2012 July 21

Low borderline plasma levels of antithrombin, protein C and protein S are risk factors for venous thromboembolism.

Jul 212012

Low borderline plasma levels of antithrombin, protein C and protein S are risk factors for venous thromboembolism.

J Thromb Haemost. 2012 Jul 20;

Authors: Bucciarelli P, Passamonti SM, Biguzzi E, Gianniello F, Franchi F, Mannucci PM, Martinelli I

Abstract

Background:?Inherited deficiencies of antithrombin (AT), protein C (PC) and protein S (PS) are risk factors for venous thromboembolism (VTE). They are usually defined by laboratory cut-offs (in our setting 81, 70 and 63 IU/dL, respectively), that give only a rough idea of the VTE risk associated with plasma levels of these proteins. Objectives:?We investigated whether the risk of VTE associated with the plasma deficiencies of AT, PC or PS has a dose-response effect, and whether low borderline levels of these proteins are associated with an increased risk of VTE, both in the whole study population and separately in carriers of either factor V Leiden or G20210A prothrombin gene mutation. Patients/Methods:?A case-control study of 1401 patients with a first objectively-documented VTE and 1847 healthy controls has been carried out. Results:?A dose-response effect on the VTE risk was observed for all the three anticoagulant proteins. Compared to individuals with AT, PC or PS levels >100 IU/dL, the adjusted odds ratio (95%CI) of VTE was 2.00 (1.44-2.78) for AT levels between 76 and 85 IU/dL, 2.21 (1.54-3.18) and 1.84 (1.31-2.59) for PC and PS levels between 61 and 75 IU/dL, respectively. The risk of unprovoked VTE in factor V Leiden or prothrombin G20210A carriers appears 2 to 3-fold increased when levels of AT or PS are low borderline. Conclusions:?Low borderline plasma levels of AT, PC and PS are associated with a 2-fold increased risk of VTE and should be considered in the assessment of the individual VTE risk. © 2012 International Society on Thrombosis and Haemostasis.

PMID: 22812604 [PubMed - as supplied by publisher]

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They Don’t Know What They Don’t Know: Internal Medicine Residents’ Knowledge and Confidence in Urine Drug Test Interpretation for Patients with Chronic Pain.

J Gen Intern Med Start a Discussion »

Jul 212012

They Don't Know What They Don't Know: Internal Medicine Residents' Knowledge and Confidence in Urine Drug Test Interpretation for Patients with Chronic Pain.

J Gen Intern Med. 2012 Jul 20;

Authors: Starrels JL, Fox AD, Kunins HV, Cunningham CO

Abstract

BACKGROUND: Urine drug testing (UDT) can help identify misuse or diversion of opioid medications among patients with chronic pain. However, misinterpreting results can lead to false reassurance or erroneous conclusions about drug use. OBJECTIVE: To examine the relationship between resident physicians' knowledge about UDT interpretation and confidence in their ability to interpret UDT results. DESIGN: Cross-sectional survey. PARTICIPANTS: Internal medicine residents in a university health system in the Bronx, from 2010 to 2011. MAIN MEASURES: We assessed knowledge using a 7-item scale (UDT knowledge score), and confidence in UDT interpretation using a single statement ("I feel confident in my ability to interpret the results of urine drug tests"). We conducted chi-square tests, t-tests, and logistic regression to determine the association between knowledge and confidence, and in exploratory analyses to examine whether resident characteristics (gender, training level, and UDT use) moderated the relationship between knowledge and confidence. KEY RESULTS: Among 99 residents, the mean UDT knowledge score was 3.0 out of 7 (SD 1.2). Although 55 (56 %) of residents felt confident in their ability to interpret UDT results, 40 (73 %) of confident residents had a knowledge score of 3 or lower. Knowledge score was not associated with confidence among the full sample or when stratified by training level or UDT use. The association between knowledge and confidence differed significantly by gender (interaction term p?<?0.01). Adjusting for training level and UDT use, knowledge was positively associated with confidence among females (AOR 1.79, 95 % CI: 1.06, 3.30), and negatively associated with confidence among males (AOR 0.47, 95 % CI: 0.23, 0.98). CONCLUSIONS: Despite poor knowledge about UDT interpretation, most resident physicians felt confident in their ability to interpret UDT results. Gender differences warrant further exploration, but even confident physicians who use UDT should evaluate their proficiency in interpreting UDT results. Educational initiatives should emphasize the complexities of UDT interpretation.

PMID: 22815062 [PubMed - as supplied by publisher]

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Internal medicine interns’ and residents’ pressure ulcer prevention and assessment attitudes and abilities: results of an exploratory study ?.

ostomy wound manage Start a Discussion »

Jul 212012

Internal medicine interns' and residents' pressure ulcer prevention and assessment attitudes and abilities: results of an exploratory study ?.

Ostomy Wound Manage. 2012 Apr;58(4):28-35

Authors: Suen W, Parker VA, Harney L, Nevin S, Jansen J, Alexander L, Berlowitz D

Abstract

???????????????? To evaluate and determine differences between attitudes of internal medicine interns and residents toward pressure ulcer (PU) prevention and to evaluate the interns' abilities to accurately identify wounds and stage PUs, an exploratory, quantitative study was conducted in a 639-bed, safety net academic center. Participants (21 internal medicine interns and 21 internal medicine residents) attending an educational session on PU prevention and care were eligible to participate. The 1-hour conference session was prepared and provided by a physician and wound care nurses. Before the lecture, participants were asked to complete an 11-question paper-and-pencil PU attitude survey. Following the lecture, they were asked to identify 11 wounds and stage PUs using the inpatient admission history and physical template used in the hospital's electronic medical record. An audience response system was used to record correct and incorrect responses. Nineteen (19) interns and 20 residents completed the survey. Twenty-one (21) interns successfully completed the wound assessment quiz. Descriptive statistics were used to examine the survey data and residents' and interns' average attitude scores were compared using independent group t-test. The results suggest that interns and residents have a positive attitude toward and are concerned about PU prevention. The significantly higher overall score among interns compared to residents (average 43.8 versus 38.8 respectively, P = 0.002) suggests interns have a more positive attitude than residents. Statistically significant differences between item scores showed that, compared to residents, interns perceived PU prevention to be more time-consuming (P = 0.01), less of a concern in practice (P = 0.02), and a lower priority than other areas of care (P = 0.003). Compared to residents, interns also were more likely to agree to with statement, "In my opinion, patients tend to not get as many pressure ulcers nowadays" (P = 0.0006). Both groups agreed that PU prevention is a greater priority than treatment and that using risk assessment tools is better than relying on clinical judgment. Wound assessment and PU staging results varied greatly, ranging from 100% for correct staging of a Stage I PU to 20% correct staging of an unstageable PU and 3% correct identification of a diabetic foot ulcer. Overall, internal medicine interns and residents have a favorable attitude toward PU prevention. Despite the limitations of this study, results suggest that enhanced medical school and residency wound care curricula are needed.

PMID: 22466131 [PubMed - indexed for MEDLINE]

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Rule of rescue or the good of the many? An analysis of physicians’ and nurses’ preferences for allocating ICU beds.

Intensive Care Med Start a Discussion »

Jul 212012

Rule of rescue or the good of the many? An analysis of physicians' and nurses' preferences for allocating ICU beds.

Intensive Care Med. 2011 Jul;37(7):1210-7

Authors: Kohn R, Rubenfeld GD, Levy MM, Ubel PA, Halpern SD

Abstract

PURPOSE: To examine intensive care unit (ICU) clinicians' willingness to trade off societal benefits in favor of a small chance of rescuing an identifiable critically ill patient.

METHODS: We sent mixed-methods questionnaires to national samples of US ICU clinicians, soliciting their preferences for allocating their last bed to a gravely ill patient with little chance to survive, versus a deceased or dying patient for whom aggressive management could help others through organ donation.

RESULTS: Complete responses were obtained from 684 of 2,206 physicians (31.0%) and 438 of 988 nurses (44.3%); there was no evidence of non-response bias. Physicians were more likely than nurses to adhere to the "rule of rescue" by allocating the last bed to the gravely ill patient (45.9 vs. 32.6%, difference = 13.2%; 95% CI 9.1-17.3%). The magnitude of the social benefit to be obtained through organ donor management (5 or 30 life-years added for transplant recipients) had small and inconsistent effects on clinicians' willingness to prioritize the donor. In qualitative analyses, the most common reason for allocating the last bed to an identifiable patient (identified by 65% of physicians and 75% of nurses) was that clinicians perceived strong obligations to identifiable living patients.

CONCLUSIONS: More than one-third of ICU clinicians forewent substantial social benefits so as to devote resources to an individual patient unlikely to benefit from them. Such allegiance to the rule of rescue suggests challenges for efforts to reform ICU triage practices.

PMID: 21647719 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

The use of high-fidelity simulation for rapid response team training: a community hospital’s story.

j nurses staff dev Start a Discussion »

Jul 212012

The use of high-fidelity simulation for rapid response team training: a community hospital's story.

J Nurses Staff Dev. 2012 Mar-Apr;28(2):50-2

Authors: Kegler AL, Dale BD, McCarthy AJ

Abstract

The authors describe how simulation training was used to improve rapid response team activation in a nonteaching, nonprofit community hospital. Goals were established, and a scenario was developed to educate the healthcare team on the importance of early activation of the rapid response ream. Organizing and implementing a large-scale simulation required a solid commitment from the staff development department. The education from the simulation has led to increased knowledge and comfort levels of clinical staff, resulting in an increased use of the rapid response team.

PMID: 22449875 [PubMed - indexed for MEDLINE]

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A CLINICAL PROGNOSTIC MODEL FOR THE IDENTIFICATION OF LOW-RISK PATIENTS WITH ACUTE SYMPTOMATIC PULMONARY EMBOLISM AND ACTIVE CANCER.

Chest Start a Discussion »

Jul 212012

A CLINICAL PROGNOSTIC MODEL FOR THE IDENTIFICATION OF LOW-RISK PATIENTS WITH ACUTE SYMPTOMATIC PULMONARY EMBOLISM AND ACTIVE CANCER.

Chest. 2012 Jul 17;

Authors: Exter1 PL, Gómez2 V, Jiménez3 D, Trujillo-Santos4 J, Muriel5 A, Huisman1 MV, Monreal6 M, for the RIETE investigators

Abstract

ABSTRACT BACKGROUND: Clinicians need a specific risk stratification tool to facilitate safe and cost-effective approaches to the management of patients with cancer and acute pulmonary embolism (PE). OBJECTIVE: To develop a simple risk score for predicting 30-day mortality in PE patients with cancer by using measures readily obtained at the time of PE diagnosis. METHODS: Investigators randomly allocated 1,556 consecutive patients with cancer and acute PE from the international, multicenter RIETE registry to derivation (67%) and internal validation (33%) samples. The external validation cohort for this study consisted of 261 patients with cancer and acute PE. Investigators compared 30-day all-cause mortality and nonfatal adverse medical outcomes across the derivation and two validation samples. RESULTS: In the derivation sample, multivariable analyses produced the risk score that contained 6 variables: age > 80 years, heart rate > 110/min, systolic blood pressure < 100 mm Hg, body weight < 60 Kg, recent immobility, and presence of metastases. In the internal validation cohort (n = 508), the 22.2% (113/508) of patients classified as low-risk by the prognostic model had a 30-day mortality of 4.4% (95% CI, 0.6 to 8.2%) compared to 29.9% (95 % CI, 25.4 to 34.4%) in high-risk group. In the external validation cohort, the 18% (47/261) of patients classified as low-risk by the prognostic model had a 30-day mortality of 0%, compared to 19.6% (95% CI, 14.3 to 25.0%) in the high-risk group. CONCLUSIONS: The developed clinical prediction rule accurately identifies low-risk cancer patients with acute PE.

PMID: 22814859 [PubMed - as supplied by publisher]

Link to Article at PubMed

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