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Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: a review.

Clin Ther. 2009 Jun;31(6):1129-41

Authors: Huo MH, Muntz J

BACKGROUND: Prophylaxis against venous thromboembolism (VTE) is routinely administered during the hospital stay in at-risk surgical and medical patients. However, in high-risk groups, the risk of deep-vein thrombosis or pulmonary embolism may persist for several weeks after discharge. The standard duration of thromboprophylaxis (6-14 days) may not provide adequate protection against such events. OBJECTIVE: This article reviews published data on the efficacy and safety profile of extended-duration thromboprophylaxis in patients at high risk for VTE, the potential cost-effectiveness of such treatment, and practical aspects of ensuring an effective transition from the inpatient to the outpatient setting. METHODS: MEDLINE and the Cochrane Database of Systematic Reviews were searched through January 2009 for relevant English-language reports of clinical trials, abstracts, and case reports. The search terms included, but were not limited to, venous thromboembolism, pulmonary embolism, anticoagulation, thromboprophylaxis, prolonged duration, and extended duration. The reference lists of the identified articles were reviewed for additional relevant publications. Congress Web sites were also consulted. The principal criteria for inclusion of a study were that it have a prospective, randomized design and include a control group. Case series and retrospective analyses were excluded. RESULTS: Studies have found that extended-duration thromboprophylaxis (28-45 days) with low-molecular-weight heparins (LMWHs) can reduce the risk of VTE in high-risk patients. In separate meta-analyses, extended-duration thromboprophylaxis with LMWH was associated with significant reductions in the likelihood of symptomatic VTE compared with standard-duration thromboprophylaxis in patients undergoing major orthopedic surgery (odds ratio [OR] = 0.38; 95% CI, 0.24-0.61) or major abdominal or pelvic surgery (Peto OR = 0.22; 95% CI, 0.06-0.80). There was large heterogeneity in the reported rates of major and minor bleeding. The occurrence of clinically relevant bleeding events was generally low (<1%), particularly during extended prophylaxis. Extended-duration thromboprophylaxis was cost-effective compared with standard-duration thromboprophylaxis, with increased pharmacy costs offset by reductions in VTE and the associated costs of hospitalization. CONCLUSIONS: In high-risk surgical and medical patients, the risk of VTE may extend beyond the period of hospitalization. Such patients may benefit from extended-duration thromboprophylaxis to reduce the risk of late VTE events. LMWHs were efficacious, were associated with low rates of clinically relevant bleeding complications, and were cost-effective in patients at high risk for VTE.

PMID: 19695383 [PubMed - indexed for MEDLINE]

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Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients: Guidelines of the infectious diseases working party of the German Society of Haematology and Oncology.

Eur J Cancer. 2009 Sep;45(14):2462-72

Authors: Maschmeyer G, Beinert T, Buchheidt D, Cornely OA, Einsele H, Heinz W, Heussel CP, Kahl C, Kiehl M, Lorenz J, Hof H, Mattiuzzi G

Patients with neutropenia lasting for more than 10d, who develop fever and pulmonary infiltrates, are at risk of treatment failure under conventional broad-spectrum antibacterial therapy. Filamentous fungi are predominant causes of failure, however, multi-resistant gram-negative rods such as Pseudomonas aeruginosa or Stenotrophomonas maltophilia may be involved. Prompt addition of mould-active systemic antifungal therapy, facilitated by early thoracic computed tomography, improves clinical outcome. Non-culture-based diagnostic procedures to detect circulating antigens such as galactomannan or 1,3-beta-d-glucan, or PCR techniques to amplify circulating fungal DNA from blood, bronchoalveolar lavage or tissue specimens, may facilitate the diagnosis of invasive pulmonary aspergillosis. CT-guided bronchoalveolar lavage is useful in order to identify causative microorganisms such as multidrug-resistant bacteria, filamentous fungi or Pneumocystis jiroveci. For pre-emptive antifungal treatment, voriconazole or liposomal amphotericin B is preferred. In patients given broad-spectrum azoles for antifungal prophylaxis, non-azole antifungals or antifungal combinations might become first choice in this setting. Antifungal treatment should be continued for at least 14 d before non-response and treatment modification are considered. Microbial isolates from blood cultures, bronchoalveolar lavage or respiratory secretions must be critically interpreted with respect to their aetiological relevance for pulmonary infiltrates.

PMID: 19467584 [PubMed - indexed for MEDLINE]

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Social science insights into improving workforce effectiveness: examples from the developing field of hospital medicine.

J Public Health Manag Pract. 2009 Nov;15(6 Suppl):S18-23

Authors: Meltzer DO

The translation of insights from the biological sciences to medical practice requires actions by clinicians, patients, and others involved in healthcare. This makes insights from the social sciences critical to improving medical care. The recent emergence of hospitalists in the United States–physicians who specialize in the care of hospitalized patients–is an important innovation in how biomedical knowledge is translated into clinical care. This article discusses work by my colleagues and me examining the emergence of the hospitalist model by using the tools of the social sciences to understand whether, and under what conditions, hospitalists reduce the costs and improve the outcomes of care, and developing tools to measure and improve the quality of hospital care. The social scientific concepts and tools that we have drawn upon reflect a wide range of the social sciences, including economics, sociology, psychology, and related fields, such as clinical epidemiology and program evaluation. Many of these issues we have examined, including how professionals learn from experience and from their peers and how to measure and reward productivity, have important potential to address challenges faced by the public health workforce and reflect the broad potential for insights from the social sciences to inform public health workforce policy.

PMID: 19829222 [PubMed - in process]

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Is the family physician in or out of hospital medicine? A discussion of pertinent perspectives to consider as we address inpatient curricular review.

Ann Fam Med. 2009 Sep-Oct;7(5):471-2

Authors:

PMID: 19752478 [PubMed - indexed for MEDLINE]

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Shared by Robert Mahoney

Link: http://dx.doi.org/10.1007/s11606-009-1145-z

Update in General Internal Medicine.
J Gen Intern Med. 2009 Oct 28;
Authors: Uchida T, Persell SD, Baker DW

PMID: 19862579 [PubMed …

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Treatment of acute hepatitis C in HIV infection.

J Antimicrob Chemother. 2009 Oct 27;

Authors: Vogel M, Rockstroh JK

Within Europe and recently in the USA and Australia an ongoing epidemic of acute hepatitis C virus (HCV) infections among HIV-positive individuals, mainly men who have sex with men, has been observed. Other concomitant sexually transmitted diseases and sexual practices with a high risk of mucosal trauma and damage have been established as risk factors for sexual transmission. In HIV-positive patients the diagnosis of acute HCV infection may be obscured by delayed anti-HCV antibody seroconversion, and HCV RNA testing may be warranted. It is estimated that up to 85% of HIV-positive patients take a chronic course after acute HCV infection, and early treatment of acute HCV infection within 12 weeks after the presumed date of infection is recommended unless spontaneous clearance of HCV has occurred. A watch and wait strategy for 4-8 weeks after the date of diagnosis with 4 weekly HCV RNA controls may help to distinguish patients who will spontaneously clear acute HCV infection from those who will not. Treatment of acute HCV infection with interferon-based therapy has been shown to be highly efficacious, with sustained virological response rates in between 60% and 70% of HIV-positive individuals. Though data are sparse, controlling treatment response at weeks 4 and 12 may further help to individualize therapy, and patients who have not reached a negative HCV RNA by week 12 may benefit from prolonged treatment beyond 24 weeks.

PMID: 19861339 [PubMed - as supplied by publisher]

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Limitations of antibiotic options for invasive infections caused by methicillin-resistant Staphylococcus aureus: is combination therapy the answer?

J Antimicrob Chemother. 2009 Oct 27;

Authors: Nguyen HM, Graber CJ

Invasive infections caused by methicillin-resistant Staphylococcus aureus (MRSA), particularly those involving persistent bacteraemia, necrotizing pneumonia, osteomyelitis and other deep-seated sites of infections, are associated with high mortality and are often difficult to treat. The response to treatment of severe MRSA infection with currently available antibiotics active against MRSA is often unsatisfactory, leading some physicians to resort to combination antibiotic therapy. Now, with the emergence of community-associated MRSA (CA-MRSA) clones that display enhanced virulence potentially related to up-regulated toxin production, the use of adjuvant protein synthesis-inhibiting antibiotics to reduce toxin production also has been advocated by some experts. In this review, we discuss the limitations of antibiotics currently available for the treatment of serious invasive MRSA infections and review the existing literature that examines the potential role of combination therapy in these infections.

PMID: 19861337 [PubMed - as supplied by publisher]

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Clinical efficacy of first- and second-line treatments for HIV-associated Pneumocystis jirovecii pneumonia: a tri-centre cohort study.

J Antimicrob Chemother. 2009 Oct 26;

Authors: Helweg-Larsen J, Benfield T, Atzori C, Miller RF

Objectives First-line therapy for Pneumocystis jirovecii pneumonia (PCP) is trimethoprim/sulfamethoxazole. Few data exist to guide the choice of second-line therapy for patients failing or developing toxicity to first-line therapy. Methods A case note review of 1122 patients with 1188 episodes of HIV-associated PCP from three observational cohorts in Copenhagen, London and Milan, between 1989 and 2004, was conducted. Results Trimethoprim/sulfamethoxazole (962 PCP episodes, 81%) was the most frequently used first-line therapy, followed by intravenous pentamidine (87 episodes, 7%), clindamycin/primaquine (72 episodes, 6%) and 'other' (atovaquone, dapsone/pyrimethamine, trimetrexate or inhaled pentamidine; 67 episodes, 6%). Rates of unchanged therapy were trimethoprim/sulfamethoxazole = 79%, clindamycin/primaquine = 65% and pentamidine = 60% (P < 0.001). First-line therapy was changed because of failure in 82 (7%) episodes and because of toxicity in 198 (17%) episodes. Three month survival rates were trimethoprim/sulfamethoxazole = 85%, clindamycin/primaquine = 81% and pentamidine = 76% (P = 0.09). After adjustment for possible confounders, pentamidine was associated with a significantly greater risk of death at 3 months [hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.2-3.4]. Second-line therapy survival rates differed: trimethoprim/sulfamethoxazole = 85%; clindamycin/primaquine = 87%; and pentamidine = 60% (P = 0.01). Multivariable time-updated Cox regression analysis showed a greater risk of death associated with pentamidine (HR = 3.3, 95% CI = 2.2-5.0), but not for clindamycin/primaquine, when both were compared with trimethoprim/sulfamethoxazole. Conclusions Pentamidine was associated with a greater risk of death when used as first- and second-line therapy for HIV-associated PCP, and was associated with more treatment changes. Clindamycin/primaquine appeared superior to pentamidine as second-line therapy for PCP in patients failing or developing toxicity with trimethoprim/sulfamethoxazole. In patients failing first-line treatment with non-trimethoprim/sulfamethoxazole regimens, second-line therapy should be trimethoprim/sulfamethoxazole.

PMID: 19858161 [PubMed - as supplied by publisher]

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Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis.

World J Gastroenterol. 2009 Oct 28;15(40):5028-5034

Authors: Liu FY, Wang MQ, Fan QS, Duan F, Wang ZJ, Song P

AIM: To summarize our methods and experience with interventional treatment for symptomatic acute-subacute portal vein and superior mesenteric vein thrombosis (PV-SMV) thrombosis. METHODS: Forty-six patients (30 males, 16 females, aged 17-68 years) with symptomatic acute-subacute portal and superior mesenteric vein thrombosis were accurately diagnosed with Doppler ultrasound scans, computed tomography and magnetic resonance imaging. They were treated with interventional therapy, including direct thrombolysis (26 cases through a transjugular intrahepatic portosystemic shunt; 6 through percutaneous transhepatic portal vein cannulation) and indirect thrombolysis (10 through the femoral artery to superior mesenteric artery catheterization; 4 through the radial artery to superior mesenteric artery catheterization). RESULTS: The blood reperfusion of PV-SMV was achieved completely or partially in 34 patients 3-13 d after thrombolysis. In 11 patients there was no PV-SMV blood reperfusion but the number of collateral vessels increased significantly. Symptoms in these 45 patients were improved dramatically without severe operational complications. In 1 patient, the thrombi did not respond to the interventional treatment and resulted in intestinal necrosis, which required surgical treatment. In 3 patients with interventional treatment, thrombi re-formed 1, 3 and 4 mo after treatment. In these 3 patients, indirect PV-SMV thrombolysis was performed again and was successful. CONCLUSION: Interventional treatment, including direct or indirect PV-SMV thrombolysis, is a safe and effective method for patients with symptomatic acute-subacute PV-SMV thrombosis.

PMID: 19859995 [PubMed - as supplied by publisher]

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Doctors’ Stress Responses and Poor Communication Performance in Simulated Bad-News Consultations.

Acad Med. 2009 Nov;84(11):1595-1602

Authors: Brown R, Dunn S, Byrnes K, Morris R, Heinrich P, Shaw J

PURPOSE: No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors’ stress responses and poor communication performance during a simulated BBN task. METHOD: In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years’ experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years’ experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout. RESULTS: High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores. CONCLUSIONS: These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.

PMID: 19858823 [PubMed - as supplied by publisher]

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Doctors’ Stress Responses and Poor Communication Performance in Simulated Bad-News Consultations.

Acad Med. 2009 Nov;84(11):1595-1602

Authors: Brown R, Dunn S, Byrnes K, Morris R, Heinrich P, Shaw J

PURPOSE: No studies have previously evaluated factors associated with high stress levels and poor communication performance in breaking bad news (BBN) consultations. This study determined factors that were most strongly related to doctors’ stress responses and poor communication performance during a simulated BBN task. METHOD: In 2007, the authors recruited 24 doctors comprising 12 novices (i.e., interns/residents with 1-3 years’ experience) and 12 experts (i.e., registrars, medical/radiation oncologists, or cancer surgeons, with more than 4 years’ experience). Doctors participated in simulated BBN consultations and a number of control tasks. Five-minute-epoch heart rate (HR), HR variability, and communication performance were assessed in all participants. Subjects also completed a short questionnaire asking about their prior experience BBN, perceived stress, psychological distress (i.e., anxiety, depression), fatigue, and burnout. RESULTS: High stress responses were related to inexperience with BBN, fatigue, and giving bad versus good news. Poor communication performance in the consultation was related to high burnout and fatigue scores. CONCLUSIONS: These results suggest that BBN was a stressful experience for doctors even in a simulated encounter, especially for those who were inexperienced and/or fatigued. Poor communication performance was related to burnout and fatigue, but not inexperience with BBN. These results likely indicate that burnout and fatigue contributed to stress and poor work performance in some doctors during the simulated BBN task.

PMID: 19858823 [PubMed - as supplied by publisher]

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Is There a Relationship Between High-Quality Performance in Major Teaching Hospitals and Residents’ Knowledge of Quality and Patient Safety?

Acad Med. 2009 Nov;84(11):1510-1515

Authors: Pingleton SK, Horak BJ, Davis DA, Goldmann DA, Keroack MA, Dickler RM

PURPOSE: The relationship of the quality of teaching hospitals’ clinical performance to resident education in quality and patient safety is unclear. The authors studied residents’ knowledge of these areas in major teaching hospitals with higher- and lower-quality performance rankings. They assessed the presence of formal and informal quality curricula to determine whether programmatic differences exist. METHOD: The authors used qualitative research methodology with purposeful sampling. They gathered data from individual structured interviews with residents and key educational and quality leaders in six medical schools and teaching hospitals, which represented a range of quality performance rankings, geographic regions, and public or private status. RESULTS: No relationship emerged between a hospital’s quality status, residents’ curriculum, and the residents’ understanding of quality. Residents’ definitions of quality and safety and their knowledge of the practice-based learning and systems-based practice competencies were indistinguishable between hospitals. Residents in all programs had extensive patient safety knowledge acquired through an informal curriculum in the hospital setting. A formal curriculum existed in only two programs, both of them ambulatory settings. CONCLUSIONS: Residents’ learning about quality and patient safety is extensive, largely through a positive informal curriculum in the teaching hospital and, less frequently, via a formal curriculum. No relationship was found between the quality performance of the teaching hospital and the residents’ curriculum or understanding of quality or safety. Residents seem to learn through an informal curriculum provided by hospital initiatives and resources, and thus these data suggest the importance of major teaching hospitals in quality education.

PMID: 19858806 [PubMed - as supplied by publisher]

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Is There a Relationship Between High-Quality Performance in Major Teaching Hospitals and Residents’ Knowledge of Quality and Patient Safety?

Acad Med. 2009 Nov;84(11):1510-1515

Authors: Pingleton SK, Horak BJ, Davis DA, Goldmann DA, Keroack MA, Dickler RM

PURPOSE: The relationship of the quality of teaching hospitals’ clinical performance to resident education in quality and patient safety is unclear. The authors studied residents’ knowledge of these areas in major teaching hospitals with higher- and lower-quality performance rankings. They assessed the presence of formal and informal quality curricula to determine whether programmatic differences exist. METHOD: The authors used qualitative research methodology with purposeful sampling. They gathered data from individual structured interviews with residents and key educational and quality leaders in six medical schools and teaching hospitals, which represented a range of quality performance rankings, geographic regions, and public or private status. RESULTS: No relationship emerged between a hospital’s quality status, residents’ curriculum, and the residents’ understanding of quality. Residents’ definitions of quality and safety and their knowledge of the practice-based learning and systems-based practice competencies were indistinguishable between hospitals. Residents in all programs had extensive patient safety knowledge acquired through an informal curriculum in the hospital setting. A formal curriculum existed in only two programs, both of them ambulatory settings. CONCLUSIONS: Residents’ learning about quality and patient safety is extensive, largely through a positive informal curriculum in the teaching hospital and, less frequently, via a formal curriculum. No relationship was found between the quality performance of the teaching hospital and the residents’ curriculum or understanding of quality or safety. Residents seem to learn through an informal curriculum provided by hospital initiatives and resources, and thus these data suggest the importance of major teaching hospitals in quality education.

PMID: 19858806 [PubMed - as supplied by publisher]

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Perspective: A Perfect Storm: The Convergence of Bullet Points, Competencies, and Screen Reading in Medical Education.

Acad Med. 2009 Nov;84(11):1500-1504

Authors: Wear D

Three distinct phenomena are currently at play in medical education: (1) the pervasive use of PowerPoint in teaching, (2) the wholesale application of competency models, and (3) the shift from paper reading to screen reading regardless of course, text, or genre. Finding themselves placed at this intersection, students encounter fewer and fewer opportunities to practice some of the very cognitive and affective habits medical educators say they value in physicians, particularly critical reflection and deliberation, an eye for nuance, context, and ambiguity, and an appreciation that becoming a doctor involves more than learning content or performing skills. This article confronts these phenomena singly and then at their intersection, which may discourage, even dismantle, many of these habits. The author proposes that the rapid shift over the past decade to a technology-driven, competency-oriented environment in medical education is the medical educators’ creation, one that sets up conditions for a perfect cognitive storm.

PMID: 19858803 [PubMed - as supplied by publisher]

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Commentary: Health Care Reform and Its Potential Impact on Academic Medical Centers.

Acad Med. 2009 Nov;84(11):1472-1475

Authors: Karpf M, Lofgren R, Perman J

President Obama’s administration has committed to significant changes in the current health care system to address three issues: access, cost, and quality. Leaders at academic medical centers (AMCs) must acknowledge the root cause of the problems within the current system, recognize potential change initiatives, contemplate the changing role that AMCs will play in the health care system of the future, and begin to adapt and respond.The underlying root cause of the problem with our health care system is excessive costs. Although many factors contribute to excess costs, the most important factor is overuse of expensive modalities. The administration will try to impact change by stressing preventive care, improving medical practice with the purpose of achieving greater value, and changing the reimbursement system from fee for service to other reimbursement approaches that provide greater incentives for more coordinated and integrated systems of care.It is argued in this commentary that ultimately reform will lead to some form of a managed care model with limits on spending. Highly integrated health care systems will be in the best position to produce more efficient care that provides value. The authors posit that AMCs have the unique opportunity of shaping integration in many regions of the country and highlight efforts at the University of Kentucky to develop a health care system to serve the commonwealth. Change is inevitable. Being proactive rather than reactive may be important to secure the future of AMCs.

PMID: 19858791 [PubMed - as supplied by publisher]

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