Showing papers in "Annals of Internal Medicine in 2006"
TL;DR: The MDRD Study equation has now been reexpressed for use with a standardized serum creatinine assay, allowing GFR estimates to be reported in clinical practice by using standardized serumcreatinine and overcoming this limitation to the current use of GFR estimating equations.
Abstract: Using standardized creatinine assays, the authors remeasured serum creatinine levels in 1628 patients whose glomerular filtration rate (GFR) had been measured by urinary clearance of 125I-isothalam...
5,115 citations
TL;DR: This work systematically review evidence on the costs and benefits associated with use of health information technology and to identify gaps in the literature in order to provide organizations, policymakers, clinicians, and consumers an understanding of the effect ofhealth information technology on clinical care.
Abstract: This review found that 4 benchmark institutions have done most of the published research on the effects of the electronic health record on medical care. The research shows that electronic health re...
3,053 citations
TL;DR: To determine the characteristics of HCV-infected persons in the general United States population today and to monitor trends in prevalence, data on HCV infection from the most recent NHANES was analyzed.
Abstract: Results: The prevalence of anti-HCV in the United States was 1.6% (95% CI, 1.3% to 1.9%), equating to an estimated 4.1 million (CI, 3.4 million to 4.9 million) anti-HCV–positive persons nationwide; 1.3% or 3.2 million (CI, 2.7 million to 3.9 million) persons had chronic HCV infection. Peak prevalence of anti-HCV (4.3%) was observed among persons 40 to 49 years of age. A total of 48.4% of anti-HCV–positive persons between 20 and 59 years of age reported a history of injection drug use, the strongest risk factor for HCV infection. Of all persons reporting such a history, 83.3% had not used injection drugs for at least 1 year before the survey. Other significant risk factors included 20 or more lifetime sex partners and blood transfusion before 1992. Abnormal serum ALT levels were found in 58.7% of HCV RNA–positive persons. Three characteristics (abnormal serum ALT level, any history of injection drug use, and history of blood transfusion before 1992) identified 85.1% of HCV RNA–positive participants between 20 and 59 years of age. Limitations: Incarcerated and homeless persons were not included in the survey. Conclusions: Many Americans are infected with HCV. Most were born between 1945 and 1964 and can be identified with current screening criteria. History of injection drug use is the strongest risk factor for infection.
1,954 citations
TL;DR: The Spanish Ministry of Health (Fondo de Investigación Sanitaria, Red G03/140) as discussed by the authors provided a grant for the Spanish National Institute of Public Health.
Abstract: Grant Support: By the Spanish Ministry of Health (Fondo de Investigacion Sanitaria, Red G03/140).
1,491 citations
TL;DR: This study found that regular exercise is associated with a reduced risk for incidence of dementia in a cohort followed biennially over 6 years and examined whether the association of physical exercise with incident dementia is modulated by other potential risk factors.
Abstract: The authors followed 1740 persons who did not have cognitive impairment at baseline. During a mean follow-up of 6.2 years, 158 participants developed dementia; the incidence rate was 13.0 per 1000 ...
1,385 citations
TL;DR: A review of reviews to describe methods used to assess the quality of prognosis studies and to describe how well current practices assess potential biases is to develop recommendations to guide future quality appraisal.
Abstract: In examining how researchers assess the quality of individual studies in systematic reviews about prognosis, the authors found that appraisal of the quality of the article, a necessary step in syst...
1,298 citations
TL;DR: Osteonecrosis of the jaws is strongly associated with the use of aminobisphosphonates, and the mechanism of disease is probably severe suppression of bone turnover, and possible mechanisms of etiopathogenesis are suggested.
Abstract: Osteonecrosis of the jaws is a recently described adverse side effect of bisphosphonate therapy. Patients with multiple myeloma and metastatic carcinoma to the skeleton who are receiving intravenous, nitrogen-containing bisphosphonates are at greatest risk for osteonecrosis of the jaws; these patients represent 94% of published cases. The mandible is more commonly affected than the maxilla (2:1 ratio), and 60% of cases are preceded by a dental surgical procedure. Oversuppression of bone turnover is probably the primary mechanism for the development of this condition, although there may be contributing comorbid factors. All sites of potential jaw infection should be eliminated before bisphosphonate therapy is initiated in these patients to reduce the necessity of subsequent dentoalveolar surgery. Conservative debridement of necrotic bone, pain control, infection management, use of antimicrobial oral rinses, and withdrawal of bisphosphonates are preferable to aggressive surgical measures for treating this condition. The degree of risk for osteonecrosis in patients taking oral bisphosphonates, such as alendronate, for osteoporosis is uncertain and warrants careful monitoring.
1,214 citations
TL;DR: In this study of a cohort of patients in a large integrated health care system, people with higher body mass index (BMI) at baseline had a higher incidence of end-stage renal disease (ESRD) even af...
Abstract: In this study of a cohort of patients in a large integrated health care system, people with higher body mass index (BMI) at baseline had a higher incidence of end-stage renal disease (ESRD) even af...
1,145 citations
TL;DR: A new prediction rule is derived that is entirely based on clinical variables and is independent of physicians' implicit judgment by using a large multicenter cohort of patients admitted to the emergency department for clinically suspected pulmonary embolism.
Abstract: To improve diagnosis of pulmonary embolism (PE), the authors constructed a simple scoring system to estimate the probability of PE. Clinical predictors included age, previous venous thromboembolism...
918 citations
TL;DR: A 2-part systematic review to guide clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery and to evaluate the efficacy of strategies to reduce the risk for postoperative pulmonary complications is prepared.
Abstract: This background review supports the American College of Physicians' clinical practice guideline on risk assessment for postoperative pulmonary complications after noncardiothoracic surgery.
860 citations
TL;DR: This study evaluated nonoutbreak community-acquired S. aureus skin and soft-tissue infections in patients in a large urban setting who were receiving care at a large hospital and its affiliated clinics in urban Atlanta, Georgia.
Abstract: In this study of 384 persons with microbiologically confirmed community-onset Staphylococcus aureus skin and soft-tissue infection, community-acquired methicillin-resistant Staphylococcus aureus (M...
TL;DR: A systematic search of the English-language literature in PubMed was conducted to find articles published between 1 January 1980 and 14 November 2005 whose main objective was to assess the use of explicit financial incentives to improve health care quality.
Abstract: This paper reviewed empirical studies that assessed the relationship between explicit financial incentives and the provision of high-quality health care. Thirteen of 17 studies examined the effect ...
TL;DR: A fifth level of evidence is proposed because it is believed that broad verification of a prediction rule's clinical impact is no less important than that of the prediction rule on which it is based, and progressive evidentiary standards emphasize that a prediction rules rises to the level of a decision rule only if clinicians use its predictions to help make decisions for patients.
Abstract: Clinical prediction rules, sometimes called clinical decision rules, have proliferated in recent years. However, very few have undergone formal impact analysis, the standard of evidence to assess their impact on patient care. Without impact analysis, clinicians cannot know whether using a prediction rule will be beneficial or harmful. This paper reviews standards of evidence for developing and evaluating prediction rules; important differences between prediction rules and decision rules; how to assess the potential clinical impact of a prediction rule before translating it into a decision rule; methodologic issues critical to successful impact analysis, including defining outcome measures and estimating sample size; the importance of close collaboration between clinical investigators and practicing clinicians before, during, and after impact analysis; and the need to measure both efficacy and effectiveness when analyzing a decision rule's clinical impact. These considerations should inform future development, evaluation, and use of all clinical prediction or decision rules.
TL;DR: A secondary analysis of data from a large trial of 2 antihypertensive drug regimens in patients with known coronary artery disease found a J-shaped relationship between diastolic blood pressure and all-cause death and myocardial infarction.
Abstract: Because blood flow in the coronary arteries takes place largely during diastole, an increase in risk for coronary artery disease with excessive lowering of diastolic blood pressure is plausible, al...
TL;DR: Patients who received abatacept more often had improved physical function, more frequently met standard response criteria, and less often had radiographic progression of joint damage, as well as serious infections and infusion reactions more often.
Abstract: Abatacept is the first drug to use inhibition of activation of T cells as a therapeutic pathway. In this 1-year, randomized, placebo-controlled trial involving 116 centers and 652 patients with rhe...
TL;DR: Clostridium difficile is the most common identifiable bacterial cause of diarrhea in the United States and the most sensitive diagnostic test, but the enzyme immunoassay is now used by most laboratories because of ease of processing, cost, and speed of results.
Abstract: Antibiotic-associated diarrhea and colitis were well established soon after antibiotics became available. Early work implicated Staphylococcus aureus, but in 1978 Clostridium difficile became the established pathogen in the vast majority of cases. In the first 5 years (1978 through 1983), the most common cause was clindamycin, the standard diagnostic test was the cytotoxin assay, and standard management was to withdraw the implicated antibiotic and treat with oral vancomycin. Most patients responded well, but 25% relapsed when vancomycin was withdrawn. During the next 20 years (1983 through 2003), the most commonly implicated antibiotics were the cephalosporins, which reflected the rates of use; the enzyme immunoassay replaced the cytotoxin assay because of speed of results and technical ease of performance; and metronidazole replaced vancomycin as standard treatment, and principles of containment hospitals became infection control and antibiotic control. During the recent past (2003 to 2006), C. difficile has been more frequent, more severe, more refractory to standard therapy, and more likely to relapse. This pattern is widly distributed in the United States, Canada, and Europe and is now attributed to a new strain of C. difficile designated BI, NAP1, or ribotype 027 (which are synonymous terms). This strain appears more virulent, possibly because of production of large amounts of toxins, and fluoroquinolones are now major inducing agents along with cephalosporins, which presumably reflects newly acquired in vitro resistance and escalating rates of use. The recent experience does not change principles of management of the individual patient, but it does serve to emphasize the need for better diagnostics, early recognition, improved methods to manage severe disease and relapsing disease, and greater attention to infection control and antibiotic restraint.
TL;DR: The Resources for Enhancing Alzheimer's Caregiver Health (REACH) study as discussed by the authors found that the intervention had no detectable effect on the number of care recipients who were institutionalized.
Abstract: Caring for a family member with dementia is extremely stressful, contributes to psychiatric and physical illness, and increases the risk for death (1, 2). The accumulating evidence on the personal, social, and health effects of dementia caregiving has generated a broad range of intervention studies, including randomized trials aimed at decreasing the burden and stress of caregiving. Several studies have demonstrated statistically significant effects in reducing caregiver burden, lowering caregiver depression, and delaying institutionalization of care recipients (1, 3, 4) through either targeted interventions that treat a specific caregiver problem, such as depression, or broad-based multicomponent interventions that include counseling, case management, and telephone support. Persistent limitations of caregiver intervention research are the paucity of well-controlled randomized trials, the limited range of outcomes examined, small sample sizes and insufficient power, geographic limitations, inadequate racial or ethnic variation, and a scarcity of comprehensive multicomponent interventions (4). Indeed, none of the 41 randomized clinical trials published in the last 5 years met Consolidated Standards of Reporting Trials (CONSORT) recommendations for reporting randomized trials (5), and many have serious methodologic problems that call into question the reported findings (4).
To address these limitations, the National Institute on Aging and the National Institute of Nursing Research funded a multisite research program designed to develop and test an effective caregiver intervention: the Resources for Enhancing Alzheimer's Caregiver Health (REACH) study. We performed the study in 2 phases. In the first phase (REACH I), we tested several different interventions at 6 U.S. sites to identify the most promising approaches to decreasing caregiver burden and depression (6). Results from the study showed that active treatments were superior to control conditions in reducing caregiver burden and that active engagement in skills training statistically significantly reduced caregiver depression (7, 8). The existing literature and findings from REACH I helped guide the design of the REACH II intervention (7, 8). We based the REACH II study on the premise that caregivers can have problems in several areas at varying levels of intensity, and thus, interventions must be responsive to variations in needs among caregivers. The findings from REACH I also suggest that interventions that use active techniques, such as role-playing and interactive practice, are more effective at improving outcomes, such as depression symptoms, compared with more passive methods, such as providing information (7). We based the REACH II intervention on these assumptions and designed the intervention to maximize outcomes by systematically targeting several problem areas, tailored the intervention to respond to the needs of each individual, and actively engaged the caregiver in the intervention process. We hypothesized that participants assigned to the intervention would do better than those in the control group on several indicators of caregiver quality of life, including depression, burden, self-care, and social support and care recipient problem behaviors, and that these differences would be largest among Hispanic or Latino persons because they have lower access to support services (8). In additional analyses, we assessed the effects of treatment on rates of caregiver clinical depression and care recipient institutional placement, as well as the benefits derived from study participation.
Context
Providing care for patients with dementia can pose enormous burdens that may be eased with assistance and support. Needs may differ by race or ethnicity.
Contributions
The investigators randomly assigned Hispanic, black, and white dementia caregivers to receive written educational materials or an intensive intervention to improve caregiver quality of life. The specific interventions were determined by caregivers, were delivered via trained personnel and telephone support groups, and targeted several dimensions of need. The study found that quality of life improved for Hispanic and white caregivers and for black spousal caregivers in the intervention group but not in the control group. The intervention had no detectable effect on the number of care recipients who were institutionalized.
Cautions
The study used only a single 6-month follow-up assessment, combined heterogeneous cultures and ethnicities into 3 groups, and excluded some ethnicities.
Implications
An intensive intervention targeting several dimensions of caregiver need improved caregiver quality of life without an apparent effect on care recipient institutionalization. The effect did not differ by caregiver race or ethnicity.
—The Editors
TL;DR: At 18 months, participants in both behavioral intervention groups had less hypertension, more weight loss, and better reduction in sodium and fat intake than those receiving advice only, and the DASH diet group also increased their intake of fruits, vegetables, and fiber.
Abstract: The authors randomly assigned 810 adults with prehypertension or early-stage hypertension to receive advice on changing diet and exercise, a behavioral intervention, or the behavioral intervention ...
TL;DR: The EUROLIVE Study aims to assess the effect of sustained daily doses of olive oil, as a function of its phenolic content, on the oxidative damage to lipid and LDL cholesterol levels and the lipid profile as cardiovascular risk factors in healthy men.
Abstract: Background Virgin olive oils are richer in phenolic content than refined olive oil. Small, randomized, crossover, controlled trials on the antioxidant effect of phenolic compounds from real-life daily doses of olive oil in humans have yielded conflicting results. Little information is available on the effect of the phenolic compounds of olive oil on plasma lipid levels. No international study with a large sample size has been done. Objective To evaluate whether the phenolic content of olive oil further benefits plasma lipid levels and lipid oxidative damage compared with monounsaturated acid content. Design Randomized, crossover, controlled trial. Setting 6 research centers from 5 European countries. Participants 200 healthy male volunteers. Measurements Glucose levels, plasma lipid levels, oxidative damage to lipid levels, and endogenous and exogenous antioxidants at baseline and before and after each intervention. Intervention In a crossover study, participants were randomly assigned to 3 sequences of daily administration of 25 mL of 3 olive oils. Olive oils had low (2.7 mg/kg of olive oil), medium (164 mg/kg), or high (366 mg/kg) phenolic content but were otherwise similar. Intervention periods were 3 weeks preceded by 2-week washout periods. Results A linear increase in high-density lipoprotein (HDL) cholesterol levels was observed for low-, medium-, and high-polyphenol olive oil: mean change, 0.025 mmol/L (95% CI, 0.003 to 0.05 mmol/L), 0.032 mmol/L (CI, 0.005 to 0.05 mmol/L), and 0.045 mmol/L (CI, 0.02 to 0.06 mmol/L), respectively. Total cholesterol-HDL cholesterol ratio decreased linearly with the phenolic content of the olive oil. Triglyceride levels decreased by an average of 0.05 mmol/L for all olive oils. Oxidative stress markers decreased linearly with increasing phenolic content. Mean changes for oxidized low-density lipoprotein levels were 1.21 U/L (CI, -0.8 to 3.6 U/L), -1.48 U/L (-3.6 to 0.6 U/L), and -3.21 U/L (-5.1 to -0.8 U/L) for the low-, medium-, and high-polyphenol olive oil, respectively. Limitations The olive oil may have interacted with other dietary components, participants' dietary intake was self-reported, and the intervention periods were short. Conclusions Olive oil is more than a monounsaturated fat. Its phenolic content can also provide benefits for plasma lipid levels and oxidative damage. International Standard Randomised Controlled Trial number: ISRCTN09220811.
TL;DR: This guideline was developed to guide clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery and evaluate the efficacy of strategies to reduce the risk for postoperative pulmonary complications.
Abstract: Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery. Ann Intern Med. 2006;144:575-580. www.annals.org For author affiliations, see end of text. RECOMMENDATIONS Recommendation 1: All patients undergoing noncardiothoracic surgery should be evaluated for the presence of the following significant risk factors for postoperative pulmonary complications in order to receive pre- and postoperative interventions to reduce pulmonary risk: chronic obstructive pulmonary disease, age older than 60 years, American Society of Anesthesiologists (ASA) class of II or greater, functionally dependent, and congestive heart failure. The following are not significant risk factors for postoperative pulmonary complications: obesity and mild or moderate asthma. Recommendation 2: Patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia. Recommendation 3: A low serum albumin level (35 g/L) is a powerful marker of increased risk for postoperative pulmonary complications and should be measured in all patients who are clinically suspected of having hypoalbuminemia; measurement should be considered in patients with 1 or more risk factors for perioperative pulmonary complications.
TL;DR: Improvements occurred in the proportion of patients with hemoglobin A1c between 6% and 8%, low-density lipoprotein (LDL) cholesterol levels less than 3.4 mmol/L, annual influenza vaccination, and aspirin use, and blood pressure.
Abstract: statistically significant increase of 21.9% (CI, 12.4% to 31.3%). Mean LDL cholesterol level decreased by 0.5 mmol/L (18.8 mg/ dL). Although mean hemoglobin A1c did not change, the proportion of persons with hemoglobin A1c of 6% to 8% increased from 34.2% to 47.0%. The blood pressure distribution did not change. Annual lipid testing, dilated eye examination, and foot examination increased by 8.3% (CI, 4.0% to 12.7%), 4.5% (CI, 0.5% to 8.5%), and 3.8% (CI, 0.1% to 7.7%), respectively. The proportion of persons reporting annual influenza vaccination and aspirin use improved by 6.8 percentage points (CI, 2.9 percentage points to 10.7 percentage points) and 13.1 percentage points (CI, 5.4 percentage points to 20.7 percentage points), respectively.
Journal Article•
TL;DR: The study found that quality of life improved for Hispanic and white caregivers and for black spousal caregivers in the intervention group but not in the control group, and that active engagement in skills training statistically significantly reduced caregiver depression.
Abstract: In this study, the investigators randomly assigned Hispanic, black, and white dementia caregivers to receive a control intervention (written educational materials) or an intensive intervention to i
TL;DR: Lower literacy and a greater number of medications being taken were associated with patient misunderstanding of pill bottle labels, and low literacy would be associated with higher rates of misunderstanding and incorrect demonstration.
Abstract: Inability to read the labels on prescription medication containers is a possible reason for poor medication adherence. In this study of patients in community health centers, many were unable to und...
TL;DR: This work analyzed data from closed malpractice claims at 4 liability insurance companies to develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention.
Abstract: The authors reviewed malpractice claims alleging injury from a missed or delayed diagnosis. In 181 cases in which there was a high likelihood that error led to the missed diagnosis, the authors ana...
TL;DR: While hs CRP improved overall model fit, the clinical utility of hsCRP in terms of reclassification was most substantial for those with a 5% or greater 10-year risk based on traditional risk factors, and most clinically relevant for those at intermediate risk.
Abstract: Background: While high-sensitivity C-reactive protein (hsCRP) is an independent predictor of cardiovascular risk, global risk prediction use. Objective: To develop and compare global cardiovascular risk prediction models with and without hsCRP. Design: Observational cohort study. Setting: U.S. female health professionals. Participants: Initially healthy nondiabetic women age 45 years and older participating in the Women’s Health Study and followed an average of 10 years. Measurements: Incident cardiovascular events (myocardial infarction, stroke, coronary revascularization, and cardiovascular death). Results: High-sensitivity CRP made a relative contribution to global risk at least as large as that provided by total, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) cholesterol individually, but less than that provided by age, smoking, and blood pressure. All global measures of fit improved when hsCRP was included, with likelihood-based measures demonstrating strong preference for models that include hsCRP. With use of 10-year risk categories of 0% to less than 5%, 5% to less than 10%, 10% to less than 20%, and 20% or greater, risk prediction was more accurate in models that included hsCRP, particularly for risk between 5% and 20%. Among women initially classified with risks of 5% to less than 10% and 10% to less than 20% according to the Adult Treatment Panel III covariables, 21% and 19%, respectively, were reclassified into more accurate risk categories. Although addition of hsCRP had minimal effect on the c-statistic (a measure of model discrimination) once age, smoking, and blood pressure were accounted for, the effect was nonetheless greater than that of total, LDL, or HDL cholesterol, suggesting that the c-statistic may be insensitive in evaluating risk prediction models. Limitations: Data were available only for women. Conclusions: A global risk prediction model that includes hsCRP improves cardiovascular risk classification in women, particularly among those with a 10-year risk of 5% to 20%. In models that include age, blood pressure, and smoking status, hsCRP improves prediction at least as much as do lipid measures.
TL;DR: It is hypothesized that cystatin C would be an important prognostic factor for risk for death, cardiovascular disease, and incident chronic kidney disease, whereas estimated GFR and creatinine would be unable to distinguish levels of risk.
Abstract: In this longitudinal study involving 4663 elderly persons without known kidney disease (estimated glomerular filtration rate ≥ 60 mL/min per 1.73 m2), increasing cystatin C concentration was associ...
TL;DR: A review of 8 controlled studies published in English-language medical literature between 1918 to 1925 found that transfusion with influenza-convalescent human blood products may have reduced ri... as discussed by the authors.
Abstract: This review of 8 controlled studies published in English-language medical literature between 1918 to 1925 found that transfusion with influenza-convalescent human blood products may have reduced ri...
TL;DR: Long-term outcomes of patients with nonacute Chagas disease treated with benznidazole are compared with the outcomes of those who did not receive treatment and the lack of reliable tests to ensure elimination of the parasite is compared.
Abstract: Background: Benznidazole is effective for treating acute-stage Chagas disease, but its effectiveness for treating indeterminate and chronic stages remains uncertain. Objective: To compare long-term outcomes of patients with nonacute Chagas disease treated with benznidazole versus outcomes of those who did not receive treatment. Design: Clinical trial with unblinded, nonrandom assignment of patients to intervention or control groups. Setting: Chagas disease center in Buenos Aires, Argentina. Patients: 566 patients 30 to 50 years of age with 3 positive results on serologic tests and without heart failure. Measurements: The primary outcome was disease progression, defined as a change to a more advanced Kuschnir group or death. Secondary outcomes included new abnormalities on electrocardiography and serologic reactivity. Intervention: Oral benznidazole, 5 mg/kg of body weight per day for 30 days (283 patients), or no treatment (283 patients). Results: Fewer treated patients had progression of disease (12 of 283 [4%] vs. 40 of 283 [14%]; adjusted hazard ratio, 0.24 [95% Cl, 0.10 to 0.59]; P = 0.002) or developed abnormalities on electrocardiography (15 of 283 [5%] vs. 45 of 283 [16%]; adjusted hazard ratio, 0.27 [Cl, 0.13 to 0.57]; P= 0.001) compared with untreated patients. Left ventricular ejection fraction (hazard ratio, 0.97 [Cl, 0.94 to 0.99]; P < 0.002) and left ventricular diastolic diameter (hazard ratio, 2.45 [Cl, 1.53 to 3.95]; P< 0.001) were also associated with disease progression. Conversion to negative results on serologic testing was more frequent in treated patients than in untreated patients (32 of 218 [15%] vs. 12 of 212 [6%]; adjusted hazard ratio, 2.1 [Cl, 1.06 to 4.06]; P = 0.034). Limitations: Nonrandom, unblinded treatment assignment was used, and follow-up data were missing for 20% of patients. Loss to follow-up was more common among patients who were less sick. Two uncontrolled interim analyses were conducted. Conclusions: Compared with no treatment, benznidazole treatment was associated with reduced progression of Chagas disease and increased negative seroconversion for patients presenting with nonacute disease and no heart failure. These observations indicate that a randomized, controlled trial should now be conducted.
TL;DR: Device-associated infections, particularly ventilator-associated pneumonia, central venous catheterrelated bloodstream infections, and catheter-associated urinary tract infections pose the greatest threat to patient safety in the ICU, according to the initial findings of an International Nosocomial Infection Control Consortium (INICC) surveillance study.
Abstract: Prospective surveillance of 21 069 patients hospitalized in 55 intensive care units in 46 hospitals in Central and South America, India, Morocco, and Turkey showed high rates (22.5 infections per 1...
Journal Article•
TL;DR: In this article, the authors developed a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention in the ambulatory setting, and developed a set of diagnostic errors associated with adverse outcomes for patients.
Abstract: Background: Although missed and delayed diagnoses have become an important patient safety concern, they remain largely unstudied, especially in the outpatient setting. Objective: To develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention. Design: Retrospective review of 307 closed malpractice claims in which patients alleged a missed or delayed diagnosis in the ambulatory setting. Setting: 4 malpractice insurance companies. Measurements: Diagnostic errors associated with adverse outcomes for patients, process breakdowns, and contributing factors. Results: A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. For 59% (106 of 181) of the errors, cancer was the diagnosis involved, chiefly breast (44 claims [24%]) and colorectal (13 claims [7%]) cancer. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]). The median number of process breakdowns and contributing factors per error was 3 for both (interquartile range, 2 to 4). Limitations: Reviewers were not blinded to the litigation outcomes, and the reliability of the error determination was moderate. Conclusions: Diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.