An urgent matter-identifying your patients’ cardiovascular risk and improving their outcomes. Assessing cardiovascular risk one patient at a time.

J Fam Pract. 2009 Nov;58(11 Suppl Urgent):S26-31

Authors: Davidson MH

Given the Growing Prevalence of coronary heart disease (CHD) in the United States, risk assessment and reduction remain fundamental to family medicine practice. Risk assessment in cardiovascular disease is a constantly evolving field. The literature can be overwhelming; more than 4300 papers on the topic of CHD and risk were published in 2008 alone. Staying current with new, important developments in cardiovascular risk assessment clearly is challenging for most family physicians. Family physicians identify cardiac risk to prevent first cardiac events in their otherwise healthy patients and recurrent events in their patients with existing CHD. The first step in reaching primary prevention goals is to determine each individual patient’s 10-year risk of CHD. Risk assessment instruments traditionally have viewed low-density lipoprotein cholesterol (LDL-C) levels as a cornerstone of individual risk and a principal target for therapeutic intervention. Although risk assessment tools are helpful, many may not be useful to family physicians because they may be cumbersome, may measure individual risk components rather than global risk, and may require excessive time to complete. Nevertheless, some form of quantitative risk assessment is useful. Traditional global risk assessment instruments may underestimate risk, especially in asymptomatic patients with subclinical atherosclerosis. Emerging data about the role of biomarkers and the benefits of aggressive reduction in LDL-C suggest the need for a paradigm shift in risk attribution and intervention for primary care patients. Risk assessment strategies and new data about cardiovascular risk of interest to family physicians are presented here.

19891945

– An urgent matter-identifying your patients’ cardiovascular risk and improving their outcomes. Assessing cardiovascular risk…

Rimonabant for prevention of cardiovascular events (CRESCENDO): a randomised, multicentre, placebo-controlled trial.

Lancet. 2010 Aug 14;376(9740):517-23

Authors: Topol EJ, Bousser MG, Fox KA, Creager MA, Despres JP, Easton JD, Hamm CW, Montalescot G, Steg PG, Pearson TA, Cohen E, Gaudin C, Job B, Murphy JH, Bhatt DL,

BACKGROUND: Blockade of the endocannabinoid receptor reduces obesity and improves metabolic abnormalities such as triglycerides, HDL cholesterol, and fasting blood glucose. We assessed whether rimonabant would improve major vascular event-free survival. METHODS: This double-blind, placebo-controlled trial was undertaken in 974 hospitals in 42 countries. 18,695 patients with previously manifest or increased risk of vascular disease were randomly assigned to receive either rimonabant 20 mg (n=9381) or matching placebo (n=9314). Randomisation was stratified by centre, implemented with an independent interactive voice response system, and all study personnel and participants were masked to group assignment. The primary endpoint was the composite of cardiovascular death, myocardial infarction, or stroke, as determined via central adjudication. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00263042. FINDINGS: At a mean follow-up of 13.8 months (95% CI 13.6-14.0), the trial was prematurely discontinued because of concerns by health regulatory authorities in three countries about suicide in individuals receiving rimonabant. All randomised participants were analysed. At the close of the trial (Nov 6, 2008), the composite primary endpoint of cardiovascular death, myocardial infarction, or stroke occurred in 364 (3.9%) patients assigned to rimonabant and 375 (4.0%) assigned to placebo (hazard ratio 0.97, 95% CI 0.84-1.12, p=0.68). With rimonabant, gastrointestinal (3038 [33%] vs 2084 [22%]), neuropsychiatric (3028 [32%] vs 1989 [21%]), and serious psychiatric side-effects (232 [2.5%] vs 120 [1.3%]) were significantly increased compared with placebo. Four patients in the rimonabant group and one in the placebo group committed suicide. INTERPRETATION: The premature termination of this trial has important lessons for drug development. A drug that was being marketed for weight loss, but being tested for improving cardiovascular outcomes, induced a level of serious neuropsychiatric effects that was deemed unacceptable by regulatory authorities, and both the drug and the trial were abruptly terminated. FUNDING: Sanofi-Aventis.

20709233

– Rimonabant for prevention of cardiovascular events (CRESCENDO): a randomised, multicentre, placebo-controlled trial.

Practice implications of recent clinical trials for the prevention of acute kidney injury in cardiovascular surgery.

Hosp Pract (Minneap). 2010 Apr;38(2):67-73

Authors: Shimada M, Dass B, Dhatt GS, Alsabbagh MM, Asmar AR, Ather IM, Sharma R, Ejaz AA

Acute kidney injury in patients undergoing cardiovascular surgery is a complex problem with associated increased risks for dialysis, short- and long-term mortality, and progression to end-stage renal disease. Interventions to prevent and treat renal complications in this cohort have seldom been uniformly satisfactory due to the differences in strategies for intervention, drug doses and duration of treatment, baseline renal functions, and population studied. Nonetheless, significant advances have been made and include recognition of the effect of preexisting organ dysfunction on renal outcomes, reassessment of existing therapeutic interventions, and exploration of the feasibility of newer agents to prevent and treat acute kidney injury in cardiovascular surgery patients. This article briefly reviews several of these issues with an emphasis on recent clinical trials in this cohort.

20469615

– Practice implications of recent clinical trials for the prevention of acute kidney injury in cardiovascular surgery.

An urgent matter-identifying your patients’ cardiovascular risk and improving their outcomes. Low-density lipoprotein cholesterol and coronary heart disease: the importance of reaching target goals with statin therapy.

J Fam Pract. 2009 Nov;58(11 Suppl Urgent):S32-40

Authors: Lewis SJ

While Managing Acute-Care Issues, family physicians are challenged daily to recognize and treat modifiable risk factors for coronary heart disease (CHD) and to educate patients on the importance of risk reduction. Time constraints and the imperatives of immediate issues make the challenge of identification and treatment of CHD risk difficult. A stunning number of family medicine patients present with 1 or more of the following CHD risk factors: low-density lipoprotein cholesterol (LDL-C) =130 mg/dL (33% of American adults), total cholesterol =200 mg/dL (45%), hypertension (33%), tobacco use (21%), sedentary lifestyle (69%), excessive body weight (body mass index =25; 67%), diabetes (8%), or pre-diabetes (26%). The objective of comprehensive therapeutic interventions in CHD, from diet and lifestyle changes, to smoking cessation, to medications, is to prevent new (primary prevention) or recurrent (secondary prevention) cardiovascular events, with the ultimate goal of preventing disability and death. Family physicians have the distinct advantage of seeing patients’ health status from a global perspective, giving them a greater opportunity to recognize risk and initiate preventive interventions. Although therapeutic efforts have been directed traditionally at patients with established CHD and asymptomatic patients at high risk for cardiac events, new data are emerging that suggest that earlier, more aggressive treatment increases clinical benefit. This article (1) reviews the importance of reaching target goals for LDL-C and other biomarkers of risk in the primary and secondary prevention of CHD, and (2) addresses dosing issues and other practical methods of identifying and treating family medicine patients who are at risk.

19891946

– An urgent matter-identifying your patients’ cardiovascular risk and improving their outcomes. Low-density lipoprotein…

Pre-operative vitamin B infusion and prevention of nitrous oxide-induced homocysteine increase.

Anaesthesia. 2010 Jul;65(7):710-5

Authors: Rao LK, Francis AM, Wilcox U, Miller JP, Nagele P

SUMMARY: Nitrous oxide inactivates vitamin B(12) with detrimental consequences for folate and methionine metabolism, detectable by an increase in total plasma homocysteine. We hypothesised that a pre-operative vitamin B(12) and folate infusion prevents nitrous oxide-induced homocysteine increase. Sixty-three healthy patients having elective surgery were randomly allocated to receive either B-vitamin plus nitrous oxide; placebo plus nitrous oxide or placebo plus air. Fifty-nine patients completed the study. After intravenous B-vitamin infusion, plasma vitamin B(12) and folate concentrations increased 35-fold and 12-fold, respectively, on the first postoperative measurement. Patients who received B-vitamins developed a similar increase (18%) in homocysteine after nitrous oxide (1.9 micromolxl(-1); 95% CI 0.2-3.6 micromolxl(-1)) as those who did not (22%; 2.7 micromolxl(-1); 95% CI 0.6-4.8 micromolxl(-1)). Patients not receiving nitrous oxide had no homocysteine change (0.5 micromolxl(-1); 95% CI -0.8-1.9 micromolxl(-1)), indicating that pre-operative intravenous B-vitamins may not prevent nitrous oxide-induced hyperhomocysteinaemia.

20477781

– Pre-operative vitamin B infusion and prevention of nitrous oxide-induced homocysteine increase.

Cost-effectiveness of fracture prevention in men who receive androgen deprivation therapy for localized prostate cancer.

Ann Intern Med. 2010 May 18;152(10):621-9

Authors: Ito K, Elkin EB, Girotra M, Morris MJ

BACKGROUND: Androgen deprivation therapy (ADT) increases the risk for fractures in patients with prostate cancer. Objective: To assess the cost-effectiveness of measuring bone mineral density (BMD) before initiating ADT followed by alendronate therapy in men with localized prostate cancer. DESIGN: Markov state-transition model simulating the progression of prostate cancer and the incidence of hip fracture. DATA SOURCES: Published literature. TARGET POPULATION: A hypothetical cohort of men aged 70 years with locally advanced or high-risk localized prostate cancer starting a 2-year course of ADT after radiation therapy. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTION: No BMD test or alendronate therapy, a BMD test followed by selective alendronate therapy for patients with osteoporosis, or universal alendronate therapy without a BMD test. OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: The ICERs for the strategy of a BMD test and selective alendronate therapy for patients with osteoporosis and universal alendronate therapy without a BMD test were $66,800 per QALY gained and $178,700 per QALY gained, respectively. RESULTS OF SENSITIVITY ANALYSES: The ICER for universal alendronate therapy without a BMD test decreased to $100,000 per QALY gained, assuming older age, a history of fractures, lower mean BMD before ADT, or a lower cost of alendronate. LIMITATIONS: No evidence shows that alendronate reduces actual fracture rates in patients with prostate cancer who receive ADT. The model predicted fracture rates by using data on the surrogate BMD end point. CONCLUSION: In patients starting adjuvant ADT for locally advanced or high-risk localized prostate cancer, a BMD test followed by selective alendronate for those with osteoporosis is a cost-effective use of resources. Routine use of alendronate without a BMD test is justifiable in patients at higher risk for hip fractures.

20479027

– Cost-effectiveness of fracture prevention in men who receive androgen deprivation therapy for localized prostate cancer.

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

Pediatrics. 2010 Mar;125(3):539-46

Authors: Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR

OBJECTIVE: Poor communication and teamwork may contribute to errors during neonatal resuscitation. Our objective was to evaluate whether interns who received a 2-hour teamwork training intervention with the Neonatal Resuscitation Program (NRP) demonstrated more teamwork and higher quality resuscitations than control subjects. METHODS: Participants were noncertified 2007 and 2008 incoming interns for pediatrics, combined pediatrics and internal medicine, family medicine, emergency medicine, and obstetrics and gynecology (n = 98). Pediatrics and combined pediatrics/internal medicine interns were eligible for 6-month follow-up (n = 34). A randomized trial was conducted in which half of the participants in the team training arm practiced NRP skills by using high-fidelity simulators; the remaining practiced with low-fidelity simulators, as did control subjects. Blinded, trained observers viewed video recordings of high-fidelity-simulated resuscitations for teamwork and resuscitation quality. RESULTS: High-fidelity training (HFT) group had higher teamwork frequency than did control subjects (12.8 vs 9.0 behaviors per minute; P < .001). Intervention groups maintained more workload management (control subjects: 89.3%; low-fidelity training [LFT] group: 98.0% [P < .001]; HFT group: 98.8%; HFT group versus control subjects [P < .001]) and completed resuscitations faster (control subjects: 10.6 minutes; LFT group: 8.6 minutes [P = .040]; HFT group: 7.4 minutes; HFT group versus control subjects [P < .001]). Overall, intervention teams completed the resuscitation an average of 2.6 minutes faster than did control subjects, a time reduction of 24% (95% confidence interval: 12%-37%). Intervention groups demonstrated more frequent teamwork during 6-month follow-up resuscitations (11.8 vs 10.0 behaviors per minute; P = .030). CONCLUSIONS: Trained participants exhibited more frequent teamwork behaviors (especially the HFT group) and better workload management and completed the resuscitation more quickly than did control subjects. The impact on team behaviors persisted for at least 6 months. Incorporating team training into the NRP curriculum is a feasible and effective way to teach interns teamwork skills. It also improves simulated resuscitation quality by shortening the duration.

20156896

– Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

Medical decision making: guide to improved CPT coding.

South Med J. 2010 Apr;103(4):316-22

Authors: Holt J, Warsy A, Wright P

BACKGROUND: The Current Procedural Terminology (CPT) coding system for office visits, which has been in use since 1995, has not been well studied, but it is generally agreed that the system contains much room for error. In fact, the available literature suggests that only slightly more than half of physicians will agree on the same CPT code for a given visit, and only 60% of professional coders will agree on the same code for a particular visit. In addition, the criteria used to assign a code are often related to the amount of written documentation. The goal of this study was to evaluate two novel methods to assess if the most appropriate CPT code is used: the level of medical decision making, or the sum of all problems mentioned by the patient during the visit. METHODS: The authors-a professional coder, a residency faculty member, and a PGY-3 family medicine resident-reviewed 351 randomly selected visit notes from two residency programs in the Northeast Tennessee region for the level of documentation, the level of medical decision making, and the total number of problems addressed. The authors assigned appropriate CPT codes at each of those three levels. RESULTS: Substantial undercoding occurred at each of the three levels. Approximately 33% of visits were undercoded based on the written documentation. Approximately 50% of the visits were undercoded based on the level of documented medical decision making. Approximately 80% of the visits were undercoded based on the total number of problems which the patient presented during the visit. Interrater agreement was fair, and similar to that noted in other coding studies. CONCLUSIONS: Undercoding is not only common in a family medicine residency program but it also occurs at levels that would not be evident from a simple audit of the documentation on the visit note. Undercoding also occurs from not exploring problems mentioned by the patient and not documenting additional work that was performed. Family physicians may benefit from minor alterations in their documentation of office visit notes.

20224505

– Medical decision making: guide to improved CPT coding.

Prevention of atrial fibrillation by Renin-Angiotensin system inhibition a meta-analysis.

J Am Coll Cardiol. 2010 May 25;55(21):2299-307

Authors: Schneider MP, Hua TA, Böhm M, Wachtell K, Kjeldsen SE, Schmieder RE

OBJECTIVES: The authors reviewed published clinical trial data on the effects of renin-angiotensin system (RAS) inhibition for the prevention of atrial fibrillation (AF), aiming to define when RAS inhibition is most effective. BACKGROUND: Individual studies examining the effects of RAS inhibition on AF prevention have reported controversial results. METHODS: All published randomized controlled trials reporting the effects of treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in the primary or secondary prevention of AF were included. RESULTS: A total of 23 randomized controlled trials with 87,048 patients were analyzed. In primary prevention, 6 trials in hypertension, 2 trials in myocardial infarction, and 3 trials in heart failure were included (some being post-hoc analyses of randomized controlled trials). In secondary prevention, 8 trials after cardioversion and 4 trials assessing the medical prevention of recurrence were included. Overall, RAS inhibition reduced the odds ratio for AF by 33% (p < 0.00001), but there was substantial heterogeneity among trials. In primary prevention, RAS inhibition was effective in patients with heart failure and those with hypertension and left ventricular hypertrophy but not in post-myocardial infarction patients overall. In secondary prevention, RAS inhibition was often administered in addition to antiarrhythmic drugs, including amiodarone, further reducing the odds for AF recurrence after cardioversion by 45% (p = 0.01) and in patients on medical therapy by 63% (p < 0.00001). CONCLUSIONS: This analysis supports the concept of RAS inhibition as an emerging treatment for the primary and secondary prevention of AF but acknowledges the fact that some of the primary prevention trials were post-hoc analyses. Further areas of uncertainty include potential differences among specific RAS inhibitors and possible interactions or synergistic effects with antiarrhythmic drugs.

20488299

– Prevention of atrial fibrillation by Renin-Angiotensin system inhibition a meta-analysis.

Prevention of drowning.

Pediatrics. 2010 Jul;126(1):e253-62

Authors: Weiss J,

Drowning is a leading cause of injury-related death in children. In 2006, approximately 1100 US children younger than 20 years died from drowning. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning.

20498167

– Prevention of drowning.

Acute radiation syndrome: assessment and management.

South Med J. 2010 Jun;103(6):541-6

Authors: Donnelly EH, Nemhauser JB, Smith JM, Kazzi ZN, Farfán EB, Chang AS, Naeem SF

Primary care physicians may be unprepared to diagnose and treat rare, yet potentially fatal, illnesses such as acute radiation syndrome (ARS). ARS, also known as radiation sickness, is caused by exposure to a high dose of penetrating, ionizing radiation over a short period of time. The time to onset of ARS is dependent on the dose received, but even at the lowest doses capable of causing illness, this will occur within a matter of hours to days. This article describes the clinical manifestations of ARS, provides guidelines for assessing its severity, and makes recommendations for managing ARS victims.

20710137

– Acute radiation syndrome: assessment and management.

Provider knowledge, attitudes, and treatment preferences for early pregnancy failure.

Am J Obstet Gynecol. 2010 Jun;202(6):531.e1-8

Authors: Dalton VK, Harris LH, Gold KJ, Kane-Low L, Schulkin J, Guire K, Fendrick AM

OBJECTIVE: We sought to describe health care provider knowledge, attitudes, and treatment preferences for early pregnancy failure (EPF). STUDY DESIGN: We surveyed 976 obstetrician/gynecologists, midwives, and family medicine practitioners on their knowledge and attitudes toward treatment options for EPF, and barriers to adopting misoprostol and office uterine evacuations. We used descriptive statistics to compare practices by provider specialty and logistic regression to identify associations between provider factors and treatment practices. RESULTS: Seventy percent of providers have not used misoprostol and 91% have not used an office uterine evacuation to treat EPF in the past 6 months. Beliefs about safety and patient preferences, and prior induced abortion training were significantly associated with use of both of these treatments. CONCLUSION: Increasing education and training on the use of misoprostol and office uterine evacuation, and clarifying patient treatment preferences may increase the willingness of providers to adopt new practices for EPF treatment.

20227674

– Provider knowledge, attitudes, and treatment preferences for early pregnancy failure.

Recommendations for the prevention of Streptococcus pneumoniae infections in infants and children: use of 13-valent pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23).

Pediatrics. 2010 Jul;126(1):186-90

Authors:

Routine use of the 7-valent pneumococcal conjugate vaccine (PCV7), available since 2000, has resulted in a dramatic reduction in the incidence of invasive pneumococcal disease (IPD) attributable to serotypes of Streptococcus pneumoniae contained in the vaccine. However, IPD caused by nonvaccine pneumococcal serotypes has increased, and nonvaccine serotypes are now responsible for the majority of the remaining cases of IPD occurring in children. A 13-valent pneumococcal conjugate vaccine has been licensed by the US Food and Drug Administration, which, in addition to the 7 serotypes included in the original PCV7, contains the 6 pneumococcal serotypes responsible for 63% of IPD cases now occurring in children younger than 5 years. Because of the expanded coverage provided by PCV13, it will replace PCV7. This statement provides recommendations for (1) the transition from PCV7 to PCV13; (2) the routine use of PCV13 for healthy children and children with an underlying medical condition that increases the risk of IPD; (3) a supplemental dose of PCV13 for (a) healthy children 14 through 59 months of age who have completed the PCV7 series and (b) children 14 through 71 months of age with an underlying medical condition that increases the risk of IPD who have completed the PCV7 series; (4) “catch-up” immunization for children behind schedule; and (5) PCV13 for certain children at high risk from 6 through 18 years of age. In addition, recommendations for the use of pneumococcal polysaccharide vaccine for children at high risk of IPD are also updated.

20498180

– Recommendations for the prevention of Streptococcus pneumoniae infections in infants and children: use of 13-valent…

Status of asthma control in pediatric primary care: results from the pediatric Asthma Control Characteristics and Prevalence Survey Study (ACCESS).

J Pediatr. 2010 Aug;157(2):276-281.e3

Authors: Liu AH, Gilsenan AW, Stanford RH, Lincourt W, Ziemiecki R, Ortega H

OBJECTIVE: To estimate the prevalence of uncontrolled asthma in pediatric patients with asthma visiting their primary care provider for any medical reason. STUDY DESIGN: This was a cross-sectional survey conducted at 29 pediatric care sites across the United States. Children age 4-17 years with self- or caregiver-reported asthma completed the Childhood Asthma Control Test (C-ACT) or the Asthma Control Test (ACT) and responded to demographic and health-related questions. Uncontrolled asthma was defined as a C-ACT or ACT score

20472251

– Status of asthma control in pediatric primary care: results from the pediatric Asthma Control Characteristics and Prevalence…

Adherence to perinatal group B streptococcal prevention guidelines.

Obstet Gynecol. 2010 Jun;115(6):1217-24

Authors: Goins WP, Talbot TR, Schaffner W, Edwards KM, Craig AS, Schrag SJ, Van Dyke MK, Griffin MR

OBJECTIVE: To estimate compliance with the 2002 revised perinatal group B streptococci (GBS) prevention guidelines in Tennessee, which recommend universal GBS screening of pregnant women at 35-37 weeks of gestation and, when indicated, administration of intrapartum chemoprophylaxis. METHODS: Active Bacterial Core surveillance conducts active, population-based surveillance for invasive GBS disease in 11 Tennessee counties. A retrospective case-cohort study was conducted using a stratified random sample of all live births in surveillance hospitals during 2003-2004, including all early-onset GBS cases. Factors associated with GBS screening and lack of optimal GBS chemoprophylaxis were analyzed using logistic regression. RESULTS: Screening was performed for 84.7% of pregnant women, but 26.3% of prenatal tests with documented test dates were performed before 35 weeks of gestation. Among women with an indication for GBS prophylaxis, 61.2% received optimal chemoprophylaxis, defined as initiation of a recommended antibiotic 4 hours or more before delivery. When the analysis was restricted to women who were admitted 4 hours or more before delivery, 70.9% received optimal chemoprophylaxis. Women not receiving optimal chemoprophylaxis were more likely to have penicillin allergy (11.7% compared with 2.5%, adjusted odds ratio [OR] 8.58, 95% confidence interval [CI] 1.57-47.04) or preterm delivery (45.5% compared with 13.2%, adjusted OR 5.52, 95% CI 2.29-13.30) and were less likely to have received the recommended prenatal serologic testing for other infectious diseases (77.9% compared with 91.1%, adjusted OR 0.30, 95% CI 0.09-0.98). Forty cases of early-onset GBS were identified (0.36 per 1,000 live births); 25% of these neonates were born to women who received screening at 35 weeks of gestation or later and, when indicated, optimal chemoprophylaxis. CONCLUSION: Universal prenatal GBS screening was implemented widely in Tennessee, although the timing of screening and administration of chemoprophylaxis often were not optimal. A substantial burden of early-onset GBS disease occurs despite optimal prenatal screening and chemoprophylaxis, suggesting that alternative strategies, such as vaccination, are needed. LEVEL OF EVIDENCE: II.

20502293

– Adherence to perinatal group B streptococcal prevention guidelines.

Attributes affecting the medical school primary care experience.

Acad Med. 2010 Apr;85(4):605-13

Authors: Jerant A, Srinivasan M, Bertakis KD, Azari R, Pan RJ, Kravitz RL

PURPOSE: Favorable primary care (PC) experiences might encourage more medical students to pursue generalist careers, yet academicians know little about which attributes influence the medical school PC experience. The authors sought to identify such attributes and weight their importance. METHOD: Semistructured interviews with 16 academic generalist leaders of family medicine, general internal medicine, and general pediatrics led to the development of a Web-based survey, administered to a national sample of 126 generalist faculty. Survey respondents rated (on a nine-point Likert-like scale) the importance of each interview-generated PC medical school attribute and indicated (yes/no) whether outside experts’ assessment of the attributes would be valid. The authors assessed interrater agreement. RESULTS: Interview thematic analysis generated 58 institutional attributes in four categories: informal curriculum (23), institutional infrastructure (6), educational/curricular infrastructure (6), and specific educational experiences (23). Of these 58, 31 (53%) had median importance ratings of >7 (highly important). For 14 of these (45%), more than two-thirds of respondents indicated external expert surveys would provide a valid assessment. Of the 23 informal curriculum attributes, 20 (87%) received highly important ratings; however, more than two-thirds of respondents believed that external expert survey ratings would be valid for only 4 (20%) of them. Strong agreement occurred among respondents across the generalist fields. CONCLUSIONS: Academic generalist educators identified several attributes as highly important in shaping the quality of the medical school PC experience. Informal curriculum attributes appeared particularly influential, but these attributes may not be validly assessed via expert surveys, suggesting the need for other measures.

20354375

– Attributes affecting the medical school primary care experience.

Development of an evidence-based pressure ulcer program at the National Naval Medical Center: nurses’ role in risk factor assessment, prevention, and intervention among young service members returning from OIF/OEF.

Nurs Clin North Am. 2010 Jun;45(2):153-68

Authors: Crumbley DR, Kane MA

Since the beginning of the wars in Iraq and Afghanistan, the incidence of pressure ulcers from various causes has increased. This article discusses the knowledge nurses need to care for casualties returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) who may be at risk for developing pressure ulcers. This article also describes the development of an evidence-based pressure ulcer awareness program for young adults aged 18 to 35 years at a military treatment facility that receives casualties from OIF/OEF. This evidence-based program enables nurses to rapidly assess casualties for risk factors and initiate nursing interventions to mitigate the development of pressure ulcers. Improving the detection of pressure ulcers among the young OIF and OEF casualties may, in turn, reduce mortality and morbidity among these service members.

20510701

– Development of an evidence-based pressure ulcer program at the National Naval Medical Center: nurses’ role in risk factor…

The development and validation of a brief performance-based fall risk assessment tool for use in primary care.

J Gerontol A Biol Sci Med Sci. 2010 Aug;65(8):896-903

Authors: Tiedemann A, Lord SR, Sherrington C

BACKGROUND: To report the development, external validity, reliability, and feasibility of a falls risk assessment tool for use in primary care. METHODS: Two prospective cohort studies, a test-retest reliability study, and a feasibility study were included. Seven hundred and sixty four older community-living people (mean age = 75.3 years, SD = 5.8) participated in the tool development study, 362 people (mean age = 80.25 years, SD = 4.5) participated in the external validation study, 30 older people took part in the test-retest reliability study, and 32 clinicians participated in the feasibility study. RESULTS: The fall risk assessment score (number of risk factors) displayed a good ability to discriminate between multiple fallers (those who experienced two or more falls) and non-multiple fallers in the external validation study (area under the receiver operating characteristic curve = 0.72, 95% confidence interval = 0.66-0.79). Each of the performance items; low contrast visual acuity, tactile sensitivity, sit to stand, alternate step, and near tandem stand ability; and measures of previous falls and medications could discriminate between prospectively categorized multiple fallers and non-multiple fallers with relative risk values ranging from 1.4 to 2.4 in the development study. The probability of future multiple falls increased from 7% with the identification of zero or one risk factor up to a probability of 49% with the identification of six or more risk factors. The assessment items exhibited moderate to excellent test-retest reliability and a high degree of acceptance by health professionals. CONCLUSION: The assessment tool is an externally validated, reliable, and feasible falls risk assessment that can accurately predict multiple falls and assist with guiding interventions in community living older people.

20522529

– The development and validation of a brief performance-based fall risk assessment tool for use in primary care.

The phosphodiesterase inhibitor cilostazol induces regression of carotid atherosclerosis in subjects with type 2 diabetes mellitus: principal results of the Diabetic Atherosclerosis Prevention by Cilostazol (DAPC) study: a randomized trial.

Circulation. 2010 Jun 15;121(23):2584-91

Authors: Katakami N, Kim YS, Kawamori R, Yamasaki Y

BACKGROUND: Antiplatelet drugs are effective in preventing recurrence of atherosclerosis in type 2 diabetic patients. However, the efficacy and usefulness of 2 different antiplatelet drugs, aspirin and cilostazol, in the progression of carotid intima-media thickening are unknown. METHODS AND RESULTS: To compare prevention by cilostazol and aspirin of progression of atherosclerosis, we conducted a prospective, randomized, open, blinded end point study in 4 East Asian countries. A total of 329 type 2 diabetic patients suspected of peripheral artery disease were allocated to either an aspirin-treated (81 to 100 mg/d) group or a cilostazol-treated (100 to 200 mg/d) group. The changes in intima-media thickness of the common carotid artery during a 2-year observation period were examined as the primary end point. The regression in maximum left, maximum right, mean left, and mean right common carotid artery intima-media thickness was significantly greater with cilostazol compared with aspirin (-0.088 + or – 0.260 versus 0.059 + or – 0.275 mm, P<0.001; -0.042 + or - 0.274 versus 0.045 + or - 0.216 mm, P=0.003; -0.043 + or - 0.182 versus 0.028 + or - 0.202 mm, P=0.004; and -0.024 + or - 0.182 versus 0.048 + or - 0.169 mm, P<0.001). In a regression analysis adjusted for possible confounding factors such as lipid levels and hemoglobin A(1c), the improvements in common carotid artery intima-media thickness with cilostazol treatment over aspirin treatment remained significant. CONCLUSIONS: Compared with aspirin, cilostazol potently inhibited progression of carotid intima-media thickness, an established surrogate marker of cardiovascular events, in patients with type 2 diabetes mellitus. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: C000000215.

20516379

– The phosphodiesterase inhibitor cilostazol induces regression of carotid atherosclerosis in subjects with type 2 diabetes…

Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals: advocacy or evidence-based practice?

Ann Intern Med. 2010 Jul 6;153(1):40-3

Authors: Saitz R

The Joint Commission recently proposed candidate performance measures addressing unhealthy substance use in hospitalized patients. The proposed measures of screening and brief intervention (SBI) assume that interventions that work in one setting (primary care outpatient practice) would work in another (hospital); treatment would have the same benefits for persons identified by screening as for those with symptoms who seek help; treatments that work for persons less severely affected by substance use would also work for those with more severe illness; and an approach that works for nondependent, unhealthy alcohol use would work for drug use. However, these assumptions extrapolate evidence of the effectiveness of SBI for primary care outpatients with nondependent, unhealthy alcohol use to the inpatient setting, persons with dependence, and other substances. Although quality of care for unhealthy substance use in all medical settings needs to improve, the evidence base for SBI in the hospital is too limited for the implementation of performance measures assessing this care.

20621901

– Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals: advocacy or…

Core clerkship directors: their current resources and the rewards of the role.

Acad Med. 2010 Apr;85(4):710-5

Authors: Ephgrave K, Margo KL, White C, Hammoud M, Brodkey A, Painter T, Juel VC, Shaw D, Ferguson K

PURPOSE: To conduct a national multidisciplinary investigation assessing core clinical clerkships and their directors, variances in resources from national guidelines, and the impact of the clerkship director role on faculty members’ academic productivity, advancement, and satisfaction. METHOD: A multidisciplinary working group of the Alliance for Clinical Education (ACE), representing all seven core clinical disciplines, created and distributed a survey to clerkship directors at 125 U.S. MD-granting medical schools, in academic year 2006-2007. RESULTS: A total of 544 clerkship directors from Internal Medicine (96), Family Medicine (91), Psychiatry, (91), Pediatrics (79), Surgery (71), Neurology (60), and Obstetrics-Gynecology (56) responded, representing over 60% of U.S. core clinical clerkships. The clerkship directors were similar across disciplines in demographics and academic productivity, though clinical and clerkship activities varied. Departmental staff support for clerkships averaged 0.69 people, distinctly less than the ACE’s 2003 guideline of a full-time coordinator in all disciplines’ clerkships. Clerkship directors reported heavy clinical responsibilities, which, as in previous studies, were negatively related to academic productivity. However, many clerkship directors felt the role enhanced their academic advancement; a large majority felt it significantly enhanced their career satisfaction. CONCLUSIONS: The resources and rewards of the clerkship director role were similar across disciplines. Expectations of clerkship directors were considerable, including responsibility for clinical material and the learning environment. Resources for many fall short of those stated in the ACE guidelines, particularly regarding support staff. However, the findings indicate that the clerkship director role can have benefits for academic advancement and strongly enhances career satisfaction.

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– Core clerkship directors: their current resources and the rewards of the role.

Variables associated with full-time faculty appointment among contemporary U.S. Medical school graduates: implications for academic medicine workforce diversity.

Acad Med. 2010 Jul;85(7):1250-7

Authors: Andriole DA, Jeffe DB, Hageman HL, Ephgrave K, Lypson ML, Mavis B, McDougle L, Roberts NK

PURPOSE: The authors sought to identify variables independently associated with full-time faculty appointment among recent medical graduates. METHOD: With institutional review board approval, the authors developed a database of individualized records for six midwestern medical schools’ 1997-2002 graduates. Using multivariate logistic regression, they identified variables independently associated with full-time faculty appointment from among demographic, medical-school-related, and career-intention variables. They report adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Of 1,965 graduates in the sample, 263 (13.4%) held full-time faculty appointments in 2007-2008, including 14.4% (123/853) of women graduates and 8.6% (17/198) of underrepresented minority (URM) graduates. Women (OR: 1.386; 95% CI: 1.023-1.878), MD/PhD program graduates (OR: 2.331; 95% CI: 1.160-4.683), and graduates who reported a career-setting preference for “full-time university faculty” on the Association of American Medical Colleges’ Graduation Questionnaire (OR: 3.164; 95% CI: 2.231-4.486) were more likely to have a full-time faculty appointment. Graduates who chose family medicine (OR: 0.433; 95% CI: 0.231-0.811) and surgical specialties (OR: 0.497; 95% CI: 0.249-0.994) were less likely to have a full-time faculty appointment. URM race/ethnicity was not independently associated with full-time faculty appointment (OR: 0.788; 95% CI: 0.452-1.375). CONCLUSIONS: Efforts to increase representation of women graduates in academic medicine seem to have met with greater success than efforts to increase representation of URM graduates. Greater participation of URM students in MD/PhD programs and in interventions during medical school that promote interest in academic medicine careers may increase URM graduates’ representation in academic medicine.

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– Variables associated with full-time faculty appointment among contemporary U.S. Medical school graduates: implications for…

Knowledge of interim recommendations and use of Hib vaccine during vaccine shortages.

Pediatrics. 2010 May;125(5):914-20

Authors: Kempe A, Babbel C, Wallace GS, Stokley S, Daley MF, Crane LA, Beaty B, Black SR, Barrow J, Dickinson LM

OBJECTIVES: The goals were to determine among pediatricians and family physicians (1) knowledge of interim recommendations regarding Haemophilus influenzae type b (Hib) vaccine administration, (2) current practices, and (3) factors associated with nonadherence. METHODS: An Internet-based survey was conducted in April 2008 among national samples. RESULTS: Response rates were 68% (220 of 325 physicians) among pediatricians and 51% (153 of 302 physicians) among family physicians. Seventy-three percent of pediatricians and 45% of family medicine physicians reported insufficient Hib vaccine supplies, and 22% to 24% reported having to defer doses for infants 2 to 6 months of age > or =10% of the time. Ninety-eight percent of pediatricians and 81% of family physicians were aware of the interim recommendations (P < or = .0001), and virtually all knew that the booster dose should be deferred; however, 22% of pediatricians and 33% of family medicine physicians reported not deferring this dose. Physicians in both specialties were less likely to adhere to recommendations to defer in this age group if they thought that their practice had sufficient vaccine supplies (pediatricians, odds ratio: 0.01 [95% confidence interval: 0.003-0.03]; family medicine physicians, odds ratio: 0.10 [95% confidence interval: 0.03-0.33]). Family medicine physicians were less likely to adhere to recommendations if they had not heard about the interim recommendations (odds ratio: 0.04 [95% confidence interval: 0.01-0.21]). CONCLUSIONS: Most primary care physicians experienced Hib vaccine shortages, and many have had to defer doses for 2- to 6-month-old children. Most are knowledgeable regarding interim recommendations, but one-fifth to one-third reported nonadherence.

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– Knowledge of interim recommendations and use of Hib vaccine during vaccine shortages.

Contextual errors and failures in individualizing patient care: a multicenter study.

Ann Intern Med. 2010 Jul 20;153(2):69-75

Authors: Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Schapira MM, Persell SD, Jacobs E, Abrams RI

BACKGROUND: A contextual error occurs when a physician overlooks elements of a patient’s environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care. OBJECTIVE: To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes. DESIGN: An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. SETTING: 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities. MEASUREMENTS: Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans. RESULTS: Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters. Limitations: Only 4 case scenarios were used. The study assessed physicians’ propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context. CONCLUSION: Inattention to contextual information, such as a patient’s transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs Health Services Research and Development Service

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– Contextual errors and failures in individualizing patient care: a multicenter study.

Systematic review: factors associated with risk for and possible prevention of cognitive decline in later life.

Ann Intern Med. 2010 Aug 3;153(3):182-93

Authors: Plassman BL, Williams JW, Burke JR, Holsinger T, Benjamin S

BACKGROUND: Many biological, behavioral, social, and environmental factors may contribute to the delay or prevention of cognitive decline. PURPOSE: To summarize evidence about putative risk and protective factors for cognitive decline in older adults and the effects of interventions for preserving cognition. DATA SOURCES: English-language publications in MEDLINE, HuGEpedia, AlzGene, and the Cochrane Database of Systematic Reviews from 1984 through 27 October 2009. STUDY SELECTION: Observational studies with 300 or more participants and randomized, controlled trials (RCTs) with 50 or more adult participants who were 50 years or older, drawn from general populations, and followed for at least 1 year were included. Relevant, good-quality systematic reviews were also eligible. DATA EXTRACTION: Information on study design, outcomes, and quality were extracted by one researcher and verified by another. An overall rating of the quality of evidence was assigned by using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. DATA SYNTHESIS: 127 observational studies, 22 RCTs, and 16 systematic reviews were reviewed in the areas of nutritional factors; medical factors and medications; social, economic, or behavioral factors; toxic environmental exposures; and genetics. Few of the factors had sufficient evidence to support an association with cognitive decline. On the basis of observational studies, evidence that supported the benefits of selected nutritional factors or cognitive, physical, or other leisure activities was limited. Current tobacco use, the apolipoprotein E epsilon4 genotype, and certain medical conditions were associated with increased risk. One RCT found a small, sustained benefit from cognitive training (high quality of evidence) and a small RCT reported that physical exercise helps to maintain cognitive function. LIMITATIONS: The categorization and definition of exposures were heterogeneous. Few studies were designed a priori to assess associations between specific exposures and cognitive decline. The review included only English-language studies, prioritized categorical outcomes, and excluded small studies. CONCLUSION: Few potentially beneficial factors were identified from the evidence on risk or protective factors associated with cognitive decline, but the overall quality of the evidence was low. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality and the National Institute on Aging, through the Office of Medical Applications of Research, National Institutes of Health.

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– Systematic review: factors associated with risk for and possible prevention of cognitive decline in later life.