Anne E. Sayers, MD, FHM

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Can an objective measurement of critical illness inform intensive care unit (ICU) transfer timeliness?

Background: Early intervention has shown mortality benefit in many critical illness syndromes, yet heterogeneity in timing of ICU transfer exists. Previous studies examining ICU transfer timeliness have mostly focused on subjective criteria.

Study Design: Retrospective observational cohort study.

Setting: Medical-surgical units at five hospitals including the University of Chicago and NorthShore University HealthSystem in Illinois.

Synopsis: All medical-surgical ward patients between November 2008 and January 2013 were scored using eCART, a previously validated objective scoring system, to decide when transfer was appropriate. Of those, 3,789 patients reached the predetermined threshold for critical illness. Transfers more than six hours after crossing the threshold were considered delayed. Patients with delayed transfer had a statistically significant increase in length of stay (LOS) and in-hospital mortality (33.2% versus 24.5%; P < 0.001), and the mortality increase was linear, with a 3% increase in odds for each one hour of further transfer delay (P < 0.001). The rate of change of eCART score did influence time of transfer, and the authors suggest that rapid changes were more likely to be recognized. They postulate that routine implementation of eCART or similar objective scoring may lead to earlier recognition of necessary ICU transfer and thus improve mortality and LOS, and they suggest this as a topic for future trials.

Bottom Line: Delayed ICU transfer negatively affects LOS and in-hospital mortality. Objective criteria may identify more appropriate timing of transfer. Clinical trials to investigate this are warranted.

Citation: Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation [published online ahead of print June 28, 2016]. J Hosp Med. doi:10.1002/jhm.2630.

Short Take

Intranasal Live Attenuated Influenza Vaccine Not Recommended

The Centers for Disease Control and Prevention recommends against use of the nasal spray live attenuated influenza vaccine. This is based on data showing poor effectiveness in prior years.

Citation: ACIP votes down use of LAIV for 2016-2017 flu season [press release]. CDC website.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Does increased fluid administration in patients with sepsis with intermediate lactate levels improve outcomes?

Background: The Surviving Sepsis Campaign bundle, which improves ED mortality, targets patients with hypotension or lactate levels >4 mmol/L. No similar optimal treatment strategy exists for less severe sepsis patients even though such patients are more common in hospitalized populations.

Study Design: Retrospective study of a quality improvement bundle.

Setting: 21 community-based hospitals in the Kaiser Permanente Northern California system.

Synopsis: This study evaluated implementation of a treatment bundle for 18,122 hemodynamically stable sepsis patients presenting to the ED with lactate levels between 2 and 4 mmol/L during the 12 months prior to and after bundle implementation. The bundle included antibiotic administration within three hours, repeated lactate levels within four hours, and 30 mL/kg or ≥2 L of intravenous fluids within three hours of initial lactate result. Patients with kidney disease and/or heart failure were separately evaluated because of the perceived risk of fluid administration.

Treatment after bundle implementation was associated with an adjusted hospital mortality odds ratio of 0.81 (95% CI, 0.66–0.99; P = 0.04). Significant reductions in hospital mortality were observed in patients with heart failure and/or kidney disease (P < 0.01) but not without (P > 0.4). This correlated with increased fluid administration in patients with heart failure and/or kidney disease following bundle implementation. This is not a randomized controlled study, which invites biases and confounding.

Bottom Line: Increased fluid administration improved mortality in patients with kidney disease and heart failure presenting with sepsis.

Reference: Liu V, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264-1270.

Short Take

New Framework for Learners’ Clinical Reasoning

A qualitative study involving 37 emergency medicine residents found that clinical reasoning through individual cases progresses from case framing (phase 1) to pattern recognition (phase 2), then self-monitoring (phase 3).

Citation: Adams E, Goyder C, Heneghan C, Brand L, Ajjawi R. Clinical reasoning of junior doctors in emergency medicine: a grounded theory study [published online ahead of print June 23, 2016]. Emerg Med J. doi:10.1136/emermed-2015-205650.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Is there a difference in family-rated quality of care for patients dying with different serious illnesses?

Background: End-of-life care has focused largely on cancer patients. However, other conditions lead to more deaths than cancer in the United States.

Study Design: A retrospective cross-sectional study.

Setting: 146 inpatient Veterans Affairs (VA) facilities.

Synopsis: This study included 57,753 patients who died in inpatient facilities with a diagnosis of cancer, dementia, end-stage renal disease (ESRD), cardiopulmonary failure (heart failure or chronic obstructive pulmonary disease), or frailty. Measures included palliative care consultations, do-not-resuscitate (DNR) orders, death in inpatient hospice, death in the intensive care unit (ICU), and family-reported quality of end-of-life care. Palliative care consultations were given to 73.5% of patients with cancer and 61.4% of patients with dementia, which was significantly more than patients with other diagnoses (P < .001).

Approximately one-third of patients with diagnoses other than cancer or dementia died in the ICU, which was more than double the rate among patients with cancer or dementia (P < .001). Rates of excellent quality of end-of-life care were similar for patients with cancer and dementia (59.2% and 59.3%) but lower for other conditions (P = 0.02 when compared with cancer patient). This was mediated by palliative care consultation, setting of death, and DNR status. Difficulty defining frailty and restriction to only the VA system are limitations of this study.

Bottom Line: Increasing access to palliative care, goals-of-care discussions, and preferred setting of death may improve overall quality of end-of-life care.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102. doi:10.1001/jamainternmed.2016.1200.

Clinical Question: Is there a difference in family-rated quality of care for patients dying with different serious illnesses?

Background: End-of-life care has focused largely on cancer patients. However, other conditions lead to more deaths than cancer in the United States.

Study Design: A retrospective cross-sectional study.

Setting: 146 inpatient Veterans Affairs (VA) facilities.

Synopsis: This study included 57,753 patients who died in inpatient facilities with a diagnosis of cancer, dementia, end-stage renal disease (ESRD), cardiopulmonary failure (heart failure or chronic obstructive pulmonary disease), or frailty. Measures included palliative care consultations, do-not-resuscitate (DNR) orders, death in inpatient hospice, death in the intensive care unit (ICU), and family-reported quality of end-of-life care. Palliative care consultations were given to 73.5% of patients with cancer and 61.4% of patients with dementia, which was significantly more than patients with other diagnoses (P < .001).

Approximately one-third of patients with diagnoses other than cancer or dementia died in the ICU, which was more than double the rate among patients with cancer or dementia (P < .001). Rates of excellent quality of end-of-life care were similar for patients with cancer and dementia (59.2% and 59.3%) but lower for other conditions (P = 0.02 when compared with cancer patient). This was mediated by palliative care consultation, setting of death, and DNR status. Difficulty defining frailty and restriction to only the VA system are limitations of this study.

Bottom Line: Increasing access to palliative care, goals-of-care discussions, and preferred setting of death may improve overall quality of end-of-life care.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102. doi:10.1001/jamainternmed.2016.1200.

Clinical Question: Is there a difference in family-rated quality of care for patients dying with different serious illnesses?

Background: End-of-life care has focused largely on cancer patients. However, other conditions lead to more deaths than cancer in the United States.

Study Design: A retrospective cross-sectional study.

Setting: 146 inpatient Veterans Affairs (VA) facilities.

Synopsis: This study included 57,753 patients who died in inpatient facilities with a diagnosis of cancer, dementia, end-stage renal disease (ESRD), cardiopulmonary failure (heart failure or chronic obstructive pulmonary disease), or frailty. Measures included palliative care consultations, do-not-resuscitate (DNR) orders, death in inpatient hospice, death in the intensive care unit (ICU), and family-reported quality of end-of-life care. Palliative care consultations were given to 73.5% of patients with cancer and 61.4% of patients with dementia, which was significantly more than patients with other diagnoses (P < .001).

Approximately one-third of patients with diagnoses other than cancer or dementia died in the ICU, which was more than double the rate among patients with cancer or dementia (P < .001). Rates of excellent quality of end-of-life care were similar for patients with cancer and dementia (59.2% and 59.3%) but lower for other conditions (P = 0.02 when compared with cancer patient). This was mediated by palliative care consultation, setting of death, and DNR status. Difficulty defining frailty and restriction to only the VA system are limitations of this study.

Bottom Line: Increasing access to palliative care, goals-of-care discussions, and preferred setting of death may improve overall quality of end-of-life care.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102. doi:10.1001/jamainternmed.2016.1200.

Clinical Question: What are current recommendations for diagnosis, management, and prevention of acute gastrointestinal infection in immune-competent adults?

Background: Acute diarrheal infection is a leading cause of healthcare visits and lost quality of life. The Centers for Disease Control and Prevention estimates there are 47.8 million cases annually, with a healthcare economy burden of $150 million.

Study Design: American College of Gastroenterology (ACG) practice guideline.

Setting: Expert panel.

Synopsis: Stool diagnostic studies may be used for dysentery with moderate-severe disease and symptoms lasting more than seven days (strong recommendation, low level of evidence). Traditional diagnostic methods in most cases fail to reveal etiology (strong recommendation, low level of evidence). Treatment with probiotics or prebiotics is not recommended (strong recommendation, moderate level of evidence). Bismuth subsalicylates may be considered for prophylaxis against traveler’s diarrhea (strong recommendation, high level of evidence). Short-term antibiotic chemoprophylaxis also may be considered for high-risk groups (strong recommendation, high level of evidence). Empiric antimicrobial therapy is not recommended except in cases of traveler’s diarrhea (strong recommendation, high level of evidence). Loperamide may be used as an adjunct to antibiotics for traveler’s diarrhea (strong recommendation, moderate level of evidence).

Bottom Line: ACG acute diarrheal illness guidelines have been updated. Few recommendations are strong, and very few have high levels of evidence.

Citation: Riddle MS, DuPont HL, Conner BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622.

Clinical Question: What are current recommendations for diagnosis, management, and prevention of acute gastrointestinal infection in immune-competent adults?

Background: Acute diarrheal infection is a leading cause of healthcare visits and lost quality of life. The Centers for Disease Control and Prevention estimates there are 47.8 million cases annually, with a healthcare economy burden of $150 million.

Study Design: American College of Gastroenterology (ACG) practice guideline.

Setting: Expert panel.

Synopsis: Stool diagnostic studies may be used for dysentery with moderate-severe disease and symptoms lasting more than seven days (strong recommendation, low level of evidence). Traditional diagnostic methods in most cases fail to reveal etiology (strong recommendation, low level of evidence). Treatment with probiotics or prebiotics is not recommended (strong recommendation, moderate level of evidence). Bismuth subsalicylates may be considered for prophylaxis against traveler’s diarrhea (strong recommendation, high level of evidence). Short-term antibiotic chemoprophylaxis also may be considered for high-risk groups (strong recommendation, high level of evidence). Empiric antimicrobial therapy is not recommended except in cases of traveler’s diarrhea (strong recommendation, high level of evidence). Loperamide may be used as an adjunct to antibiotics for traveler’s diarrhea (strong recommendation, moderate level of evidence).

Bottom Line: ACG acute diarrheal illness guidelines have been updated. Few recommendations are strong, and very few have high levels of evidence.

Citation: Riddle MS, DuPont HL, Conner BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622.

Clinical Question: What are current recommendations for diagnosis, management, and prevention of acute gastrointestinal infection in immune-competent adults?

Background: Acute diarrheal infection is a leading cause of healthcare visits and lost quality of life. The Centers for Disease Control and Prevention estimates there are 47.8 million cases annually, with a healthcare economy burden of $150 million.

Study Design: American College of Gastroenterology (ACG) practice guideline.

Setting: Expert panel.

Synopsis: Stool diagnostic studies may be used for dysentery with moderate-severe disease and symptoms lasting more than seven days (strong recommendation, low level of evidence). Traditional diagnostic methods in most cases fail to reveal etiology (strong recommendation, low level of evidence). Treatment with probiotics or prebiotics is not recommended (strong recommendation, moderate level of evidence). Bismuth subsalicylates may be considered for prophylaxis against traveler’s diarrhea (strong recommendation, high level of evidence). Short-term antibiotic chemoprophylaxis also may be considered for high-risk groups (strong recommendation, high level of evidence). Empiric antimicrobial therapy is not recommended except in cases of traveler’s diarrhea (strong recommendation, high level of evidence). Loperamide may be used as an adjunct to antibiotics for traveler’s diarrhea (strong recommendation, moderate level of evidence).

Bottom Line: ACG acute diarrheal illness guidelines have been updated. Few recommendations are strong, and very few have high levels of evidence.

Citation: Riddle MS, DuPont HL, Conner BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.