2011 October 21

Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack.

Oct 212011

Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack.

CMAJ. 2011 Jul 12;183(10):1137-45

Authors: Perry JJ, Sharma M, Sivilotti ML, Sutherland J, Symington C, Worster A, Émond M, Stotts G, Jin AY, Oczkowski WJ, Sahlas DJ, Murray HE, MacKey A, Verreault S, Wells GA, Stiell IG

Abstract
BACKGROUND: The ABCD2 score (Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes) is used to identify patients having a transient ischemic attack who are at high risk for imminent stroke. However, despite its widespread implementation, the ABCD2 score has not yet been prospectively validated. We assessed the accuracy of the ABCD2 score for predicting stroke at 7 (primary outcome) and 90 days.
METHODS: This prospective cohort study enrolled adults from eight Canadian emergency departments who had received a diagnosis of transient ischemic attack. Physicians completed data forms with the ABCD2 score before disposition. The outcome criterion, stroke, was established by a treating neurologist or by an Adjudication Committee. We calculated the sensitivity and specificity for predicting stroke 7 and 90 days after visiting the emergency department using the original "high-risk" cutpoint of an ABCD2 score of more than 5, and the American Heart Association recommendation of a score of more than 2.
RESULTS: We enrolled 2056 patients (mean age 68.0 yr, 1046 (50.9%) women) who had a rate of stroke of 1.8% at 7 days and 3.2% at 90 days. An ABCD2 score of more than 5 had a sensitivity of 31.6% (95% confidence interval [CI] 19.1-47.5) for stroke at 7 days and 29.2% (95% CI 19.6-41.2) for stroke at 90 days. An ABCD2 score of more than 2 resulted in sensitivity of 94.7% (95% CI 82.7-98.5) for stroke at 7 days with a specificity of 12.5% (95% CI 11.2-14.1). The accuracy of the ABCD2 score as calculated by either the enrolling physician (area under the curve 0.56; 95% CI 0.47-0.65) or the coordinating centre (area under the curve 0.65; 95% CI 0.57-0.73) was poor.
INTERPRETATION: This multicentre prospective study involving patients in emergency departments with transient ischemic attack found the ABCD2 score to be inaccurate, at any cut-point, as a predictor of imminent stroke. Furthermore, the ABCD2 score of more than 2 that is recommended by the American Heart Association is nonspecific.

PMID: 21646462 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Heart failure with preserved left ventricular ejection fraction: concepts, misconceptions and future directions.

Blood Press Start a Discussion »

Oct 212011

Heart failure with preserved left ventricular ejection fraction: concepts, misconceptions and future directions.

Blood Press. 2011 Jun;20(3):129-33

Authors: Soma J

Abstract
Heart failure with preserved left ventricular ejection fraction (HFPEF) represents a huge medical problem, especially in light of an increasing elderly population. Dysfunction of both left ventricular filling and ejection, combined with adverse loading conditions related to advanced age, arterial hypertension, diabetes mellitus, obesity and atrial fibrillation are fundamental pathophysiological mechanisms. Hypertension is probably the most important modifiable risk factor. The diagnosis has largely been based on signs of increased left ventricular filling pressure. Additional matters of debate are the interpretation of left ventricular ejection fraction in concentric remodelling and the cut-off used for the definition of HFPEF, as well as inconsistencies related to prevalence and prognosis, and lack of benefit of drugs in randomized trials.

PMID: 21142436 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

In-hospital management of atrial fibrillation: the CHADS? score predicts increased cost.

Can J Cardiol Start a Discussion »

Oct 212011

In-hospital management of atrial fibrillation: the CHADS? score predicts increased cost.

Can J Cardiol. 2011 Jul-Aug;27(4):506-13

Authors: Kotowycz MA, Filion KB, Joza J, Dube D, Reynolds MR, Pilote L, Eisenberg MJ, Essebag V

Abstract
BACKGROUND: Hospitalizations for atrial fibrillation (AF) impose a substantial burden on our health care system, and AF management strategies are increasingly focused on hospitalization reduction. The objectives of this study were to determine the cost of hospitalization for AF and to identify the main determinants of this cost in a Canadian setting.
METHODS: Our study population consisted of patients hospitalized for AF and/or atrial flutter at a tertiary care hospital in Canada between April 1, 2001, and March 31, 2007. Patient-level demographics and data on clinical resource use and cost of treatment were collected from a computerized resource use and cost accounting system. The main determinants of in-hospital costs were identified through Bayesian model averaging.
RESULTS: Data were collected on 325 consecutive hospitalizations for AF. The median length of stay was 5 days (interquartile range [IQR], 3-9). The mean cost of an AF admission was CAD$4740 (SD = CAD$4457), and the median was CAD$3532 (IQR, CAD$2013-CAD$5944). Multivariate analysis identified 2 independent predictors of increased cost: CHADS? score (relative increase in cost: 1.24; 95% CI, 1.16-1.33) and warfarin use (relative increase in cost: 1.41; 95% CI, 1.20-1.67). These 2 variables were also independent predictors of increased length of stay.
CONCLUSIONS: The main clinical determinants of increased cost and increased length of stay were CHADS? score and warfarin use. Strategies for reducing AF-related costs should focus on preventing hospitalization or decreasing its length in patients with high CHADS? scores and on finding alternatives to the use of warfarin or using outpatient bridging anticoagulation to facilitate earlier hospital discharge.

PMID: 21546210 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Rapid response team in an academic institution: does it make a difference?

Chest Start a Discussion »

Oct 212011

Rapid response team in an academic institution: does it make a difference?

Chest. 2011 Jun;139(6):1361-7

Authors: Shah SK, Cardenas VJ, Kuo YF, Sharma G

Abstract
BACKGROUND: Although data remain contradictory, rapid response systems are implemented across US hospitals. We aimed to determine whether implementation of a rapid response team (RRT) in a tertiary academic hospital improved outcomes.
METHODS: Our hospital is a tertiary academic medical center with 24-h in-house resident coverage. We conducted a retrospective cohort study comparing 27 months after implementation of the RRT (April 1, 2006, to June 31, 2008) and 9 months before (January 1, 2005, to September 31, 2005). Outcomes included incidence of codes (cardiac and/or respiratory arrests), outcome of the codes, and overall hospital mortality.
RESULTS: We analyzed 16,244 nonobstetrics hospital admissions and 70,208 patient days in the control period and 45,145 nonobstetrics hospital admissions and 161,097 patient days after the RRT was implemented. The RRT was activated 1,206 times (7.7 calls per 1,000 patient days). There was no difference in the code rate (0.83 vs 0.98 per 1,000 patient days, P = .3). There was a modest but nonsustained improvement in nonobstetrics hospital mortality during the study period (2.40% vs 2.15%; P = .05), which could not be explained by the RRT effect on code rates. The mortality was 2.40% in the control group and 2.06%, 1.94%, and 2.46%, respectively, during the next three consecutive 9-month intervals.
CONCLUSIONS: In our single-institution study involving an academic hospital with 24-h in-house coverage, we found that RRT implementation did not reduce code rates in the 27 months after intervention. Although there was a decrease in overall hospital mortality, this decrease was small, nonsustained, and not explained by the RRT effect on code rates.

PMID: 20864618 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Management of patients with obstructive jaundice: experience in a developing country.

Nig Q J Hosp Med Start a Discussion »

Oct 212011

Management of patients with obstructive jaundice: experience in a developing country.

Nig Q J Hosp Med. 2011 Jan-Mar;21(1):75-9

Authors: Rahman GA, Yusuf IF, Faniyi AO, Etonyeaku AC

Abstract
BACKGROUND: Surgical Obstructive Jaundice can be life-threatening. Management of these patients can be a major diagnostic and therapeutic challenge.
OBJECTIVE: The aim of this study is to determine the sociodemographic data of patients with obstructive jaundice, clinical, laboratory and radiological findings as well as surgical procedures done and immediate postoperative outcome in a tertiary health institution.
METHODS: Patients who presented in a Nigerian tertiary health institution with surgical obstructive jaundice between. January 1991 and December 2004 were retrospectively studied. Information was extracted from clinical records, operation notes and histopathology records. Data was entered into SPSS version 11.0 for windows to generate frequency table, percentages, proportion, histogram and pie chart.
RESULTS: Sixty-four patients with obstructive jaundice were managed during the study period. Majority of the patients were in the 6th decade of life. More than 50% of the patients have had symptoms for more than 4 weeks before presentation. Carcinoma of the head of pancreas was the cause of obstructive jaundice in more than 60% of the patients. About 47% of the patients had cholecystojejunostomy and operative mortality was 15.6%.
CONCLUSION: Carcinoma head of pancreas is the commonest cause of obstructive jaundice in Nigeria with many of the patients in the 6th decade. Diagnosis and management continue to be a challenge especially as a result of late presentation and limited radiological facilities. Patients benefited from palliative surgical intervention in form of bili-enteric diversion.

PMID: 21913546 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey.

Clin Nutr Start a Discussion »

Oct 212011

Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey.

Clin Nutr. 2011 Jun;30(3):289-96

Authors: Thibault R, Chikhi M, Clerc A, Darmon P, Chopard P, Genton L, Kossovsky MP, Pichard C

Abstract
BACKGROUND & AIMS: A food quality control and improvement permanent process was initiated in 1999. To evaluate the food service evolution, protein-energy needs coverage were compared in 1999 and 2008 with the same structure survey in all hospitalized patients receiving 3 meals/day.
METHODS: Nutritional values of food provided, consumed and wasted over 24h including non-exclusive nutritional support were calculated individually. Nutritional needs were estimated as 110% of Harris-Benedict formula for energy and 1.2 or 1.0 g protein/kg/day for patients <65 or ?65 years old, respectively. Multivariate analysis identified factors associated with low nutritional intake in both populations standardized to body mass index (BMI) of 1999's patients.
RESULTS: Out of 1677 patients, 1291 were included. Mean BMI was higher in 2008 than 1999 (P<0.001). The proportion of underfed patients was unchanged (69 vs. 70%, NS). The consumption of ?1 oral nutritional supplements (ONS) daily increased the protein needs coverage from 80% to 115% (P<0.001). The year 1999, high BMI, 1st week of hospital stay, specific diet, ONS absence and low meal quality were associated with low nutritional intakes.
CONCLUSION: The nutritional needs coverage could have improved in 2008 if BMI was similar to 1999's. ONS consumption is associated with a lower risk of underfeeding in hospitalized patients.

PMID: 21067850 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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