480 research outputs found
The frequency of missed test results and associated treatment delays in a highly computerized health system
<p>Abstract</p> <p>Background:</p> <p>Diagnostic errors associated with the failure to follow up on abnormal diagnostic studies ("missed results") are a potential cause of treatment delay and a threat to patient safety. Few data exist concerning the frequency of missed results and associated treatment delays within the Veterans Health Administration (VA).</p> <p>Objective:</p> <p>The primary objective of the current study was to assess the frequency of missed results and resulting treatment delays encountered by primary care providers in VA clinics.</p> <p>Methods:</p> <p>An anonymous on-line survey of primary care providers was conducted as part of the health systems ongoing quality improvement programs. We collected information from providers concerning their clinical effort (e.g., number of clinic sessions, number of patient visits per session), number of patients with missed abnormal test results, and the number and types of treatment delays providers encountered during the two week period prior to administration of our survey.</p> <p>Results:</p> <p>The survey was completed by 106 out of 198 providers (54 percent response rate). Respondents saw and average of 86 patients per 2 week period. Providers encountered 64 patients with missed results during the two week period leading up to the study and 52 patients with treatment delays. The most common missed results included imaging studies (29 percent), clinical laboratory (22 percent), anatomic pathology (9 percent), and other (40 percent). The most common diagnostic delays were cancer (34 percent), endocrine problems (26 percent), cardiac problems (16 percent), and others (24 percent).</p> <p>Conclusion:</p> <p>Missed results leading to clinically important treatment delays are an important and likely underappreciated source of diagnostic error.</p
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Personality trait structures across three species of Macaca, using survey ratings of responses to conspecifics and humans
Comparative studies reliant on single personality surveys to rate wild primates are scarce yet remain critical for developing a holistic comparative understanding of personality. Differences in survey design, item exclusion, and factor selection impede cross-study comparisons. To address these challenges, we used consistently collected data to assess personality trait structures in wild rhesus (Macaca mulatta), bonnet (M. radiata), and long-tailed (M. fascicularis) macaques that varied in their degree of phylogenetic closeness, species-typical social styles, and anthropogenic exposure in urban or urban-rural environments. We administered 51-item personality surveys to familiar raters, and, after reliability and structure screenings, isolated 4–5 factor solutions among the species. Four consistent factors emerged: Confident, Sociable, Active, and Irritable/Equable. This latter factor had differential expression across species. Item composition of the Irritable/Equable factor was consistent with their anticipated differences in social styles, but confounded by cross-site anthropogenic variation. We also administered a 43-item survey confined to human-primate situations which paralleled our findings of social style variation, while also exhibiting variation that aligned with population differences in human density. Our findings indicate that macaque personality trait structures may be emergent outcomes of evolutionary and/or socioecological processes, but further research is needed to parse these processes’ relative contributions
The association between histamine 2 receptor antagonist use and Clostridium difficile infection: a systematic review and meta-analysis.
Background
Clostridium difficile infection (CDI) is a major health problem. Epidemiological evidence suggests that there is an association between acid suppression therapy and development of CDI.
Purpose
We sought to systematically review the literature that examined the association between histamine 2 receptor antagonists (H2RAs) and CDI.
Data source
We searched Medline, Current Contents, Embase, ISI Web of Science and Elsevier Scopus from 1990 to 2012 for all analytical studies that examined the association between H2RAs and CDI.
Study selection
Two authors independently reviewed the studies for eligibility.
Data extraction
Data about studies characteristics, adjusted effect estimates and quality were extracted.
Data synthesis
Thirty-five observations from 33 eligible studies that included 201834 participants were analyzed. Studies were performed in 6 countries and nine of them were multicenter. Most studies did not specify the type or duration of H2RAs therapy. The pooled effect estimate was 1.44, 95% CI (1.22–1.7), I2 = 70.5%. This association was consistent across different subgroups (by study design and country) and there was no evidence of publication bias. The pooled effect estimate for high quality studies was 1.39 (1.15–1.68), I2 = 72.3%. Meta-regression analysis of 10 study-level variables did not identify sources of heterogeneity. In a speculative analysis, the number needed to harm (NNH) with H2RAs at 14 days after hospital admission in patients receiving antibiotics or not was 58, 95% CI (37, 115) and 425, 95% CI (267, 848), respectively. For the general population, the NNH at 1 year was 4549, 95% CI (2860, 9097).
Conclusion
In this rigorous systematic review and meta-analysis, we observed an association between H2RAs and CDI. The absolute risk of CDI associated with H2RAs is highest in hospitalized patients receiving antibiotics
Long-Term Follow-Up of the Intergroup Exemestane Study
Purpose: The Intergroup Exemestane Study, an investigator-led study of 4,724 postmenopausal patients with early breast cancer (clinical trial information: ISRCTN11883920), has previously demonstrated that a switch from adjuvant endocrine therapy after 2 to 3 years of tamoxifen to exemestane was associated with clinically relevant improvements in efficacy. Here, we report the final efficacy analyses of this cohort. Patients and Methods: Patients who remained disease free after 2 to 3 years of adjuvant tamoxifen were randomly assigned to continue tamoxifen or switch to exemestane to complete a total of 5 years of adjuvant endocrine therapy. Given the large number of non–breast cancer–related deaths now reported, breast cancer–free survival (BCFS), with censorship of intercurrent deaths, was the primary survival end point of interest. Analyses focus on patients with estrogen receptor-positive or unknown tumors (n = 4,599). Results: At the time of the data snapshot, median follow-up was 120 months. In the population that was estrogen receptor positive or had unknown estrogen receptor status, 1,111 BCFS events were observed with 508 (22.1%) of 2,294 patients in the exemestane group and 603 (26.2%) of 2,305 patients in the tamoxifen group. The data corresponded to an absolute difference (between exemestane and tamoxifen) at 10 years of 4.0% (95% CI, 1.2% to 6.7%), and the hazard ratio (HR) of 0.81 (95% CI, 0.72 to 0.92) favored exemestane. This difference remained in multivariable analysis that was adjusted for nodal status, prior use of hormone replacement therapy, and prior chemotherapy (HR, 0.80; 95% CI, 0.71 to 0.90; P < .001). A modest improvement in overall survival was seen with exemestane; the absolute difference (between exemestane and tamoxifen) at 10 years in the population that was estrogen receptor positive or had unknown estrogen receptor status was 2.1% (95% CI, −0.5% to 4.6%), and the HR was 0.89 (95% CI, 0.78 to 1.01; P = .08). For the intention-to-treat population, the absolute difference was 1.6% (95% CI, −0.9% to 4.1%); the HR was 0.91 (95% CI, 0.80 to 1.03, P = .15). No statistically significant difference was observed in the proportion of patients who reported a fracture event in the post-treatment period. Conclusion: The Intergroup Exemestane Study and contemporaneous studies have established that a strategy of switching to an aromatase inhibitor after 2 to 3 years of tamoxifen can lead to sustained benefits in terms of reduction of disease recurrence and breast cancer mortality
Effect of Contour Shape of Nervous System Electromagnetic Stimulation Coils on the Induced Electrical Field Distribution
BACKGROUND: Electromagnetic stimulation of the nervous system has the advantage of reduced discomfort in activating nerves. For brain structures stimulation, it has become a clinically accepted modality. Coil designs usually consider factors such as optimization of induced power, focussing, field shape etc. In this study we are attempting to find the effect of the coil contour shape on the electrical field distribution for magnetic stimulation. METHOD AND RESULTS: We use the maximum of the induced electric field stimulation in the region of interest as the optimization criterion. This choice required the application of the calculus of variation, with the contour perimeter taken as a pre-set condition. Four types of coils are studied and compared: circular, square, triangular and an 'optimally' shaped contour. The latter yields higher values of the induced electrical field in depths up to about 30 mm, but for depths around 100 mm, the circular shape has a slight advantage. The validity of the model results was checked by experimental measurements in a tank with saline solution, where differences of about 12% were found. In view the accuracy limitations of the computational and measurement methods used, such differences are considered acceptable. CONCLUSION: We applied an optimization approach, using the calculus of variation, which allows to obtain a coil contour shape corresponding to a selected criterion. In this case, the optimal contour showed higher intensities for a longer line along the depth-axis. The method allows modifying the induced field structure and focussing the field to a selected zone or line
Patient- and system-related barriers for the earlier diagnosis of colorectal cancer
<p>Abstract</p> <p>Background</p> <p>A cohort of colorectal cancer (CRC) patients represents an opportunity to study missed opportunities for earlier diagnosis. Primary objective: To study the epidemiology of diagnostic delays and failures to offer/complete CRC screening. Secondary objective: To identify system- and patient-related factors that may contribute to diagnostic delays or failures to offer/complete CRC screening.</p> <p>Methods</p> <p>Setting: Rural Veterans Administration (VA) Healthcare system. Participants: CRC cases diagnosed within the VA between 1/1/2000 and 3/1/2007. Data sources: progress notes, orders, and pathology, laboratory, and imaging results obtained between 1/1/1995 and 12/31/2007. Completed CRC screening was defined as a fecal occult blood test or flexible sigmoidoscopy (both within five years), or colonoscopy (within 10 years); delayed diagnosis was defined as a gap of more than six months between an abnormal test result and evidence of clinician response. A summary abstract of the antecedent clinical care for each patient was created by a certified gastroenterologist (GI), who jointly reviewed and coded the abstracts with a general internist (TW).</p> <p>Results</p> <p>The study population consisted of 150 CRC cases that met the inclusion criteria. The mean age was 69.04 (range 35-91); 99 (66%) were diagnosed due to symptoms; 61 cases (46%) had delays associated with system factors; of them, 57 (38% of the total) had delayed responses to abnormal findings. Fifteen of the cases (10%) had prompt symptom evaluations but received no CRC screening; no patient factors were identified as potentially contributing to the failure to screen/offer to screen. In total, 97 (65%) of the cases had missed opportunities for early diagnosis and 57 (38%) had patient factors that likely contributed to the diagnostic delay or apparent failure to screen/offer to screen.</p> <p>Conclusion</p> <p>Missed opportunities for earlier CRC diagnosis were frequent. Additional studies of clinical data management, focusing on following up abnormal findings, and offering/completing CRC screening, are needed.</p
Tag-Trigger-Consolidation: A Model of Early and Late Long-Term-Potentiation and Depression
Changes in synaptic efficacies need to be long-lasting in order to serve as a
substrate for memory. Experimentally, synaptic plasticity exhibits phases
covering the induction of long-term potentiation and depression (LTP/LTD) during
the early phase of synaptic plasticity, the setting of synaptic tags, a trigger
process for protein synthesis, and a slow transition leading to synaptic
consolidation during the late phase of synaptic plasticity. We present a
mathematical model that describes these different phases of synaptic plasticity.
The model explains a large body of experimental data on synaptic tagging and
capture, cross-tagging, and the late phases of LTP and LTD. Moreover, the model
accounts for the dependence of LTP and LTD induction on voltage and presynaptic
stimulation frequency. The stabilization of potentiated synapses during the
transition from early to late LTP occurs by protein synthesis dynamics that are
shared by groups of synapses. The functional consequence of this shared process
is that previously stabilized patterns of strong or weak synapses onto the same
postsynaptic neuron are well protected against later changes induced by LTP/LTD
protocols at individual synapses
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