Maria Lucarelli

Body mass index is independently associated with hospital mortality in mechanically ventilated adults with acute lung injury

Objective:To determine the association between body mass index (BMI) and hospital mortality for critically ill adults. Design:Retrospective cohort study. Setting:One-hundred six intensive care units (ICUs) in 84 hospitals. Patients:Mechanically ventilated adults (n = 1,488) with acute lung injury (ALI) included in the Project IMPACT database between December 1995 and September 2001. Interventions:None. Measurements and Main Results:Over half of the cohort had a BMI above the normal range. Unadjusted analyses showed that BMI was higher among subjects who survived to hospital discharge vs. those who did not (p < .0001). ICU and hospital mortality rates were lower in higher BMI categories. After risk-adjustment, BMI was independently associated with hospital mortality (p < .0001) when modeled as a continuous variable. The adjusted odds were highest at the lowest BMIs and then declined to a minimum between 35 and 40 kg/m2. Odds increased after the nadir but remained below those seen at low BMIs. With use of a categorical designation, BMI was also independently associated with hospital mortality (p = .0055). The adjusted odds were highest for the underweight BMI group (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.05–3.60) relative to the normal BMI group. As in the analysis using the continuous BMI variable, the odds of hospital mortality were decreased for the groups with higher BMIs (overweight adjusted OR, 0.72; 95% CI, 0.51–1.02; obese adjusted OR, 0.67; 95% CI, 0.46–0.97; severely obese adjusted OR, 0.78; 95% CI, 0.44–1.38). Differences in the use of heparin prophylaxis mediated some of the protective effect of severe obesity. Conclusions:BMI was associated with risk-adjusted hospital mortality among mechanically ventilated adults with ALI. Lower BMIs were associated with higher odds of death, whereas overweight and obese BMIs were associated with lower odds.

Differences in the evaluation and management of exercise-induced bronchospasm between family physicians and pulmonologists.

Previous studies have demonstrated that specialists and generalists differ in the evaluation and management of asthma especially in terms of use of objective testing. We speculated that there also may be differences in the diagnosis and management of exercise-induced respiratory complaints. An Internet survey was sent to samples of pulmonologists and family physicians. Our data suggests that pulmonologists are much more likely to order bronchoprovocation testing than family physicians, and family physicians are more likely to start any empiric therapy than perform bronchoprovocation testing when exercise-induced bronchospasm is suspected. These differences may lead to inaccurate or missed diagnoses and unnecessary morbidity.

Survey of current practices in fellowship orientation.

Background: The transition from medical resident to subspecialty fellow is a critical time period in fellowship training that has not been well described. The current practices of fellow orientation in pulmonary and critical care training programs are not known. Objectives: The aim of this study was to describe orientation practices for training programs in the United States. Methods: A 10-question survey was sent via e-mail to program directors of pulmonary/critical care fellowship programs identified on the American Thoracic Society (ATS) webpage of current programs. Results: Eighty-seven programs responded (61.7%), of which 86% had a formal orientation program. The mean time spent in fellow orientation was 5–10 h in didactic sessions and 0–5 h in wet labs. The most frequent didactic sessions were bronchoscopy in 69 programs (80.2%), pulmonary function testing in 63 programs (73.3%) and orientation to hospital services in 63 programs (73.3%). The most frequent use of wet labs was in bronchoscopy training in 60 programs (81.1%) and ventilators in 45 programs (60.8%). Simulators were used in 37 programs (43%). The majority reported that these areas were covered with on the job training, without a formal designated orientation. Conclusion: This survey demonstrated that early fellow training differs across programs in both time spent and clinical and procedural topics covered. An early, standardized approach to clinical and procedural training can assure appropriate exposure that cannot be guaranteed by on the job training. To provide justification for such an approach, clinical outcomes need to be correlated with training methods.

The search−inference framework: a proposed strategy for novice clinical problem solving

Context  Medical education in the clinical clerkship years emphasises the systematic collection and organisation of patient information to be combined with domain‐specific knowledge of disease processes. Eventually, novice clinical problem solvers will learn to recognise patterns within the patient data (‘illness scripts’) which suggest the main diagnostic possibilities. Before novice problem solvers develop these illness scripts, pattern recognition may not be effective for solving clinical problems.

Thromboembolic Events During Continuous Vasopressin Infusions: A Retrospective Evaluation

Background: Published guidelines suggest that vasopressin has a role in shock treatment, although its safety has not been adequately evaluated in a clinical setting. Vasopressin causes platelet aggregation and has been associated with the release of factor VIII coagulant and von Willebrand factor. Objective: To compare the incidence of venous thromboembolism (VTE) in patients with a diagnosis of shock who received vasopressin with those who did not receive vasopressin for hemodynamic support. Methods: A retrospective, single-center, cohort study was conducted at an academic, tertiary care center with 350 patients with a diagnosis of shock. Patients from the intensive care unit were randomly selected and separated into 2 groups for comparison of those receiving only catecholamines with those receiving vasopressin with or without catecholamines for hypotension. Patients with diabetes insipidus or variceal hemorrhage and those with any documented history of VTE were excluded. The primary outcome, VTE occurrence, was defined as a positive Doppler ultrasound, spiral computed tomography, or documented diagnosis in the discharge records. Frequency and type of risk factors for VTE were compared between the 2 study arms. A risk factor modeling approach was performed, using logistic regression to identify potential confounders and effect modifiers in the relationship between vasopressin and VTE. Results: There were 175 patients in each arm of the study. The crude incidence of VTE was 7.4% and 8% in the vasopressin and catecholamine groups, respectively (p = 0.84). No significant difference in the incidence of deep venous thrombosis (vasopressin 5.1%, control 7.4%; p = 0.51) or pulmonary embolism (vasopressin 2.3%, control 0.6%; p = 0.37) was found between groups. After adjusting for covariates, there was no statistically significant difference in the incidence of VTE between the 2 arms (p = 0.72). Conclusions: This investigation provides initial evidence that vasopressin infusions do not increase the risk of VTE in patients with shock.

Changes in the National Residency Matching Program Policy: Are Internal Medicine Program Directors “All-In”?

Michael Adams, MD, FACP, is Program Director of Medicine at Georgetown University; Thomas B. Morrison, MD, is Fellow in Cardiovascular Medicine at Vanderbilt University; Stephanie Call, MD, is Program Director of Medicine at Virginia Commonwealth University; Andrew J. Halvorsen, MS, is Biostatistician and Project and Data Manager in the Internal Medicine Residency Office of Educational Innovations at Mayo Clinic; Jared Moore, MD, is Chief Medical Resident in Internal Medicine at Ohio State University; Maria Lucarelli, MD, is Associate Program Director in Internal Medicine at Ohio State University; Steven Angus, MD, is Program Director of Medicine at the University of Connecticut Health Center; and Furman S. McDonald, MD, MPH, is Program Director of Internal Medicine Residency Office of Educational Innovations at the Mayo Clinic. Funding: This study was supported in part by the Mayo Clinic Internal Medicine Residency Office of Educational Innovations as part of the ACGME Educational Innovations Project. The Mayo Clinic Survey Research Center provided assistance with the survey design and data collection. We are grateful for the support of the Association of Program Directors of Internal Medicine and the members of the Survey Committee and to the residency program directors who completed the Association of Program Directors in Internal Medicine (APDIM) survey. While we are reporting the results of the APDIM Survey Committee, we are not presuming to speak for the organization and our paper does not constitute an official policy statement of APDIM, the APDIM Council, or any other organzation with which any of the authors may be affiliated.