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Clinically valid cardiac evaluation via treadmill stress testing requires patients to achieve specific target heart rates and to successfully complete the cardiac examination. Methods; A comparison of the standard Bruce protocol and the ramped Bruce protocol was performed using data collected over a 1-y period from a targeted patient population with a body mass index (BMI) equal to or greater than 30 to determine which treadmill protocol provided more successful examination results. Results; The functional capacity, metabolic equivalent units achieved, pressure rate product, and total time on the treadmill as measured for the obese patients were clinically valid and comparable to normal-weight and overweight patients (P < 0.001). Data gathered from each protocol demonstrated that the usage of the ramped Bruce protocol achieved more consistent results in comparison across all BMI groups in achieving 80%-85% of their age-predicted maximum heart rate. Conclusion: This study did not adequately establish that the ramped Bruce protocol was superior to the standard Bruce protocol for the examination of patients with a BMI equal to or greater than 30. [ABSTRACT FROM AUTHOR]

Organizations that would like to evaluate the effectiveness of different therapy methods are often forced to use existing outcomes measures and to match subjects that received one form of treatment compared to another. This study of adolescents compared two different forms of treatment used in two different states. One state used Dialectical Behavior Therapy (DBT), and the other used Standard Therapeutic Milieu (STM). Data were abstracted from the hospital system and adolescents were matched on age, gender, and primary Axis I diagnosis, yielding a primary "perfect" match sample (n = 14), and a secondary match sample (n = 24) where the secondary Axis I diagnosis was used. Outcomes were measured by the BPRS-C, which is the standard outcome measure used by KidsPeace Lee Salk Center for Research. Results indicated that DBT was clinically and statistically more effective than STM for the Depression subscale of the BPRS-C. In addition, Organicity symptoms were eliminated by DBT treatment. STM demonstrated greater efficacy on the Psychomotor Excitation subscale, but the power of the statistical model was low. [ABSTRACT FROM AUTHOR]

Peripheral intravenous catheter (PIVC) postinsertion failure rates are unacceptable. Ultrasonography is an adjunctive tool that may improve PIVC utilization success. Determine if ultrasonographically guided (USG) PIVCs placed in the emergency department (ED) significantly decreases postinsertion failure rate, increases utility time, and decreases postremoval complication rate. Determine if catheter-to-vein ratio (CVR) predicts postinsertion failure. Participants were randomized to either standard or USG cohort. Data collection included participant and PIVC characteristics, vein measurements, postinsertion failure, and postremoval complication. Chi-square analysis compared postinsertion failure rates. Group t -test compared utility times. Postremoval complication rates were compared with standard rate analysis. The receiver operating characteristic curve was calculated to determine if CVR could predict postinsertion failure. An enrollment of 582 was estimated. A total of 223 patients were enrolled, with 222 PIVCs investigated. Standard cohort included 116 PIVCs and USG cohort included 106 PIVCs. A total of 212 vein diameters were analyzed. USG PIVC insertion did not result in fewer postinsertion failures (p = 0.654) or longer utility time (p = 0.808). Postremoval complications were not significantly lower (p = 0.414). Receiver operating characteristic curve showed a cut-off CVR of ∼ 0.21. Area under the curve was 0.621 (p = 0.063, 95% confidence interval 0.508–0.734). The USG technique did not decrease postinsertion failure rate, increase utility time, or significantly decrease postremoval complication rate. A CVR predictive of postinsertion failure could not be determined. [ABSTRACT FROM AUTHOR]

In this meta-analysis, the authors examine published studies on the consistency (homogeneity) of study outcomes of magnetic resonance angiography (MRA), conventional angiography (XRA), and duplex ultrasound (DU) scanning in assessment of the degree of carotid artery disease.The sensitivity, specificity, and accuracy of the MRA as a noninvasive diagnostic test are exceptional. Given an adequate two-dimensional time-of-flight (2D-TOF) study, it provides a robust test for the evaluation of carotid stenosis. The authors conclude from this meta-analysis that MRA is at least as accurate as DU in a selected group of patients. The question of superiority for all patients with suspected carotid artery disease is not, however, answered by this meta-analysis. Another question not answered is the question of DU/MRA-XRA concordance/discordance. If DU and MRA were concordant across all, rather than a selected group of patients, would the clinical decision tree be in favor of elimination of XRA? The cost for a DU scan is approximately one third of the cost of an MRA and, from an economic point of view, one could not argue the use of MRA over DU. However, as MRA technology and accuracy improve and when the cost of MRA approaches that of DU, MRA may replace DU as a screening method.Clearly, a consecutive series of all patients suspected of having carotid artery disease needs to be evaluated by use of the best available diagnostic technologies. A comprehensive protocol would include an evaluation of the sources of difficulties in conducting these tests. [ABSTRACT FROM PUBLISHER]

Inpatient oncology care is expensive and often characterized by discontinuity and fragmentation of services. In 2003 a proposal was funded to improve the care of hospitalized heme/onc patients at this major community teaching hospital. The Integrated Oncology Care (IOC) initiative supported a nurse practitioner ("NP") to develop, pilot, and implement a collaborative practice model with Oncology and Hematology attending physicians. The purpose of the project was to reduce costs, LOS (length of stay), and practice variation, as well as to increase patient and provider satisfaction through the interventions of an NP. With the IOC steering committee, the NP identified need for and developed symptom management protocols, rounded daily with oncology attendings to provide continuity of care, held daily nursing rounds with staff, entered orders, provided "hospitalist" support to staff and patients for medical emergencies and other issues when attendings were not on the unit, and provided patient and family communication on medical, symptom management and supportive issues. For six months after project initiation, the NP observed and developed the practice model and a plan for piloting the intervention. Pilot intervention took place over 6 months with both oncology practices. After evaluation of the pilot, the NP worked only with one of the oncology practices for an additional 6 months. Data was collected for a variety of outcomes including total costs (TC), variable costs (VC) and LOS. Although TC decreased over baseline during the intervention period, it was not statistically significant. However VC were reduced by over $1300/ case for both oncology practices: p<0.032 in one group and p<0.059 on the other. The LOS in the group with the NP intervention at the second six month time point was significantly less (p<0.037) than the "control" group. Decrease practice variation was seen in reduction in standard deviation in all measures. The clinical expertise of an oncology NP can make a significant contribution to inpatient care to patients, staff, and the institution through provision of continuity of care and expert clinical judgment. At a time when hospital costs are rising, the contributions that can be made by NPs can be well worth their salary. [ABSTRACT FROM AUTHOR]

Introduction: Nerve conduction study (NCS) and electromyography (EMG) are electrodiagnostic studies that are highly tolerated by patients despite their nature of causing pain and discomfort. However, few studies have focused on the true tolerability of these procedures in patients. This study aimed to determine the true tolerance rate of NCS and EMG in patient populations and the factors that might be associated with them., Methods: Participants scheduled for electrodiagnostic studies were prospectively recruited between March 2023 and September 2023. After completion of the study, the physicians completed a questionnaire on each patient's tolerance of the studies., Results: Of the 103 patients enrolled in the study, 98 were able to tolerate both tests, and 5 patients were intolerant to 1 or both tests. The overall tolerance rate of NCS and EMG was 95.1% (0.951, 95% CI 0.897 to 0.981). Age, sex, ethnicity, the type of NCS performed and the type of EMG performed were not associated with NCS or EMG intolerance., Conclusion: Most patients tolerated the NCS and EMG; however, a small percentage of patients were intolerant. Clinicians should recognise the intolerance of certain patients when introducing and performing electrodiagnostic tests., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population., Objective: To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility., Design: Retrospective cohort study., Setting: An acute rehabilitation hospital associated with a community-based tertiary medical center., Patients: A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022., Main Outcome Measure: The study outcome measure was readmission to acute care from an acute rehabilitation unit., Results: Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006)., Conclusions: This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Objectives: Remitting seronegative symmetrical synovitis with pitting oedema (RS(3)PE) syndrome is a rare inflammatory arthritis, characterised by symmetrical distal synovitis, pitting oedema of the hands and feet, absence of rheumatoid factor, and favourable response to glucocorticoids. The aim of our study is to further delineate the clinical and laboratory features, and response to treatment., Methods: We performed a systematic electronic search of Medline, PubMed, EMBASE, ACR and EULAR databases for case reports, case series, and related articles of RS(3)PE. Statistical analysis was done comparing categorical variables with Chi-square tests and frequencies of means via t-tests. Binary logistic regression analysis was performed to identify predictors of erosions, recurrence, malignancy and rheumatologic disorders., Results: 331 cases of RS(3)PE were identified from 121 articles. RS(3)PE was found in older patients (71±10.42 years) predominantly in males (n= 211, 63.36%), was symmetrical (n=297/311, 95.50%) involved the hands (n=294/311, 94.53%) A concurrent rheumatologic condition was reported in 22 cases (6.65%), and malignancy in 54 cases (16.31%). Radiographic joint erosions were found in 5.5%. Most patients responded to medium-dose glucocorticoids (16.12±9.5 mg/day). Patients with concurrent malignancy requiring non-significantly higher doses of prednisone (18.12 vs. 15.76 mg, p 0.304) and higher likelihood of recurrence of disease (OR 4.04, 95% CI 1.10-14.88, p=0.03)., Conclusions: The symptoms and unique findings that make up RS(3)PE appear to represent a steroid-responsive disease that may be a harbinger of an underlying malignancy. More study is needed to understand the molecular origins of RS(3)PE in order to determine whether it is a separate disease process. Patients with concurrent cancer tend to have more severe presentations and higher rates of recurrence.

Objective: Previous research reports higher rates of depression in Hispanic women than Caucasian or African American women. The effectiveness and tolerability of paroxetine CR (controlled release) was examined in women of Hispanic heritage with depression or anxiety., Methods: Thirty-six Hispanic female patients 18 years or older meeting DSM-IV criteria for major depression or generalized anxiety disorder diagnosis with an initial Hamilton Depression Rating scale (17 item) Ž20 or Hamilton Anxiety Rating scale Ž18 measuring no less than 4 on the Clinical Global Impression Severity scale received paroxetine CR (12.5-50mg/day) for 29 weeks of open label treatment. Analysis was conducted using repeated measures methodology., Results: Significant symptom reduction was observed on all scales. Mean dose was 31.7mg. The side effect of sexual dysfunction (17%) appeared most frequently but did not cause any patients to cease study participation., Conclusions: Paroxetine CR was an effective and generally well tolerated treatment in this population.