Identifying and reducing inappropriate aspirin use in primary care.

Objective: Recent studies have called into question the safety of aspirin use for the primary prevention of atherosclerotic cardiovascular disease, particularly in older adults. Therefore, the objectives of this study were to (1) develop a systematic approach to identifying patients aged 70 and older taking aspirin for primary prevention, (2) provide patient and provider education about updated literature and recommendations regarding aspirin safety and (3) evaluate the impact of this intervention on aspirin de-prescribing.

Design: This was a quality improvement intervention with prospective, longitudinal follow-up.

Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level.

Burnout has been implicated in higher physician turnover, reduced patient satisfaction, and worsened safety, but understanding the degree of burnout in a given physician or team does not direct leaders to solutions. The model proposed integrates a long list of variables that may ameliorate burnout into a prioritized, easy-to-understand hierarchy. Modified from Maslow's hierarchy, the model directs leaders to address physicians' basic physical and mental health needs first; patient and physician physical safety second; and then address higher-order needs, including respect from colleagues, patients, processes, and the electronic health record; appreciation and connection; and finally, time and resources to heal patients and contribute to the greater good.

The expanding role of the nurse practitioner in an academic medical center and its impact on graduate medical education.

Purpose: Academic medical centers (AMCs) have used nurse practitioners (NPs) for the provision of direct patient care for many years. However, as more NPs are hired to fill in the void created by both the 80-hour work week and the increased demands on attendings' time, their role has evolved in terms of patient care and graduate medical education. We sought to evaluate the expanded role of the NP in our large tertiary AMC to help clarify the interrelationships with the patient care delivery model and GME.

Integrating simulation into a surgical residency program: is voluntary participation effective?

Objective: Surgical training programs nationwide are struggling with the integration of simulation training into their curriculum given the constraints of the 80-h work week. We examine the effectiveness of voluntary training in a simulation lab as part of the surgical curriculum.

Methods: The ProMIS simulator was introduced into the general surgery residency at Boston University Medical Center.

Hospitalization and emergency department visits among seniors receiving homecare: a pilot study.

Background: Despite the recent growth in home health services, data on clinical outcomes and acute health care utilization among older adults receiving homecare services are sparse. Obtaining such data is particularly relevant in Ontario where an increasing number of frail seniors receiving homecare are awaiting placement in long-term care facilities. In order to determine the feasibility of a large-scale study, we conducted a pilot study to assess utilization of acute health care services among seniors receiving homecare to determine associated clinical outcomes.

Overweight and obese patients in a primary care population report less sleep than patients with a normal body mass index.

Background: Insufficient sleep and obesity are common in the United States. Restricted sleep causes important neurocognitive changes, including excessive daytime sleepiness and altered mood. This may result in work-related injuries and automotive crashes.

Cancer in the oldest old.

Our previous work revealed that 88% of centenarians delay or escape the age-related lethal diseases cardiac disease, stroke and diabetes. In the cases of those having a history of cancer we have observed anecdotes of centenarians presenting with large primary tumors that would have otherwise been expected to have metastasized and to have been lethal. However, these tumors were removed without consequence.

Indications for total parenteral nutrition in the hospitalized patient: a prospective review of evolving practice.

The indications for initiating total parenteral nutrition (TPN) were prospectively evaluated in 100 consecutive patients at a tertiary referral hospital with a long-standing Nutritional Support Service to illustrate the reasons why the parenteral route was chosen at this unique institution in terms of patient population. Sixty male and 40 female patients, average age 59 +/- 17 years (range 22-86 years), were classified a priori as to the underlying reasons for initiation of TPN. The study was conducted by a Nutrition Support Service at this hospital without pediatric, trauma, or burn services specializing in the care of patients with diabetes mellitus.

The "cost" of operative training for surgical residents.

Hypothesis: There is an increase in the amount of time required to perform an operation when the procedure involves training a surgical resident. This increased time does not translate into a financial burden for the hospital.

Design: Retrospective review of prospectively collected data.

Effect of PGG-glucan on the rate of serious postoperative infection or death observed after high-risk gastrointestinal operations. Betafectin Gastrointestinal Study Group.

Background: Postoperative infections remain common after high-risk gastrointestinal procedures. PGG-glucan (Betafectin; Alpha Beta Technology Inc, Worcester, Mass), derived from yeast cell walls, promotes phagocytosis and intracellular killing of bacterial pathogens by leukocytes, prevents infection in an animal model of wound infection, and acts synergistically with antibiotics to reduce mortality in rat peritonitis.

Hypothesis: We hypothesized that infectious complications in these patients might be reduced by the administration of a nonspecific immune-enhancing agent.

Laparoscopic cholecystectomy in patients with hepatic cirrhosis: a five-year experience.

Our institution is a tertiary referral center that specializes in hepatobiliary surgery. To evaluate the safety, efficacy, and conversion rate of laparoscopic cholecystectomy in patients with hepatic cirrhosis, we conducted a retrospective analysis of all cirrhotic patients undergoing attempted laparoscopic cholecystectomy during the period from 1991 to 1996. The diagnosis of cirrhosis was made on the basis of either a preoperative history, a liver biopsy, or the surgeon's operative description of the liver.

Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition.

Background: Elevations in liver function tests have been reported in patients receiving total parenteral nutrition (TPN). The clinical aspects of end-stage liver disease (ESLD) associated with the prolonged use of home TPN have not been fully clarified. In previous series patients with duodenocolostomies appeared to be at higher risk than persons with some jejunum or ileum remaining in situ.

Nutrition support for patients after cardiopulmonary bypass: required modifications of the TPN solution.

Objective: This study was designed to identify the unique metabolic characteristics of patients undergoing cardiopulmonary bypass (CPB) surgery who require postoperative parenteral nutrition.

Summary Background Data: Patients undergoing CPB surgery occasionally develop postoperative complications that result in the need for nutrition support. Although enteral nutrition is generally the preferred feeding route, symptomatic hyperlipasemia has been described in critically ill CPB patients receiving enteral nutrition proximal to the ligament of Treitz.