2012 August 04

The digital rectal examination: a multicenter survey of physicians’ and students’ perceptions and practice patterns.

Aug 042012

The digital rectal examination: a multicenter survey of physicians' and students' perceptions and practice patterns.

Am J Gastroenterol. 2012 Aug;107(8):1157-63

Authors: Wong RK, Drossman DA, Bharucha AE, Rao SS, Wald A, Morris CB, Oxentenko AS, Ravi K, Van Handel DM, Edwards H, Hu Y, Bangdiwala S

Abstract

Objectives:The digital rectal examination (DRE) may be underutilized. We assessed the frequency of DREs among a variety of providers and explored factors affecting its performance and utilization.Methods:A total of 652 faculty, fellows, medical residents, and final-year medical students completed a questionnaire about their use of DREs.Results:On average, 41 DREs per year were performed. The yearly number of examinations was associated with years of experience and specialty type. Patient refusal rates were lowest among gastroenterology (GI) faculty and highest among primary-care doctors. Refusal rates were negatively correlated with comfort level of the physician in performing a DRE. More gastroenterologists used sophisticated methods to detect anorectal conditions, and gastroenterologists were more confident in diagnosing them. Confidence in making a diagnosis with a DRE was strongly associated with the number of DREs performed annually.Conclusions:The higher frequencies of performing a DRE, lower refusal rate, degree of comfort, diagnostic confidence, and training adequacy were directly related to level of experience with the examination. Training in DRE technique has diminished and may be lost. The DRE's role in medical school and advanced training curricula needs to be re-established.

PMID: 22858996 [PubMed - in process]

Link to Article at PubMed

Clinical Evaluation of Defibrillation Testing in an Unselected Population of 2,120 Consecutive Patients Undergoing First Implantable Cardioverter-Defibrillator Implant.

J Am Coll Cardiol Start a Discussion »

Aug 042012

Clinical Evaluation of Defibrillation Testing in an Unselected Population of 2,120 Consecutive Patients Undergoing First Implantable Cardioverter-Defibrillator Implant.

J Am Coll Cardiol. 2012 Jul 24;

Authors: Brignole M, Occhetta E, Bongiorni MG, Proclemer A, Favale S, Iacopino S, Calò L, Vado A, Buja G, Mascioli G, Quartieri F, Tritto M, Parravicini U, Castro A, Tomasi C, Villani GQ, D'Acri MG, Klersy C, Gasparini M, SAFE-ICD Study Investigators

Abstract

OBJECTIVES: The purpose of this study is to assess the effectiveness of defibrillation testing (DT) in patients undergoing implantable cardioverter-defibrillator (ICD) insertion. BACKGROUND: Although DT is considered a standard procedure during ICD implantation, its usefulness has not been definitively proven. METHODS: The SAFE-ICD (Safety of Two Strategies of ICD Management at Implantation) study is a prospective observational study designed to evaluate the outcome of 2 strategies: performing defibrillation testing (DT+) versus not performing defibrillation testing (DT-) during de novo ICD implants. No deviation from the centers' current practice was introduced. In all, 2,120 consecutive patients (836 DT+ and 1,284 DT-) age ?18 years were enrolled at 41 Italian centers from April 2008 to May 2009 and followed up for 24 months until June 2011. The primary endpoint was a composite of severe complications at ICD implant and sudden cardiac death or resuscitation at 2 years. RESULTS: The primary endpoint occurred in 34 patients: 12 intraoperative complications (8 in DT+ group; 4 in DT- group) and 22 during follow-up (10 in DT+ group; 12 in DT- group). Overall, the estimated yearly incidence (95% confidence interval) was DT+ 1.15% (0.73 to 1.83) and DT- 0.68% (0.42 to 1.12). The difference between the 2 groups was negligible: 0.47% per year (-0.15 to 1.10). Mortality from any cause was similar at 2 years (adjusted hazard ratio: 0.97 [0.76 to 1.23], p = 0.80). CONCLUSIONS: In this large cohort of new ICD implants, event rates were similar and extremely low in both groups. These data indicate a limited clinical relevance for DT testing, thus supporting a strategy of omitting DT during an ICD implant. (Safety of Two Strategies of ICD Management at Implantation [SAFE-ICD]; NCT00661037).

PMID: 22858384 [PubMed - as supplied by publisher]

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End-of-life Care in the ICU: Can We Simultaneously Increase Quality and Reduce Costs?

Am J Respir Crit Care Med Start a Discussion »

Aug 042012

End-of-life Care in the ICU: Can We Simultaneously Increase Quality and Reduce Costs?

Am J Respir Crit Care Med. 2012 Aug 2;

Authors: Curtis JR, Engelberg RA, Bensink ME, Ramsey SD

Abstract

The incidence and costs of critical illness are increasing in the US at a time when there is a focus both on limiting the rising costs of healthcare and improving the quality of end-of-life care. Over 25% of healthcare costs are spent in the last year of life and approximately 20% of deaths occur in the ICU. Consequently, there has been speculation that end-of-life care in the ICU represents an important target for cost savings. It is unclear whether efforts to improve end-of-life care in the ICU could significantly reduce healthcare costs. Here, we summarize recent studies suggesting that important opportunities may exist to improve quality and reduce costs through two mechanisms: advance care planning for patients with life-limiting illness and use of time-limited trials of ICU care for critically ill patients. The goal of these approaches is to ensure patients receive the intensity of care that they would choose at the end of life, given the opportunity to make an informed decision. Although these mechanisms hold promise for increasing quality and reducing costs, there are few clearly described, effective methods to implement these mechanisms in routine clinical practice. We believe basic science in communication and decision-making, implementation research, and demonstration projects are critically important if we are to translate these approaches into practice and, in so doing, provide high-quality and patient-centered care while limiting rising healthcare costs.

PMID: 22859524 [PubMed - as supplied by publisher]

Link to Article at PubMed

Unsuspected pulmonary embolism in patients with cancer.

Thromb Res Start a Discussion »

Aug 042012

Unsuspected pulmonary embolism in patients with cancer.

Thromb Res. 2012 Apr;129 Suppl 1:S16-9

Authors: Soler S, Delgado C, Ballaz A, Cisneros E, Malý R, Babalis D, Monréal M, RIETE Investigators

Abstract

BACKGROUND: The natural history of unsuspected pulmonary embolism (PE) in patients with cancer has not been thoroughly studied.

METHODS: We used the RIETE Registry data to compare the clinical characteristics, treatment strategies and outcome in cancer patients with unsuspected PE and in those presenting with symptomatic, acute PE.

RESULTS: Up to December 2011, 78 cancer patients with unsuspected PE and 1,994 with symptomatic PE had been enrolled. Patients with unsuspected PE more likely had colorectal cancer than those with symptomatic PE (28% vs. 13%), and less likely had prostate (3.8% vs. 10%) or hematologic (1.3% vs. 6.4%) cancer, or prior venous thromboembolism (3.8% vs. 12%). While the patients were receiving anticoagulant therapy, the incidence of PE recurrences (0% vs. 1.9%) or major bleeding (2.6% vs. 4.8%) were similar. After completion of anticoagulation, recurrent PE developed in 2.6% vs. 1.4% of patients, and major bleeding in 0% vs. 0.4%, respectively.

CONCLUSIONS: Our findings suggest that the clinical characteristics and outcome in cancer patients with unsuspected PE are quite similar to those in patients with symptomatic PE.

PMID: 22682127 [PubMed - in process]

Link to Article at PubMed

A Phase 2, randomized, partially blinded, active-controlled study assessing the efficacy and safety of variable anticoagulation reversal using the REG1 system in patients with acute coronary syndromes: results of the RADAR trial.

Eur Heart J Start a Discussion »

Aug 042012

A Phase 2, randomized, partially blinded, active-controlled study assessing the efficacy and safety of variable anticoagulation reversal using the REG1 system in patients with acute coronary syndromes: results of the RADAR trial.

Eur Heart J. 2012 Aug 2;

Authors: Povsic TJ, Vavalle JP, Aberle LH, Kasprzak JD, Cohen MG, Mehran R, Bode C, Buller CE, Montalescot G, Cornel JH, Rynkiewicz A, Ring ME, Zeymer U, Natarajan M, Delarche N, Zelenkofske SL, Becker RC, Alexander JH, on behalf of the RADAR Investigators

Abstract

AimsWe sought to determine the degree of anticoagulation reversal required to mitigate bleeding, and assess the feasibility of using pegnivacogin to prevent ischaemic events in acute coronary syndrome (ACS) patients managed with an early invasive approach. REG1 consists of pegnivacogin, an RNA aptamer selective factor IXa inhibitor, and its complementary controlling agent, anivamersen. REG1 has not been studied in invasively managed patients with ACS nor has an optimal level of reversal allowing safe sheath removal been defined.Methods and resultsNon-ST-elevation ACS patients (n = 640) with planned early cardiac catheterization via femoral access were randomized 2:1:1:2:2 to pegnivacogin with 25, 50, 75, or 100% anivamersen reversal or heparin. The primary endpoint was total ACUITY bleeding through 30 days. Secondary endpoints included major bleeding and the composite of death, myocardial infarction, urgent target vessel revascularization, or recurrent ischaemia. Enrolment in the 25% reversal arm was suspended after 41 patients. Enrolment was stopped after three patients experienced allergic-like reactions. Bleeding occurred in 65, 34, 35, 30, and 31% of REG1 patients with 25, 50, 75, and 100% reversal and heparin. Major bleeding occurred in 20, 11, 8, 7, and 10% of patients. Ischaemic events occurred in 3.0 and 5.7% of REG1 and heparin patients, respectively.ConclusionAt least 50% reversal is required to allow safe sheath removal after cardiac catheterization. REG1 appears a safe strategy to anticoagulate ACS patients managed invasively and warrants further investigation in adequately powered clinical trials of patients who require short-term high-intensity anticoagulation. Clinical Trials Registration: ClinicalTrials.gov NCT00932100.

PMID: 22859796 [PubMed - as supplied by publisher]

Link to Article at PubMed

Diagnosis of acute pyelonephritis with recent trends in management.

Nephrol Dial Transplant Start a Discussion »

Aug 042012

Diagnosis of acute pyelonephritis with recent trends in management.

Nephrol Dial Transplant. 2012 Aug 1;

Authors: Abraham G, Reddy YN, George G

PMID: 22859793 [PubMed - as supplied by publisher]

Link to Article at PubMed

August 2012
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