Interventions to increase physician efficiency and comfort with an electronic health record system.

OBJECTIVE: To determine comfort when using the Electronic Health Record (EHR) and increase in documentation efficiency after an educational intervention for physicians to improve their transition to a new EHR. METHODS: This study was a single-center randomized, parallel, non-blinded controlled trial of real-time, focused educational interventions by physician peers in addition to usual training in the intervention arm compared with usual training in the control arm. Participants were 44 internal medicine physicians and residents stratified to groups using a survey of comfort with electronic media during rollout of a system-wide EHR and order entry system. Outcomes were median time to complete a progress note, notes completed after shift, and comfort with EHR at 20 and 40 shifts. RESULTS: In the intervention group, 73 education sessions averaging 14.4 (SD: 7.7) minutes were completed with intervention group participants, who received an average of 3.47 (SD: 2.1) interventions. Intervention group participants decreased their time to complete a progress note more quickly than controls over 30 shifts (p \u3c 0.001) and recorded significantly fewer progress notes after scheduled duty hours (77 versus 292, p \u3c 0.001). Comfort with EHRs increased significantly in both groups from baseline but did not differ significantly by group. Intervention group participants felt that the intervention was more helpful than their standard training (3.47 versus 1.95 on 4-point scale). CONCLUSION: Physicians teaching physicians during clinical work improved physician efficiency but not comfort with EHRs. More study is needed to determine best methods to assist those most challenged with new EHR rollouts

Efficacy of High-dose Statin for Prevention of Contrast- Induced Nephropathy (CIN) in Patients Undergoing Coronary Angiography: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Background Contrast-induced nephropathy (CIN) is a leading cause of hospital-acquired acute kidney injury. Previous trials on statins for CIN prevention are conflicting and meta-analyses of these are inconclusive. We systematically reviewed randomized controlled trials (RCTs) comparing high-dose versus low-dose or no statin for CIN prevention in patients undergoing coronary angiography, incorporating several large trials performed since publication of prior meta-analyses. Methods Relevant studies were identified via searches of MEDLINE, Cochrane, Web of Science, CINAHL and EMBASE from inception to October 2013. RCTs on high-dose statins for CIN prevention in patients undergoing coronary angiography were included. Study-specific odds-ratios (OR) and 95% confidence interval (CI) were calculated and combined using random-effects model meta-analysis. Between-study heterogeneity was assessed using I2 statistics. Results Twelve RCTs with 5564 patients were included. CIN was defined as 25% or 0.5 mg/dl or more serum Creatinine rise from baseline or at least 10% rise in Cystatin C within one week of contrast exposure. CIN occurred in 3.4% of 2769 patients pre-treated with high-dose statins and 7.6% of 2795 patients in the low-dose or no statin group [OR 0.43, 95% CI 0.33-0.55, I2 = 19%, p\u3c 0.001]. Atributable risk reduction was 4.2%. Number needed to treat to prevent CIN was 24. Analysis of 1598 patients in Atorvastatin (lipophilic) studies showed CIN occurred in 4.3% of 788 high-dose and 11.7% of 810 of low-dose or placebo participants.[OR 0.35; 95% CI 0.23-0.52, I2 =31%, p\u3c 0.001]. Analysis of Rosuvastatin (hydrophilic) studies with 3502 enrollees yielded similar results. CIN incidence in 1750 rosuvastatin patients was 2.5% versus 4.5% of 1752 placebo group patients [OR 0.54; 95% CI 0.37-0.79, I2 =0%, p\u3c 0.001]. Conclusion High-dose statin compared to low-dose or no statin pre-treatment for coronary angiography reduces the incidence of CIN. Both hydrophilic and lipophilic statins showed similar effects. Further trials should be geared towards identifying those who will derive maximum benefit from statins as well as effective statins and dosing strategies for preventing CIN

Meta-analysis on efficacy of statins for prevention of contrast-induced acute kidney injury in patients undergoing coronary angiography.

Contrast-induced acute kidney injury (CIAKI) is a leading cause of hospital-acquired acute kidney injury, and pretreatment with hydroxymethylglutaryl CoA reductase inhibitors (statins) have shown promise in prevention. A systematic review and meta-analysis was performed including randomized controlled trials of short-term high-dose statins (compared with either low-dose statin or placebo) for CIAKI prevention in patients undergoing coronary angiography. Study-specific odds ratios (ORs) were calculated, and between-study heterogeneity was assessed using the I(2) statistic. We used a random-effects model meta-analysis to pool the OR. Twelve RCTs, including 5,564 patients, were included. CIAKI occurred in 94 of 2,769 patients (3.4%) pretreated with high-dose statins and 213 of 2,795 patients (7.6%) in the low-dose or no-statin group (OR 0.43, 95% confidence interval [CI] 0.33 to 0.55, I(2) = 19%,

Meta-analysis of efficacy and safety of rivaroxaban compared with warfarin or dabigatran in patients undergoing catheter ablation for atrial fibrillation.

Several studies have been conducted to study the efficacy and safety of rivaroxaban in the atrial fibrillation periprocedural ablation period with similar rates of thromboembolism and major bleeding risks compared with warfarin or dabigatran. We sought to systematically review this evidence using pooled data from multiple studies. Studies comparing rivaroxaban with warfarin or dabigatran in patients undergoing catheter ablation for atrial fibrillation were identified through electronic literature searches of MEDLINE, EMBASE, clinicaltrials.gov, and the Cochrane library up to March 2014. Study-specific risk ratios (RRs) were calculated and combined using a random-effects model meta-analysis. In an analysis involving 3,575 patients, thromboembolism (composite of stroke, transient ischemic attack, and systemic and pulmonary emboli) occurred in 3 of 789 patients (0.4%) in the rivaroxaban group and 10 of 2,786 patients (0.4%) in the warfarin group (RR 0.71, 95% CI 0.26 to 1.96, I(2) = 0%, p = 0.51). Major hemorrhage occurred in 9 of 749 patients (1.2%) in the rivaroxaban group and 22 of 975 patients (2.3%) in the warfarin group (RR 0.49, 95% CI 0.24 to 1.02, I(2) = 0%, p = 0.06). Furthermore, direct efficacy and safety comparisons between rivaroxaban and dabigatran showed nonsignificant differences in rates of thromboembolism (0.5% vs 0.4%, respectively, RR 1.12, 95% CI 0.25 to 4.99, I(2) = 0%, p = 0.88) and major bleeding (1.0% vs 1.6%, respectively, RR = 0.71, 95% CI 0.16 to 3.15, I(2) = 22%, p = 0.66). In conclusion, our study suggests that patients treated with rivaroxaban during periprocedural catheter ablation have similar rates of thromboembolic events and major hemorrhage. Similar results were seen in direct comparisons between dabigatran and rivaroxaban

Transdermal Scopolamine for the Prevention of Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis

Background: Transdermal scopolamine (TDS) is a potential long-acting prophylactic antiemetic initially developed to prevent motion sickness. TDS is a centrally acting anticholinergic agent that was approved in 2001 by the US Food and Drug Administration for the prevention of postoperative nausea and vomiting (PONV). Although TDS has been reported to be clinically efficacious in the prevention of PONV, several adverse events (AEs), such as sedation, dry mouth, blurred vision, central cholinergic syndrome, and confusion (particularly in elderly patients with mild cognitive impairment), are potential concerns

RS3PE revisited: a systematic review and meta-analysis of 331 cases.

OBJECTIVES: Remitting seronegative symmetrical synovitis with pitting oedema (RS(3)PE) syndrome is a rare inflammatory arthritis, characterised by symmetrical distal synovitis, pitting oedema of the hands and feet, absence of rheumatoid factor, and favourable response to glucocorticoids. The aim of our study is to further delineate the clinical and laboratory features, and response to treatment. METHODS: We performed a systematic electronic search of Medline, PubMed, EMBASE, ACR and EULAR databases for case reports, case series, and related articles of RS(3)PE. Statistical analysis was done comparing categorical variables with Chi-square tests and frequencies of means via t-tests. Binary logistic regression analysis was performed to identify predictors of erosions, recurrence, malignancy and rheumatologic disorders. RESULTS: 331 cases of RS(3)PE were identified from 121 articles. RS(3)PE was found in older patients (71±10.42 years) predominantly in males (n= 211, 63.36%), was symmetrical (n=297/311, 95.50%) involved the hands (n=294/311, 94.53%) A concurrent rheumatologic condition was reported in 22 cases (6.65%), and malignancy in 54 cases (16.31%). Radiographic joint erosions were found in 5.5%. Most patients responded to medium-dose glucocorticoids (16.12±9.5 mg/day). Patients with concurrent malignancy requiring non-significantly higher doses of prednisone (18.12 vs. 15.76 mg, p 0.304) and higher likelihood of recurrence of disease (OR 4.04, 95% CI 1.10-14.88, p=0.03). CONCLUSIONS: The symptoms and unique findings that make up RS(3)PE appear to represent a steroid-responsive disease that may be a harbinger of an underlying malignancy. More study is needed to understand the molecular origins of RS(3)PE in order to determine whether it is a separate disease process. Patients with concurrent cancer tend to have more severe presentations and higher rates of recurrence