Comparison of omeprazole and ranitidine for stress ulcer prophylaxis.

Stress ulcer prophylaxis protects against clinically important gastrointestinal bleeding and has gained widespread use. This study compares the efficacy of omeprazole to ranitidine for this indication. This was a prospective, randomized clinical trial. Sixty-seven high-risk patients were randomized to receive either ranitidine 150 mg (N = 35) intravenously daily or omeprazole 40 mg (N = 32) daily orally or by nasogastric route. Patients were monitored for clinically important bleeding. There was no statistically significant difference between treatment groups in the number of patients enrolled, gender, race, or age. The study groups were comparable in regard to the severity of illness based on their similar APACHE II score, duration of ICU stay, duration of ventilator dependence, and mortality rate. A significant difference was found only in regard to the number of risk factors per patient. The ranitidine-treated group had 2.7 risk factors per patient while the omeprazole-treated group had 1.9 (P < 0.05). Eleven patients (31%) given ranitidine and two patients (6%) given omeprazole developed clinically important bleeding (P < 0.05). Nosocomial pneumonia developed in five patients (14%) receiving ranitidine and one patient (3%) receiving omeprazole (P > 0.05). We conclude that oral omeprazole is safe, effective, and clinically feasible for stress ulcer prophylaxis.

Monitoring of r-hirudin anticoagulation during cardiopulmonary bypass--assessment of the whole blood ecarin clotting time.

The use of recombinant (r) hirudin as an anticoagulant in performing extracorporeal circulation systems including cardiopulmonary bypass (CPB) devices requires a specific and easy to handle monitoring system. The usefulness of the celite-induced activated clotting time (ACT) and the activated partial thromboplastin time (APTT) for r-hirudin monitoring has been tested on ex vivo blood samples obtained from eight patients treated with r-hirudin during open heart surgery. The very poor relationship between the prolongation of the ACT and APTT values and the concentration of r-hirudin as measured using a chromogenic factor IIa assay indicates that both assays are not suitable to monitor r-hirudin anticoagulation. As an alternative approach a whole blood clotting assay based on the prothrombin-activating snake venom ecarin has been tested. In vitro experiments using r-hirudin-spiked whole blood samples showed a linear relationship between the concentration of hirudin added and the prolongation of the clotting times up to a concentration of r-hirudin of 4.0 micrograms/ml. Interassay coefficients (CV) of variation between 2.1% and 5.4% demonstrate the accuracy of the ecarin clotting time (ECT) assay. Differences in the interindividual responsiveness to r-hirudin were analyzed on r-hirudin-spiked blood samples obtained from 50 healthy blood donors. CV-values between 1.8% and 6% measured at r-hirudin concentrations between 0.5 and 4 micrograms/ml indicate remarkably slight differences in r-hirudin responsiveness. ECT assay results of the ex vivo blood samples linearily correlate (r = 0.79) to the concentration of r-hirudin. Moreover, assay results were not influenced by treatment with aprotinin or heparin. These findings together with the short measuring time with less than 120 seconds warrant the whole blood ECT to be a suitable assay for monitoring of r-hirudin anticoagulation in cardiac surgery.

Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group.

Our objective was to determine whether an educational intervention and prompting intervention for physicians improved dietary counseling of patients with high blood cholesterol and resulted in beneficial changes in patients' diets and cholesterol levels. We instituted a factorial design, multicenter, randomized, placebo-controlled trial to test two interventions. We tested the trial at continuity care clinics of internal medicine residents at seven community and university medical centers in the northern and eastern United States. Our participants were 130 internal medicine residents and 254 adult outpatients with blood cholesterol levels of 240-300 mg/dL. Interventions included an educational program for resident physicians designed to improve their skills and confidence in dietary counseling (two one-hour sessions with specially prepared printed materials for use in counseling) and a prompting intervention, which was a fingerstick blood cholesterol determination prior to the patient's clinic visit. Resident physicians' knowledge, attitudes, and self-reported behaviors were assessed prior to the intervention and 10 months later using chart audits and questionnaires. Residents' behaviors were also assessed by exit interviews with patients. Patients' knowledge, attitudes, behaviors, and fingerstick blood cholesterol levels were measured at baseline and 10 months later. The educational program increased the percentage of physicians who were confident in providing effective dietary counseling (baseline of 26% to 67%-78%; P < .01). The prompting intervention approximately doubled the frequency of physician counseling (P = .0005) and increased the likelihood that patients would try to change their diets. When both interventions were combined, most outcomes were better, although not statistically significant. Cholesterol levels, however, decreased only marginally and were no different among groups at 10-month follow-up. Despite success in changing physicians' attitudes and behaviors and increasing patients' willingness to change their diets, there was no significant change in patients' cholesterol levels. Medical Subject Headings (MeSH): randomized controlled trial; cholesterol; patient education; behavior therapy; education, medical; diet.

Persistent paralysis after prolonged use of atracurium in the absence of corticosteroids.

Neuromuscular blocking agents (NMBAs) are often used for patients requiring prolonged mechanical ventilation. Reports of persistent paralysis after the discontinuance of these drugs have most often involved aminosteroid-based NMBAs such as vecuronium bromide, especially when used in conjunction with corticosteroids. Atracurium besylate, a short-acting benzylisoquinolinium NMBA that is eliminated independently of renal or hepatic function, has also been associated with persistent paralysis, but only when used with corticosteroids. We report a case of atracurium-related paralysis persisting for approximately 50 hours in a patient who was not treated with corticosteroids.

Development and validation of a scaled questionnaire for evaluation of residency programs.

As residency programs adapt to the need to promote primary care, the importance of quantitating qualitative issues increases. In this study, a questionnaire based on reported residency stressors was answered by 238 internal medicine residents. The Profile of Mood States (POMS) was also completed by 64. Factor analysis derived three scales reflecting emotional distress and satisfaction with the workload and learning environment. Emotional distress correlated positively with POMS scores indicating depression and dejection and was inversely related to workload. Workload satisfaction was significantly higher in programs with fewer admissions and lower in programs with greater patient loads. Responses did not differ by postgraduate year of training. Residents in different programs showed significant differences in emotional distress and workload but not learning environment. Residents in university programs indicated more stress and less satisfaction with workload than those in community programs. This study supports the validity of the three scales and provides insights into elements of the educational process that are difficult to quantitate.

Acquired protein C dysfunction but not decreased activity of thrombomodulin is a possible marker of thrombophilia in patients with lupus anticoagulant.

Lupus anticoagulants (LAs) are acquired antiphospholipid antibodies, and the occurrence of LA is associated with an increased risk of developing thrombosis. In a population of 46 patients with LA with or without LA-associated thrombophilia, it was analyzed whether the concentration of LA could be correlated to the individual thrombotic risk in patients with LA. No significant difference was found in the concentrations of LA measured by routinely used functional and immunologic assays in patients with LA with thrombophilia when compared with patients with LA without thrombophilia. Inhibition of thrombomodulin (TM) activity by LA has been postulated to be one of the major pathogenic mechanisms causing thrombophilia in LA. Therefore the inhibition of endothelial cell-dependent TM activity by LA was analyzed by using a protein C (PC) activation assay. Reduced rates of PC activation were found in only 2 out of the 46 cases, ruling out that inhibition of TM activity is a common phenomenon in patients with LA. However, anionic phospholipids are necessary to ascertain the anticoagulant activity of activated PC (APC). To prove the hypothesis that the anticoagulant activity of APC is inhibited by LA, the anticoagulant response of purified APC added to LA-containing plasma was measured through the amount of factor VIII inactivation. Thirteen out of 14 patients with recurrent thrombotic events and 10 out of 19 patients with one single episode of thrombosis showed an APC response outside the mean--2 SD range of normal human controls. In contrast, among 13 patients with LA without symptoms, only one showed an abnormal APC response. From these data it is concluded that LA inhibits the APC anticoagulant activity and that this type of acquired APC dysfunction may contribute to the pathogenesis of LA-associated thrombophilia. Moreover, the APC anticoagulant response assay may prove to be a useful marker to identify patients with LA with a high thrombotic risk.

The lipase to amylase ratio in acute pancreatitis.

OBJECTIVES: The ratio of serum lipase to serum amylase has been proposed to distinguish acute episodes of alcoholic from nonalcoholic pancreatitis. We evaluated the efficacy of this test in a community hospital setting. METHODS: Charts of all patients discharged with a diagnosis of acute pancreatitis over 19 months were retrospectively reviewed. Patients were excluded if their creatinine was greater than 3.0 mg/dl, if the amylase and lipase were not measured within 72 h of the onset of symptoms, or if the cause of pancreatitis was not known by the time of discharge. RESULTS: Of the 56 patients, 31 had alcoholic pancreatitis. The lipase to amylase ratio did not differ significantly between patients with alcoholic and nonalcoholic pancreatitis. Median amylase and lipase were significantly higher in nonalcoholic pancreatitis; however, the wide ranges of both meant that neither amylase nor lipase accurately determined the cause of pancreatitis. CONCLUSION: The lipase to amylase ratio does not appear to be sufficiently sensitive or specific to distinguish alcoholic from nonalcoholic acute pancreatitis.

Magnesium sulfate loading: preeclampsia vs preterm labor (a clinical pearl).

OBJECTIVE: To measure the apparent volume of distribution (AVOD) for magnesium (Mg) in preeclampsia and preterm labor and determine if a standard 4 gm loading dose of magnesium sulfate (MgSO4) is sufficient to attain therapeutic levels. METHODS: Twenty-five patients with preeclampsia and 25 with preterm labor received 4 g of MgSO4 intravenously over 15 minutes. Serum Mg levels were determined before and one minute after loading and the AVOD for Mg was calculated. Stepwise linear regression with AVOD as the dependent variable was performed and comparisons between the groups were made. RESULTS: Preeclamptics were heavier, had greater surface areas, and presented at a later stage of pregnancy than did patients with preterm labor. Despite these differences AVOD did not differ between the groups. Predose magnesium levels were slightly higher in the preeclamptic group (p = .04). Post-loading levels were nearly identical due to similar AVOD's and, because of the lower levels required for seizure prevention as opposed to tocolysis, were therapeutic 88% of the time in preeclampsia but only 12% of the time in preterm labor (p < .001). Multivariate analysis revealed that only ideal body weight, degree of underweight, and current therapy with betamimetics were significantly related to AVOD. CONCLUSION: AVOD was found to be similar in preeclamptic and preterm labor patients. A 4 g loading dose of MgSO4 is usually adequate to achieve therapeutic levels in preeclampsia but not in preterm labor.

Quantitating qualitative issues in residency training: development and testing of a scaled program evaluation questionnaire.

OBJECTIVES: To develop and test a scaled program evaluation questionnaire focusing on resident satisfaction with workload, learning environment, and stress. DESIGN/PARTICIPANTS: Phase 1: A cross-section of 92 residents from five programs completed questionnaires for factor analysis and descriptive statistics. Phase 2: A three-year prospective study of questionnaire responses in a single program. QUESTIONNAIRE DEVELOPMENT: After extensive literature review, 33 Likert-scaled statements were written, dealing with situational, personal, and professional issues. After pilot testing, the 92 questionnaires obtained in Phase 1 were factor analyzed, resulting in three distinct scales: workload, faculty/learning environment, and stress. INTERVENTIONS: Program changes in Phase 2 included the introduction of a night float between 1989 and 1990, and an increase in senior resident call between 1990 and 1991. RESULTS: Phase 1: The first-year residents reported significantly less stress and generally greater satisfaction with workload and learning environment than did the second- or third-year residents. Marked differences between programs were also present in the mean scores on all three scales. Phase 2: The introduction of a night float did not significantly affect response to the questionnaire, but the increase in nights on call significantly increased stress and dissatisfaction with the faculty/learning environment. CONCLUSIONS: This study demonstrates the techniques needed to develop and use scaled program evaluation questionnaires. It is hoped that widespread use and validation of such instruments may result in greater responsiveness to the needs of trainees and more facilitative environments in which to acquire medical knowledge.

Changes over time in the knowledge acquisition practices of internists.

Medical advances make continuing medical education (CME) necessary. Thirty practicing internists and 14 medical residents completed questionnaires and tests of critical appraisal knowledge designed to compare attitudes, behaviors, and skills for maintaining current knowledge. Eighteen internists were then given practical guidelines for "keeping up" with the literature, and this group and a control group were restudied 4 months later. Internists and residents perceived largely the same informational needs and performed similarly on tests of critical appraisal knowledge. Internists preferred reading journals and attending CME courses; residents relied on rounds and textbooks. Internists spent no more time reading than residents and reported only enough CME to maintain hospital privileges. The educational intervention had little effect on the internists who attended. Despite a conviction that journal reading is the "best way to keep up," internists may not increase the quantity or quality of time spent reading. CME courses should include instruction intended to promote individualized critical reading of pertinent medical literature.

Changes in residents' attitudes in response to residency program modifications: a prospective study.

Interventions to modify stress during residency training have rarely been formally analyzed for effectiveness. Using a 33-item, closed-ended questionnaire based on factors previously reported to cause residency stress, we studied how program modifications affected the attitudes of residents in a university-affiliated community internal medicine residency training program. Training program modifications, targeting specific questions, were prospectively introduced, and questionnaire responses were compared from year to year and by resident year of training. Between 1988 and 1989, the noon conferences and ward rotations were modified. Between 1989 and 1990, a "night float" was introduced. Residents' responses varied little by year of training, but the mean responses to seven of the fourteen "targeted" questions showed significant changes over time. In particular, the introduction of a night float resulted in markedly improved attitudes regarding time demands. This study demonstrates that residents' attitudes can be objectively measured, and that residents accurately perceive and respond to program modifications. Efforts should be made to standardize, validate, and develop attitudinal scales from such questionnaires to aid in the assessment of the numerous changes in residency programs currently being considered or implemented nationwide.

Dietary counseling of hypercholesterolemic patients by internal medicine residents.

OBJECTIVE: To assess the knowledge, attitudes, and practices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients. DESIGN: Cross-sectional, self-administered questionnaire survey. SETTING: Survey conducted August 1989 in seven internal medicine residency programs in four southeastern and middle Atlantic states. PARTICIPANTS: All 130 internal medicine residents who were actively participating in outpatient continuity clinic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Only 32% of the residents felt prepared to provide effective dietary counseling, and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree of practical knowledge about dietary facts varied. Residents reported giving dietary counseling to 58% of their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use of effective behavior modification techniques in counseling. Forty-three percent of residents had received no training in dietary counseling skills during medical school or residency. CONCLUSION: Internal medicine residents know much more about the rationale for treatment for hypercholesterolemia than about the practical aspects of dietary therapy, and they feel ineffective and ill-prepared to provide dietary counseling to patients.

Validity of the in-training examination for predicting American Board of Internal Medicine certifying examination scores.

OBJECTIVE: To determine whether the results of the Internal Medicine In-Training Examination (ITE) can predict subsequent performance on the American Board of Internal Medicine certifying examination (ABIMCE). DESIGN: Retrospective data review. SETTING: A mixture of six community hospital and university-based internal medicine training programs in the Eastern United States. SUBJECTS: 109 residents who first took the ABIMCE in 1988 or 1989, and who had also taken at least one ITE. MEASUREMENTS: Scores for the composite and subspecialty sections of the ITE were compared with those for the ABIMCE. An R2 was obtained to relate the scores on the two examinations. A cutoff score was derived to maximize the ability of the ITE to discriminate between residents who were likely to pass and those who were likely to fail the ABIMCE. MAIN RESULTS: ABIMCE scores were available for 109 residents who had also taken the ITE during PGY-2 (19), PGY-3 (50), or both years (40). Composite scores on the ABIMCE were highly correlated with those on the ITE-PGY-2 (R2 = 0.593) and the ITE-PGY-3 (R2 = 0.677) (p less than 0.0001 for each). Most of the subspecialty sections on the two examinations were significantly correlated, although less strongly (range of R2 = 0.041 to 0.32) than were the composite scores. An empirically derived cutoff score of the 35th percentile on the ITE-PGY-2 had a positive predictive value of 89% (probability of passing ABIMCE) and a negative predictive value of 83% (probability of failing ABIMCE). CONCLUSIONS: Performance on the ITE can accurately predict and is highly correlated with performance on the ABIMCE. ITE results may therefore be useful in counseling residents about their educational needs in preparation for the ABIMCE.

Affecting residents' literature reading attitudes, behaviors, and knowledge through a journal club intervention.

OBJECTIVE: To investigate whether a limited teaching intervention, based on principles of adult education, could change residents' literature reading attitudes, behaviors, and knowledge. DESIGN: The educational intervention supplemented an ongoing bimonthly journal club. The effects on residents were studied prospectively before and four months following the intervention. SETTING: A community hospital internal medicine training program. PARTICIPANTS: All 14 residents: six in the first year, and four each in the second and third years of training. INTERVENTION: A one-hour seminar incorporating principles of adult education, including the use of multiple teaching modalities. The content was based on the critical literature reading guidelines published by the McMaster group. Reinforcement of learning objectives was achieved by learner participation, written assignments, active feedback, and follow-up in subsequent journal clubs. RESULTS: Residents improved their performances on objective testing of critical appraisal knowledge by 60% (p = 0.02). They reported improved ability to appraise original research articles critically (p = 0.01) and reported spending more useful time reading. Unaffected were the total time spent reading journals, the reasons for reading them, and the perceived value of journals in "keeping up" with advances in medical knowledge. CONCLUSION: Journal clubs are important to residents, and their effectiveness in teaching critical appraisal and promoting reading of the literature may be augmented by applying principles of adult education.

Nephrotoxicity associated with concomitant ACE inhibitor and NSAID therapy.

Angiotensin-I converting enzyme (ACE) inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDs) can be nephrotoxic and may synergistically compromise renal function. A computer-assisted study was done to asses the prevalence of compromised renal function and the clinical importance of this drug interaction. A search of the records of all patients seen in the University of Nebraska Medical Center Internal Medicine Clinic was conducted to identify cases involving renal insufficiency, therapy with ACE inhibitors, or therapy with NSAIDs. Records of cases meeting these criteria were reviewed for clinical correlation and revealed 2278 patients treated with NSAIDs, 328 with ACE inhibitors, and 162 with both. No nephrotoxicity was found in conjunction with monotherapy, but three cases of reversible renal failure were found in conjunction with combination therapy. Significant nephrotoxicity during the concomitant use of ACE inhibitors and NSAIDs is not uncommon, and attention should be drawn to this potentially important interaction.

Magnesium deficiency in two hypertensive patient groups.

Magnesium (Mg) deficiency can contribute to cardiac dysrhythmias and may predispose to ischemic heart disease. Most diuretic agents cause loss of Mg, but serum levels may be normal despite cellular depletion. We studied the clinical characteristics of hypertensive patients treated for at least 6 months with either hydrochlorothiazide (HCTZ) or a single nondiuretic drug. To evaluate Mg status in our patients, we measured the percentage retention of a parenterally administered Mg load as an accurate indicator of functionally available total body Mg. Serum lipid, blood chemistry, and serum Mg values were obtained, and cardiac exercise testing and Holter monitoring were done. Levels of potassium were lower, but those of serum Mg were higher with HCTZ treatment despite double the Mg load retention. The Mg load retention data indicate relative Mg depletion in the HCTZ-treated group. Eighty percent of all patients studied had abnormal retention of Mg, even though their serum levels were normal. A percentage Mg load retention determination is needed to assess accurately Mg status.