 |
|
In This Issue of Archives of Internal Medicine
Arch Intern Med. 2002;162:1215.
Efficacy of a Nicotine Lozenge for Smoking Cessation
This article introduces a new form of nicotine replacement therapy,
a nicotine lozenge, and documents the safety and efficacy. The lozenge comes
in 2 doses: 2 mg and 4 mg of nicotine for low- and high-dependence smokers,
respectively. In a randomized, placebo-controlled clinical trial with 1818
smokers, the lozenge was highly effective in both low (odds ratio, 2.1) and
high-dependence (odds ratio, 3.7) smokers. Efficacy was maintained for 1 year.
Patients who used more lozenges experienced stronger treatment effects. Adverse
effects were mostly minor and local. The nicotine lozenge is a safe and effective
new treatment for smoking cessation.
(SEE ARTICLE)
Reducing Legal Risk by Practicing Patient-Centered Medicine
Although the fear of legal action against physicians is based in the
reality of today's practice of medicine, practicing defensive medicine places
physicians at greater risk for being sued. Actual negligence appears not to
predict whether a physician will be sued. Rather, the defensive behaviors
that physicians and others tend to see as protective may pose the greatest
legal risk. What protects physicians from legal liability is practicing patient-centered
medicine—the kind that calls for regular and straightforward communication
with patients and families, attention to patients' emotional and psychological
needs, and thoughtful justification for, and clear documentation of, medical
recommendations.
(SEE ARTICLE)
Clinician-Patient Interactions About Requests for Physician-Assisted
Suicide: A Patient and Family View
Back et al report a qualitative study on patients' and family members'
interactions with clinicians regarding requests for physician-assisted suicide
(PAS). The authors identify 3 themes that describe qualities of clinician-patient
interactions about PAS that patients and family members valued. These themes
included (1) an openness to discussion about PAS, (2) expertise in dealing
with the dying process, and (3) maintenance of a therapeutic patient-clinician
relationship, even when the patient and clinician disagree about PAS. Responding
to a patient request for PAS is an important and complex clinical skill. The
article by Back et al provides results from a unique data set and suggests
a set of guidelines that clinicians might use when responding to patient requests
for PAS or when teaching communication skills relevant to end-of-life care.
(SEE ARTICLE)
Instability on Hospital Discharge and the Risk of Adverse Outcomes
in Patients With Pneumonia
This multicenter, prospective cohort study defined and validated a simple,
clinically usable measure of clinical stability on hospital discharge for
patients with community-acquired pneumonia. Unstable factors in the 24 hours
prior to discharge were defined as temperature greater than 37.8°C (100°F),
heart rate greater than 100/min, respiratory rate greater than 24/min, systolic
blood pressure lower than 90 mm Hg, oxygen saturation lower than 90%, inability
to maintain oral intake, and abnormal mental status. Among the 680 patients,
19.1% left the hospital with 1 or more instabilities on discharge. By 30 days,
10.5% of patients with no instabilities on discharge died or were readmitted
compared with 13.7% of those with 1 instability and 46.2% of those with 2
or more instabilities (P<.003). Instability on
discharge (defined as  1 unstable factor) was associated with higher risk-adjusted
rates of death or readmission (odds ratio, l.6; 95% confidence interval, 1.0-2.8)
and failure to return to usual activities (odds ratio, l.5; 95% confidence
interval, 1.0-2.4). Patients with 2 or more unstable factors on discharge
had dramatically increased risk-adjusted rates of death or readmission (odds
ratio, 5.4; 95% confidence interval, 1.6-18.4).
|
|
Number of instabilities on discharge and rates of 30-day adverse
outcomes. Not RTUA indicates not returned to usual activities within 30 days
of discharge.
|
(SEE ARTICLE)
|
