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Showing posts from May, 2010

GeriPal Housekeeping – Feeds, Comments, and Suggestions

It has almost been a year since our first post here on GeriPal. Since this first post we have had 56,341 pageviews and 29,087 visits from over 106 countries, in addition to the 600 people that regularly subscribe to our feed.  Our community is growing stronger everyday and our goal is to make the site grow with it.  Here are a couple of important changes that you should know about:

1.  Email subscriptions: we will be changing the email address that our blog uses to send out our posts. Starting on Friday night it will change to feeds@geripal.org. If you stop getting our emails please check your spam filters (Let me know if you still don’t get them by emailing me at eric.widera@ucsf.edu).
2.  Comments: Our Year 2 goal is to increase the amount of comments for each post. Comments are the heart of this blog – serving as the main way we can learn from each other. To comment on GeriPal please go to the bottom on the post in the GeriPal website and click the "Post a Comment" link. …

PROGNOSIS

Clinicians should routinely incorporate prognosis into clinical decision making for older adults. Alex Smith, Sei Lee, and I are seeking your insights to help inform a web-based prognostic calculator and systematic review for prognosis in older adults. We thank you in advance for any feedback on either of the following two questions!:

1) systematic review: what prognostic indices do you use for your patients, or have you read about? There is no Medical Subject Heading (Mesh in PubMed) for Prognostic Model. I am now soliciting Geripal advice to supplement our exhaustive literature search. We are especially interested in prognostic indices that use a multivariate algorithm to predict life expectancy via a risk score, but if in doubt, please still send your suggestion.

2) prognostic calculator: any opinions on a catchy and simple name for a website that contains a prognosis calculator for older adults? This calculator would utilize the prognostic indices we identify in the systematic revie…

May’s Health Affairs, A Case of Medical Homelessness, and Reinventing Primary Care

May 4th’s Health Affairs contains a lot of food for thought for Geriatricians and Palliative Care providers thinking about the future of medicine and health care reform.

“A Case of Medical Homelessness” by Dr. Jack M. Colwill (full disclosure, my former chair) sounds like a typical case for any palliative care provider. A patient with advanced emphysema, John--the brother-in-law of the author, doesn’t respond to therapies and becomes progressively weaker, with dyspnea and anxiety. Visits to primary care, a pulmonologist, an interventionalist to drain an effusion do not relieve his symptoms. Then, despite dramatic decline over the next half year, John undergoes surgery for his hand just two months before his death and has a complete set of dentures made (that continue to require payments after his death.) In all 11 doctors were seen, and yet the family felt abandoned. It took a visit from the author/brother-in-law/MD to finally address the issue of advanced directives and prognosis and…

Rethinking Prisoner Release Policies from a Geriatrics Perspective

Tina Chiu of the VERA Institute of Criminal Justice recently wrote a report It’s About Time: Aging Prisoners, Increasing Costs, and Geriatric Release on the status of geriatric and end-of-life prisoner release policies in the U.S. There's a strange contradiction: despite the existence of geriatric early-release laws in several states, few older prisoners are actually being released early. We were asked to contribute a response from the medical perspective. From a geriatrics point of view, the lack of functional assessment seems like a gaping hole in current prisoner release policies.
Cross-posted to the VERA Current Thinking Blog

We agree with Tina Chiu that current geriatric prisoner release policies need to be reexamined and reworked. What’s needed is a new set of guidelines that criminal justice systems can use proactively to identify older individuals who are appropriate for early release. In order to consider the competing agendas of cost, safety, and justice, an interdisciplin…

The Opposite of Love

The Emergency Department phoned my office right before lunch. I was on call for our general IM group, so when I was done with my morning schedule I walked across the street to the hospital. Greg, my partner's 38 year old patient, was a woodworker admitted with fever, chills, cough, a sharp pain in his right side, and a WBC of 18,000. On the chest x-ray, I saw what I expected: a right middle lobe infiltrate. What I didn't expect were the massive lymph nodes bulging between his lungs, pushing them outward into his chest wall.

"Has anyone mentioned lymphoma to you?" I asked Greg. His face was gaunt, the pallor of his cheeks contrasting with his red flannel shirt.

"Yeah, I’m pretty familiar with lymphoma," he said. "I’ve had all the radiation therapy my chest can take. My oncologist just told me we need to start on another chemotherapy regimen. This’ll be my third. The first two didn't shrink the tumors."

"OK," I said. "Are you read…

Nurses are the best!

“No man, not even a doctor, ever gives any other definition of what a nurse should be than this -- 'devoted and obedient.' This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.”

-Florence Nightingale, 1859

This is Nurses’ Week (May 6-12) and the celebration of Florence Nightingale’s birthday. Please take a moment to celebrate the nurses in your life. Florence Nightingale was the first to publicly decry the sorry reputation of nurses - as in the quote - but nurses remain vastly underappreciated for the work they do. Let’s take a moment to consider how nurses contribute to the interdisciplinary teams in the nursing home, the hospital, the hospice, and the clinic.

I think we’ve underappreciated the role of nurses as teachers. I must give thanks first to the nurses who have taught me and continue to teach me. As a physician-in-training and now as a junior attending, nurses have taught me at least as much about clinical …

NEED YOUR EXPERTISE

Geripal experts:
If you have to share ONE TIP with your fellow Geriatricians and Gerontologists about palliative care of older adults, what would it be?
The American Academy of Hospice and Palliative Medicine is co-sponsoring a pre-conference work shop with the American Geriatrics Society during the AGS annual meeting May 12-15th 2010.
Please share your favorite geripal tip and we will compile it and share it during the workshop with all the attendees.

Should Medical Societies Boycott Arizona?

Roughly 150 members gathered last week at a Town Hall meeting at last week's annual meeting of the Society of General Internal Medicine (SGIM). This meeting was put together by the SGIM Council to discuss member's opinions about holding the 2011 annual meeting in Phoenix, Arizona, in the light of the new immigration legislation recently passed by the state.

Arizona's new immigration law, SB-1070, dominated news headlines for about two weeks straight, at least up until the growing disaster with the Deepwater Horizon. SB-1070, the nation’s most stringent state-mandated immigration measure, was approved by the Arizona State legislature and signed by the Governor Jan Brewer. It is aimed at curbing undocumented immigrants from living and working in Arizona. The law makes the failure to carry immigration documents a crime and gives police broad power to detain anyone suspected of being in the country illegally. Proponents call it a necessary response to a growing crisis. Oppon…

Substance Use Disorders in Older Adults

It is commonly thought that older adults are not the usual suspects when it comes to substance abuse disorders. But what do we really know about how common substance abuse is in the elderly? Is this really a problem? Should we do more to screen for substance abuse? Dan Blazer helped answer some of these questions at the UCSF Division of Geriatrics Grand Rounds when he described his some of his most recent work looking at substance use in the elderly.

Dr. Blazer and his colleague at Duke, Li-Tzy Wu, worked with data from the public use files of the 2005 and 2006 National Survey on Drug Use and Health (NSDUH), a nationally representative annual survey of noninstitutionalized civilians aged 12 years or older. They restricted their analyses to the 10,953 survey subjects age 50 years and older, and further split them into two groups that included 6,717 subjects age 50–64 years and 4,236 subjects age 65+ years.

What they found was the following:
Illegal substance use was very low (2.6% m…

"Demented Patients": A terminology rant

I would love the input of GeriPal readers on an issue. The commonly used phrases, "demented patient," or "demented person," or "the demented" have long made me feel uneasy. I am much more comfortable with phrasing such as "patient with dementia." My question: Am I allowing myself to be consumed by semantics? Or am I onto something here?

I can not fully articulate why "demented patient" bothers me---in part because the reaction may be more emotional, and perhaps because I am not facile enough with language to understand how subtle changes in wording impact the emotional response to how we speak. But here is my best effort:

Perhaps it is because when "demented" is used as an adjective or noun, there is a suggestion that dementia has become a fundamental part of someone's personhood or identity. Also, "demented" as a term may carry historic baggage. Historically, "demented" has had a broader and more pejo…

Advance directives say “I’m not dead yet”

“Enough. The living will has failed, and it is time to say so.” So said Angela Fagerlin and Carl Schneider in 2004. “Living wills are still widely and confidently urged on patients, and they retain the allegiance of many. For these loyal advocates, we offer systematic proof that such persistence in error is but the triumph of dogma over inquiry and hope over experience.” Joann Lynn wrote an essay titled Why I Don’t Have a Living Will, saying, “I do not have a living will because I fear that the effects of having one would be worse, in my situation, than not having one. How could this be? A living will of the standard format attends to priorities that are not my own, addresses procedures rather than outcomes, and requires substantial interpretation without guaranteeing a reliable interpreter.” Thomas Pendergast said, “[Since the passage of the Patient Self Determination Act in 1990] advance directives are recorded by medical personnel more often but are not completed by patients more f…