Anita Kurt

Comparison of 12-hour Urine Protein and Protein: Creatinine Ratio with 24-hour Urine Protein for the Diagnosis of Preeclampsia

OBJECTIVE The purpose of this study was to evaluate the performance of the 12-hour urine protein >165 mg and protein:creatinine ratio >0.15 for the prediction of 24-hour urine protein of ≥300 mg in patients with suspected preeclampsia. STUDY DESIGN We performed a prospective observational study of 90 women who had been admitted with suspected preeclampsia. Protein:creatinine ratio and 12- and 24-hour urine specimens were collected for each patient. Test characteristics for the identification of 24-hour urine protein ≥300 mg were calculated. RESULTS A 12-hour urine protein >165 mg and protein:creatinine ratio of >0.15 correlated significantly with 24-hour urine protein ≥300 mg (r = 0.99; P < .001; and r = 0.54; P < .001, respectively). A 12-hour urine protein >165 mg performed better than protein:creatinine ratio as a predictor of a 24-hour urine protein ≥300 mg (sensitivity, 96% and 89%; specificity, 100% and 49%; positive predictive value, 100% and 32%; negative predictive value, 98% and 91%, respectively). CONCLUSION The high correlation of a 12-hour urine protein >165 mg with a 24-hour urine protein ≥300 mg (with the benefit of a shorter evaluation time) and the high negative predictive value of protein:creatinine ratio suggest that the use of both these tests have a role in the evaluation and treatment of women with suspected preeclampsia.

Factors Influencing Participation in Clinical Trials: Emergency Medicine vs. Other Specialties.

Introduction This study investigated factors that influence emergency medicine (EM) patients’ decisions to participate in clinical trials and whether the impact of these factors differs from those of other medical specialties. Methods A survey was distributed in EM, family medicine (FM), infectious disease (ID), and obstetrics/gynecology (OB/GYN) outpatient waiting areas. Eligibility criteria included those who were 18 years of age or older, active patients on the day of the survey, and able to complete the survey without assistance. We used the Kruskal-Wallis test and ordinal logistic regression analyses to identify differences in participants’ responses. Results A total of 2,893 eligible subjects were approached, and we included 1,841 surveys in the final analysis. Statistically significant differences (p≤0.009) were found for eight of the ten motivating factors between EM and one or more of the other specialties. Regardless of a patient’s gender, race, and education, the relationship with their doctor was more motivating to patients seen in other specialties than to EM patients (FM [odds ratio {OR}:1.752, 95% confidence interval {CI}{1.285–2.389}], ID [OR:3.281, 95% CI{2.293–4.695}], and OB/GYN [OR:2.408, 95% CI{1.741–3.330}]). EM’s rankings of “how well the research was explained” and whether “the knowledge learned would benefit others” as their top two motivating factors were similar across other specialties. All nine barriers showed statistically significant differences (p≤0.008) between EM and one or more other specialties. Participants from all specialties indicated “risk of unknown side effects” as their strongest barrier. Regardless of the patients’ race, “time commitment” was considered to be more of a barrier to other specialties when compared to EM (FM [OR:1.613, 95% CI{1.218–2.136}], ID [OR:1.340, 95% CI{1.006–1.784}], or OB/GYN [OR:1.901, 95% CI{1.431–2.526}]). Among the six resources assessed that help patients decide whether to participate in a clinical trial, only one scored statistically significantly different for EM (p<0.001). EM patients ranked “having all material provided in my own language” as the most helpful resource. Conclusion There are significant differences between EM patients and those of other specialties in the factors that influence their participation in clinical trials. Providing material in the patient’s own language, explaining the study well, and elucidating how their participation might benefit others in the future may help to improve enrollment in EM-based clinical trials.

Effect of Triage-Based Use of the Ottawa Foot and Ankle Rules on the Number of Orders for Radiographic Imaging

CONTEXT Reducing unnecessary testing lessens the cost burden of medical care, but decreasing use depends on consistently following evidence-based clinical decision rules. The Ottawa foot and ankle rules (OFARs) are validated, longstanding evidence-based guidelines to predict fractures. Frequently, radiography is automatically ordered for acute ankle injuries despite findings from OFARs suggesting no fracture. OBJECTIVES First, to determine whether implementation of protocol-driven use of the OFARs at triage would decrease the number of radiography orders and length of stay (LOS) in the emergency department. Second, to quantify the incidence of OFARs use at triage and to assess patient expectations of radiography use and patient satisfaction as rated by both patients and clinicians. METHODS In this prospective, 2-stage sequential pilot study, patients with acute ankle and foot injuries were screened in the emergency department between January 2013 and October 2013. In the first stage, clinicians (physician assistants, residents, and attending physicians) performed their usual practice habits for radiography use in the control group. For the second stage, they were educated to appropriately apply the OFARs before ordering radiography. For patients who were suspected of having a fracture at triage, nursing staff ordered radiography. For patients who were not suspected of having a fracture at triage, a clinician reassessed them using the OFARs after their triage assessment. Radiography was then ordered at the discretion of the clinician. Results gathered after training in the OFARs comprised the intervention group. After discharge, patients were surveyed regarding their expectations and satisfaction, and clinicians were surveyed on their perceptions of patient satisfaction. RESULTS A total of 131 patients were screened, 62 patients were enrolled in the study after consent was obtained, and 2 patients withdrew from the study prematurely, leaving 30 patients in each group. Fifty-eight of the 60 patients (97%) underwent radiography. Emergency department LOS decreased from 103 minutes to 96.5 minutes (P=.297) after the OFARs were applied. There was also a decrease in LOS in patients with a fracture (137 minutes vs 103 minutes [P=.112]). Radiography was expected to be ordered by 27 of 30 patients in the control group (90%) and 24 of 30 in the intervention group (80%) (P=.472). Patients were equally satisfied among the groups (54 of 60 [90%]) (with no difference between groups), and 27 of 30 (90%) vs 30 of 30 (100%) clinicians in the control and intervention groups, respectively, perceived that patients were satisfied with their treatment. CONCLUSION There was no statistical evidence that application of the OFARs decreases the number of imaging orders or decreases LOS. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

Impact of Race Versus Education and Race Versus Income on Patients’ Motivation to Participate in Clinical Trials

Our study investigates whether levels of motivation and barriers to participation in clinical trials vary with patients’ education and income. A self-administered survey asked outpatients to rank potential influential factors on a “0” to “4” significance scale for their motivation to participate in clinical trials. Principal component analysis (PCA), analysis of variance (ANOVA), Kruskal-Wallis, and Mann-Whitney U tests analyzed the impact of race, education, and income on their motivation to participate. Analysis included 1841 surveys; most respondents had a high school education or some college, and listed annual income < 

Characteristics of participants in peripartum interventional research

30,000. There was a significant interaction between race and income on our motivation scale 1 scores (p = .0261). Compared with their counterparts, subjects with less education/lower income ranked monetary compensation (p = .0420 and p < .0001, respectively) as a higher motivator. Minorities and patients with less education and lower income appear to be more influenced by their desire to please the doctor, the race and sex of the doctor, and the language spoken by the doctor being the same as theirs. For all races, education appeared to have a direct relationship with motivation to participate, except for African-Americans, whose motivation appeared to decline with more education. Income appeared to have an inverse relationship with motivation to participate for all races.

Racial Differences Among Factors Associated with Participation in Clinical Research Trials

Abstract Objective: To identify characteristics of pregnant women potentially influencing the decision to participate in peripartum interventional research. Methods: Women screened as eligible to participate in two prospective interventional trials conducted in the labor and delivery unit at a single center were included. Characteristics of eligible women were compared based on their decision whether to participate or not. The best predictors of research participation were identified using multivariable logistic regression analyses. Results: Of the 605 subjects who screened as eligible to participate, 363 (60%) agreed to participate and 242 (40%) declined. Women using a private obstetric provider or who had prior obstetrical complications were less likely to participate [aOR 0.6 (95% CI: 0.4–0.8)] and [aOR 0.6 (95% CI: 0.4–0.9)], respectively. A history of a mental health condition and a higher body mass index (BMI) were marginally more likely to participate [aOR 1.5 (95% CI: 1.0–2.3)] and [aOR 1.03 (95% CI: 1.0–1.1)], respectively. Overall logistic regression model R2 was 0.23. Conclusions: There are differences between eligible subjects who decide to participate or not participate in prospective peripartum interventional research. There is a need to better understand non-participation in order to improve recruitment of representative populations that allow more generalizable research results.