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Sunday, April 30, 2017

See Something, Say Something in Medicine

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.
Speaking up when a safety concern arises is essential to patient safety. This study was a survey of 1800 U.S. medical and surgical interns and residents. The response rate was 47%.  Unprofessional behavior was observed by 75% of respondees, and traditional safety threats observed by 50%. Most interns and residents spoke up when they observed a traditional safety threat (71%) but less than half spoke up when they observed unprofessional behavior (49%).

Comment: speaking up can be difficult and potentially create resentment in the person being reported for unprofessional behavior. This study highlights the need for alternative reporting methods, which maintain anonymity.

BMJ Qual Saf. 2017 Apr 25


Improving Quality by Combining Qualitative and Quantitative Methodologies

This research study of children with congenital heart disease looked at combining qualitative and quantitative research methods to improve quality of care. The used Classification and Regression Trees as part of the analysis along with a Rich Picture generation, as shown here: The authors conclude that their research demonstrates that a combination of qualitative and quantitative approaches may help improve quality in complex systems.

For complex systems, combining quantitative and qualitative approaches may be the best way to improve quality. BMJ Qual Saf. 2017 Jan 06

Comment: A lot of this research seems to be focused on the communication of results using graphical approaches such as \"Rich Pictures\" and \"Activity Diagrams.\" This are interesting approaches, but this research does not answer whether or not they are superior methods of communication.


Mortality and the Mediterranean diet

In the UK, the Mediterranean diet was associated with lower heart disease incidence and decreased all-cause mortality. BMC Med. 2016 Sep 29;14(1):135.

Comment: This study, unlike another recent study (Ann Intern Med. 2016 Oct 4;165(7):491-500) found that all-cause mortality was decreased by the Mediterranean diet. My impression is that the majority of studies point to a significant gain in life in terms of both years and quality. Until evidence points elsewhere, the Mediterranean diet is probably the best, and most studied.


How to Survive Your Hospitalization: Drink Coffee

Coffee reduces the risk of death after acute myocardial infarction: a meta-analysis.

Drinking coffee regularly after an acute myocardial infarction was found to be associated with a reduced risk of mortality. Coron Artery Dis. 2016 Nov;27(7):566-72.

Comment: This study found that routine heavy coffee drinkers (over 2 cups a day) had a lower mortality after acute myocardial infarction than routine light coffee drinkers (1 to 2 cups a day), who had a lower mortality after acute myocardial infarction than noncoffee drinkers. The risk reductions observed were significant: heavy versus light (31% risk reduction), heavy vs noncoffee drinkers (46% reduction), and light vs noncoffee drinkers (21% reduction).

Should we allow, and possibly even encourage patients after an acute myocardial infarction to drink coffee?
Labels: _J6516, cardiovascular disease

How to Survive Your Hospitalization: Arrive Early

Symptom-to-door delay among patients with ST-segment elevation myocardial infarction in Singapore.

Waiting longer from symptom onset to arrival at the emergency department for people with an acute myocardial infarction is associated with higher morbidity and mortality. Emerg Med Australas. 2016 Oct 11

Comment: This research found that the factors associated with a longer symptom-to-ER time included:
There are important implications of this research. First of all, it may likely be that older people and those with diabetes have less intense pain, and thus do not call emergency services right away. Therefore, these groups of people need to be more aware of the signs and symptoms of a heart attack, and have a low threshold for calling emergency services. Back and epigastric pain are not the "typical" symptoms of a heart attack, so having the general public more aware of this possibility, and making individual patients at high risk aware of the relationship between back pain, epigastric pain, and acute myocardial infarction may help. Certain cultures and ethnicities may also be less inclined to activate emergency services; this barrier may be overcome at least in part through improved community education about the benefits of rapid treatment in acute myocardial infarction.

The take-home message: if you have symptoms of a heart attack, activate emergency services promptly, and you will be more likely to survive and less likely to have complications in the hospital.

Sunday, October 9, 2016

How to Survive Your Hospitalization: Control Your Sugar Consumption Afterwards

After a myocardial infarction, long term prognosis is much worse for patients with an abnormal glucose tolerance test at post-hospitalization follow-up. Kardiol Pol. 2016 Oct 7

Comment: This study found that acute myocardial infarction patients had a much worse prognosis if their glucose metabolism was abnormal at a 7 month follow-up visit. This was regardless of whether or not their glucose metabolism was abnormal at hospital discharge. This study suggests that the glucose tolerance test (and likely the HgbA1c) is a strong prognostic factor. Normalizing glucose metabolism early after a myocardial infarction may have significant mortality benefits. Patients with abnormal glucose metabolism at follow-up had a 2.5 year mortality rate of 2 to 4 times that of patients with normal glucose metabolism (3% versus 6% - 11%). Diet and exercise appear to be critical factors to prolong mortality after acute myocardial infarction.


KARMEL mneumonic for high anion gap acidosis

The mnemonic MUDPILES is pretty long, so I like this one that I just came across on Wikipedia. Easy to remember!


K — Ketoacidosis
A — aspirin
R — Renal failure
M — Methanol
E — Ethylene glycol
L — Lactic acidosis

Dual aspirin and anticoagulant therapy in patients with atrial fibrillation.

In patients with non-valvular atrial fibrillation, there appears to be no or little benefit of aspirin therapy in addition to coumadin therapy. Dual antiplatelet and anticoagulant therapy increases major bleeding risk. J Thromb Thrombolysis. 2016 Sep 24;

Comment: There may be a role for dual antiplatelet / anticoagulant therapy in patients with non-valvular atrial fibrillation who are within 12 months of acute coronary syndrome or revascularization. However, with these exclusions in place, the researchers still found that 45% of the patients in their retrospective review were receiving both an anticoagulant and aspirin.

Sunday, September 25, 2016

Using the Blockchain for Medical Record Privacy

Blockchain technology has proven its worth in financial markets; another use may be for patients to securely own, control, and share their own healthcare data. J Med Syst. 2016 Oct;40(10):218

Comment: Instead of patient data stored on different electronic medical records, an alternative would be for clinics and hospitals to have blockchain data readers which (with patient permission) will allow them to temporarily access an individuals medical data. Once the patient left the clinic and/or hospital, access to the private data would be revoked.


Combination pain medication therapy in acute postoperative pain

The combination pain medication containing dexketoprofen 25 mg with tramadol 75 mg was effective, and more effective than either alone, in the treatment of acute post-op pain. Cochrane Database Syst Rev. 2016 Sep 22;9:CD012232.

Comment: To decrease opiod use, we are going to have to come up with other safe and effective pain medications. Using a combination of an NSAID with tramadol appears to work well, and is associated with a low rate of side-effects.