Lynn Shaffer

Frequency and Characteristics of Coagulopathy in Trauma Patients Treated With a Low- or High-Plasma-Content Massive Transfusion Protocol

A massive transfusion protocol (MTP) in which most non-RBC transfusions were laboratory result-driven was updated to a 1:1:1 RBC/plasma/platelet formula-driven protocol. Platelet count, fibrinogen level, and prothrombin time (PT) were monitored. In the patients who survived the first 12 hours, the results of coagulation tests were analyzed. Irrespective of the MTP or transfused RBC/plasma ratio, a majority of patients became coagulopathic, usually within the first 2 hours, and a fibrinogen deficiency (fibrinogen level, <100 mg/dL [2.9 μmol/L]) was almost always the initial abnormality. The laboratory value trends under each MTP were indistinguishable: PTs were prolonged and platelet counts and fibrinogen levels fell during the first 100 minutes and then corrected back toward baseline. More than 80% of patients in each group were noncoagulopathic at 12 hours. A 1:1:1 formula-driven MTP did not affect the frequency, nature, or duration of coagulopathy according to laboratory test results.

Effect of a Community-Based Weight Management Program on Weight Loss and Cardiovascular Disease Risk Factors

Objective: The purpose of our retrospective database analysis was to describe and evaluate the outcomes of a weight loss intervention in a community medical wellness center.

Weight and body fat changes in postpartum depot-medroxyprogesterone acetate users

BACKGROUND Although postpartum depot-medroxyprogesterone acetate (DMPA) recipients often cite weight gain as the reason for discontinuing DMPA, little is known about body composition changes in postpartum DMPA recipients. STUDY DESIGN Women who used DMPA during the postpartum year were measured on several anthropometric dimensions of body composition and compared with women who elected surgical sterilization with bilateral partial salpingectomy (BPS). RESULTS After 1 year, DMPA recipients did not differ from the BPS group in weight or percent body fat changes. Almost half the women using DMPA returned to pregravid weight; nearly half gained weight. Higher pre-pregnancy body mass index was associated with weight gain among DMPA recipients. CONCLUSIONS DMPA recipients who were overweight or obese before pregnancy may have greater risk for weight gain in the first year postpartum. However, when counseling women, the risk for DMPA-related weight gain should be balanced against the potential for increased weight from subsequent pregnancies.

Randomized trial assessing the impact of a musculoskeletal intervention for pain before participating in a weight management program.

PURPOSE Obesity increases the risk of developing physical disability and pain. Persons with a body mass index (BMI) of 30 kg/m2 or more have an increased risk for osteoarthritis compared with those with a BMI between 25 and 29 kg/m2. The purpose of this study was to examine the effect of treatment directed at reducing musculoskeletal pain on weight loss in obese subjects prior to participation in a 6-month weight management (WM) program. METHODS Subjects (BMI ≥ 30 kg/m2; n = 54, female = 41, male = 13) with musculoskeletal pain, as assessed by a visual analog scale score of more than 5, were randomized to a physician musculoskeletal evaluation with treatment and physical therapy prior to participation in a 6-month WM program (intervention) or direct entry into the WM program (control) between November 10, 2003, and January 20, 2005. RESULTS Seventy-six percent of subjects completed the study (intervention, n = 18 [67%]; control, n = 23 [85%], P = .10). The intervention group demonstrated a significant decrease in visual analog scale score after musculoskeletal therapy (2.3 ± 1.8, P < .0001). Despite a reduction in pain levels in the intervention group compared with the control group at the start of the WM program, there were no significant differences between the groups in percentage weight loss (P = .80), body fat composition (P = .20), or BMI (P = .06), all significantly improved in both groups. CONCLUSIONS Musculoskeletal and physical therapy intervention directed at decreasing musculoskeletal pain in obese individuals prior to participation in a WM program reduces reported musculoskeletal pain for those participants completing the program but does not significantly improve weight loss over 6 months, compared with individuals with comparable musculoskeletal pain who enter directly into a WM program.

CARDIAC REHABILITATION PARTICIPATION REDUCES 90-DAY HOSPITAL READMISSIONS AFTER ACUTE MYOCARDIAL INFARCTION OR PERCUTANEOUS CORONARY INTERVENTION

Cardiac rehabilitation (CR) after acute myocardial infarction (AMI) or percutaneous coronary intervention (PCI) decreases cardiac morbidity and mortality, but the effect on hospital readmission is not clear. We identified patients with AMI and/or PCI from 2008-2009 Medicare claims data for the

Regulation and Comparative Effectiveness Research

In Reply We performed the analyses requested by Dr Poulton and colleagues, selecting a different age cutoff to better reflect differences in etiology for pediatric seizures. When we compared the younger age group (<2 years) with the older age group (≥2 years), both treatments were less effective in the older children (P = .03), but there were no differences between lorazepam and diazepam (Table). When we compared febrile seizure etiology with all other etiologies, there were similar treatment differences comparing febrile seizure etiology with other etiologies, but this was not statistically significant (P = .06). There were no differences in safety when comparing these age groups or etiologies.

Utilization of vitamin K in an outpatient anticoagulation clinic

Background The options for management of elevated INRs in the outpatient setting include holding and/or reducing the dose of warfarin, administering oral vitamin K or sending the patient to the emergency department. Since these various options have not been directly compared, the optimal management of excessive anticoagulation remains somewhat controversial. Objectives To investigate the efficacy and safety of vitamin K administration compared to holding/reducing the dose of warfarin in patients with INR levels [6. Efficacy is defined as an INR which returns to a target range of 2.0–4.0 with 72 h. Safety is defined as no occurrence of an adverse event within 30 days of vitamin K treatment. Methods A retrospective analysis of patients with an INR [6 between March 2000 and March 2006 was performed. In total, 152 patients were analyzed; 73 patients received vitamin K and 79 had warfarin held. Results Patients who received vitamin K were more likely to be older and have AF; the INR value was higher while the average weekly warfarin dose was lower. Active cancer was more prevalent in the vitamin K group. Bleeding risk was similar between the two groups while risk of thrombosis was higher in the no vitamin K group. There was a trend towards increased bleeding in the vitamin K group. Patients who received vitamin K had their INR checked sooner than those who did not receive vitamin K. Warfarin resistance was not a significant concern. Conclusion Preliminary results of this study support the American College of Chest Physicians guidelines for the management of elevated INRs. By evaluating the risk factors for bleeding and thrombosis, the patients with an elevated INR were safely and effectively managed with either vitamin K administration or by withholding warfarin in our outpatient clinic.