Jerry McLarty

Decreased hospital length of stay associated with presentation of cases at morning report with librarian support

OBJECTIVEnThe research sought to determine whether case discussion at residents morning report (MR), accompanied by a computerized literature search and librarian support, affects hospital charges, length of stay (LOS), and thirty-day readmission rate.nnnMETHODSnThis case-control study, conducted from August 2004 to March 2005, compared outcomes for 105 cases presented at MR within 24 hours of admission to 19,210 potential matches, including cases presented at MR and cases not presented at MR. With matching criteria of patient age (+/- 5 years), identical primary diagnosis, and secondary diagnoses (within 3 additional diagnoses) using International Classification of Diseases (ICD-9) codes, 55 cases were matched to 136 controls. Statistical analyses included Students t tests, chi-squared tests, and nonparametric methods.nnnRESULTSnLOS differed significantly between matched MR cases and controls (3 days vs. 5 days, P < 0.024). Median total hospital charges were

American College of Chest Physicians consensus statement on the respiratory health effects of asbestos. Results of a Delphi study.

7,045 for the MR group and

Relationship between eosinophils and chronic endometritis

10,663 for the control group. There was no difference in 30-day readmission rate between the 2 groups.nnnDISCUSSION/CONCLUSIONnPresentation of a case at MR, followed by the timely dissemination of the results of an online literature review, resulted in a shortened LOS and lower hospital charges compared with controls. MR, in association with a computerized literature search guided by the librarians, was an effective means for introducing evidence-based medicine into patient care practices.

The effect of a clinical medical librarian on in-patient care outcomes

BACKGROUNDnThe diagnosis of and criteria for the evaluation of asbestos-related disease impairment remains controversial after decades of research. Assessing agreement among experts who study pneumoconiosis, and diagnose and treat patients with asbestos-related respiratory conditions may be the first step in clarifying clinical and forensic/administrative issues associated with asbestos-related pulmonary conditions.nnnMETHODSnWe conducted a Delphi study, an iterative method of obtaining consensus among a group of experts. An expert panel was identified using an objective, nonbiased algorithm, based on the number of asbestos-related disease publications authored during the preceding 10-year period. Identified experts were invited to participate by accessing an Internet site. Each expert was presented statements developed by the authors regarding the diagnosis or treatment of asbestos-related disease; experts then ranked their degree of agreement or disagreement utilizing an 11-level modified Likert scale for each statement. Each expert was asked to justify their selection and to suggest references in support of their opinion. The Wilcoxon signed rank test and the interquartile range were used to define consensus. The results of the collective Likert rankings, deidentified comments, and suggested references as well as the initial consensus results were then provided to the participating experts. Each panel member then ranked their extent of agreement with a modified statement for which consensus was not achieved. The process was repeated three times.nnnRESULTSnConsensus was achieved on all but 9 of 32 statements.nnnCONCLUSIONSnConsensus was not achieved for nine statements. These statements may be topics for future research.

Critical appraisal process: step-by-step.

The histopathologic diagnosis of chronic endometritis is based on the presence of plasma cells in the endometrial stroma. However, many conditions can mimic or interfere with the search for plasma cells, including the plasmacytoid stroma cells and predecidual changes of stroma cells. Eosinophils are another type of chronic inflammatory cells, which can be easily identified with routine hematoxylin and eosin stain by their characteristic eosinophilic granules. This study was conducted to investigate whether eosinophils can be used as diagnostic markers of chronic endometritis. The hematoxylin and eosin-stained glass slides of 422 consecutive endometrial biopsies were reviewed. The biopsies that have eosinophils were subjected to immunohistochemical staining with CD138, a marker for plasma cells. In all, 91 of 422 biopsies contained eosinophils with 72.5% (66/91) showing presence of plasma cells (positive staining with CD138). Of these 66 cases, only 4 cases were previously diagnosed as chronic endometritis. These results suggest the presence of eosinophils in endometrial biopsy specimen indicates a need to search for plasma cells (with immunohistochemical stain if needed) for the diagnosis of chronic endometritis.

The Shreveport Myeloma Experience: Survival, Risk Factors and Other Malignancies in the Age of Stem Cell Transplantation

OBJECTIVEnThe research sought to determine the effect of a clinical medical librarian (CML) on outcomes of in-patients on the internal medicine service.nnnMETHODSnA prospective study was performed with two internal medicine in-patient teams. Team 1 included a CML who accompanied the team on daily rounds. The CML answered questions posed at the point of care immediately or in emails post-rounds. Patients on Team 2, which did not include a CML, as well as patients who did not require consultation by the CML on Team 1, served as the control population. Numerous clinical and library metrics were gathered on each question.nnnRESULTSnPatients on Team 1 who required an answer to a clinical question were more ill and had a longer length of stay, higher costs, and higher readmission rates compared to those in the control group. Using a matched pair analysis, we showed no difference in clinical outcomes between the intervention group and the control group.nnnCONCLUSIONSnThis study is the largest attempt to prospectively measure changes in patient outcomes when physicians were accompanied by a CML on rounds. This approach may serve as a model for further studies to define when and how CMLs are most effective.

Assessing the FACTTS: An Evidence-Based Medicine and Critical Appraisal Course for Medical Students

We present information describing how to search to identify those reports that provide insight into the answer to the query. We have presented a reasonable approach to searching, with our end-point being the identification of published articles which appear to answer our queries. The decision as to whether these articles are applicable to the patient under discussion is determined by our clinical knowledge and the specifics of the patients medical concerns. This process is recognized as critical analysis. Our structure for optimal searching includes use of the PICO model, formulating a focused clinical question, and defining key search terms. Using these principles, we have addressed an example important controversy in the practice of clinical medicine; in other words, the effectiveness of screening for prostate cancer and whether it alters the natural history of this illness.

Tyler asbestos workers: A mortality update in a cohort exposed to amosite

Background: The overall prognosis of multiple myeloma has improved significantly over the last 15 years. We wondered whether the overall improvement would also be seen in unselected patients in an academic center in Northwest Louisiana with a high proportion of minority patients, and if second malignant neoplasms are relevant for our patients. Materials and Methods: Between 1998 and 2009, 215 patients were treated for multiple myeloma at our center and had complete follow-up until May 2013. Results: The mean survival of patients with multiple myeloma increased from 3.25 to 5.34 years, which is comparable to patients treated at larger centers. No prognostic difference was observed in the subgroups of myeloma patients. Among 215 patients followed for the development of secondary cancers, 16 already had a preexisting or concomitant malignancy (7.4%) and 10 developed secondary cancers. Our data indicate a significant background of histologically unrelated cancers and a cumulative incidence of new cancers of about 20% after 10 years of follow-up. Based on SEER data, preexisting or secondary cancers were not statistically increased in our population. Conclusions: The use of autologous transplantation and the introduction of new agents resulted in a significant improvement in the prognosis of multiple myeloma. Other cancers are not statistically increased before or after multiple myeloma is diagnosed and are not prognostically relevant.

Abstracts From: The 10th International Lung Cancer Congress June 17-20, 2009; Kohala Coast, HI

The Fourth-year Academic Clinical Training and Teaching Selective (FACTTS) is a course taught by medical and library faculty on the practice of evidence-based medicine and critical appraisal of the medical literature. This study assesses the impact of the course on students understanding of the subject matter by examining three years of pre- and post-test data and addresses whether the number of sessions in the course affects the knowledge gained by the students. The data show an improvement in the students understanding of course material, but no benefit was found in having two versus three sessions.

6 – A new paradigm for morning report: a collaborative effort between the Department of Internal Medicine and the Medical Library

ABSTRACT The Tyler asbestos plant produced pipe insulation from 1954 to 1972 and exclusively used amosite asbestos. There were 1130 former workers of this plant during the period of operation. A death certificate mortality analysis was published regarding this plant in 1998 for the period through 1993. This study represents an update of the mortality analysis with additional certificates collected for deaths occurring through 2011.Searches of the National Death Index database were conducted in 2004 and again in 2013. At the time of the latter search, only deaths occurring through 2011 were available. In total, 265 distinct additional death certificates were secured and added to 304 available from the original study. After the new certificates were coded (ICD-9), data were analyzed using the Centers for Disease Control and Prevention Life Table Analysis System (LTAS) and standard mortality ratios (SMR) generated with 95% confidence limits (CL). LTAS constructs cause-specific mortality rates by age, gender, race, and person-time at risk, and compares observed rates with a referent population in order to derive SMR. A significant excess number of deaths due to nonmalignant respiratory disease (asbestosis) and from select malignant neoplasms were identified. There were in total 23 mesothelioma deaths (4% of deaths), with 16 pleural and 7 peritoneal. The SMR for malignant neoplasms of the trachea, bronchus, and lung was 244 (with 95% CL 196, 300), suggesting that exposed workers from this cohort were nearly 2.5-fold (244 %) more likely to die from this cause as the general referent population. The analysis also showed that exposures of short duration (<6 mo) produced significantly elevated SMR for all respiratory cancers, lung cancer, and pleural mesothelioma. There was a significant difference in median duration of exposure for mesothelioma types, confirming association of peritoneal mesothelioma with longer duration of exposure. Deaths due to intestinal cancer (predominantly colon; not including rectum) were also found in excess. The mortality experience of the Tyler cohort continues to be followed with great interest, given the exclusivity of exposure to amosite. Data confirm the inherent pathogenicity of this fiber type for nonmalignant disease as well as select cancers, particularly relevant given the importance of this amphibole’s use in the United States.