Integrating Yoga Into Undergraduate American Medical Education.

Undergraduate medical education (UGME) is the time when doctors' attitudes toward patients and their profession are formed. It is also a period of tremendous stress for future physicians, including high levels of negative stress. Such stress can be maladaptive and may sow the seeds of burnout and long-term dissatisfaction.

Threading the Needle: When a Cranial Burr Hole Is Palliative Therapy.

Subdural hematoma (SDH) impacts up to 58.1 per 100,000 individuals aged ≥65 years. Some patients or proxies elect to focus exclusively on comfort care treatments, whereas others may consider surgical procedures such as a craniotomy or cranial trephination (burr hole) to relieve intracranial pressure.

Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework.

Objectives: Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents.

Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project.

Context: There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU).

Objective: To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria.

Methods: In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates.

Results of a Hospital-Based Palliative Care Intervention for Patients With an Acute Exacerbation of Chronic Heart Failure.

Background: Palliative interventions are an important part of advanced heart failure (HF) care. However, these interventions are historically underutilized, particularly by African Americans.

Methods And Results: We performed a prospective randomized intervention trial in patients with advanced HF who were hospitalized for acute decompensation at 3 urban hospitals, comparing the effect of palliative care consultation (PCC) with that of usual care.

Test characteristics of electrocardiography for detection of left ventricular hypertrophy in asymptomatic emergency department patients with hypertension.

Objectives: The objective was to evaluate the diagnostic test characteristics of three validated electrocardiographic (ECG) criteria for the diagnosis of left ventricular hypertrophy (LVH) in undifferentiated, asymptomatic emergency department (ED) patients with hypertension (HTN).

Methods: This was a prospective cohort study of ED patients with asymptomatic HTN at a single tertiary care facility. Patients 35 years of age or older with systolic blood pressure (sBP) ≥ 140 mm Hg or diastolic blood pressure (dBP) ≥ 90 mm Hg on two separate readings (at least 1 hour apart) were eligible for inclusion.

Evaluation of screening criteria for palliative care consultation in the MICU: a multihospital analysis.

Background: There are currently no comprehensive studies in critical care settings that have set out to examine the association of palliative care screening criteria with multiple, adverse patient outcomes.

Methods: A 7-item palliative care screen was developed from consensus reports. Medical intensive care unit (MICU) nurses at four hospitals screened patients upon admission during a 16-week period.

When a patient declines curative care: management of a ruptured aortic aneurysm.

The management of major vascular emergencies in the emergency department (ED) involves rapid, aggressive resuscitation followed by emergent definitive surgery. However, for some patients this traditional approach may not be consistent with their goals and values. We explore the appropriate way to determine best treatment practices when patients elect to forego curative care in the ED, while reviewing such a case.

Atherosclerotic risk factors and their association with hospital mortality among patients with first myocardial infarction (from the National Registry of Myocardial Infarction).

Few studies have examined associations between atherosclerotic risk factors and short-term mortality after first myocardial infarction (MI). Histories of 5 traditional atherosclerotic risk factors at presentation (diabetes, hypertension, smoking, dyslipidemia, and family history of premature heart disease) and hospital mortality were examined among 542,008 patients with first MIs in the National Registry of Myocardial Infarction (1994 to 2006). On initial MI presentation, history of hypertension (52.

Subclinical hypertensive heart disease in black patients with elevated blood pressure in an inner-city emergency department.

Study Objective: We examine the point prevalence of subclinical hypertensive heart disease in a cohort of urban emergency department (ED) patients with elevated blood pressure.

Methods: A convenience sample of hypertensive (blood pressure ≥ 140/90 mm Hg on 2 measurements) patients aged 35 years or older with no history of cardiac or renal disease who presented to a single urban ED and were asymptomatic from a cardiovascular perspective (ie, no symptoms of dyspnea or chest pain) were enrolled. All patients underwent a standardized evaluation (including echocardiography), and subclinical hypertensive heart disease was defined by the presence of one or more of the following criterion-based echocardiographic [corrected] findings: left-ventricular hypertrophy, systolic dysfunction, or diastolic dysfunction.

Study design for the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial: A double-blind randomized controlled trial of intravenous glucose, insulin, and potassium for acute coronary syndromes in emergency medical services.

Background: Experimental studies suggest that metabolic myocardial support by intravenous (IV) glucose, insulin, and potassium (GIK) reduces ischemia-induced arrhythmias, cardiac arrest, mortality, progression from unstable angina pectoris to acute myocardial infarction (AMI), and myocardial infarction size. However, trials of hospital administration of IV GIK to patients with ST-elevation myocardial infarction (STEMI) have generally not shown favorable effects possibly because of the GIK intervention taking place many hours after ischemic symptom onset. A trial of GIK used in the very first hours of ischemia has been needed, consistent with the timing of benefit seen in experimental studies.

Life disruption, life continuation: contrasting themes in the lives of African-American elders with advanced heart failure.

This study addresses the need for more information about how urban African-American elders experience advanced heart failure. Participants included 35 African Americans aged 60 and over with advanced heart failure, identified through records from a community hospital in Detroit, Michigan. Four focus groups (n = 13) and 22 individual interviews were conducted.

Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction.

Context: Few studies have examined the association between the number of coronary heart disease risk factors and outcomes of acute myocardial infarction in community practice.

Objective: To determine the association between the number of coronary heart disease risk factors in patients with first myocardial infarction and hospital mortality.

Design: Observational study from the National Registry of Myocardial Infarction, 1994-2006.

Family-witnessed resuscitation: bereavement outcomes in an urban environment.

Background: After 20 years of debate regarding the appropriateness of family-witnessed resuscitations (FWR), little substantive data exist to suggest a benefit or harm to the family member.

Objective: To compare bereavement-related depression and post-traumatic stress disorder (PTSD) symptoms among cardiopulmonary resuscitation (CPR) patients' family members who remain in the waiting room of an urban emergency department (ED) with those who are invited to witness CPR.

Methods: A prospective comparison study was conducted at two large, urban, Midwestern teaching hospitals.

Descriptive analysis of the in-hospital course of patients who initially survive out-of-hospital cardiac arrest but die in-hospital.

Objective: To describe the postresuscitative hospital course of emergency department patients who initially survive nontraumatic out-of-hospital cardiac arrests (OOHCA) but die in the hospital.

Methods: A 12-month case series of all nontraumatic OOHCA patients at two large urban Midwestern teaching hospitals who survived to hospital admission but died before discharge. Medical records from identified patients were reviewed for demographics, resuscitation sequelae, do-not-attempt-resuscitation (DNAR) code status, pain declarations, and withdrawal of life support.

A percutaneous coronary intervention-thrombolytic predictive instrument to assist choosing between immediate thrombolytic therapy versus delayed primary percutaneous coronary intervention for acute myocardial infarction.

Based on the thrombolytic predictive instrument (TPI), we sought to create electrocardiographically based, real-time decision support to immediate identification of patients with ST-segment elevation myocardial infarction (STEMI) likely to benefit from primary percutaneous coronary intervention (PCI) compared with thrombolysis. Using data from the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) Trial, we tested a mathematical model predicting mortality in patients with STEMI if treated with PCI and if treated with thrombolytic therapy. We adapted the model for incorporation into computerized electrocardiograms as a PCI-TPI.

Diagnostic classifications and resource utilization of decedents served by the Department of Veterans Affairs.

Background: Given the volume and cost of inpatient care during the last year of life, there is a critical need to identify patterns of dying as a means of planning end-of-life care services, especially for the growing number of older persons who receive services from the Veterans Health Administration (VHA).

Methods: A retrospective computerized record review was conducted of 20,933 VHA patients who died as inpatients between October 1, 2001 and September 30, 2002. Diagnoses were aggregated into one of five classification patterns of death and analyzed in terms of health care resource utilization (mean number of inpatient days and cumulative outpatient visits in the year preceding the patient's death).

Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis.

Study Objective: We perform a feasibility and outcome assessment of the treatment of severe decompensated heart failure with high-dose nitroglycerin.

Methods: This study was designed as a nonrandomized, open-label, single-arm study of high-dose nitroglycerin. Patients with hypertension (systolic blood pressure > or = 160 mm Hg or mean arterial pressure > or = 120 mm Hg) who were refractory to initial therapy were eligible for inclusion.

Comparison of mortality benefit of immediate thrombolytic therapy versus delayed primary angioplasty for acute myocardial infarction.

Primary percutaneous coronary intervention (PPCI) yields superior mortality outcomes compared with thrombolysis in ST-elevation acute myocardial infarction (STEMI) but takes longer to administer. Previous meta-regressions have estimated that a procedure-related delay of 60 minutes would nullify the benefits of PPCI on mortality. Using a combined database from randomized clinical trials and registries (n = 2,781) and an independently developed model of mortality risk in STEMI, we developed logistic regression models predicting 30-day mortality for PPCI and thrombolysis by examining the influence of baseline risk on the treatment effect of PPCI and on the hazard of treatment delay.

Outcomes from out-of-hospital cardiac arrest in Detroit.

Objective: To determine the out-of-hospital cardiac arrest survival rate, and prevalence of modifiable factors associated with survival, in Detroit, Michigan, over a 6-month period of time in 2002.

Methods: A retrospective review of all out-of-hospital cardiac arrests responded to by the Detroit Fire Department, Division of Emergency Medical Services. All elements of the EMS runsheet were transcribed to a database for analysis.

Maslow's hierarchy of needs: a framework for achieving human potential in hospice.

Although the widespread implementation of hospice in the United States has led to tremendous advances in the care of the dying, there has been no widely accepted psychological theory to drive needs assessment and intervention design for the patient and family. The humanistic psychology of Abraham Maslow, especially his theory of motivation and the hierarchy of needs, has been widely applied in business and social science, but only sparsely discussed in the palliative care literature. In this article we review Maslow's original hierarchy, adapt it to hospice and palliative care, apply the adaptation to a case example, and then discuss its implications for patient care, education, and research.