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1.
Am J Med Qual ; : 1062860619879977, 2019 Oct 04.
Artículo en Inglés | MEDLINE | ID: mdl-31581786

RESUMEN

This prospective cohort study aimed to improve hospital outcomes through geographic location of hospitalist patients and conducting daily multidisciplinary team rounds-Goal-directed Achievements through Geographic Location (GAGL). Patients were admitted to a geographic (GAGL) study unit where daily multidisciplinary rounds took place among nursing, case management, a hospitalist, pharmacy, physical and occupational therapy, respiratory therapy, and nutrition services. A total of 985 (56.4%) patients were admitted to the GAGL study unit and 760 patients (43.6%) were admitted to non-GAGL units. Patients admitted to the GAGL study unit had a shorter average length of stay (3.64 days vs 4.35 days, P = .0001) and a lower number of risk events (91 [9.2%] vs 93 [12.2%], P = .038). There was no significant difference in 30-day readmissions, avoidable day events, or code blue team activations. GAGL provides a framework for hospital organizations to improve provider communication, hospital efficiency, and patient safety.

2.
J Neurosci Nurs ; 51(5): 238-242, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31469704

RESUMEN

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that is life threatening with high rates of mortality, and many survivors are left with permanent neurologic deficits. Nimodipine is the treatment of choice for aSAH with the goal of reduction of delayed cerebral ischemia. It is the only evidence-based medication that has been shown to have improved outcomes for delayed cerebral ischemia; therefore, it is important for neuroscience nurses to be knowledgeable of the pharmacology and pharmacogenomics properties of this medication, including cytochrome P450 (CYP450) enzymes. METHODS AND RESULTS: This article reviews the CYP450 enzyme system including a review of the pharmacotherapy and pharmacogenomics of nimodipine for patients with aSAH illustrated with case study of a patient with abnormal drug metabolism. CONCLUSION: CYP450 enzymes can be inhibited or induced by multiple medications resulting in clinically significant differences in drug metabolism. Food and Drug Administration-approved medication nimodipine is the only medication shown to improve outcomes in patients with aSAH. Hence, it is important to have awareness of potential drug-to-drug interactions and pharmacogenomics of nimodipine when caring for critically ill patients with aSAH.


Asunto(s)
Bloqueadores de los Canales de Calcio/administración & dosificación , Sistema Enzimático del Citocromo P-450/metabolismo , Nimodipina/administración & dosificación , Farmacogenética , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/tratamiento farmacológico , Administración Oral , Adulto , Isquemia Encefálica/etiología , Isquemia Encefálica/prevención & control , Esquema de Medicación , Adhesión a Directriz , Humanos , Masculino
3.
J Gen Intern Med ; 34(10): 2288-2289, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31342323
4.
J Am Heart Assoc ; 8(14): e012137, 2019 Jul 16.
Artículo en Inglés | MEDLINE | ID: mdl-31286816

RESUMEN

Background An increasing number of residents and fellows have children during training. However, little is known about the specific experience of cardiology fellows who become parents during training. Methods and Results A 66-question Internet-based survey about experiences of pregnancy during graduate medical training was administered between May 1 and July 15, 2013, to all trainees (N=1516) in the Mayo School of Graduate Medical Education across 3 academic sites. Questions explored the experiences of new mothers, fathers, and their fellow trainees. There were 644 survey respondents overall (response rate, 42%), and of 73 cardiovascular trainees, 29 (10 women [35%]) completed the survey. Of those surveyed, 59% reported having children. All trainee mothers reported making alterations to their training schedule due to pregnancy and maternity leave. Twenty percent of trainee fathers also reported changing their training because of their partner's pregnancy. Of trainees with children, 41% reported difficulty completing research because of pregnancy and childcare obligations. Nontrainee mothers were significantly more likely to breastfeed beyond 6 months compared with trainee mothers ( P=0.018). A perceived stigma attached to pregnancy was reported by 62% of trainees. Both male and female trainees felt that their programs did not promote pregnancy-related schedule flexibility. Conclusions Our study shows that both men and women entering parenthood during cardiology training often have to change their schedule, research, and career path. Cardiology training programs should focus on curriculum design and supportive parenthood policies to both avoid negative stigma and optimize fellowship training during this time period.

5.
Oxf Med Case Reports ; 2018(10): omy072, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30302263

RESUMEN

Diffuse alveolar hemorrhage (DAH) is a rare, but potentially fatal, complication of antiphospholipid syndrome, and may present with acute and fulminant symptoms. We report a case of DAH presenting as sudden onset dyspnea in a gentleman with known antiphospholipid syndrome. Chest computed tomography angiography with pulmonary embolism protocol showed right lower lobe segmental filling defects, upper-lobe predominant diffuse ground-glass opacities, and centrilobular nodules bilaterally. The presence of DAH can be confirmed by bronchoalveolar lavage with serial aliquots, but this procedure typically does not elucidate the specific etiology for the hemorrhage. The treatment for patients with severe disease typically consists of a combination of immunosuppressive medications in the form of high-dose intravenous glucocorticoids plus rituximab, cyclophosphamide or mycophenolate; and/or plasma exchange. This case both provides an example of high-quality diagnostic imaging of diffuse alveolar hemorrhage as well as demonstrates the clinical and image-based improvement after treatment.

6.
J Emerg Med ; 54(6): e117-e120, 2018 06.
Artículo en Inglés | MEDLINE | ID: mdl-29685465

RESUMEN

BACKGROUND: Spontaneous pneumomediastinum with concurrent pneumorrhachis (air in the spinal canal) and subcutaneous emphysema can be an alarming presentation, both clinically and radiographically. These clinical entities often require only conservative measures after ruling out any worrisome underlying causes. Management often involves appropriate imaging, hospital admission, and sub-specialty consultation as needed to help determine any potential causes for the presentation that may require anything more than a period of medical observation. CASE REPORT: A 20-year-old man presented to the Emergency Department (ED) with acute onset of chest pain. Physical examination was significant for subcutaneous emphysema across the anterior chest wall. Radiographs of the neck revealed extensive soft tissue emphysema extending into the upper mediastinum. Computed tomography (CT) of the neck with contrast revealed a small amount of air within the central canal of the spinal cord, in addition to extensive pneumomediastinum and subcutaneous emphysema. The patient remained stable and was discharged home on hospital day 2, after significant threats for morbidity or mortality were ruled out. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous pneumomediastinum, pneumorrhachis, and subcutaneous emphysema are rare clinical entities, but each requires thorough investigation in the ED to rule out any underlying life-threatening cause. A conservative treatment approach is appropriate for most patients without evidence of cardiorespiratory compromise or neurologic deficits accruing due to these problems.


Asunto(s)
Tos/complicaciones , Enfisema Mediastínico/diagnóstico , Neumorraquis/diagnóstico , Antibacterianos/uso terapéutico , Dolor en el Pecho/etiología , Servicio de Urgencia en Hospital/organización & administración , Humanos , Masculino , Enfisema Mediastínico/etiología , Neumorraquis/etiología , Radiografía/métodos , Perforación Espontánea/complicaciones , Enfisema Subcutáneo/etiología , Tomografía Computarizada por Rayos X/métodos , Adulto Joven
9.
MedEdPORTAL ; 13: 10595, 2017 Jun 15.
Artículo en Inglés | MEDLINE | ID: mdl-30800797

RESUMEN

Introduction: Patient safety education is required in medical, nursing, and pharmacy training, and interprofessional education offers an ideal format for teaching the core concepts of patient safety. This training activity was developed to fulfill interprofessional education core competencies for communication and teamwork and was nested within a required patient safety course taught at a medical school. However, the activity can easily be adapted as a stand-alone offering that can be included in a preclinical doctoring course, offered as an elective, or hosted at a college of nursing or pharmacy. Our goal was to prepare learners for the clinical environment by providing a context for patient safety, communication, and teamwork. Methods: Students participate in a 1.5-hour large-group activity that explores a case from the perspectives of each discipline. Faculty from all three disciplines sequentially present and debrief the case using focused questions to guide students' reflections and interactions between team members. Results: We have presented this activity for 4 consecutive years. Students complete a questionnaire with retrospective pre-post ratings of their perspectives on the activity and its impact on their awareness of disciplinary roles and responsibilities, communication errors, and strategies for addressing interdisciplinary conflicts. Results show statistically significant increases in the items of interest. Discussion: This interprofessional education offering is effective in terms of increasing awareness and knowledge among members of three health care disciplines, improving awareness of potential kinds of communication errors, and helping students consider the role of interdisciplinary interactions.

10.
Am J Cardiol ; 118(8): 1144-1149, 2016 Oct 15.
Artículo en Inglés | MEDLINE | ID: mdl-27553104

RESUMEN

Cardiovascular disease (CVD) is a systemic process involving multiple vascular beds and includes coronary heart disease (CHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). All these manifestations are associated with an increased risk of subsequent myocardial infarction, stroke, and death. Guideline-directed medical therapy is recommended for all patients with CVD. In a cohort of US veterans, we identified 1,242,015 patients with CVD receiving care in 130 Veterans Affairs facilities from October 1, 2013 to September 30, 2014. CVD included diagnoses of CHD, PAD, or ICVD. We assessed the frequency of risk factor optimization and the use of guideline-directed medical therapy in patients with CHD, PAD alone, ICVD alone, and PAD + ICVD groups. A composite of 4 measures (blood pressure <140/90 mm Hg, A1c <7% in diabetics, statin use, and antiplatelet use in eligible patients), termed optimal medical therapy (OMT) was compared among groups. Multivariate logistic regression was performed with CHD as the referent category. CHD comprised 989,380 (79.7%), PAD alone 70,404 (5.7%), ICVD alone 163,730 (13.2%), and PAD + ICVD 18,501 (1.5%) of the cohort. Overall, only 36% received OMT with adjusted odds ratios of 0.54 (95% CI 0.53 to 0.55), 0.77 (0.76 to 0.78), and 0.97 (0.94 to 1.00) for patients with PAD alone, ICVD alone, and PAD + ICVD, respectively, compared with patients with CHD. In conclusion, OMT was low in all groups. Patients with PAD alone and ICVD alone were less likely to receive OMT than those with CHD and PAD + ICVD.


Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Trastornos Cerebrovasculares/tratamiento farmacológico , Enfermedad Coronaria/tratamiento farmacológico , Adhesión a Directriz/estadística & datos numéricos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Enfermedad Arterial Periférica/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Veteranos , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Presión Sanguínea , Isquemia Encefálica/complicaciones , Isquemia Encefálica/epidemiología , Trastornos Cerebrovasculares/epidemiología , Enfermedad Coronaria/epidemiología , Diabetes Mellitus/tratamiento farmacológico , Diabetes Mellitus/epidemiología , Diabetes Mellitus/metabolismo , Femenino , Hemoglobina A Glucada/metabolismo , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/epidemiología , Guías de Práctica Clínica como Asunto , Factores de Riesgo , Conducta de Reducción del Riesgo , Estados Unidos
11.
Int J Qual Health Care ; 28(1): 59-65, 2016 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26660442

RESUMEN

OBJECTIVE: In 2011, our institution developed a venous thromboembolism (VTE) prophylaxis order set to monitor prophylaxis management through physician-generated risk assessment orders. Prophylaxis rates obtained using the risk assessment orders were falsely low compared with chart review. Our goal was to redesign the order set to increase the percentage of VTE risk assessments ordered, both to improve care and to better reflect performance. DESIGN: Quality Improvement Project. SETTING: Veterans Health Administration. PARTICIPANTS: Patients admitted to acute care and intensive care medical units. INTERVENTIONS: Process analysis was used to identify systems failures limiting use of the original order set. The order set was redesigned using a human factors approach. MAIN OUTCOME MEASURE: VTE risk assessment orders. RESULTS: The order set was redesigned to reduce complexity and improve integration into provider workflow. The rate of risk assessment orders placed within 24 h increased from 48.6 to 80.4% (P < 0.001). There was no difference in the actual use of prophylaxis. However, for patients on prophylaxis, the rates of having a documented 'moderate' or 'high' risk assessment within 24 h increased from 66.7 to 95.7% (P < 0.001). CONCLUSIONS: Using human factor principles to redesign an order set led to a significant increase in the percentage of patients with a risk assessment order placed within 24 h of admission. Although the risk assessments using the redesigned order set better reflected physician performance, it remained an imperfect measure for VTE prophylaxis. New technology used to measure human performance must be evaluated following implementation to assess accuracy.


Asunto(s)
Mejoramiento de la Calidad , Tromboembolia Venosa/prevención & control , Anticoagulantes/administración & dosificación , Humanos , Medición de Riesgo , Factores de Riesgo , Estados Unidos , United States Department of Veterans Affairs
12.
Curr Hypertens Rep ; 14(4): 324-32, 2012 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-22661332

RESUMEN

Hypertension is a common disorder linked to increases in cardiovascular mortality and morbidity. Effective treatment decreases this excess mortality. Therapy with a single antihypertensive agent fails to achieve blood pressure goals in up to 75 % of patients. Compared to monotherapy, combination antihypertensive therapy, especially with fixed-dose (single pill) formulations, may more effectively control blood pressure and improve medication persistence while decreasing adverse effects, healthcare costs, and physician therapeutic inertia. Certain combinations, such as a calcium channel blocker and angiotensin converting enzyme inhibitor, have been associated with similar or fewer adverse effects and better outcomes than other combinations. In contrast, other combinations such as thiazide diuretics and ß-blockers may cause more adverse effects than monotherapy. When choosing a thiazide diuretic, chlorthalidone is preferable to hydrochlorothiazide, given better efficacy and cardiovascular outcomes. Initial combination antihypertensive therapy may benefit patients with stage I or II hypertension and more widespread use should be encouraged.


Asunto(s)
Antihipertensivos/uso terapéutico , Quimioterapia Combinada , Hipertensión/tratamiento farmacológico , Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antihipertensivos/administración & dosificación , Bloqueadores de los Canales de Calcio/administración & dosificación , Bloqueadores de los Canales de Calcio/uso terapéutico , Diuréticos/administración & dosificación , Diuréticos/uso terapéutico , Humanos , Hipertensión/patología , Sistema Renina-Angiotensina/efectos de los fármacos
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