Archives of internal medicine
-
BACKGROUND Delirium is characterized by acute cognitive impairment. We examined the association of delirium with long-term cognitive trajectories in older adults with Alzheimer disease (AD). METHODS We evaluated prospectively collected data from a nested cohort of hospitalized patients with AD (n = 263) in the Massachusetts Alzheimer Disease Research Center patient registry between January 1, 1991, and June 30, 2006 (median follow-up duration, 3.2 years). ⋯ Sensitivity analyses that excluded rehospitalized patients and included matching on baseline cognitive function and baseline rate of cognitive deterioration produced essentially identical results. CONCLUSIONS Delirium is highly prevalent among persons with AD who are hospitalized and is associated with an increased rate of cognitive deterioration that is maintained for up to 5 years. Strategies to prevent delirium may represent a promising avenue to explore for ameliorating cognitive deterioration in AD.
-
Multicenter Study
One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T.
High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI. ⋯ Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.
-
Critical care resource use accounts for almost 1% of US gross domestic product and varies widely among hospitals. However, we know little about the initial decision to admit a patient to the intensive care unit (ICU). ⋯ The proportion of low- and high-risk patients admitted to the ICU, variation in ICU admitting patterns among hospitals, and the sensitivity of hospital rankings to patient risk all likely reflect a lack of consensus about which patients most benefit from ICU admission.
-
Limited evidence suggests that the risk of acute myocardial infarction (AMI) may be increased shortly after total hip replacement (THR) and total knee replacement (TKR) surgery. However, risk of AMI in these patients has not been compared against matched controls who have not undergone surgery. The objective of this study was to evaluate the timing of AMI in patients undergoing THR or TKR surgery compared with matched controls. ⋯ Risk of AMI is substantially increased in the first 2 weeks after THR (25-fold) and TKR (31-fold) surgery compared with controls. Risk assessment of AMI should be considered during the first 6 weeks after THR surgery and during the first 2 weeks after TKR surgery.
-
Whether safety-net hospitals (SNHs) provide patient-centered care has important implications both for patient outcomes and for how these hospitals will fare under value-based purchasing (VBP). We sought to determine performance and improvement on measures of patient-reported hospital experience among SNHs compared with non-SNHs. ⋯ Safety-net hospitals have lower performance than non-SNHs on metrics of patient-reported experience, improved somewhat more slowly under public reporting, and are likely to fare poorly under VBP.