Month: May 2016

New Shelf Exams at Board Vitals

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​The National Board of Medical Examiners (NBME) Shelf Exams are now available to all current PCOM students and faculty. These test prep resources make it easier to comprehend the materials you’ll need to know to pass your exam. Simply sign up for any one of the exams, as well as study tips. The shelf exams are divided into 7 specific practice categories:

  • Neurology
  • OBGYN
  • Family medicine
  • Pediatrics
  • Internal medicine
  • Surgery
  • Psychiatry
Posted in Front Page, Library News, New Resources

Risk literacy in medical decision-making

Risk literacy in medical decision-making – How can we better represent the statistical structure of risk?

Imagine that you have received a positive result on a routine cancer screening test. Follow-up biopsies were inconclusive, and the decision to treat aggressively or monitor conservatively is yours. Consider the following information: 0.1% of the population has a terminal version of this form of cancer, 99% of those people will appear positive on the test you have been administered, and 5% of those without terminal cancer will still have a benign condition that tests positive. Given your test result, what is the probability that you have terminal cancer and should treat it aggressively? When judging risks and trying to predict the future, how should you decide? We need to better understand the structure of risks and how the human mind creates representations of risk and probability.

 

Posted in Hot Topics in Research, May, Research Commentary

Dietary patterns and the risk of major adverse cardiovascular events in a global study of high-risk patients with stable coronary heart disease

Dietary patterns and the risk of major adverse cardiovascular events in a global study of high-risk patients with stable coronary heart disease

Objectives To determine whether dietary pattern assessed by a simple self-administered food frequency questionnaire is associated with major adverse cardiovascular events (MACE) in high-risk patients with stable coronary artery disease.

Background A Mediterranean dietary pattern has been associated with lower cardiovascular (CV) mortality. It is less certain whether foods common in western diets are associated with CV risk.

Methods At baseline, 15 482 (97.8%) patients (mean age 67 ± 9 years) with stable coronary heart disease from 39 countries who participated in the Stabilisation of atherosclerotic plaque by initiation of darapladib therapy (STABILITY) trial completed a life style questionnaire which included questions on common foods. A Mediterranean diet score (MDS) was calculated for increasing consumption of whole grains, fruits, vegetables, legumes, fish, and alcohol, and for less meat, and a ‘Western diet score’ (WDS) for increasing consumption of refined grains, sweets and deserts, sugared drinks, and deep fried foods. A multi-variable Cox proportional hazards models assessed associations between MDS or WDS and MACE, defined as CV death, non-fatal myocardial infarction, or non-fatal stroke.

Results After a median follow-up of 3.7 years MACE occurred in 7.3% of 2885 subjects with an MDS ≥15, 10.5% of 4018 subjects with an MDS of 13–14, and 10.8% of 8579 subjects with an MDS ≤12. A one unit increase in MDS >12 was associated with lower MACE after adjusting for all covariates (+1 category HR 0.95, 95% CI 0.91, 0.98, P = 0.002). There was no association between WDS (adjusted model +1 category HR 0.99, 95% CI 0.97, 1.01) and MACE.

Conclusion Greater consumption of healthy foods may be more important for secondary prevention of coronary artery disease than avoidance of less healthy foods typical of Western diets.

 

 

Ralph A. H. Stewart1*, Lars Wallentin2, Jocelyne Benatar1, Nicolas Danchin3, Emil Hagstro¨m2, Claes Held2, Steen Husted4, Eva Lonn5, Amanda Stebbins6, Karen Chiswell6, Ola Vedin2, David Watson7, and Harvey D. White

Posted in Cardiology, coronary artery disease, Hot Topics in Research, May

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

BACKGROUND Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease.

METHODS In this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction.

RESULTS By 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003).

CONCLUSIONS In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.)

 

W.N. Kernan, C.M. Viscoli, K.L. Furie, L.H. Young, S.E. Inzucchi, M. Gorman, P.D. Guarino, A.M. Lovejoy, P.N. Peduzzi, R. Conwit, L.M. Brass,* G.G. Schwartz, H.P. Adams, Jr., L. Berger, A. Carolei, W. Clark, B. Coull, G.A. Ford, D. Kleindorfer, J.R. O’Leary, M.W. Parsons, P. Ringleb, S. Sen, J.D. Spence, D. Tanne, D. Wang, and T.R. Winder

 

N Engl J Med 2016;374:1321-31. DOI: 10.1056/NEJMoa1506930 Copyright © 2016 Massachusetts Medical Society

Posted in Cardiology, Hot Topics in Research, May

10 top patient safety issues for 2016

10 top patient safety issues for 2016

Healthcare has no doubt made giant strides in patient safety in recent years: According to an HHS report released in December, hospital-acquired condition rates dropped 17 percent from 2010 to 2014, leading to 87,000 fewer patient deaths in hospitals.

 

Becker’s Hospital Review,  January 12, 2016

Shannon Barnet, Max Green and Heather Punke

Posted in Hot Topics in Research, May, Research Commentary

Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery

Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery

 

Hospital readmission rates following surgery are increasingly being used as a marker of quality of care and are used in pay-for-performance metrics. To our knowledge, comprehensive data on readmissions to the initial hospital or a different hospital after emergency general surgery (EGS) procedures do not exist.

Objective  To define readmission rates and identify risk factors for readmission after common EGS procedures.

Design, Setting, and Participants  Patients undergoing EGS, as defined by the American Association for the Surgery of Trauma, were identified in the California State Inpatient Database (2007-2011) on January 15, 2015. Patients were 18 years and older. We identified the 5 most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Patient demographics (sex, age, race/ethnicity, and insurance type) as well as Charlson Comorbidity Index score, length of stay, complications, and discharge disposition were collected. Factors associated with readmission were determined using multivariate logistic regression models analysis.

Main Outcomes and Measures  Thirty-day hospital readmission.

Results  Among 177 511 patients meeting inclusion criteria, 57.1% were white, 48.8% were privately insured, and most were 45 years and older (51.3%). Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures. The overall 30-day readmission rate was 5.91%. Readmission rates ranged from 4.1% (upper gastrointestinal) to 16.8% (cardiothoracic). Of readmitted patients, 16.8% were readmitted at a different hospital. Predictors of readmission included Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio: 2.26 [95% CI, 2.14-2.39]), leaving against medical advice (adjusted odds ratio: 2.24 [95% CI, 1.89-2.66]), and public insurance (adusted odds ratio: 1.55 [95% CI, 1.47-1.64]). The most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%).

Conclusions and Relevance  Readmission after EGS procedures is common and varies widely depending on patient factors and diagnosis categories. One in 5 readmitted patients will go to a different hospital, causing fragmentation of care and potentially obscuring the utility of readmission as a quality metric. Assisting socially vulnerable patients and reducing postoperative complications, including infections, are targets to reduce readmissions.

Posted in Hot Topics in Research, May