Nov 192014
 
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Do echo-enhanced needles make a difference in sonographically guided vascular access?

J Ultrasound Med. 2014 Apr;33(4):623-8

Authors: Crum T, Adhikari S, Lander L, Blaivas M

Abstract
OBJECTIVES: The purpose of this study was to compare sonographically guided vascular access using standard and echo-enhanced needles in a variety of tissue-simulating vascular phantoms.
METHODS: We conducted a prospective single-blinded observational study at an academic medical center. All participants performed real-time sonographically guided vascular access using both a standard 18-gauge needle and an echo-enhanced needle in both in-plane and out-of plane approaches on 3 different vascular access phantoms. The outcome measures included time to dye flash, first-pass success, visibility of the needle tip at the time of puncture, total number of attempts, number of redirections, and incidence of posterior wall penetration.
RESULTS: A total of 408 sonographically guided cannulations were performed by 34 participants. The time from needle stick to dye flash, first-pass success, and the total number of attempts were not significantly different between the two needles (P> .05). The tip of the needle was seen at the time of puncture in 79% of attempts with the standard needle (95% confidence interval [CI], 68%-86%) and in 86% of attempts with the echo-enhanced needle (95% CI, 76%-92%), although this difference was not significant (P= .103). The posterior wall was penetrated with the standard needle in 14% of attempts (95% CI, 9.6%-20%) and in 6% of attempts with the echo-enhanced needle (95% CI, 3.5%-11%), and the difference was significant (P < .02).
CONCLUSIONS: Echo-enhanced needles decreased the incidence of posterior wall punctures when compared to standard needles during sonographically guided vascular access. However, there were no significant differences in other sonographically guided vascular access metrics.

PMID: 24658941 [PubMed - indexed for MEDLINE]

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Nov 192014
 
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Health disparities training in residency programs in the United States.

Fam Med. 2014 Mar;46(3):186-91

Authors: Hasnain M, Massengale L, Dykens A, Figueroa E

Abstract
BACKGROUND AND OBJECTIVES: Our objective was to review and summarize extant literature on US-based graduate medical education programs to guide the development of a health disparities curriculum.
METHODS: The authors searched Medline using PubMed, Web of Science, and Embase for published literature about US-based graduate medical education programs focusing on training residents to care for underserved and vulnerable populations and to address health disparities. Articles were reviewed and selected per study eligibility criteria and summarized to answer study research questions.
RESULTS: Of 302 initially identified articles, 16 (5.4%) articles met study eligibility criteria. A majority, 15 (94%), of reported programs were from primary care; one (6.25%) was from surgery. Eight (50%) programs reported longitudinal training; seven (44%) reported block experiences, while one (6.25%) described a one-time Internet-based module. Four (25%) programs required residents to develop and complete a research project, and six (37.5%) included community-based clinical training. All 16 programs utilized some form of evaluation to assess program impacts.
CONCLUSIONS: There are few published reports of graduate medical education programs in the United States that focus on preparing residents to address health disparities. Reported programs are mostly from primary care disciplines. Programs vary in curricular elements, using a wide variety of training aims, learner competencies, learning activities, and evaluation methods. This review highlights the need for published reports of educational programs aimed at training residents in health disparities and underserved medicine to include the evidence for effectiveness of various training models.

PMID: 24652636 [PubMed - indexed for MEDLINE]

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Nov 192014
 
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Ischemic heart disease hospitalization among older people in a subtropical city--Hong Kong: does winter have a greater impact than summer?

Int J Environ Res Public Health. 2014 Apr;11(4):3845-58

Authors: Chau PH, Wong M, Woo J

Abstract
Globally, excess winter morbidity from ischemic heart disease (IHD) is reported. In subtropical regions, there is a need to quantify the difference in the adverse effect of cold winters compared with hot summers, particularly among the older people. Our objectives were to: (i) compare the effect of winter on IHD hospitalizations with that of summer; (ii) examine temporal trends in the excess winter hospitalizations; and (iii) investigate the effect of age, gender, and meteorological factors on predicting such excess. Inpatient admissions due to IHD as principal cause during June 2000 to February 2009 in public hospitals of Hong Kong were extracted for the population aged ≥65. An Excess Hospitalization in Winter vs. Summer (EHWS) Index was used to contrast the adverse effect of weather on hospitalizations in winter vs. summer. Multiple linear regressions were used to investigate the trend and the predictors of such index. It was found that in a subtropical city, greater effect of winter on IHD hospitalizations than summer was observed, particularly among the oldest old (an index of 61.5% (95% CI: 49.5%-74.4%) for men aged ≥85 and 32.3% (95% CI: 25.5%-39.5%) for women aged ≥85). There was significant increasing trend in the index among those aged ≥85 but the age difference was less prominent among the women. Absolute level of coldness was not a significant factor, whereas the change in temperature was a significant factor, which implies that great fluctuation in temperature within a winter day had greater impact on occurrence of circulatory disease than an absolute temperature threshold.

PMID: 24714058 [PubMed - indexed for MEDLINE]

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Nov 192014
 
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Early predictors of responses and clinical outcomes of corticosteroid treatment for severe ulcerative colitis.

Scand J Gastroenterol. 2014 Apr;49(4):424-33

Authors: Han W, Xu JM, Hu NZ, Mei Q, Liu MW

Abstract
BACKGROUND: Patients with severe ulcerative colitis (SUC) have a high risk of requiring colectomy or resorting to a second-line treatment. However, neither clinical outcomes nor factors predictive of poor response have been clearly established in the treatment of SUC.
OBJECTIVE: To assess prospectively the effects and predictors of corticosteroids (CS) use in clinical outcomes of SUC during 1 year of follow-up.
MATERIAL AND METHODS: Consecutive inpatients with SUC, who had been treated with intravenous CS, were enrolled. Patients were monitored by clinical, laboratory, and endoscopic examinations, and the data were recorded for 1 year. Univariate and multivariate analyses were performed at 1 week.
RESULTS: There were 22.6% (14/62) nonresponders at 7 days. Several predictors were associated with nonresponse to CS. These included Mayo Score at baseline (p = 0.007), partial Mayo Score, number of bowel movements, blood presence in stool, abdominal pain, and levels of C-reactive protein (CRP), hemoglobin (Hgb), platelet count (PLT), and erythrocyte sedimentation rate (ESR) on day 3 (p < 0.05). Multiple logistic regression analysis identified the Partial Mayo Score at day 3 as an independent predictor of outcome (p = 0.012). A total of 12 patients underwent colectomy within 1 year. The short-term response rates to intravenous cyclosporin (CsA) and infliximab (IFX) in SUC were 71.4% (5/7) and 77.8% (7/9), respectively.
CONCLUSIONS: Many patients with SUC eventually became refractory to or dependent on CS. The Mayo score and laboratory characteristics were factors useful in predicting short-term outcome of CS treatment. Secondary medical therapy can help avoid emergency surgery.

PMID: 24533622 [PubMed - indexed for MEDLINE]

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Nov 192014
 
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Clinical predictors of port infections within the first 30 days of placement.

J Vasc Interv Radiol. 2014 Mar;25(3):419-23

Authors: Bamba R, Lorenz JM, Lale AJ, Funaki BS, Zangan SM

Abstract
PURPOSE: To identify risk factors for port infections within 30 days of placement.
MATERIAL AND METHODS: A retrospective chart review of port placements from 2002-2009 was conducted. Patients who had port removals secondary to infection within the first 30 days of placement were included. This group of patients was compared with a control group of patients with ports with no evidence of infection. For every one patient with a port infection, two control subjects were chosen of the same gender and new port placement during the same month as the corresponding patient with an infected port.
RESULTS: From 2002-2009, 4,404 ports were placed. Of the 4,404 patients, 33 (0.7%) were found to have a port infection within 30 days of placement. Compared with the control group, the early infection group had a higher prevalence of leukopenia (21.2% vs 6.1%, P = .039) and thrombocytopenia (33% vs 12%, P = .0158). There was also a higher prevalence of an inpatient hospital stay during port placement and high international normalized ratio in the early infection group.
CONCLUSIONS: Low preoperative white blood cell and platelet counts were risk factors for early infection. Abnormal coagulation profiles and inpatient access of ports after placement could be additional risk factors.

PMID: 24581465 [PubMed - indexed for MEDLINE]

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Nov 192014
 
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Evaluation of dabigatran utilization and risk among hospitalized patients.

Ann Pharmacother. 2014 Mar;48(3):349-53

Authors: Sidman E, Probst LA, Darko W, Miller CD

Abstract
BACKGROUND: Few data exist to evaluate the use of dabigatran among hospitalized patients and this population that may be at increased risk for toxicity or reduced efficacy. As such, the objectives of this study were to describe the characteristics of hospitalized patients prescribed dabigatran and to compare select characteristics with patients included in the Randomized Evaluation of Long-Term Anticoagulation (RE-LY) phase III clinical trial.
METHODS: A cross-sectional study was performed at Upstate University Hospital. Select patient characteristics, including age, renal function, and drug interaction exposure, were compared with those for patients in the RE-LY trial.
RESULTS: The study included 140 patients. Mean age was 69.7 years (SD = 13.8) and 72 (51.4%) were male. The mean CHADS2 score was 2.48 as compared with 2.2 in RE-LY. Significantly more patients in our study had moderate to severe renal dysfunction (creatinine clearance [CrCl] < 50 mL/min) as compared with the RE-LY trial (27.5% vs 19.4%, P = .0207) when analyzing our study patients' worst recorded CrCl. Among the 29 patients prescribed dose-adjusted dabigatran, 3 were correctly dose adjusted, 2 were overdosed, and 26 were underdosed. At least 1 pharmacokinetic drug interaction with dabigatran occurred in 110 study patients (78.6%). Use of proton pump inhibitors was more predominant in our study population when compared with RE-LY (64.3% vs 13.9%, P < .0001).
CONCLUSIONS: Hospitalized patients exhibit multiple characteristics that place them at heightened risk for altered dabigatran drug concentrations and may have a heightened risk for clinical sequelae related to dabigatran use.

PMID: 24259660 [PubMed - indexed for MEDLINE]

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