Volume 106, Issue 7

Context: Guidelines on the use of prophylaxis in venous thromboembolism (VTE) are poorly implemented in clinical practice. Objective: To evaluate the extent to which the American College of Chest Physicians (ACCP) 2001 guidelines on VTE prophylaxis are adhered to in clinical practice by determining whether patients admitted to a medical center with an objective diagnosis of VTE had received adequate prophylaxis. Methods: The medical records of medical and surgery patients with an objective diagnosis of VTE were reviewed. Patients were classified as having either preventable or nonpreventable VTE according to indication for prophylaxis, VTE risk, and adequacy of prophylaxis if administered. Adequacy was determined by adherence to the ACCP 2001 guidelines. Results: Of 44 patients, 17 (38.6%) had not received adequate prophylaxis and were classified as having potentially preventable VTE. Venous thromboembolism developed in the remaining 27 (61.4%) patients despite adequate prophylaxis. In general, adequate prophylaxis rates were lower among surgery patients compared with medical patients. Four (80%) of the very-high-risk surgery patients received inadequate prophylaxis. The most common VTE risk factor in both categories was immobility. Conclusions: Adherence to the ACCP guidelines is suboptimal, with a substantial proportion of patients with VTE receiving inadequate prophylaxis. The additional finding that the incidence of VTE is high despite adequate prophylaxis indicates that the guidelines may need to be reevaluated.

Objective: To determine the use of treatment and prevention practices in postmenopausal women who have received the results of an osteoporosis screening. Methods: Telephone survey to follow-up with women who underwent dual-energy x-ray absorptiometry scanning at a community-wide osteoporosis screening project. Participants categorized by their scan results as having normal bone mineral density or low bone mineral density were asked about their osteoporosis treatment and prevention practices since receiving their scan results. Results: Two hundred nineteen women were interviewed. Calcium supplement use increased significantly in both groups (P=.002). There was no significant difference in the number of women using alendronate sodium, calcitonin, and selective estrogen receptor modulators before and after screening. Both groups reported increases in exercise levels and dairy intake, but the difference was not statistically significant. Conclusions: Our results indicate that the use of over-the-counter calcium supplements increases after osteoporosis screening. However, the use of treatments that require a physician prescription does not increase after screening regardless of the patient's bone mineral density status.

Context: On hospital admission, many elderly patients make the decision to enact a do-not-resuscitate (DNR) order. However, few studies have evaluated the beliefs of elderly patients regarding the likelihood of surviving cardiopulmonary resuscitation (CPR) if it should become necessary during their hospitalization. Objectives: To quantify elderly patients' beliefs about their chances of survival to discharge following CPR; to ascertain the sources of information that may lead to these beliefs; and to determine how these beliefs affect decisions regarding DNR orders. Methods: An oral standardized survey was administered to 100 patients aged 70 years or older. Patients were randomly selected from the emergency department, internal medicine clinic, and general medical wards at one urban medical center. Results: Most respondents (81%) believed that their chance of surviving inpatient CPR and leaving the hospital was 50% or better, and 23% of those respondents believed that their chance was 90% or better. Forty-four percent of patients reported having a standing DNR order. Most patients reported obtaining healthcare information from television, physicians, or both. Conclusion: Elderly patients often hold erroneous beliefs regarding the outcomes of inpatient CPR. A significant number of our participants had standing DNR orders despite demonstrating extremely optimistic beliefs about CPR. Educating patients and their families about these poor outcomes would allow them to make more informed decisions regarding end-of-life issues.

Context : Although the circumstances are not well studied, grandparents' medications account for 10% to 20% of unintentional pediatric intoxications in the United States. Objectives : To characterize circumstances leading to and outcomes from pediatric pharmaceutical exposures. To identify preventable risk factors associated with this pattern of injury, referred to as the “granny syndrome.” Design, Setting, and Participants : Retrospective review of records of telephone calls made to a certified regional poison control center in the United States. Records were analyzed for all calls concerning children aged 6 years or younger who were exposed to grandparents' medication(s). For statistical analysis, regression and χ 2 analysis as well as Fisher exact tests were used. The sample size provided 80% power to detect a 10% difference at the 5% level of significance. Statistical significance was set at P ≤.05. Main Outcomes Measured : Use of child-resistant containers (CRCs), the location of pharmaceuticals prior to pediatric ingestion, and drug classes involved (eg, analgesics, cardiovascular drugs). Results : Of the 200 incidents analyzed, 90 (45%) cases involved CRCs, and 110 (55%) involved containers that were not child resistant. For these incidents, the average age of the child was 18.8 months; the grandparent was aged on average 58.7 years. Most medications had been placed on tables or countertops (91 [46%]), low shelves (57 [29%]), or in pocketbooks (34 [17%]). The type of container in which the pharmacologic agent was stored (CRC vs non-CRC) was not statistically significant ( P >.1). Ease of access to medication, regardless of the type of container used, was the only statistically significant outcome ( P <.001). In the present study, accidental pediatric exposures most frequently involved cardiovascular (90 [45%]), analgesic (84 [42%]), and psychotropic (32 [16%]) medications. Conclusion : Pediatric exposure to pharmaceutical agents is a preventable cause of injury. Physicians have an important opportunity to assist in preventing pediatric pharmaceutical exposures by instructing parents and grandparents on how to better limit children's access to medications as an essential component to enhance child safety.

Objective: To determine the association between neuropsychiatric symptoms and the presence of medical illness among outpatients with mild dementia. Method: The Neuropsychiatric Inventory (NPI) was used to assess neuropsychiatric symptoms, and the Cumulative Illness Rating Scale (CIRS) was used to evaluate physical impairment, in 44 outpatients diagnosed as having dementia (Alzheimer disease, n=22; vascular dementia, n=13; mixed dementia, n=9). The tests used were standard parts of a memory assessment program at a college of osteopathic medicine. Pearson product moment correlations were used to assess any associations between NPI and CIRS scores. Results: Significant associations were identified between several NPI-assessed symptoms and degree of medical illness as measured by the CIRS. Neurobehavioral problems were significantly correlated ( P <.05) with illness in the following body organ systems: gastrointestinal (lower), genitourinary, neurologic, ophthalmologic/otolaryngologic, psychiatric, and respiratory. Conclusion: The authors' preliminary data underscore the importance of primary care physicians assessing patients with dementia for comorbidity of psychiatric illnesses when conducting medical examinations.

Data from the Centers for Disease Control and Prevention indicate that more than 20 million people (approximately 7% of the population) in the United States have diabetes mellitus. Physicians often fail to examine the mouths and teeth of their patients, even though the condition of the mouth and teeth have clinical relevance for the treatment of patients with diabetes mellitus. The authors examine the current state of knowledge regarding periodontal disease and the effect of periodontal disease on worsening of glycemic control. They review several studies investigating how the management of periodontal disease affects the ability of patients to control symptoms of diabetes mellitus. The authors conclude with several recommendations for the treatment of patients with periodontal disease to improve glycemic control.