Doctors learn new tricks, but do they remember them? Lack of effect of an educational intervention in improving Oxygen prescribing.

BACKGROUND AND OBJECTIVE: The 'audit cycle' is a fundamental part of improving clinical performance. For this to be effective, improvements made must be sustained. We observed that the prescription of Oxygen is often poor. Our aim was to audit Oxygen prescription before and after an educational intervention, and then again 4 years on. We hypothesized that improvements made immediately after the intervention would not be sustained over a longer period of time. METHODS: Oxygen prescription was assessed in 102 inpatients between June and August 2009. Following this, an educational intervention to improve Oxygen prescription was staged. Oxygen prescription was then re-audited in a further 102 inpatients between September 2009 and February 2010. A third audit of 72 inpatients took place between February and May 2014. RESULTS: One-way analysis of variance showed significant variance between audit groups (F 8.74, F-crit 4.26, P = 0.008). Post-hoc analysis with paired t-tests confirmed significant improvement in the rate of Oxygen prescription in the second audit (24.5-58.8%, P = 0.01), immediately after the intervention. Four years on in the third audit, there was significant deterioration in the rate of Oxygen prescription compared with the second audit (58.8-13.9%, P = 0.01). CONCLUSIONS: The rate of Oxygen prescription improves significantly after an educational intervention; however, this improvement is not sustained. This observation is likely reflected in a range of areas where the audit cycle is used to improve performance. It is important to be aware of this potential for regression to ensure that improvements are maintained over time.

Unilateral Pleural Effusions with More Than One Apparent Etiology. A Prospective Observational Study.

RATIONALE: Evaluation of a pleural effusion has historically focused on establishing a single etiology. Pleural fluid may accumulate through multiple pathophysiological processes. The prevalence of multiple causes for pleural effusions has not been established. The identification of contributing processes may improve clinical outcomes. OBJECTIVES: The objective of this prospectively collected case series was to establish the prevalence and nature of multiple etiologies for a unilateral pleural effusion. METHODS: Consecutive patients presenting with an undiagnosed unilateral pleural effusion were recruited at a tertiary pleural center. Patients underwent a comprehensive structured diagnostic clinical evaluation and were followed up for a minimum of 12 months, after which one or more diagnoses were recorded independently by two experienced clinicians. MEASUREMENTS AND MAIN RESULTS: One hundred thirty patients were recruited to the study over a 24-month period, and 126 patients completed follow up. Altogether, 88 patients (70%) had a single cause for their pleural effusion, and 38 (30%) had multiple causes. Serum N-terminal pro-brain natriuretic peptide (NT-pro BNP) greater than or equal to 1,500 pg/ml was predictive of multiple etiologies. NT-pro BNP had a sensitivity and specificity of 79 and 88%, respectively, for establishing heart failure as a primary or contributory cause. Thirteen patients with a malignant pleural effusion also had an NT-pro BNP greater than or equal to 1,500 pg/ml. CONCLUSIONS: This study is the first to estimate the prevalence of more than one identifiable cause for a unilateral pleural effusion. Out of 130 study subjects, 38 (30%) had multiple causes for an effusion. The identification of multiple pathologies underlying an accumulation of fluid in the pleural space may be important in determining optimum treatment and improving patients' symptoms.

Postmortem findings of malignant pleural mesothelioma: a two-center study of 318 patients.

BACKGROUND: Malignant pleural mesothelioma (MPM) is an incurable cancer with a rising incidence. MPM is often perceived as a locally invasive cancer, and the exact cause of death is poorly understood.This two-center study describes the anatomic features of patients with MPM at postmortem. METHODS: The Western Australia Mesothelioma Registry (Australia) and Coroner's Office reports from the Avon region (England) were interrogated for the postmortem records of confirmed mesothelioma cases. RESULTS: Postmortem records of 318 patients with pleural mesothelioma (169 from Western Australia and 149 from Avon) were identified. Most patients (91.5%) were men (mean age, 68.4 ± 11.5 years), and MPM was right-sided in 55.3%. Extrapleural dissemination of tumor was found in 87.7% of cases and lymph node involvement in 53.3%. Tumor dissemination in extra thoracicsites was common (55.4% of patients), and almost all organs were involved, including liver(31.9%), spleen (10.8%), thyroid (6.9%), and the brain (3.0%). Pulmonary emboli were found in 6% of cases and considered as directly contributing to death in 13 patients (4.1%). The precise cause of death could only be determined in 63 (19.8%) cases even after postmortem. The BMI was significantly lower in cases that had no identifiable anatomic cause of death at postmortem(18.8 ± 4.3 vs 21.0 ± 4.7, P = .034). CONCLUSIONS: In this largest, to our knowledge, postmortem series on MPM, extrathoracic dissemination of mesothelioma was common and often under recognized. No anatomic cause of death was identified in the majority of patients even at autopsy, raising the possibility of physiologic and metabolic causes of death.