Acute heart failure and iron deficiency: a prospective, multicentre, observational study.

AIMS: The prevalence and the natural course of iron deficiency (ID) in acute heart failure (AHF) are still unclear. We investigated the prevalence of ID in unselected patients admitted with AHF on admission, at discharge and up to 3 months thereafter. METHODS AND RESULTS: In this prospective, multicentre, observational study, 742 patients admitted with AHF were enrolled. The main study outcome was the percentage of patients with ID (ferritin <100 µg/L = absolute ID or ferritin 100-299 µg/L and transferrin saturation <20% = functional ID) at admission (T0), after clinical stabilization prior to discharge (T1), and 10 ± 6 weeks after discharge (T2). At T0, ID was present in 71.8% of the patients (44.1% absolute and 27.7% functional ID). At T1 and T2, ID was present in 56.4% (32.4% absolute and 24% functional ID) and 50.3% (36.8% absolute and 13.5% functional ID), respectively. Absolute ID persisted from T0 to T2 in 66% of the patients, while functional ID resolved in 56% of the patients. Ferritin (median [interquartile range] 124 µg/L [56-247] to 150 µg/L [73-277]), transferrin saturation (15% [10-20] to 18% [12-27]), and iron levels (9 µmol/L [6-13] to 11 µmol/L [8-16]) increased significantly (all P < 0.001) from T0 to T1. Transferrin saturation (to 21% [15-29]) and iron levels (to 13 µmol/L [9-17]) also increased significantly (both P < 0.01) from T1 to T2 without iron supplementation. CONCLUSIONS: Iron deficiency is highly prevalent in patients with AHF, but resolves during treatment in some patients, even without iron supplementation. Absolute ID is more likely to persist over time, whereas functional ID often resolves during treatment of AHF, representing probably a reduced iron availability rather than a true deficiency.

Validity, reliability and feasibility of a new observation rating tool and a post encounter rating tool for the assessment of clinical reasoning skills of medical students during their internal medicine clerkship: a pilot study.

BACKGROUND: Systematic assessment of clinical reasoning skills of medical students in clinical practice is very difficult. This is partly caused by the lack of understanding of the fundamental mechanisms underlying the process of clinical reasoning. METHODS: We previously developed an observation tool to assess the clinical reasoning skills of medical students during clinical practice. This observation tool consists of an 11-item observation rating form (ORT). In the present study we verified the validity, reliability and feasibility of this tool and of an already existing post-encounter rating tool (PERT) in clinical practice among medical students during the internal medicine clerkship. RESULTS: Six raters each assessed the same 15 student-patient encounters. The internal consistency (Cronbach's alfa) for the (ORT) was 0.87 (0.71-0.84) and the 5-item (PERT) was 0.81 (0.71-0.87). The intraclass-correlation coefficient for single measurements was poor for both the ORT; 0.32 (p < 0.001) as well as the PERT; 0.36 (p < 0.001). The Generalizability study (G-study) and decision study (D-study) showed that 6 raters are required to achieve a G-coefficient of > 0.7 for the ORT and 7 raters for the PERT. The largest sources of variance are the interaction between raters and students. There was a consistent correlation between the ORT and PERT of 0.53 (p = 0.04). CONCLUSIONS: The ORT and PERT are both feasible, valid and reliable instruments to assess students' clinical reasoning skills in clinical practice.