New updated guidelines provide guidance for what to do when a solitary pulmonary nodule is discovered on imaging. Among the recommendations: Obtain prior imaging; stability over 2 years does not require any further follow up. If no prior imaging for solid nodules <8mm, follow the Fleischner Society guidelines; if solid >8mm assess risk of cancer based on imaging and clinical history and proceed based on guidelines from the ACCP. Subsolid <5mm do not require follow up, but >5mm does. The full guidelines can be found here (guidelines).
This large retrospective analysis of VA medical centers found that patients who received perioperative beta blockers (for noncardiac surgery) had significantly lower 30 day mortality if their revised cardiac risk index was 2 or higher. This study adds more evidence base to the practice of continuing or starting perioperative beta blockers in those with a RCRI of 2 or more (abstract).
This single center trial randomized elderly (age >75) inpatients to usual care, or to a team which specialized in the care of the elderly; those in the latter group were less likely to experience adverse events (10% vs 17%) and had shorter LOS (by 0.8 days). There was no difference in readmission rates (abstract). Another study of an inpatient elderly multidisciplinary care unit found that the unit was associated with reduced direct costs, and reduced 30 day readmission rates (8% vs 13%) (abstract). These types of specialty geriatric teams seem to improve outcomes for elderly inpatients
This large analysis of closed malpractice claims from 1986 to 2010 found 29% were due to diagnostic errors, which accounted for 35% of total payments. Diagnostic errors resulted in death 41% of the time, as opposed to only 24% with other types of allegations. Diagnostic errors account for substantial morbidity, mortality, and malpractice claims in the US (abstract).
This randomized trial of 250 patients with sepsis, who were randomized to 14 days of statin or placebo, found no difference in serum markers of inflammation, organ dysfunction scores or morality between the groups. However, they did find that among prior statin users, those randomized to placebo had significantly higher 28 day mortality than those randomized to a statin (28% vs 5). Although more studies are needed, this study suggests that those already on statins who develop sepsis should be continued on their statin (abstract).
This cohort from the VA found those confirmed with pneumococcal pneumonia had a 12% 1 month mortality, and a 10 year mortality rate of~30%, which is higher than age-matched expectations. The prognosis was worse with bacteremic disease, and with higher PORT scores (abstract).
This controlled trial found that displaying the cost of lab tests reduced utilization only modestly by 9%; this benign intervention can modestly reduce lab test utilization (abstract).
This large cohort found the contribution margin in patients who suffered a post surgical complication was actually higher for most payers, compared to patients who did not suffer a complication. Unfortunately, in the short term, reducing complications may have a negative financial impact on hospitals (abstract).
This study of audio recorded physician encounters found that when physicians addressed contextual “red flags” in clinical decision making, clinical outcomes were improved in 71% of the patients, compared to 46% of those whose physicians did not address the contextual red flag. Addressing contextual issues as they arise can improve patient outcomes (abstract).
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