Mark Young

The Influence of Positive Affect on Clinical Problem solving

This study investigated the influence of positive affect, induced by report of success on an anagram task, on medical decision making among third-year medical students. The subjects were asked to decide which one of six hypothetical patients, each of whom had a solitary pulmonary nodule, was most likely to have lung cancer. They were asked to verbalize their clinical reasoning as they solved the problem. The positive-affect and control groups did not differ in the tendency to make a correct choice, but subjects in the positive-affect condition were significantly earlier in identifying their choices. These subjects were also significantly more likely to go beyond the assigned task, expressing interest in the cases of the other patients and trying to think about their diagnoses, even though that task was not assigned. The positive-affect subjects also showed evidence of configural or integrative consideration of the material to a reliably greater extent than did control subjects, and there was significantly less evidence of confusion or disorganization in their protocols than in those of controls. These findings are compatible with earlier work suggesting a different organizational process and greater efficiency in decision making among people in whom positive affect had been induced, and with recent work suggesting that positive affect facilitates flexibility and inte gration in problem solving. They also indicate that these effects may apply to the problem- solving strategies of professionals in clinical probem-solving situations. Key words: positive affect; medical decision making; problem solving; diagnostic reasoning. (Med Decis Making 1991;11:221-227)

Using a SANE Interdisciplinary Approach to Care of Sexual Assault Victims

BACKGROUNDnMany hospitals have recognized the need to develop policies and procedures for female sexual assault victims prompt access to emergency medical care and for collecting law enforcement evidence. At Lehigh Valley Hospital (Allentown, Penn), care in the emergency department (ED) for sexual assault victims was covered by oncall obstetricians and gynecologists. Although many aspects of rape management were in place, a busy ED with varying levels of physician response and exposure to the process of rape management contributed to a lack of standardized, objective, timely, and compassionate medical management of sexual assault victims. DEVELOPING THE PROGRAM: The Sexual Assault Nurse Examiner (SANE) interdisciplinary approach to care of sexual assault victims was implemented in May 1998. Community education and awareness projects emphasized prevention of sexual assault and domestic violence, as well as minimization of trauma for victims by promoting services that provide a supportive, caring, and healing environment.nnnRESULTSnComparing a baseline group of 130 sexual assault victims with 39 patients who were evaluated after the SANE approach was implemented indicated increased clinical interaction and significant improvements in quality indicators, such as completeness of evaluation and information gathered relevant to medical-legal issues.nnnDISCUSSIONnLaw enforcement staff developed a more collaborative relationship with SANE examiners through the interdisciplinary team approach. Collaborative relationships were initiated with several other hospitals in the hospitals integrated delivery system to help offset some of the programs training, continuing education, and on-call costs and to allow for joint outcomes collection. The SANE program became a core ED service in July 1999.

Assessing Physicians' Estimates of the Probability of Coronary Artery Disease: The Influence of Patient Characteristics.

The authors assessed physicians probability estimates of coronary artery disease (CAD) in 250 patients undergoing a screening exercise stress test. True likelihood of disease (prev alence) was derived from the literature. Discrimination and calibration were assessed by comparing physicians probability estimates and prevalence using pairwise comparisons, rank correlation, and linear regression. There were differences in the discriminative abilities of the physicians based on patient characteristics For example, the physicians had better discriminative ability for patients with typical cardiac chest pain compared with atypical chest pain. The physicians were able to predict the prevalences of CAD in broad groups of patients. However, they overestimated probabilities for patients with low prevalence of disease and underestimated probabilities for patients with high prevalence of disease The authors con clude that physicians make consistent errors in the use of probability estimates The quality of these estimates depends on patient characteristics such as type of chest pain and true likelihood of disease. Key words: calibration; decision making, probabilistic judgments; heart disease; exercise stress test; women; linear regression; medical judgments; discrimination; models (Med Decis Making 1992; 12:109-114)

The Single-Cutoff Trap: Implications For Bayesian Analysis of Stress Electrocardiograms.

Quantitative analysis of exercise electrocardiograms has been emphasized by many inves tigators. Specific problems have been found when a single cutoff is used to define a positive or a negative test: a single cutoff does not distinguish stress electrocardiography results that are slightly positive from those that are markedly positive. This may lead clinicians to un derweigh strong evidence for or against coronary artery disease. This study evaluated cli nicians quantitative analysis of stress electrocardiograms. Two hundred and thirty-five physicians interpreted the results of mildly positive (1.2 mm ST-segment depression) and strongly pos itive (2.2 mm ST-segment depression) stress electrocardiograms. Their posttest probability estimates were too high for a mildly positive test (0.62 ± 0.02 versus actual of 0.38; p <0.001) and too low for a strongly positive test (0.77 ± 0.01 versus actual of 0.98; p <0.001). Physicians should understand decision aids and should use multiple rather than single cutoffs to interpret the results of stress electrocardiography.

Two Cultures Revisited: Continuously Improving in a Dichotomous World

An analogous view of the two approaches to quality in health care as two cultures may be useful. The medical-decision-making &dquo;culture&dquo; emphasizes doing the right things, at the policy level or the level of the individual patient, while the continuous-quality-improvement &dquo;culture&dquo; emphasizes doing the things right-improving the processes of patient care. Clinical processes may best be served, however, by taking advantage of both cultures, as I will now explain. To elucidate my thesis I use a framework adapted from one devised by W. Edwards Deming for use in industry. The Deming framework prescribes &dquo;knowledge for continual improvement.&dquo; Deming’s methodl’-

Presidential Reflections on the 25th Anniversary of the Society for Medical Decision Making

Compared to where we were in 1978, much more information is readily available to patients and clinicians, on the Internet, from widely available photocopying of printed materials, and via medical and health care newsletters aimed at the general public. As a result, patients (especially younger patients) seek a greater role in the decision process. Consequently, shared decision making has become more prominent in the doctor-patient relationship. SMDM is not directly responsible for most of these developments, but our writing and point of view have contributed to their content and influence. Two movements can be identified as offshoots or children of Medical Decision Making: Evidence-Based Medicine and Shared Decision Making. The shared decision making movement is clearly about bringing decision analytic insights to clinical decision-making situations in a practical, useful way. Many of its chief proponents have been active in this society for many years. Evidence-based medicine (EBM) pursued a more independent course. Part 1 of the early Clinical Epidemiology text of Sackett, Haynes, and Tugwell was an introductory textbook of decision analysis. Part 2 was about critical appraisal. As time went on, formal decision analysis was less front-and-center in EBM and critical appraisal of the literature became the focus that dominates texts in that field. But recently, central figures in that movement have argued that evidence alone is insufficient for decision making, at least in some cases, and that values and preferences have to be considered. At the same time, the recent Hunink-Glasziou text pays much more attention than did the early Weinstein-Fineberg text to searching the literature for

Acute pancreatitis: Trends in outcomes and the role of acute kidney injury in mortality- A propensity-matched analysis

OBJECTIVESnTo assess national trends of AP (acute pancreatitis) admissions, outcomes, prevalence of AKI (acute kidney injury) in AP, and impact of AKI on inpatient mortality.nnnMETHODSnWe queried the Nationwide Inpatient Sample database from 2003 to 2012 to identify AP admissions using ICD-9-CM codes. After excluding patients with missing information on age, gender, and inpatient mortality, we used ICD-9-CM codes to identify complications of AP, specifically AKI. We examined trends with survey-weighted multivariable regressions and analyzed predictors of AKI and inpatient mortality by multivariate logistic regression. Additionally, both AKI and non-AKI groups were propensity-matched and regressed against mortality.nnnRESULTSnA total of 3,466,493 patients (1.13% of all discharges) were hospitalized with AP, of which 7.9% had AKI. AP admissions increased (1.02%→1.26%) with rise in concomitant AKI cases (4.1%→11.7%) from year 2003-2012. Mortality rate decreased (1.8%→1.1%) in the AP patients with a substantial decline noted in AKI subgroup (17.4%→6.4%) during study period. Length of stay (LOS) and cost of hospitalization decreased (6.1→5.2 days and

3411 Endoscopy in those who require long term anticoagulation.

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3414 Cost effective approach to patients on long term anticoagulation who need endoscopy.

10,895, respectively) in AKI subgroup. Complications such as AKI (OR: 6.08, pu202f<u202f0.001), septic shock (OR: 46.52, pu202f<u202f0.001), and acute respiratory failure (OR: 22.72, pu202f<u202f0.001) were associated with higher mortality. AKI, after propensity matching, was linked to 3-fold increased mortality (propensity-matched OR: 3.20, Pu202f<u202f0.001).nnnCONCLUSIONnMortality, LOS, and cost of hospitalization in AP has decreased during the study period, although hospitalization and AKI prevalence has increased. AKI is independently associated with higher mortality.

A multifunctional protein possessing glycinamide ribonucleotide synthetase, glycinamide ribonucleotide transformylase, and aminoimidazole ribonucleotide synthetase activities in de novo purine biosynthesis.

Patients maintained on anticoagulation (AC) often need endoscopy. Little information is available about this cohort of patients. Aim: To determine the indications, findings, and therapeutic impact of endoscopy in these patients. Methods: Retrospective chart analysis of inpatients undergoing endoscopy while on coumadin or i.v. heparin therapy from 1997 to 1999 was done. Patients who had AC stopped at admission were excluded. Data collected were indication for admission and endoscopy, type of procedures, findings and impact of endoscopy. Results: 86 endoscopies were done in 64 patients who met inclusion criteria. [38 EGD, 30 colonoscopies, 9 enteroscopies, 7 ERCPs, 1 flexible sigmoidoscopy and 1 PEG]. 45 patients (70%) were admitted for a gastrointestinal (GI) diagnosis [GI bleeding (14), elective EGD/colonoscopy (11), for enteroscopy (6) and others (14)]. 19 patients (30%) had non-GI diagnoses [DVT (9), infections (5), atrial fibrillation (2), others (3)]. Indication for AC was prosthetic valves in 20 (31%), atrial fibrillation in 10 (16%), prosthetic valve and atrial fibrillation in 9 (14%), DVT/PE in 21 (33%), and other in 4 (6%). Indication for endoscopy in 40 patients (63%)was bleeding which was significant in 21 [drop in hematocrit or melena]. Other indications were surveillance/screening in 6 (9%), for ERCP: CBD stone/pabnormal LFT/pancreatitis in 7 (11%) and other in 11 (17%). Most common indication in those with prosthetic valves was melena (10/29) and in patients with DVT was heme positive stool (4/20). Of the significant bleeders, 12/21 had prosthetic valves and AVMs were the most common finding (9/21). In patients with prosthetic valves,AVMs were frequently found (9/29 vs 2/35 for other patients, p