The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study

INTRODUCTION

The Modified Early Warning Score (MEWS) is a simple, physiological score that may allow improvement in the quality and safety of management provided to surgical ward patients. The primary purpose is to prevent delay in intervention or transfer of critically ill patients.

PATIENTS AND METHODS

A total of 334 consecutive ward patients were prospectively studied. MEWS were recorded on all patients and the primary end-point was transfer to ITU or HDU.

RESULTS

Fifty-seven (17%) ward patients triggered the call-out algorithm by scoring four or more on MEWS. Emergency patients were more likely to trigger the system than elective patients. Sixteen (5% of the total) patients were admitted to the ITU or HDU. MEWS with a threshold of four or more was 75% sensitive and 83% specific for patients who required transfer to ITU or HDU.

CONCLUSIONS

The MEWS in association with a call-out algorithm is a useful and appropriate risk-management tool that should be implemented for all surgical in-patients.

Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients

Much work on psychosocial sequelae of breast cancer has been guided by the assumption that body image and partner reaction issues are focal. In a tri-ethnic sample of 223 women treated for early-stage breast cancer within the prior year, the authors assessed a wider range of concerns and relations to well-being. Strongest concerns were recurrence, pain, death, harm from adjuvant treatment, and bills. Body-image concerns were moderate; concern about rejection was minimal. Younger women had stronger sexual and partner-related concerns than older women. Hispanic women had many stronger concerns and more disruption than other women. Life and pain concerns and sexuality concerns contributed uniquely to predicting emotional and psychosexual disruption; life and pain concerns and rejection concerns contributed to predicting social disruption. In sum, adaptation to breast cancer is a process bearing on several aspects of the patient's life space.

Peri-operative care of the elderly 2014: Association of Anaesthetists of Great Britain and Ireland

Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline, frailty and polypharmacy. Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after elective and (especially) emergency surgery. Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide care effectively, but must be individualised to suit each patient. The AAGBI strongly supports an expanded role for senior geriatricians in coordinating peri-operative care for the elderly, with input from senior anaesthetists (consultants/associate specialists) and surgeons. The aims of peri-operative care are to treat elderly patients in a timely, dignified manner, and to optimise rehabilitation by avoiding postoperative complications. Effective peri-operative care improves the likelihood of very elderly surgical patients returning to their same pre-morbid place of residence, and maintains the continuity of their community care when in hospital. Postoperative delirium is common, but underdiagnosed, in elderly surgical patients, and delays rehabilitation. Multimodal intervention strategies are recommended for preventing postoperative delirium. Peri-operative pain is common, but underappreciated, in elderly surgical patients, particularly if they are cognitively impaired. Anaesthetists should administer opioid-sparing analgesia where possible, and follow published guidance on the management of pain in older people. Elderly patients should be assumed to have the mental capacity to make decisions about their treatment. Good communication is essential to this process. If they clearly lack that capacity, proxy information should be sought to determine what treatment, if any, is in the patient's best interests. Anaesthetists must not ration surgical or critical care on the basis of age, but must be involved in discussions about the utility of surgery and/or resuscitation. The evidence base informing peri-operative care for the elderly remains poor. Anaesthetists are strongly encouraged to become involved in national audit projects and outcomes research specifically involving elderly surgical patients.

Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients

Much work on psychosocial sequelae of breast cancer has been guided by the assumption that body image and partner reaction issues are focal. In a tri-ethnic sample of 223 women treated for early-stage breast cancer within the prior year, the authors assessed a wider range of concerns and relations to well-being. Strongest concerns were recurrence, pain, death, harm from adjuvant treatment, and bills. Body-image concerns were moderate; concern about rejection was minimal. Younger women had stronger sexual and partner-related concerns than older women. Hispanic women had many stronger concerns and more disruption than other women. Life and pain concerns and sexuality concerns contributed uniquely to predicting emotional and psychosexual disruption; life and pain concerns and rejection concerns contributed to predicting social disruption. In sum, adaptation to breast cancer is a process bearing on several aspects of the patient's life space.

Cost-effective management of breast cancer

The 5-year survival of cancer of the breast in socioeconomically disadvantaged women is much too low because treatment is given for late stage disease. A screening mammography program at primary-care facilities for medically underserved women has markedly increased in situ and local stage of disease and decreased distant disease. This has produced an estimated 50% decrease in mortality and a significant decrease in treatment costs. Unacceptable delay from positive mammogram to biopsy and pathologic diagnosis remained, so a one-stop breast center was established to perform breast physical examination, screening mammography, biopsy, and pathologic interpretation at one site on one visit for optimal cost-effectiveness.

Why patients delay seeking care for cancer symptoms. What you can do about it

Patient delay in seeking care for cancer symptoms is common and well documented by research studies. Fear and denial, lack of information about cancer, and financial considerations all contribute to this delay. Patient education may be an important factor in decreasing the length of delay and thereby improving treatment outcome. By making good use of opportunities for patient education, primary care physicians may positively influence the prognosis of several types of cancer, particularly breast cancer and malignant melanoma of the skin.

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

Breast cancer control program for the socioeconomically disadvantaged. Screening mammography for the poor

A 6-year experience of providing mammograms to the socioeconomically disadvantaged in Dade County, Florida, through Primary Health Care Centers has defined a breast cancer control program that minimizes the barriers to early breast cancer detection for these women. First, an education and recruitment phase that reaches into the community to solicit the target group: Recruitment is needed more than education. Second, a low-cost mammography service that also reaches into the community and makes it available, accessible, and acceptable. Third, a one-stop breast center that minimizes the barriers to diagnostic evaluation. Finally, a multidisciplinary evaluation and treatment planning program offers optimum treatment options to the patient with newly diagnosed breast cancer and an opportunity for bonding between her and the staff. A research overly has allowed data to be collected continuously and provides an evaluation of the effectiveness of the program. This program has saved lives by reducing the projected mortality rate and has saved money by reducing the cost of treatment through earlier diagnosis. All four components are essential to a breast cancer control program for the socioeconomically disadvantaged.

Treatment of localized prostate cancer. Choosing the best alternative

Thousands of men will be faced with a diagnosis of prostate cancer this year and will turn to their primary care physician for advice about which treatment is best. Unfortunately, there are no easy answers, and multiple factors, including the patient's age, must be weighed in decision making. In this article, Drs Williams and Love sift through the pros and cons of the available treatment options for various profiles of organ-confined disease.

Follow-up after therapy for prostate cancer. Treating the problems and caring for the man

With prostate cancer being diagnosed and treated in more than 300,000 men each year, the pool of long-term survivors is dramatically increasing. Because these patients are usually elderly, they are often receiving follow-up care for unrelated problems in a primary care setting. This offers the physician an excellent opportunity to assist in management of any long-term complications of therapy and in monitoring for cancer recurrence. In addition to performing follow-up evaluations, the physician can provide counseling about a number of testing and treatment issues, including the variability of prostate-specific antigen levels, the appropriateness of a watchful waiting approach to some cancers, and the management of treatment-induced incontinence and impotence, which often have a deleterious effect on quality of life but may be amenable to therapy and psychosocial support.

Legal issues in managing breast disease

The impact of legal issues in breast cancer care reflects the significance of breast cancer as a health concern of women. Breast cancer has emerged as a leading liability risk for primary care physicians, with most cases focusing on delayed diagnosis. Although the clinical impact of delayed diagnosis of breast cancer is often controversial, physicians should strive to diagnose breast cancer as early as possible in the natural history of the disease. No currently available data suggest that a delay of less than 2 months between the onset of symptoms and diagnosis or treatment adversely influences outcome. Techniques that help physicians reduce the liability risks associated with breast cancer care include patient education, adequate documentation and follow-up, and referral or consultation in high-risk situations.

Breast imaging. A practical look at its capabilities and its limitations

The film-screen technique is evolving as the standard for mammography. Sonography is the only other method that currently has a defined role in breast imaging. Mammography should be performed at facilities that have received American College of Radiology accreditation or its equivalent, because technical quality assurance is an important part of mammographic practice. Interpretive quality may be assured by outcome audits performed by mammography facilities. Primary care physicians are best suited to encouraging eligible women to undergo screening studies and should consider these recommendations: Refer patients for screening mammography to accredited facilities according to established guidelines. Educate patients about the need for regular screening. Provide annual breast physical examination. Refresh your knowledge on breast health and the techniques of physical examination if necessary. Teach patients breast self-examination techniques. Demand low-cost, high-quality screening mammography; be aware of local variability of charges and quality.

The pediatric medical triangle

The pediatric patient has many needs which are often ignored in the ambulatory environment partially due to participation in a medical triangle. This medical triangle and its participants frequently contribute to the development of an ineffective physician-patient encounter which, in turn, may lead to numerous problems including parental dissatisfaction, altered health care behavior and noncompliance with clinic appointments and drug therapy. This article attempts to summarize some of these problems with the pediatric medical triangle as well as some of the special needs of this patient.

Advanced prostate cancer. Endocrine therapies and palliative measures

Management of patients with metastatic prostate cancer differs from that of patients with other metastatic solid tumors. Because the treating physician is usually the patient's urologist, the primary care physician's main role may be to relieve pain and treat the patient for common side effects of hormone therapies. By being familiar with the forms of systemic treatment-including orchiectomy and the use of estrogens, luteinizing hormone-releasing hormone agonists, and antiandrogens-the primary care physician can also assist patients in making treatment decisions that are individualized to the specifics of disease state, comorbid conditions, age, and value systems.

A strategy for curriculum integration of information skills instruction

The ever increasing need of health professionals for information and the inclusion of active learning experiences in the medical school curriculum require that students learn the effective use of health information tools. Curriculum integration is gaining acceptance as an effective approach to teaching information skills in this setting. At the University of Miami School of Medicine, information skills components taught by library faculty are integrated into the Freshman Orientation Program and two sophomore curriculum courses. Beginning with a core set of skills and basic information management tools, more complex and subject-specific skills are introduced sequentially throughout the basic sciences curriculum. During the first two years, a wide range of information skills are taught, and students receive many opportunities to seek and identify information using both printed sources and computerized bibliographic databases. This paper describes how curriculum integration of information skills instruction was achieved and the many benefits of this approach. Included are a description of the information skills components, evaluation data, and future plans.

Primary localized breast cancer. Treatment options and informed choices

As understanding of the natural history of breast cancer has increased, radical mastectomy has given way to a preference for breast-sparing surgery and greater reliance on radiation therapy and chemotherapy. Probably the most important factor for selection of treatment is consultation with a multidisciplinary team skilled in the various procedures and techniques that might be efficacious. The key to successful management is selection of an appropriate course of treatment with which the patient feels comfortable.

Psychosocial issues in breast cancer. Helping patients get the support they need

Patients are becoming increasingly involved in making informed choices regarding their care. However, in the case of breast cancer, more than medical treatment of a body part is at stake. The breast is an important cultural symbol of femininity and an intimate part of the patient's self-esteem. The disease and its treatment may cause ongoing sadness, fear, anxiety, and anger. Primary care physicians, because of their close relationship with patients, are often in a position to notice when natural and reasonable emotional reactions go too far or last too long. Sensitive support and education of patients who are trying to choose a treatment method may minimize anxiety. Formal programs, such as the American Cancer Society's Reach to Recovery and Look Good... Feel Better, can be very supportive. For interested patients, support groups provide a chance to freely express their thoughts and feelings. However, not all women wish to participate in programs and groups. In some cases, careful listening on the part of the primary care physician is the most powerful intervention.

Emergent signs of cancer. Recognizing them early in the office or ER

Primary care physicians have a crucial role in recognition of potentially emergent conditions in patients with known or suspected cancer. This task presents a significant challenge because the initial manifestations of these conditions are usually nonspecific. In most cases, therapy is far more effective when diagnosis is made at the earliest possible point. Thus, physicians should become familiar with conditions commonly seen in cancer patients, such as superior vena cava syndrome, malignant pericardial effusion, spinal-epidural metastasis, and altered mentation from brain metastases, metabolic encephalopathy, or hypoglycemia.

Evaluation of common breast masses

Most breast lesions, including those that are malignant, are found by women themselves, which emphasizes the importance of breast self-examination. Comprehensive knowledge of breast anatomy and the characteristics that suggest that a mass is benign or suspicious aids primary care physicians in choosing the proper sequence of action. Drs Bland and Love discuss the common breast lesions and provide a detailed algorithm for management.

Screening and diagnostic breast imaging procedures. A look at lesions through a radiologist's eyes

Breast cancer is the most common cancer among American women, and primary care physicians can be instrumental in ensuring a timely diagnosis. Women should be taught breast self-examination by the time they are in their late teens. Patients of all ages should be encouraged to have regular physician-conducted breast examinations and mammographic screening at a high-quality center. The consistent care and individualized follow-up provided in a primary care office are vital components of the total effort toward good breast health.

Local and regional therapy for primary breast tumors. Answers to major questions

Because all primary care physicians see patients with breast cancer, it is imperative that they maintain an up-to-date working knowledge of its diagnosis and treatment. The diagnosis of breast cancer requires awareness and diligence on the part of both physician and patient, and surgical consultation is most appropriate before any invasive diagnostic procedures are done. The ultimate treatment plan evolves from consideration of tumor- and patient-related factors. Of these, the ratio of tumor size to breast size, the invasiveness and distribution of the tumor, and the individual patient's attitude and concerns are most important.