OBJECTIVE: To better understand the life expectancy of patients who have an abnormal videofluoroscopic swallowing study.DESIGN: Retrospective cohort study. The common starting point was the time of the severely abnormal swallowing study. Hospital charts were reviewed for clinical variables of potential prognostic significance by reviewers blinded to the outcome of interest, survival time.SETTING: A university-affiliated, community teaching hospital. PATIENTS:One hundred forty-nine hospitalized patients who were deemed nonoral feeders based on their swallowing study. Patients excluded were those with head, neck, or esophageal cancer, or those undergoing a thoracotomy procedure. MEASUREMENTS AND MAIN RESULTS:Clinical and demographic variables and time until death or censoring were measured. Overall 1-year mortality was 62%. Multivariable Cox proportional hazards analyses identified four variables that independently predicted death: advanced age, reduced serum albumin concentration, disorientation to person, and higher Charlson comorbidity score. Eighty patients (54%) subsequently underwent placement of a percutaneous endoscopic gastrostomy (PEG) tube after their swallowing study. CONCLUSIONS:Mortality is high in patients with severely abnormal swallowing studies. Common clinical variables can be used to identify groups of patients with particularly poor prognoses. This information may help guide discussions regarding possible PEG placement.KEY WORDS: videofluoroscopic swallowing study; percutaneous endoscopic gastrostomy (PEG); nonoral feeding; survival. J GEN INTERN MED 1997;12:88-94.

Mortality is high in patients with severely abnormal swallowing studies. Common clinical variables can be used to identify groups of patients with particularly poor prognoses. This information may help guide discussions regarding possible PEG placement.

Pain management is a core competency of hospital medicine, and effective acute pain management should be a goal for all hospital medicine providers. The prevalence of opioid use in the United States, both therapeutic and non-medical in origin, has dramatically increased over the past decade. Although nonopioid medications and nondrug treatments are essential components of managing all acute pain, opioids continue to be the mainstay of treatment for severe acute pain in both opioid-naïve and opioid-dependent patients. In this review, we provide an evidence-based approach to appropriate and safe use of opioid analgesics in treating acute pain in hospitalized patients who are opioid-dependent.

IntroductionEffective chronic pain management is a core competency of internal medicine. Opioid use in the United States, both therapeutic and nonmedical in origin, has dramatically increased, as has the number of deaths due to opioid overdose. Despite this, formal training in pain management and responsible opioid prescribing is lacking for internal medicine residents.MethodsOur educational workshop for PGY 1-PGY 3 internal medicine residents was designed to provide a functional knowledge base and improve motivation to change behaviors in chronic pain management and responsible opioid prescribing. A secondary aim was to align our intervention with our new clinic opioid-prescribing protocol with the goal of increasing the adoption of opioid risk-reduction strategies in our resident clinic, specifically, use of urine drug screening (UDS). We collected data using pre- and postsession knowledge and motivation to change questionnaires as well as pre- and postintervention data regarding UDS in our ambulatory clinic.ResultsSixty-three residents participated in a workshop session. Based on pre- to posttest results, medical knowledge of principles of responsible opioid prescribing increased overall (p = .01). Most residents reported high motivation to change behaviors around management of chronic pain and opioid prescribing. There was also a significant postintervention ordering of UDS in patients on long-term opioid therapy.DiscussionOur workshop resulted in a short-term improvement in knowledge of principles of responsible opioid prescribing, a significant motivation to change behaviors, and increased adoption of opioid risk-reduction strategies in our resident clinic.

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