Kristine M. Thompson

Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

Objective To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction. Data sources Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013. Study selection Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included. Data extraction Studies’ characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I2. Results 48 studies with fair quality, enrolling 1 896 859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1 892 424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70 534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity. Conclusion This systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility.

Intravascular Catheter-Related Bloodstream Infection

Intravascular catheters required for the care of many hospitalized patients can give rise to bloodstream infection, a complication of care that has occurred most frequently in intensive care unit (ICU) settings. Elucidation of the pathogenesis of catheter-related bloodstream infections (CRBSIs) has guided development of effective diagnostic, management, and prevention strategies. When CRBSIs occur in the ICU, physicians must be prepared to recognize and treat them. Prevention of these infections requires careful attention to optimal catheter selection, insertion and maintenance, and to removal of catheters when they are no longer needed. This review provides a succinct summary of the epidemiology, pathogenesis, and microbiology of CRBSIs and a review of current guidance for the diagnosis, management, and prevention of these infections.

Breast cancer survivors and vitamin D: A review

Recent evidence has suggested a role for vitamin D in breast cancer prevention and survival. Studies have reported an inverse relation between vitamin D intake and the risk of breast cancer, improvements in survival after a diagnosis of breast cancer in women with higher levels of vitamin D, and vitamin D insufficiency in up to 75% of women with breast cancer. Preclinical data have indicated that vitamin D affects up to 200 genes that influence cellular proliferation, apoptosis, angiogenesis, terminal differentiation of normal and cancer cells, and macrophage function. Vitamin D receptors have been found in up to 80% of breast cancers, and vitamin D receptor polymorphisms have been associated with differences in survival. Although ongoing studies have investigated a possible link between adequate levels of vitamin D and improved cancer prognosis, breast cancer survivors may derive additional, non-cancer-related benefits from adequate vitamin D levels, including improvements in bone mineral density, quality of life, and mood. Maintaining adequate vitamin D stores is recommended for breast cancer survivors throughout their lifetime.

Off-hour presentation and outcomes in patients with acute ischemic stroke: a systematic review and meta-analysis.

BACKGROUND Studies have suggested that patients with acute ischemic stroke who present to the hospital during off-hours (weekends and nights) may or may not have worse clinical outcomes compared to patients who present during regular hours. METHODS We searched Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through August 2013, and included any study that evaluated the association between time of patient presentation to a healthcare facility and mortality or modified Rankin Scale in acute ischemic stroke. Quality of studies was assessed with the Newcastle-Ottawa Scale. A random-effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2). A priori subgroup analyses were used to explain observed heterogeneity. RESULTS A total of 21 cohort studies (23 cohorts) with fair quality enrolling 1,421,914 patients were included. Off-hour presentation for patients with acute ischemic stroke was associated with significantly higher short-term mortality (OR, 1.11, 95% CI 1.06-1.17). Presenting at accredited stroke centers (OR 1.04, 95% CI 0.98-1.11) and countries in North America (OR 1.05, 95% CI 1.01-1.09) were associated with smaller increase in mortality during off-hours. The results were not significantly different between adjusted (OR, 1.11, 95% CI 1.05-1.16) and unadjusted (OR, 1.13, 95% CI 0.95-1.35) outcomes. The proportion of patients with modified Rankin Scale at discharge ≥ 2-3 was higher in patients presenting during off-hours (OR, 1.14, 95% CI 1.06-1.22). DISCUSSION The evidence suggests that patients with acute ischemic stroke presenting during off-hours have higher short-term mortality and greater disability at discharge.

Advances in the care of patients with intracerebral hemorrhage

Intracerebral hemorrhage (ICH), which comprises 15 percent to 30 percent of all strokes, has an estimated incidence of 37,000 cases per year. One third of patients are actively bleeding when they present to the emergency department, and hematoma growth during the first hours after ICH onset is thought to be a prime determinant of clinical deterioration. Inflammation, as opposed to ischemia, also negatively affects patient condition. Recombinant activated factor VII is emerging as a potential first-line therapy, especially in warfarin-associated hemorrhage. Corticosteroid therapy is not supported by contemporary studies or by current management guidelines. Aggressive blood pressure reduction is under investigation. Surgical intervention has shown no statistically significant benefit over medical management for patients with ICH in general, although subgroup analysis in a large randomized trial suggested potential benefits from surgery for patients with lobar ICH. Not long ago, ICH was considered virtually untreatable. Diligent efforts in both bench and clinical research are generating hope for patients who experience this catastrophic event.

Polly can make you sick: pet bird-associated diseases.

Pet birds can harbor diseases that can be transmitted to their owners. This review describes the presentation, evaluation, and basic treatment of infectious syndromes caused by these bacterial, viral, protozoal, fungal, and parasitic zoonoses. Bird owners are at risk of a number of bacterial, protozoal, fungal, viral, and parasitic zoonoses. We review the presentation, evaluation, and basic treatment of these diseases.

Quality Improvement Education for Health Professionals: A Systematic Review

Effective quality improvement (QI) education should improve patient care, but many curriculum studies do not include clinical measures. The research team evaluated the prevalence of QI curricula with clinical measures and their association with several curricular features. MEDLINE, Embase, CINAHL, and ERIC were searched through December 31, 2013. Study selection and data extraction were completed by pairs of reviewers. Of 99 included studies, 11% were randomized, and 53% evaluated clinically relevant measures; 85% were from the United States. The team found that 49% targeted 2 or more health professions, 80% required a QI project, and 65% included coaching. Studies involving interprofessional learners (odds ratio [OR] = 6.55; 95% confidence interval [CI] = 2.71-15.82), QI projects (OR = 13.60; 95% CI = 2.92-63.29), or coaching (OR = 4.38; 95% CI = 1.79-10.74) were more likely to report clinical measures. A little more than half of the published QI curricula studies included clinical measures; they were more likely to include interprofessional learners, QI projects, and coaching.

Standardizing Central Line Safety: Lessons Learned for Physician Leaders

A comprehensive central venous catheter (CVC) safety program reduces mechanical and infectious complications and requires an integrated multidisciplinary effort. A multistate health care system implemented a discovery and diffusion project addressing CVC insertion, maintenance, and removal. Process and outcome measures were collected before and after the intervention. The project was completed in 12 months. It was associated with statistically significant improvement in 6 process measures and reduction in the rate of ICU central line-associated bloodstream infection (from 1.16 to 0.80 infections/1000 catheter days; incidence rate ratio = 0.69; 95% confidence interval = 0.51, 0.93). A comprehensive CVC standardization project increased compliance with several established best practices, was associated with improved outcomes, produced a refined definition of discovery and diffusion project components, and identified several discrete leadership principles that can be applied to future clinical improvement initiatives.

Reducing unnecessary testing: an intervention to improve resident ordering practices.

Purpose of the study To reduce the number of unnecessary laboratory tests ordered through a measurement of effects of education and cost awareness on laboratory ordering behaviour by internal medicine residents for common tests, including complete blood cell count (CBC) and renal profile (RP), and to evaluate effects of cost awareness on hospitalisation, 30-day readmission rate and mortality rate. Study design 567 patients admitted during February, March and April 2014 were reviewed as the control group. Total CBC, CBC with differential and RP tests were counted, along with readmission and mortality rates. Interventions were education and visual cost reminders. The same tests were reassessed for 629 patients treated during 12 months after intervention in 2015. Results Data showed a significant increase in CBCs ordered after the intervention (mean number per hospitalisation changed from 1.7 to 2.3 (p<0.001)), a decrease in CBCs with differential (mean number changed from 1.7 to 1.2 (p<0.001)) and no change in RPs ordered (mean number, 3.7 both before and after intervention (p=0.23)). No change was found in mortality rate, but the decrease in the readmission rate was significant (p=0.008). Conclusions Education in the form of cost reminders did not significantly reduce the overall ordering of the most common daily laboratory testing in our academic teaching service. We believe further research is needed to fully evaluate the effectiveness of other education forms on the redundant ordering of tests in the hospital setting.

Airway Compromise After Dental Extraction

Subcutaneous emphysema, a known complication of dental extraction, is most often benign, and frequently confused with an allergic reaction to local anesthetic agents. This condition can be life-threatening if the volume of air leads to airway or vascular compression. The most common cause of subcutaneous emphysema as a complication of dental procedures is the use of an air turbine drill. This report describes an unusual cause of this rare complication.