2011 December 20

Inpatient warfarin: Experience with a pharmacist-led anticoagulation management service in a tertiary care medical center.

Am J Health Syst Pharm Start a Discussion »

Dec 202011

Inpatient warfarin: Experience with a pharmacist-led anticoagulation management service in a tertiary care medical center.

Am J Health Syst Pharm. 2012 Jan 1;69(1):44-8

Authors: Fowler S, Gulseth MP, Renier C, Tomsche J

Abstract
Purpose The implementation of a pharmacist-led anticoagulation management service (AMS) and the clinical outcomes of inpatients receiving warfarin management are described. Summary An AMS was established at St. Mary's Medical Center (SMMC) in Duluth, Minnesota, in November 2003 at the request of orthopedic surgeons to manage warfarin for their patients postoperatively. The AMS was also available to other inpatients by physician request. All AMS pharmacists received didactic and experiential training. Each day, the managing pharmacist, usually the decentralized pharmacist, was responsible for checking the patients' International Normalized Ratio (INR); reviewing other pertinent laboratory test values, any medication changes, and vital signs; monitoring changes in the patients' clinical status, and writing an order for a warfarin dose. A database was created to help monitor patients managed by the AMS and to analyze monthly outcomes data. Clinical outcomes data were evaluated to identify areas of improvement for the AMS. All hospitalizations for patients who received anticoagulation therapy with warfarin managed by the AMS from January 1, 2006, through August 31, 2007, were analyzed. Primary endpoints, including thrombosis and bleeding complications during hospitalization, were identified for inclusion in the final hospital discharge data. Of the 2794 hospitalizations for patients managed by the AMS evaluated, 59 complications were identified. Of these, 14 (0.5%) were thrombosis events and 45 (1.6%) were bleeding events. INR results were also analyzed as secondary endpoints. Conclusion The evaluation of outcomes of the inpatient-based AMS at SMMC provided critical information to the anticoagulation subcommittee for consideration of quality-improvement efforts.

PMID: 22180551 [PubMed - in process]

Link to Article at PubMed

Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.

Ann Emerg Med Start a Discussion »

Dec 202011

Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.

Ann Emerg Med. 2011 Dec 14;

Authors: Singh B, Parsaik AK, Agarwal D, Surana A, Mascarenhas SS, Chandra S

Abstract
STUDY OBJECTIVE: To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED). METHODS: We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios. RESULTS: We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I(2)=97.2%) and positive likelihood ratio (I(2)=84.2%). CONCLUSION: The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability.

PMID: 22177109 [PubMed - as supplied by publisher]

Link to Article at PubMed

Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial.

Blood Start a Discussion »

Dec 202011

Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial.

Blood. 2011 Dec 16;

Authors: Prandoni P, Noventa F, Quintavalla R, Bova C, Cosmi B, Siragusa S, Bucherini E, Astorri F, Cuppini S, Dalla Valle F, Lensing AW, Prins MH, Villalta S

Abstract
Although below-knee compression elastic stockings (CES) are effective for prevention of the post-thrombotic syndrome (PTS), a substantial proportion of patients with deep venous thrombosis (DVT) still develop the PTS. In an open-label, randomized clinical trial, we compared thigh-length with below-knee CES for prevention of the PTS. 267 patients with the first episode of proximal DVT were randomized to wear either thigh-length or below-knee CES for 2 years. After 3, 6, 12, 18, 24 and 36 months, they were assessed for PTS manifestations according to the Villalta scale. PTS developed in 44 (32.6%) of the 135 patients randomized to thigh-length CES, and in 47 (35.6%) of the 132 allocated to below-knee CES, for an adjusted hazard ratio of 0.93 (95% CI, 0.62 to 1.41). Severe PTS developed in 3 patients in each group. Stockings-related side-effects developed in 55 (40.7%) of the 135 patients allocated to thigh-length CES, and in 36 (27.3%) of those randomized to the below-knee group (p=0.017), and led to premature discontinuation of their use in 29 (21.5%) and 18 (13.6%) patients, respectively. We conclude that thigh-length CES do not offer a better protection against PTS than below-knee CES and are less well tolerated (Clinical Trial number: NCT00426075).

PMID: 22180438 [PubMed - as supplied by publisher]

Link to Article at PubMed

Clinical versus statistical significance: interpreting P values and confidence intervals related to measures of association to guide decision making.

j pharm pract Start a Discussion »

Dec 202011

Clinical versus statistical significance: interpreting P values and confidence intervals related to measures of association to guide decision making.

J Pharm Pract. 2010 Aug;23(4):344-51

Authors: Ferrill MJ, Brown DA, Kyle JA

Abstract
Pharmacists need to apply outcomes from studies to reduce risk and improve patient care. Interpretation of outcomes is based on a variety of assessment tools, such as P values and confidence intervals (CIs). P values determine statistical significance of data, while CIs suggest the degree of clinical application. Many health care providers might not have the skill set required to carefully examine and interpret statistical results and then are required to assume that the researchers of the study correctly interpreted and presented the statistical results. The reluctance to examine statistical data often reflects a misconception that concepts such as P values and CIs are difficult to understand, while in reality, both can be interpreted once basic definitions and applications are understood. Measures of association such as number needed to treat can serve as effective tools for quantifying important parameters that ultimately affect patient care. A basic understanding of how to interpret and apply P values and CIs enhances one's ability to effectively assess the validity of results from the literature. An informed reader, armed with tools for critical analysis, is in the best position to evaluate studies and thereby discern which information is applicable to a specific patient care decision.

PMID: 21507834 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Acute heart failure in patients with diabetes mellitus: Clinical characteristics and predictors of in-hospital mortality.

Int J Cardiol Start a Discussion »

Dec 202011

Acute heart failure in patients with diabetes mellitus: Clinical characteristics and predictors of in-hospital mortality.

Int J Cardiol. 2011 Dec 15;

Authors: Parissis JT, Rafouli-Stergiou P, Mebazaa A, Ikonomidis I, Bistola V, Nikolaou M, Meas T, Delgado J, Vilas-Boas F, Paraskevaidis I, Anastasiou-Nana M, Follath F

Abstract
OBJECTIVE/METHODS: ALARM-HF was an in-hospital observational survey that included 4953 patients admitted for acute heart failure (AHF) in six European countries, Mexico and Australia. This article is a secondary analysis of the survey which evaluates differences in clinical phenotype, treatment regimens and in-hospital outcomes in AHF patients with diabetes mellitus (DM) compared to non-diabetics. The data were collected retrospectively by the investigators, and the diagnosis of AHF (reported at discharge) was based on the definition and classification of ESC guidelines, while the diagnosis of DM was based on medical record (past medical and medication history). RESULTS: This sub-analysis demonstrates substantial differences regarding both baseline features and in-hospital outcome among diabetic and non-diabetic AHF patients. Diabetic patients (n=2229, 45%) presented more frequently with acute pulmonary edema (p<0.001) than non-diabetics, had more often acute coronary syndrome (p<0.001) as precipitating factors of AHF, and multiple comorbidities such as renal dysfunction (p<0.001), arterial hypertension (p<0.001), anemia (p<0.001) and peripheral vascular disease (p<0.001). All-cause in-hospital mortality of diabetics was higher compared to non-diabetics (11.7% vs 9.8%, p=0.01). The multivariate analysis revealed that older age (p=0.032), systolic blood pressure <100mm Hg (p<0.001), acute coronary syndrome and non compliance as precipitating factors (p=0.05 and p=0.005, respectively), history of arterial hypertension (p=0.022), LVEF<50% (p<0.001), serum creatinine >1.5mg/dl (p=0.029), absence of life saving therapies such as ACE inhibitors/ARBs (p<0.001) and beta-blockers (p=0.014) at admission, as well as absence of interventional treatment by PCI (p<0.001), were independently associated with adverse in-hospital outcome. CONCLUSION: Diabetics with AHF have higher in-hospital mortality than non-diabetics despite their intensive treatment regimens (regarding care for HF and ACS), possibly due to underlying ischemic heart disease and the presence of multiple comorbidities.

PMID: 22178056 [PubMed - as supplied by publisher]

Link to Article at PubMed

Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs.

Am J Infect Control Start a Discussion »

Dec 202011

Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs.

Am J Infect Control. 2011 Dec 15;

Authors: Nordstrom JM, Reynolds KA, Gerba CP

Abstract
BACKGROUND: As a cost-saving measure, an increasing number of hospitals allow personnel to launder their uniforms, lab coats, and operating room scrubs at home. With rising nosocomial infection rates and increasing levels of multidrug-resistant bacteria in hospital settings, uniform contamination may be an environmental factor in the spread of infection. METHODS: We quantified the number and identity of bacteria found on swatches cut from unwashed operating room, hospital-laundered, home-laundered, new cloth, and new disposable scrubs. RESULTS: Of the 29 unwashed hospital operating room scrub swatches analyzed, 23 (79%) were positive for some type of gram-positive cocci, with 3 (10%) of those classified as Staphylococcus aureus, and 20 (69%) were positive for coliform bacteria, 3 of which were Escherichia coli. Home-laundered scrubs had a significantly higher total bacteria count than hospital-laundered scrubs (P = .016). There was no statistical difference in the bacteria counts between hospital-laundered scrubs and unused new and disposable scrubs. In the home-laundered scrubs 44% (18/41) were positive for coliform bacteria, but no isolates were Escherichia coli. CONCLUSIONS: Significantly higher bacteria counts were isolated from home-laundered scrubs and unwashed scrubs than from new, hospital-laundered, and disposable scrubs.

PMID: 22177668 [PubMed - as supplied by publisher]

Link to Article at PubMed

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