The Cochrane Library is the most important online evidence retrieval database of systematic reviews. Since 2007, the National Health Research Institutes has offered Taiwan's regional hospitals free access to the Cochrane Library. This study investigated how these hospitals disseminate its utilisation.
The usage rate of Cochrane reviews was measured in the participating hospitals from January 2008 to December 2009. Thereafter, a questionnaire survey was conducted for each regional hospital disseminator at the beginning of 2010 to analyse their methods of disseminating Cochrane reviews.
The hospitals were stratified into three groups according to the relative rate of access: high (n=15), medium (n=16) and low (n=13). In comparison with the low-usage hospitals, the high-usage hospitals tended to assign a disseminator of evidence-based medicine to take charge of the dissemination of Cochrane reviews (p<0.001). In addition, the high-usage hospitals more often used the following six methods: providing relevant information via email (p<0.05), investing in early adopters (p<0.05), using assistance from designated personnel (p<0.05), highlighting the activity of early adopters (p<0.05), conducting workshops (p=0.001), and inviting experts to speak (p<0.001). There was no significant difference between high- and low-usage hospitals in organisational barriers.
This study has identified several helpful strategies used by Taiwan's hospitals to enhance dissemination of the Cochrane Library, including raising of awareness, active delivery of information, mentoring relationships, and educational training. The data suggest that disseminating evidence-based medicine simultaneously is a key element.
Errors involving drug prescriptions are a key target for patient safety initiatives. Recent studies have focused on error rates across different grades of doctors in order to target interventions. However, many prescriptions are not instigated by the doctor who writes them. It is important to clarify how often this occurs in order to interpret these studies and create interventions. This study aimed to provisionally quantify and describe prescriptions where the identity of the decision maker and prescription writer differed.
Observational data was collected in six wards, 2 weeks per ward, at a single large UK teaching hospital over a 12-week period from January to April 2011.
In 112/183 (61%) cases where a new medicine was prescribed, the decision maker was not the prescription writer.
Decision making and the writing of prescriptions are generally not undertaken by the same doctor. Moreover, communication about prescriptions is poor. Further research in a larger sample of hospitals is required to confirm generalisability of the results, and to inform educational interventions to reduce error rates.
A 39-year-old man, an ex-smoker, was brought to our respiratory department due to dry cough and progressive exertional dyspnoea for 7 months. He had been an antimonial worker for 6 years. Physical examination was significant for perioral cyanosis, mild clubbing and diffuse rales. Arterial blood gas analysis on room air showed oxygen partial pressure (PaO2) 71.5 mm Hg. The serum lactate dehydrogenase level was elevated at 301 U/l (normal...]]>
Cardiac troponins are measured in acute coronary syndrome (ACS) and other conditions. The authors investigate the prognostic significance of cardiac troponin T (TnT) test and comorbid medical conditions.
Consecutive patients admitted to the Aintree University Hospital, Liverpool, between 2 January 2004 and 29 February 2004 who had TnT measurement were included. Patients were separated into normal (<0.01 μg/l) or raised TnT levels (≥0.01 μg/l), and further categorised into: (1) normal TnT with unstable angina; (2) normal TnT with non-ACS; (3) raised TnT with ACS; and (4) raised TnT with non-ACS. Cox regression was used to identify prognostic variables, and logrank test to compare 7-year survival.
Of 1021 patients, 313 had raised TnT (195 ACS, 118 non-ACS) and 708 normal TnT (80 ACS, 628 non-ACS). Age (HR 1.06; 95% CI 1.05 to 1.07), congestive cardiac failure (HR 1.37; 95% CI 1.11 to 1.69), cerebrovascular disease (HR 1.37; 95% CI 1.10 to 1.71), chronic obstructive airway disease (HR 1.44; 95% CI 1.19 to 1.75), liver disease (HR 4.16; 95% CI 2.37 to 7.31), renal disease (HR 1.83; 95% CI 1.27 to 2.64), tumour (HR 1.39; 95% CI 1.07 to 1.79), lymphoma (HR 4.81; 95% CI 2.07 to 11.16), metastatic cancer (HR 3.55; 95% CI 2.32 to 5.45) and a higher Charlson's comorbidity score (HR 1.20, 95% CI 1.13 to 1.26) were adverse predictors. Both raised TnT with ACS (HR 1.92, 95% CI 1.54 to 2.39) and raised TnT with non-ACS (HR 2.37, 95% CI 1.87 to 3.00) were associated with worse survival. Raised TnT with non-ACS had a worse survival than raised TnT with ACS (p=0.001).
Hospitalised patients with raised TnT levels from any cause predicted a higher mortality than normal TnT, with worst survival in those without an obvious ACS.
Previous studies have demonstrated that fibrates have an effect on creatinine concentrations. The pattern of change with fibrates in estimated glomerular filtration rate (eGFR), widely used in clinical practice, has not been previously described.
Data was retrospectively collected from 132 consecutive case notes of patients started on fibrates in a lipid clinic between 2002 and 2008. Pre- and post-fibrate creatinine concentrations were measured and eGFR measurements were obtained.
Of the 79 patients with both pre and post-treatment eGFR values <90 ml/min/1.73 m2, a significant mean eGFR reduction of 8.2 ml/min/1.73 m2 was noted. Of these patients, 50% demonstrated a reduction in eGFR >8 ml/min/1.73 m2, 25% demonstrated a reduction >16 ml/min/1.73 m2, and 10% demonstrated a reduction >21 ml/min/1.73 m2.
The authors demonstrate a significant effect of fibrates on eGFR in clinical practice. Awareness of the pattern of eGFR change is important for decisions regarding the continued use of fibrate therapy and/or commonly co-prescribed diabetic drugs and renal specialist referrals.
Thrombotic thrombocytopaenic purpura (TTP) is a rare life-threatening disease. Plasma exchange has significantly decreased the mortality from this disease, which still tends to recur in a substantial proportion of patients. This study describes the clinical spectrum and response to treatment and explores the risks of relapse in a cohort of patients.
Patients treated for TTP at the Clinical Haematology Unit, Cairo University, Egypt, between 2000 and 2008 were identified. Complete demographic, clinical history and full clinical examination, laboratory, treatment modalities and duration, and outcome data were collected and analysed. The follow-up duration was 24 months.
30 patients; 13 men (43%) and 17 women (57%) with a median age of 42 years were treated for 46 episodes of TTP. The median duration of disease onset to diagnosis for the first episode was 7 days. Twenty-three patients (76.66%) were diagnosed as idiopathic primary and seven patients (23.33%) were secondary TTP. Four patients died during the first 24 h. Of the 26 patients, 22 (85.6%) achieved remission with an average of 7.55 plasma exchange sessions, Another nine patients had 25 relapses (mean 2.7). Splenectomy was performed in three patients (11.5%). The 24-month overall survival was 80%. The initial low platelet count and high LDH were the only two statistically significant relapse predictors.
The current results conform to the reported literature on the outcome of TTP. The very early mortality due to late referral highlights the need of education about the disease among primary healthcare providers.
A 69-year-old male subject was admitted to our emergency department with a 2-week history of exertional breathlessness, which was preceded by an acute episode of precordial discomfort for which the patient did not seek medical attention. On clinical examination, the resting heart rate was regular at 100 beats per minute. The supine blood pressure was 95/75 mm Hg. There were signs of moderate biventricular failure and a loud pan-systolic murmur loudest at the lower-left sternal edge.
The ECG confirmed the presence of an inferior myocardial infarct. Transthoracic echocardiography showed a defect in the posterior-basal part of the inter-ventricular septum...]]>
Multiple factors contribute to muscle weakness and reduced muscle mass in chronic obstructive pulmonary disease (COPD) and this impacts patients' quality of life. One factor implicated in this process is systemic inflammation, an accompaniment of acute exacerbations. Recurrent exacerbations are associated with lower health status. This study examines the relationship between muscle weaknesses, health status and exacerbation frequency in a cohort of patients with COPD.
This is an observational study of 188 (95 female) patients with COPD attending two hospital clinics in the northeast of England between 2004 and 2007. We measured spirometry, body mass index, health status (St George's Respiratory Questionnaire) and grip strength and recorded Medical Research Council dyspnoea scores and the frequency of exacerbations in the previous year.
Patients were aged 72.5±8.3 years (data expressed as mean±SD) with Medical Research Council score of 3.6±0.8, forced expiratory volume in one second (FEV1) of 49.2±21.5 per cent predicted and a total St George's Respiratory Questionnaire score of 72.2±15.5. Grip strength, expressed as per cent predicted, was 72.0±21.8 in men and 81.0±18.2 in women. Exacerbations ranged from zero to five in the previous year and there were associations of reduced grip strength with exacerbation frequency (2=9.634; p=0.0019) and lower health status (2=34.00; p<0.001).
Our data clearly demonstrate that reduction in grip strength occurs more frequently and to a greater extent in patients with a history of frequent exacerbations and is associated with reduced health status.
To review the role of outpatient parenteral antibiotic therapy (OPAT) in the management of infective endocarditis (IE) with the aim to guide further development of the service modality both locally and at other centres, in light of the evolving recommendations on patient suitability in international guidelines.
A retrospective case review of all patients receiving OPAT for IE in Sheffield between January 2006 and October 2010 was conducted. Data were collected on site and microbiology of infection, antibiotic regimens, adverse events during OPAT therapy and outcomes were studied.
A total of 36 episodes of IE were treated in 34 patients. All patients received initial treatment as inpatients. Treatment was successful in 34/36 episodes (94.4%) with no evidence of recurrence at a median of 30 months follow-up. One patient had a relapse 2 months after completion of OPAT for enterococcal endocarditis and was found to have concurrent chronic prostatitis. One patient died of a ruptured pulmonary root abscess while receiving OPAT. Adverse events occurred in 12 episodes (33.3%), of which seven were line associated. In four cases adverse events resulted in re-hospitalisation. A successful outcome was achieved in 22/24 episodes (91.7%) deemed to be less suitable for OPAT due to higher risk of complications by Infectious Diseases Society of America guidelines.
OPAT is a safe and effective means of completing therapy for IE, including prosthetic valve endocarditis and other cases at a higher risk of complicated disease. However, the relatively high rate of adverse events highlights the need for well-developed protocols and policies for patient selection and follow-up within the context of a formal OPAT service.
The ability to recognise acutely unwell patients and to instigate generic resuscitation is essential for all newly qualified doctors. The aim of this review is to synthesise recent work examining the perceived preparedness of UK medical graduates in acute care, relative to the other outcomes detailed in Tomorrow's Doctors (2009).
A systematic literature search was performed using five databases. It sought literature related to preparedness in acute care and other Tomorrow's Doctors outcomes from the perspectives of the graduates themselves and their professional colleagues. Two researchers undertook data extraction and quality scoring, and preparedness ratings in each outcome were mapped to a generic rating scale to allow comparison between studies.
256 articles were recovered, with 10 included in the final analysis. The 10 articles suggested that graduates perceive themselves to be least well prepared in acute care and prescribing. Their professional colleagues perceive them to be less prepared in acute care than in any of the other outcomes and perceive preparedness in acute care to have declined since the first publication of Tomorrow's Doctors. Furthermore, there is evidence that preparedness in acute care is an area of concern for UK graduates.
The assimilation of evidence in this review suggests that recent changes in UK undergraduate training, while improving preparedness in some areas, may have neglected acute care. While not a good surrogate for actual preparedness, perceived preparedness is important in influencing the behaviour of new graduates and therefore warrants further consideration.