary physicians for ICU patients, 67% reported at least moderate difficulty transferring patients to higher levels of ICU care. Difficulty transferring patients was the only item significantly correlated with the perception of being expected to practice beyond one's scope (P < .05 for association). CONCLUSIONS: Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals. Without major changes in intensivist staffi ng or patient distribution, this is unlikely to change.

Nontyphoidal cardiac salmonellosis: two case reports and a review of the literature.

Nontyphoidal Salmonella, especially Salmonella enterica, is a rare cause of endocarditis and pericarditis that carries a high mortality rate. Proposed predisposing conditions include immunodeficiency states, congenital heart defects, and cardiac valve diseases. We present 2 cases of cardiovascular salmonellosis. The first case is that of a 73-year-old woman with mechanical mitral and bioprosthetic aortic valves who died from sequelae of nontyphoidal Salmonella mitral valve vegetation, aortic valve abscess, and sepsis. The second case is that of a 62-year-old man with a recent systemic lupus erythematosus exacerbation treated with oral steroids, who presented with obstructive features of tamponade and sepsis secondary to a large S. enteritidis purulent pericardial cyst. He recovered after emergent pericardial drainage and antibiotic therapy. Identifying patients at risk of cardiovascular salmonellosis is important for early diagnosis and treatment to minimize sequelae and death. We reviewed the literature to identify the predisposing risk factors of nontyphoidal Salmonella cardiac infection.

Comparing academic and community-based hospitalists.

In 2006, hospitalist programs were formally introduced at both an academic and community hospital in the same city providing an opportunity to study the similarities and differences in workflows in these two settings. The data were collected using a time-flow methodology allowing the two workflows to be compared quantitatively. The results showed that the hospitalists in the two settings devoted similar proportions of their workday to the task categories studied. Most of the time was spent providing indirect patient care followed by direct patient care, travel, personal, and other. However, after adjusting for patient volumes, the data revealed that academic hospitalists spent significantly more time per patient providing indirect patient care (Academic: 54.7 +/- 11.1 min/patient, Community: 41.9 +/- 9.8 min/patient, p < 0.001). Additionally, we found that nearly half of the hospitalists' time at both settings was spent multitasking. Although we found subtle workflow differences between the academic and community programs, their similarities were more striking as well as greater than their differences. We attribute these small differences to the higher case mix index at the academic program as well greater complexity and additional communication hand-offs inherent to a tertiary academic medical center. It appears that hospitalists, irrespective of their work environment, spend far more time documenting, communicating and coordinating care than they do at the bedside raising the question, is this is a necessary feature of the hospitalist care model or should hospitalists restructure their workflow to improve outcomes?

Just because you can, doesn't mean that you should: A call for the rational application of hospitalist comanagement.

Medical comanagement has become a mainstay of hospital medicine. Several studies, however, suggest that medical consultation and comanagement may not be as effective as originally anticipated. The expansion of comanagement services has helped fuel massive demand for hospitalists and with it a critical and potentially destabilizing hospitalist manpower shortage. Comanagement may also drive unanticipated consequences such as facilitating surgeon and specialist disengagement and hospitalist career dissatisfaction and burnout. Comanagement services should be developed carefully and methodically, paying close attention to consequences, intended and unintended.

Acute aortic dissection.

Acute aortic dissection is an uncommon but lethal cause of acute chest, back, and abdominal pain. Establishing a timely diagnosis is paramount, as mortality from acute aortic dissection rises by the hour. Physical findings are protean and may include acute aortic valve insufficiency, peripheral pulse deficits, a variety of neurologic deficits, or end-organ ischemia. The keys to establishing a timely diagnosis are maintaining a high index of suspicion and quickly obtaining a diagnostic study. CT angiography, magnetic resonance imaging, transesophageal echocardiography, and, to a lesser extent, aortography are all highly accurate imaging modalities. The choice of study should be driven by the clinical stability of the patient, the information required and the resources available at presentation. Proximal dissections are surgical emergencies, but distal dissections are generally treated medically. Endovascular stents are gaining favor for use in the repair of both acute and chronic distal dissections. Long-term outcome data for endovascular stenting are still limited, and it remains unclear when stenting should be favored over surgery or medical therapy.