Physician Use of Advance Care Planning Discussions in a Diverse Hospitalized Population

Two decades after the Patient Self Determination Act it is unknown how often physicians have advance care planning (ACP) discussions with hospitalized patients. The objective of this study is to investigate use of ACP discussions in a multi-ethnic, multi-lingual hospitalized population. Cross-sectional communication study of hospitalized patients. The Participants are 369 patients at one urban county hospital and one academic medical center. Interventions are not applicable. Participants were asked at baseline and a post-discharge interview whether hospital physicians had discussed either (a) what type of treatment they would want if they could not make decisions for themselves or (b) whether they would want cardiopulmonary resuscitation if needed. We compared patient characteristics for those who did and did not have an ACP discussion. Only 151 (41%) participants reported an ACP discussion. Rates of ACP were low across ethnic, language, education and age groups. In a multivariate model, scoring higher on a co-morbidity scale was associated with higher odds of reporting having had an ACP discussion during hospitalization; this finding remained after adjusting for time period and site of data collection. Multiethnic, multi-lingual hospitalized patients reported low rates of ACP discussions with their physicians regardless of ethnicity, English proficiency, education level or age

Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission

BackgroundBioethicists and professional associations give specific recommendations for discussing cardiopulmonary resuscitation (CPR).ObjectiveTo determine whether attending hospitalist physicians' discussions meet these recommendations.DesignCross-sectional observational study on the medical services at two hospitals within a university system between August 2008 and March 2009.ParticipantsAttending hospitalist physicians and patients who were able to communicate verbally about their medical care.Main measuresWe identified code status discussions in audio-recorded admission encounters via physician survey and review of encounter transcripts. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions; Cohen's kappa was 0.64-1 for all reported elements.Key resultsAudio-recordings of 80 patients' admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2-14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2-8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients' preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.ConclusionsCode status was not discussed with many seriously ill patients. Discussions were brief, and did not include elements that bioethicists and professional associations recommend to promote patient autonomy. Local and national guidelines, research, and clinical practice changes are needed to clarify and systematize with whom and how CPR is discussed at hospital admission

An Integrated Approach Providing Scientific and Policy-Relevant Insights for South-West Bangladesh

Bangladesh is identified as an impact hotspot for sea-level rise in multiple studies. However, a range of other factors must be considered including catchment management, socio-economic development and governance quality, as well as delta plain biophysical processes. Taking an integrated assessment approach highlights that to 2050 future changes are more sensitive to human choice/policy intervention than climate change, ecosystem services diminish as a proportion of the economy with time, continuing historic trends and significant poverty persists for some households. Hence under favourable policy decisions, development could transform Bangladesh by 2050 making it less vulnerable to longer-term climate change and subsidence. Beyond 2050, the threats of climate change are much larger, requiring strategic adaptation responses and policy changes that must be initiated now

Interprofessional communication with hospitalist and consultant physicians in general internal medicine : a qualitative study

This study helps to improve our understanding of the collaborative environment in GIM, comparing the communication styles and strategies of hospitalist and consultant physicians, as well as the experiences of providers working with them. The implications of this research are globally important for understanding how to create opportunities for physicians and their colleagues to meaningfully and consistently participate in interprofessional communication which has been shown to improve patient, provider, and organizational outcomes

Extreme genetic fragility of the HIV-1 capsid

Genetic robustness, or fragility, is defined as the ability, or lack thereof, of a biological entity to maintain function in the face of mutations. Viruses that replicate via RNA intermediates exhibit high mutation rates, and robustness should be particularly advantageous to them. The capsid (CA) domain of the HIV-1 Gag protein is under strong pressure to conserve functional roles in viral assembly, maturation, uncoating, and nuclear import. However, CA is also under strong immunological pressure to diversify. Therefore, it would be particularly advantageous for CA to evolve genetic robustness. To measure the genetic robustness of HIV-1 CA, we generated a library of single amino acid substitution mutants, encompassing almost half the residues in CA. Strikingly, we found HIV-1 CA to be the most genetically fragile protein that has been analyzed using such an approach, with 70% of mutations yielding replication-defective viruses. Although CA participates in several steps in HIV-1 replication, analysis of conditionally (temperature sensitive) and constitutively non-viable mutants revealed that the biological basis for its genetic fragility was primarily the need to coordinate the accurate and efficient assembly of mature virions. All mutations that exist in naturally occurring HIV-1 subtype B populations at a frequency >3%, and were also present in the mutant library, had fitness levels that were >40% of WT. However, a substantial fraction of mutations with high fitness did not occur in natural populations, suggesting another form of selection pressure limiting variation in vivo. Additionally, known protective CTL epitopes occurred preferentially in domains of the HIV-1 CA that were even more genetically fragile than HIV-1 CA as a whole. The extreme genetic fragility of HIV-1 CA may be one reason why cell-mediated immune responses to Gag correlate with better prognosis in HIV-1 infection, and suggests that CA is a good target for therapy and vaccination strategies

Evaluation of routinely reported surgical site infections against microbiological culture results: a tool to identify patient groups where diagnosis and treatment may be improved

<p>Abstract</p> <p>Background</p> <p>Surgeons may improve their decision making by assessing the extent to which their initial clinical diagnosis of a surgical site infection (SSI) was supported by culture results. Aim of the present study was to evaluate routinely reported SSI by surgeons against microbiological culture results, to identify patient groups with lower agreement where decision making may be improved.</p> <p>Methods</p> <p>701 admissions with SSI were reported by surgeons in a university medical centre in the period 1997-2005, which were retrospectively checked for microbiological culture results. Reporting a SSI was conditional on treatment being given (e.g. antibiotics) and was classified by severity. To identify specific patient groups, patients were classified according to the surgery group of the first operation during admission (e.g. trauma).</p> <p>Results</p> <p>Of all reported SSI, 523 (74.6%) had a positive culture result, 102 (14.6%) a negative culture result and 76 (10.8%) were classified as unknown culture result (due to no culture taken). Given a known culture result, reported SSI with positive culture results less often concerned trauma patients (16% versus 26%, X²= 4.99 p = 0.03) and less severe SSI (49% versus 85%, X²= 10.11 p < 0.01) suggesting that a more conservative approach may be warranted in these patients. The trauma surgeons themselves perceived to have become too liberal in administering antibiotics (and reporting SSI).</p> <p>Conclusion</p> <p>Routine reporting of SSI was mostly supported by culture results. However, this support was less often found in trauma patients and less severe SSI, thereby giving surgeons feedback that diagnosis and treatment may be improved in these cases.</p

A Controlled Investigation of Optimal Internal Medicine Ward Team Structure at a Teaching Hospital

BACKGROUND: The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents. METHODS: Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County. Standard ward teams at HUMC, with a housestaff∶attending ratio of 5:1, were split by adding one attending and then dividing the teams into two experimental teams containing ratios of 3:1 and 2:1. Web-based Likert satisfaction surveys were completed by housestaff and attending physicians on the experimental and control teams at the end of their rotations, and objective healthcare outcomes (e.g., length of stay, hospital readmission, mortality) were compared. RESULTS: Nine hundred and ninety patients were admitted to the standard control teams and 184 were admitted to the experimental teams (81 to the one-intern team and 103 to the two-intern team). Patients admitted to the experimental and control teams had similar age and disease severity. Residents and attending physicians consistently indicated that the quality of the educational experience, time spent teaching, time devoted to patient care, and quality of life were superior on the experimental teams. Objective healthcare outcomes did not differ between experimental and control teams. CONCLUSIONS: Altering internal medicine ward team structure to reduce the ratio of housestaff to attending physicians improved the perceived educational experience without altering objective healthcare outcomes