Annals of Internal Medicine tip sheet for Oct. 21, 2014

October 20, 2014

1. Three-minute in-office test accurately diagnoses delirium

An abbreviated version of the Confusion Assessment Method, or CAM, test is highly sensitive and specific for diagnosing delirium, according to a study being published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/M14-0865). Delirium is common in hospitalized older patients but it often goes undiagnosed. Widely used since the 1990s, the CAM test is regarded as an accurate assessment tool for delirium. However, the CAM is challenging to use in clinical settings because it requires cognitive assessment and significant training for the interviewer. Seeking to develop a shorter method of diagnosing delirium using the CAM algorithm, researchers developed the 3D-CAM, a short, structured diagnostic assessment that can be administered by health care staff with minimal training. Psychologists and advanced practice nurses conducted a face-to-face standard assessment for delirium in 201 patients, taking approximately 1.5 hours to complete. A 3D-CAM assessment was also completed for each participant, and a second 3D-CAM assessment was done in half of the participants chosen at random. Compared with the reference standard for diagnosis delirium, the 3D-CAM was 96 percent sensitive and 98 percent specific. The authors concluded that 3D-CAM is quick to complete, highly reproducible and a valid tool for diagnosising delirium.

Note: The URL for this story will be live at 5:00 p.m. on October 20 and can be used in news stories. For a PDF, please contact Megan Hanks. To interview the lead author, please contact Bonnie Prescott at 617-667-7306 or bprescot@bidmc.harvard.edu.




2. Physicians often unaware when patients' catheters are left in place

Clinicians at all levels of training and specialties frequently did not know which of their patients currently had central venous catheters, or CVCs, according to an article being published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/M14-0703). CVCs are inserted in both intensive care unit patients and non-intensive care unit patients to provide reliable venous access for tasks such as laboratory monitoring and delivering medications. The two most commonly used CVCs are nontunneled triple-lumen catheters placed in the neck or femoral veins and peripherally inserted central catheters (PICCs) inserted in the arm. CVCs that are no longer needed should be promptly removed to avoid potential complications, such as bloodstream infections and blood clots, but evidence suggests that CVCs often remain in place longer than they are necessary. Researchers sought to determine how often clinicians were aware of the presence of triple-lumen or PICCs in hospitalized patients. They evaluated 990 patients to ascertain the presence of CVCs and then surveyed clinicians to determine their knowledge of the patients' CVC status. They found that clinicians at all levels of training and specialties frequently did not know which patients had CVCs. Hospitalists and teaching attendings were less likely to be aware of CVCs in place. The authors suggest that these findings have significant patient safety and policy implications and recommend policies and procedures to oversee the visibility of CVCs, especially in non-intensive care unit settings.

Note: The URL for this story will be live at 5:00 p.m. on October 20 and can be used in news stories. For a PDF, please contact Megan Hanks. To interview the lead author, please contact Beata Mostafavi at 734-764-2220 or bmostafa@med.umich.edu.




3. Knowing individual risk does not increase cancer screening rates

Knowing their individual risk for disease is not enough to pursuade previously nonadherent patients to undergo recommended colorectal cancer (CRC) screenings, according to a randomized, controlled trial being published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/M14-0765). CRC is the second leading cause of cancer death in the United States. Increasing screening rates is imperative because screening can reduce disease incidence and mortality. Researchers hypothesized that providing average-risk patients with a personalized genetic and environmental risk assessment (GERA) would increase CRC screening uptake compared with usual care. About 780 participants at average risk for CRC who were not adherent to screening at the time of the study were randomly assigned to usual care or GERA. Based on specific combinations of genetic and environmental risks, GERA participants were informed whether they were at elevated or average risk for CRC. After 6 months, there was no significant difference in screening uptake between the two groups. The researchers suggest that their findings debunk a common claim in the media that enhanced knowledge of individual genetic makeup will promote healthier behaviors.

Note: The URL for this story will be live at 5:00 p.m. on October 20 and can be used in news stories. For a PDF, please contact Megan Hanks. To interview the lead author, please contact Diana Quattrone at 215-728-7784 or Diana.Quattrone@fccc.edu.




4. Many common symptoms unrelated to disease

At least a third of common symptoms have no clear-cut, disease-related explanation, according to a review being published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/M14-0461). This fact challenges the disease-focused model of care typically followed in clinical practice. The author writes that clinician training focuses relatively little time preparing physcians to understand, evaluate, and manage common symptoms, which account for more than half of all outpatient visits. Commonly, the initial approach to symptoms starts with the goal of identifying a precise cause and a targeted treatment. The author conducted a narrative review of common physical symptoms (excluding upper respiratory symptoms, which are self-limiting and less diagnostically challenging) to answer four common epidemiologic questions about clinical condition: cause, diagnosis, prognosis, and therapy. Nine important findings of the review may help to redefine the clinical approach to symptom-prompted office visits.

Note: The URL for this story will be live at 5:00 p.m. on October 20 and can be used in news stories. For a PDF, please contact Megan Hanks. To interview the lead author, please contact Cindy Fox Aisen at 317-843-2276 or caisen@iupui.edu.
-end-


American College of Physicians

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