Surgical repair of hip fractures within the first 48 hours was associated with better health outcomes in a nationally representative sample, as observed in an acute care facility, irrespective of comorbid conditions.
Adverse drug events occur often in hospitals. They can be prevented to a large extent by minimizing the human errors of prescription writing. To evaluate the efficacy of a computerized prescription order entry (CPOE) system with the help of ancillary support in minimizing prescription errors. Retrospective study carried out in a community-based urban teaching hospital in south Brooklyn, NY from January 2004 to January 2005. Errors were categorized into inappropriate dosage adjustment for creatinine clearance, duplication, incorrect orders, allergy verification, and incomplete orders. The pharmacists identified the type of error, the severity of error, the class of drug involved, and the department that made the error. A total of 466,311 prescriptions were entered in the period of 1 year. There were 3513 errors during this period (7.53 errors per 1000 prescriptions). More than half of these errors were made by the internal medicine specialty. In our study, 50% of the errors were severe errors (overdosing medications with narrow therapeutic index or over-riding allergies), 46.28% were moderate errors (overdosing, wrong dosing, duplicate orders, or prescribing multiple antibiotics), and 3.71% were not harmful errors (wrong dosing or incomplete orders). The errors were also categorized according to the class of medication. Errors in antibiotic prescription accounted for 53.9% of all errors. The pharmacist detected all these prescription errors as the prescriptions were reviewed in the CPOE system. Prescription errors are common medical errors seen in hospitals. The CPOE system has prevented and alerted the prescriber and pharmacist to dosage errors and allergies. Involvement of the pharmacist in reviewing the prescription and alerting the physician has minimized prescription errors to a great degree in our hospital setting. The incidence of prescription errors before the CPOE has been reported to range from 3 to 99 per 1000 prescriptions. The disparity could be due to the definition of medical errors, which has changed over the years, and also number of prescriptions included in the study and the study design.
Pulmonary edema is known to develop in users of heroin and methadone. Its association with cocaine use is usually a postmortem finding. There has been only 1 report of pulmonary edema being diagnosed clinically after cocaine use. In that case the cocaine was used intravenously, and death occurred within 3 h after the onset of symptoms. Here we describe a patient who developed acute pulmonary edema after smoking "freebase" cocaine. The pulmonary edema resolved spontaneously within 72 h. The cause of the acute reversible pulmonary edema was probably related to both pressure- and permeability-related changes.
The prognosis of patients who become critically ill due to complications of the acquired immunodeficiency syndrome (AIDS) is generally believed to be poor, but no detailed studies have substantiated this impression. We performed a retrospective analysis of patients with AIDS admitted to the Medical Special Care Unit (MSCU) at Mount Sinai Medical Center in New York over a 42-month period. Of 910 patients admitted to the MSCU, 35 (4% ) had AIDS. An additional patient admitted to the pediatric intensive care unit was included in the analysis. Respiratory failure occurred in 31 patients (86% ) and was the most common problem necessitating admission. Twenty-five of these patients (69% ) had Pneumocystis carinii pneumonia. All 31 patients with respiratory failure required endotracheal intubation and mechanical ventilation, and 27 (87%) died during the same hospitalization. Pneumothorax requiring tube thoracostomy occurred in 6 of 31 patients receiving mechanical ventilatory support. Among the 4 mechanically ventilated survivors, only 2 patients remain alive. Intensive care unit intervention in patients with AIDS and respiratory failure is associated with a poor outcome and probably does not alter the ultimate course in most cases.
Abnormal spirometry was observed in (5.3%) of subjects, particularly individuals experiencing higher Exposure Intensity, Duration, or Respiratory Symptoms. The small number of smokers and subjects failing to wear protective respiratory masks showed greater declines.
Hydralazine has been widely used for treating hypertension, particularly in patients with renal failure. We report a case on a patient in whom we believe the drug was implicated in an otherwise unexplained disturbance of liver function. A 63-year-old African-American female with medical history of hypertension and end-stage renal disease (on hemodialysis) was admitted to the hospital with epigastric pain and jaundice. The symptoms started about 1 week ago. Initial laboratory tests showed abnormal liver enzymes with elevated conjugated bilirubin and alkaline phosphatase suggestive of cholestatic jaundice. Amylase and lipase were normal. Abdominal ultrasound showed normal caliber common bile duct without evidence of obstruction. Abdominal CT scan does not show any evidence of intra- or extrahepatic biliary ductal dilatation, and no mass lesions were seen in the pancreas. Further blood chemistry showed worsening of liver enzymes and increased bilirubin over the next 2-3 days. Magnetic resonance cholangiopancreatography failed to show any evidence of intra- or extrahepatic biliary ductal dilatation. No other laboratory evidence of cholestatic jaundice was found. Before proceeding for invasive diagnostic procedure, that is, endoscopic retrograde cholangiopancreatography, the patient's drug history was reviewed. She was on hydralazine 75 mg 3 times per day, started 5 months ago. At that time, her liver function tests were normal. As we could not find any other cause of cholestatic jaundice, we attributed this as a side effect of hydralazine. A trial was given by stopping the hydralazine. It was seen that there was significant improvement in the liver function enzymes over the next week. Complete clinical and biochemical recovery occurred over the next 4 weeks. Liver injury after long-term therapy with hydralazine and after short-term therapy with hydralazine (2-10 days) has been described. Hydralazine-induced hepatotoxicity may manifest as hypersensitivity-type injury, mixed hepatocellular injury, acute hepatitis, cholestatic jaundice, or centrilobular necrosis. The Hydralazine-induced cholestatic liver injury seems to be fully reversible. Complete clinical and biochemical recovery occurs after discontinuation of the drug. Also, the differential diagnosis of any patient with hepatocellular injury should include medications. This will prevent unnecessary diagnostic tests.
BackgroundThe circulating peptide, pro-B-type natriuretic peptide (pro-BNP) was examined for prediction of cardiac function and prognosis and compared with previously reported markers [cardiac troponin I (cTnI) and creatine phosphokinase (CPK)] in patients with ST-elevation myocardial infarction (STEMI).Methods and ResultsWe examined plasma levels of pro-BNP, cTnI, and CPK in 84 patients presenting with STEMI. Patients presenting with KILLIP's class 3 and 4, renal failure, and a previous history of low ejection fraction (EF) were excluded. EF was determined by echocardiography 6 months after STEMI. Of the 84 patients in this study, 60 (71%) were male and 24 (29%) female. Their ages ranged from 43 to 88 yr, with a mean of 63.6 yr (SD 13.0 yr). The correlation between pro-BNP and CPK was excellent (r=.88, p < .001), while the following correlations were on the borderline of fair to moderate: pro- BNP and cTnI (r = .52, p < .001) and cTnI and CPK (r = .50, p < .001). Left ventricular ejection fraction at 6 months was moderately negatively correlated with peak CPK (r = 2.64, p < .001) and pro-BNP (r = 2.66, p < .001); its negative correlation with cTnI (r = 2.47, p < .001) was only fair.ConclusionsWe conclude that increased concentrations of pro-BNP at initial presentation of patients with STEMI correlate well with levels of CPK and the may reflect long-term left ventricular dysfunction in these patients. These data support the value of combining markers of hemodynamic stress with traditional approaches to risk assessment in acute myocardial infarction.
ObjectiveTo compare the morbidity and mortality of patients with hip fractures operated within and after 48 hours of the occurrence of fracture and establish if timing of repair alone had a major role in deciding how the patients fared after the surgical repair or if their preexisting comorbidities were also responsible for their postoperative outcomes.SampleThe study included the medical records of 49 patients (aged 51-99 years) admitted to Coney Island Hospital between January 2003 and January 2004 with a primary diagnosis of hip fracture who underwent surgical repair.DesignAnalysis of data was done by retrospective chart review of patients admitted with the diagnosis of hip fracture to an acute care hospital setting. Patients were followed until they were transferred to rehab facility for PT/OT after their surgery.Outcome MeasuresPreoperative health status of each patient was assessed using CPRI (cardiopulmonary risk index) score allocated to each individual patient, based on their comorbid conditions, and postoperative outcome was determined by complications such as bed sore, pneumonia, urinary tract infection, deep vein thrombosis, pulmonary embolism, and death.ResultsPatients who underwent early surgical repair, ie, within 48 hours, had lesser complications in their postoperative period (14.7% as compared to 33.3% in the group operated beyond 48 hours). Also comparing CPRI scores of patients in each group (ie, those operated within 48 hours and those operated beyond 48 hours) with their postoperative mortality and morbidity, it appeared that there was a higher statistical correlation between CPRI scores and complications among patients in the within 48 hours group(p value .39), and an insignificant correlation among patients operated beyond 48 hours (p value .07).ConclusionSurgical repair of hip fractures within the first 48 hours was associated with better health outcomes in a nationally representative sample, as observed in an acute care facility, irrespective of the preexisting comorbid conditions in a patient.
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