Pilot Study on Documentation Skills: Is There Adequate Training in Emergency Medicine Residency?

Background: Thorough and accurate documentation in the medical record is important, and documentation skills should be an integral component of emergency medicine (EM) residency training. Study Objective: We sought to study the documentation skills of EM residents as they relate to emergency department (ED) reimbursement. Methods: This was a retrospective, cross-sectional study. We reviewed all charts of patients presenting to the adult ED during a 2-week period. We compared three groups: patients seen primarily by an EM resident, patients seen primarily by a physician assistant (PA), and patients seen primarily by an attending emergency physician. Outcome measures were the incidence of downcodes and dollars lost to downcodes in all groups. Results: There were 212 patients in the resident group, 683 patients in the PA group, and 437 patients in the attending group. There were 12 downcodes (5.7%, 95% confidence interval [CI] 2.96–9.70) in the resident group, 10 downcodes (1.5%, 95% CI 0.70–2.68) in the PA group, and 17 downcodes (3.9%, 95% CI 2.28–6.14) in the attending group (p = 0.002). The mean dollar lost per patient seen in the resident group was $3.21 (95% CI 1.41–5.00); $0.91 (95% CI 0.33–1.49) in the PA group; and $2.23 (95% CI 1.17–3.28) in the attending group (p = 0.002). Conclusion: Charts documented primarily by EM residents were more likely to be downcoded than charts documented primarily by PAs or ED attendings. This downcode rate resulted in a greater loss of revenue in the resident group. We believe this represents an area for improvement in EM residency education.     

Faculty Prediction of In-training Examination Scores of Emergency Medicine Residents

Background

The Emergency Medicine In-Training Examination (EMITE) is one of the only valid tools for medical knowledge assessment in current use by emergency medicine (EM) residencies. However, EMITE results return late in the academic year, providing little time to institute potential remediation.

Objective

The goal of this study was to determine the ability of EM faculty to accurately predict resident EMITE scores prior to results return.

Methods

We asked EM faculty at the study site to predict the 2012 EMITE scores of the 50 EM residents 2 weeks prior to results being available. The primary outcome was prediction accuracy, defined as the proportion of predictions within 6% of the actual score. The secondary outcome was prediction precision, defined as the mean deviation of predictions from the actual scores. We assessed several faculty background variables, including years of experience, educational leadership status, and clinical hours worked, for correlation with the two outcomes.

Results

Thirty-two of the 38 faculty (84.2%, 95% confidence interval [CI] 69.6–92.6) participated in the study, rendering a total of 1600 predictions for 50 residents. Mean resident EMITE score was 81.1% (95% CI 79.5–82.8%). Mean prediction accuracy for all faculty participants was 69% (95% CI 65.9–72.1%). Mean prediction precision was 5.2% (95% CI 4.9–5.5%). Education leadership status was the only background variable correlated with the primary and secondary outcomes (Spearman's ρ = 0.51 and −0.53, respectively).

Conclusion

Faculty possess only moderate accuracy at predicting resident EMITE scores. We recommend a multicenter study to evaluate the generalizability of the present results.     

Comparison of available gum-elastic bougies

Introduction

The purpose of this study was to compare 4 different gum-elastic bougies (GEBs) for differences in success rate, speed of intubation, and device preference.

Methods

This was a randomized study of 4 different GEBs (Sunmed, Portex, Greenfield, and Eschmann) used by emergency medicine (EM) and anesthesiology residents and attending physicians on a simulated difficult airway model. Success, time to intubation, and personal preference were recorded for each participant. Data were compared with analysis of variance, χ² and t tests, and 95% confidence intervals (95% CIs) where appropriate. P < .05 was considered significant.

Results

Twenty-one participants from EM (16 residents, 5 faculty) and 13 from anesthesia (9 residents, 4 faculty) were entered into the study. Overall success rates were 88% for Sunmed, 68% for Portex, 88% for Greenfield, and 79% for Eschmann. Participants were significantly more likely to be successful when using either the Sunmed or the Greenfield GEB compared with the Portex GEB (relative risk [RR] = 1.3, 95% CI = 1.0-15.6). Success rate by specialty was significantly different with 60 (71%) of 84 for EM physicians and 50 (96%) of 52 for anesthesiologists. Speed of intubation was a mean ± SD of 22.5 ± 9.7 seconds, with no significant difference by GEB or specialty. Participants were significantly more likely to prefer the Sunmed over the Greenfield (P = .001, RR = 6.9, 95% CI = 1.5-24.8) and the Eschmann over the Greenfield (P = .003, RR = 6.1, 95% CI = 1.6-63.0).

Conclusion

Emergency medicine physicians had better success rates using the Sunmed and Greenfield GEBs but low preference for the Greenfield GEB.     

Pediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training

Introduction

Previous studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e. “Milestones”. We developed a simulation-based teaching approach “Rapid Cycle Deliberate Practice” (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e. “first-five minutes” (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to “try again” over lengthy debriefing.

Participants

Pediatric residents from an academic medical center.

Methods

Prospective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation.

Results

Seventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5–100%) vs. post: 34% (26–53%); p < 0.001)], no-blow fraction: [pre: 39% (22–64%) median (IQR) vs. post: 30% (22–41%); p = 0.01], and pre-shock pause: [pre: 84 s (26–162) vs. post: 8 s (4–18); p < 0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1 min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0–7.2)] and defibrillating within 2 min: [HR: 1.7 (95% CI: 1.03–2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2 min: [HR: 2.8 (95% CI: 1.5–5.1)].

Conclusions

Implementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.     

Subjective dysphagia in older care home residents: A cross-sectional,multi-centre point prevalence measurement

Background

Dysphagia has been found to be strongly associated with aspiration pneumonia in frail older people. Aspiration pneumonia is causing high hospitalization rates, morbidity, and often death. Better insight in the prevalence of (subjective) dysphagia in frail older people may improve its early recognition and treatment.

Objective

First, to assess the prevalence of subjective dysphagia in care home residents in the Netherlands. Second, to assess the associations of subjective dysphagia with potential risk factors of dysphagia.

Design

Retrospective data-analysis of a cross-sectional, multi-centre point prevalence measurement.

Setting

119 care homes in the Netherlands.

Participants

Data of 8119 care home residents aged 65 years or older were included and analyzed.

Methods

Subjective dysphagia was assessed by a resident's response to a dichotomous question with regard to experiencing swallowing problems. If a resident was not able to respond (e.g. residents with dementia or aphasia), the question was answered by the ward care provider, or the resident's file was consulted for registered swallowing complaints and/or dysphagia. Several residents’ data were collected: gender, age, (number of) diseases, the presence of malnutrition, the Care Dependency Scale score, and the body mass index.

Results

Subjective dysphagia was found in 751 (9%) residents. A final model for subjective dysphagia after multivariate backward stepwise regression analysis revealed eight significant variables: age (B −0.022), Care Dependency Scale score (B −0.985), ‘malnutrition’ (OR 1.58; 95% CI 1.31–1.90), ‘comorbidity’ (OR 1.07; 95% CI 1.01–1.14), and the disease clusters ‘dementia’ (OR 0.55; 95% CI 0.45–0.66), ‘nervous system disorder’ (OR 1.55; 95% CI 1.20–1.99), ‘cardiovascular disease’ (OR 0.81; 95% CI 0.67–0.99) and ‘cerebrovascular disease/hemiparesis’ (OR 1.74; 95% CI 1.45–2.10).

Conclusion

It seems justified to conclude that subjective dysphagia is a relevant care problem in older care home residents in the Netherlands. Care Dependency Scale score, ‘malnutrition’, and the disease clusters ‘dementia’, ‘nervous system disorder’, and ‘cerebrovascular disease/hemiparesis’ were associated with the presence of subjective dysphagia in this study. Age, ‘comorbidity’ and ‘cardiovascular disease’ showed very small influence.     

Persistence of Warfarin Therapy for Residents in Long-term Care Who Have Atrial Fibrillation

Background

Among long-term care (LTC) residents with atrial fibrillation (AF), the use of warfarin to prevent stroke has been shown to be suboptimal. For those who begin warfarin prophylaxis in LTC, persistence on this therapy has not been reported.

Objective

This study was conducted to estimate persistence on warfarin among LTC residents with AF.

Methods

A retrospective analysis was conducted by using data from an LTC database. Pharmacy dispensing data were used to track warfarin use in residents with a diagnosis of AF who were newly started on warfarin therapy. The main outcome measure was persistence of warfarin over the first year of therapy. Survival analysis included Kaplan-Meier plots and a multivariate Cox proportional hazards model to test the association of resident characteristics and conditions with warfarin discontinuation.

Results

A total of 148 residents new to warfarin therapy met all study inclusion criteria. Median age was 84 years; 69% were female. Median time to therapy discontinuation was 197 days (95% CI, 137–249) across all study residents. By 90 days after the initiation of therapy, 37% (95% CI, 28–47) of study residents had discontinued warfarin; by 1 year, 65% (54%–76%) had discontinued warfarin therapy. The multivariate Cox regression analysis found that the following factors were independently associated with discontinuation of warfarin therapy: age 65 to 74 years (hazard ratio [HR] = 3.01 [95% CI, 1.04–8.73]), female sex (HR = 0.45 [95% CI, 0.24–0.87]), Hispanic race/ethnicity (HR = 2.86 [95% CI, 1.30–6.26]), Midwest region (HR = 2.13 [95% CI, 1.02–4.48]), and Alzheimer disease or dementia (HR = 1.97 [95% CI, 1.05–3.68]).

Conclusions

Although clinical practice guidelines exist for the prevention of stroke in AF patients, persistence on warfarin therapy seems suboptimal in many LTC residents with AF.     

Survival following witnessed pediatric out-of-hospital cardiac arrests during nights and weekends

Background

The relationship between survival rate following pediatric out-of-hospital cardiac arrests (OHCAs) and time of day or day of week is unknown.

Methods

A nationwide, prospective, population-based observational investigation of consecutive witnessed pediatric OHCAs (<18 years) with resuscitation attempts was conducted from January 2005 to December 2011. Days were defined as 9:00 am to 4:59 pm, nights as 5:00 pm to 8:59 am, weekdays as Mondays to Fridays, and weekends as Saturdays, Sundays, and national holidays. Primary outcome was one-month survival and secondary outcome was survival with favorable neurologic outcome, defined as cerebral performance category 1 or 2.

Results

A total of 3278 bystander-witnessed pediatric OHCAs were registered. One month survival rate was significantly lower during nights than days (15.5% [95% CI: 13.8–17.2%] versus 23.3% [95% CI: 21.1–25.6%]; P < 0.001 and during weekends/holidays (15.7% [95% CI: 13.6–18.0%] than weekdays (20.4% [95% CI: 18.7–22.2%]; P = 0.001. Survival rate with favorable neurologic outcome was substantially lower during nights 7.5% [95% CI: 6.3–8.8%] than days (12.2% [95% CI: 10.6–14.1%]; P < 0.001), and during weekends/holidays (7.7% [95% CI: 6.2–9.5%] than weekdays (10.4% [95% CI: 9.2–11.8%]; P = 0.012). After adjusting for potential confounding factors, one-month survival rate remained significantly lower during nights compared to days (odds ratio 0.68; 95% CI: 0.56–0.82), and during weekends/holidays compared to weekdays (odds ratio 0.79; 95% CI, 0.65–0.97).

Conclusions

One-month survival rate following bystander-witnessed pediatric OHCAs was lower during nights and weekends/holidays than days and weekdays, even when adjusted for potentially confounding factors.     

Comparison of Ultrasound-Guided and Standard Landmark Techniques for Knee Arthrocentesis

Background: Ultrasound is a useful adjunct to many Emergency Department (ED) procedures. Arthrocentesis is typically performed using a landmark technique but ultrasound may provide an opportunity to improve arthrocentesis performance. Objective: To assess the success of emergency physicians performing landmark (LM) vs. ultrasound (US)-guided knee arthrocentesis techniques. Methods: This was a prospective, randomized, controlled study of patients requiring knee arthrocentesis who presented to one urban university ED and two community EDs between June 2005 and February 2007. Results: There were 66 patients enrolled (39 US-guided, 27 LM). Among all users, there was no difference in arthrocentesis success (US 37/39 vs. LM 25/27); p = 1.0. Secondary Endpoints: 1) Patients reported less pain with ultrasound; US-guided 3.71 (95% confidence interval [CI] 2.61–4.80) cm vs. LM 5.19 (95% CI 3.94–6.45) cm; p = 0.02. 2) Providers felt the US-guided technique was easier to perform than LM; 1.67 units on 5-point scale (95% CI 1.37–1.97) vs. 2.11 (95% CI 1.79–2.42) units; p = 0.02. 3) The total procedure time was shorter with the US-guided technique; 10.58 (95% CI 7.36–13.80) min vs. LM 13.37 (95% CI 9.83–16.92) min; p = 0.05. 4) There was no difference in the amount of fluid obtained between techniques; US-guided 45.33 (95% CI 35.45–55.21) mL vs. LM 34.7 (95% CI 26.09–43.32) mL; p = 0.17. Conclusion: US-guided knee arthrocentesis technique does not improve overall success of obtaining joint fluid aspirate vs. the standard LM and palpation technique. An US-guided approach does not result in more pain for the patient, takes no additional time to perform and, at least for novice physicians, leads to more fluid aspiration and greater novice provider confidence with the procedure. Further studies with more participants and standardization of anesthetic quantity are required to validate these findings.     

Reduction of linezolid-associated thrombocytopenia by the dose adjustment based on the risk factors such as basal platelet count and body weight

The aim of the present study was to evaluate the efficacy of dose modification based on the risk factor for linezolid-induced thrombocytopenia. A multivariate logistic regression analysis performed in the observational study showed that low body weight of <55 kg (odds ratio [OR]: 33.2, 95% confidence interval [CI]: 2.16–510.1, P = 0.012) and the baseline platelet count of <200 × 10³/mm³ (OR: 24.9, 95% CI: 1.53–404.7, P = 0.024) were found to be risk factors for linezolid-induced thrombocytopenia. In the subsequent intervention study, in which daily dose of linezolid was set to 20 mg/kg in patients with either one of the risk factors or 1200 mg in those without any risk factor, the onset of thrombocytopenia was significantly prolonged in the intervention study group (P = 0.043), without reducing clinical efficacy. These findings suggest that dose adjustment of linezolid is effective in preventing thrombocytopenia without reducing its clinical efficacy in patients having risk factors.     

Effect of Probiotic,Prebiotic, and Synbiotic Supplementation on Cardiometabolic and Oxidative Stress Parameters in Patients With Chronic Kidney Disease: A Systematic Review and Meta-analysis

PurposeChronic kidney disease (CKD) is a major health problem worldwide. Evidence supporting the use of probiotic, prebiotic, and synbiotic supplementation in the management of CKD is mixed, although some studies suggest they may be useful. A systematic review and meta-analysis was performed to evaluate the effectiveness of probiotic, prebiotic, and synbiotic supplementation for improving cardiometabolic and oxidative stress parameters in patients with CKD.MethodsA comprehensive key word search was performed in EMBASE, Medline, Scopus, Cochrane Central, and Web of Science until April 2020. Randomized controlled trials investigating the effectiveness of probiotic, synbiotic, and prebiotic supplementation for the management of adults with CKD were included. Primary outcomes were measures of cardiometabolic parameters such as cholesterol and fasting blood glucose. Secondary outcomes were measures of oxidative stress (eg, malondialdehyde levels) and body mass index. Random effects meta-analyses were used to estimate mean treatment effects. Results are reported as standardized mean differences (SMDs) and 95% CIs.FindingsFourteen articles were included. In patients with CKD, probiotic, prebiotic, and synbiotic supplementation significantly reduced total cholesterol (SMD, ?0.25; 95% CI, ?0.46 to ?0.04; I² = 00.0%), fasting blood glucose (SMD, ?0.41; 95% CI, ?0.65 to ?0.17; I² = 00.0%), homeostatic model assessment of insulin resistance (SMD, ?0.63; 95% CI, ?0.95 to ?0.30; I² = 43.3%), insulin levels (SMD, ?0.49; 95% CI, ?0.90 to ?0.08; I² = 65.2%), high-sensitivity C-reactive protein levels (SMD, ?0.52; 95% CI, ?0.81 to ?0.22; I² = 52.7%), and malondialdehyde levels (SMD, ?0.79; 95% CI, ?1.22 to ?0.37; I² = 69.8%) compared with control interventions. Supplementation significantly increased the quantitative insulin sensitivity check index (SMD, 0.78; 95% CI, 0.51 to 1.05; I² = 00.0%), total antioxidant capacity (SMD, 0.42; 95% CI, 0.18 to 0.66; I² = 00.0%), and glutathione levels (SMD, 0.52; 95% CI, 0.19 to 0.86; I² = 37.0%).ImplicationsProbiotic, prebiotic, and synbiotic supplementation seems to be a promising intervention for improving cardiometabolic and oxidative stress parameters in patients with CKD.     

A Sedentary Job? Measuring the Physical Activity of Emergency Medicine Residents

Background

The debate on the quality of health care provided in the United States has continued to be waged as concerns have grown over the years. Stress, sleep deprivation, poor diet, and lack of exercise may lead to inadequate work performance by physicians.

Objective

This study was undertaken to determine whether Emergency Medicine (EM) residents satisfy daily recommendations for total number of steps taken per day set forth by the Centers for Disease Control and Prevention and Surgeon General in a 12-h shift.

Methods

An observational prospective cohort study was conducted between August 2009 and November 2009 at an urban Level I trauma center with an annual census of over 165,000 Emergency Department (ED) visits per year. The mean number of steps taken by EM residents during 12-h shifts was measured.

Results

Mean steps taken during a shift were 7333 (95% confidence interval 6901–7764). Only nine (9.9%) pedometer readings reached the target level of 10,000 (10 K) steps or above. A t-test was used to compare steps with the hypothesized 10 K steps target. Recordings of 10 K steps or greater were not correlated with ED sections (p = 0.60) shift (medical vs. surgical, p = 0.65) or ED census (r² < 0.0017).

Conclusion

A majority of residents (90%) did not meet the target number of steps for shifts. More rigorous charting needs, overcrowding, or even spatial limitations may explain this. This warrants further investigation to determine if some daily physical activity regimens may help improve the overall well-being of EM residents.     

A comparison of etanercept vs. infliximab for the treatment of post-arrest myocardial dysfunction in a swine model of ventricular fibrillation

Aims

To compare the effects of two TNF-α antagonists, etanercept and infliximab, on post-cardiac arrest hemodynamics and global left ventricular function (LV) in a swine model following ventricular fibrillation (VF).

Methods

Domestic swine (n = 30) were placed under general anesthesia and instrumented before VF was induced electrically. After 7 min of VF, standard ACLS resuscitation was performed. Animals achieving return of spontaneous circulation (ROSC) were randomized to immediately receive infliximab (5 mg/kg, n = 10) or etanercept (0.3 mg/kg [4 mg/m²], n = 10) or vehicle (250 mL normal saline [NS], n = 10) and LV function and hemodynamics were monitored for 3 h.

Results

Following ROSC, mean arterial pressure (MAP), stroke work (SW), and LV dP/dt fell from pre-arrest values in all groups. However, at the 30 min nadir, infliximab-treated animals had higher MAP than either the NS group (difference 14.4 mm Hg, 95% confidence interval [CI] 4.2–24.7) or the etanercept group (19.2 mm Hg, 95% CI 9.0–29.5), higher SW than the NS group (10.3 gm-m, 95% CI 5.1–15.5) or the etanercept group (8.9 gm-m, 95% CI 4.0–14.4) and greater LV dP/dt than the NS group (282.9 mm Hg/s, 95% CI 169.6–386.1 higher with infliximab) or the etanercep group (228.9 mm Hg/s, 95% CI 115.6–342.2 higher with infliximab).

Conclusions

Only infliximab demonstrated a beneficial effect on post cardiac arrest hemodynamics and LV function in this swine model. Etanercept was no better in this regard than saline.     

Does the Emergency Medical Treatment and Labor Act Affect Emergency Department Use?

Background

Emergency departments (EDs) face increasing patient volumes and economic pressures. These problems have been attributed to the Emergency Medical Treatment and Labor Act (EMTALA).

Study objective

To determine whether modifying EMTALA might reduce ED use.

Methods

We surveyed ED patients to assess their knowledge of hospitals’ obligations to treat all patients regardless of insurance and to determine whether knowledge is associated with ED use.

Results

Among 4136 study subjects, 72% reported awareness of the law. Sixty-one percent of subjects were moderate ED users (≥ 1 additional ED visit in 12 months). Moderate users more often knew the law (74% vs. 70%, p = 0.005). Multivariate regression showed that factors associated with moderate use were: awareness of EMTALA (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.24–1.67), adult patient (OR 1.94; 95% CI 1.69–2.22), and government insurance (OR 2.67; 95% CI 2.30–3.08) or uninsured (OR 1.72; 95% CI 1.42–2.08). Only 8% of subjects were high-frequency users (≥5 visits). High-frequency users were more often aware of EMTALA (78% vs. 72%, p = 0.02). Covariates associated with high frequency were EMTALA awareness (OR 1.69; 95% CI 1.28–2.24), adult patient (OR 2.59; 95% CI 2.00–3.36), and government insurance (OR 3.73; 95% CI 2.76–5.06) or uninsured (OR 3.77; 95% CI 2.65–5.35).

Conclusion

Many patients know that the law requires hospitals to provide care. This knowledge is associated with more frequent ED use. EMTALA changes might reduce ED use, but broader policy implications should be considered.     

An Opposite-Direction Modulation of the COMT Val158Met Polymorphism on the Clinical Response to Intrathecal Morphine and Triptans

Genetic variation in the COMT gene is thought to have clinical implications for pain perception and pain treatment. In the present study, we first evaluated the association between COMT rs4680 and the analgesic response to intrathecal morphine in patients with chronic low back pain to provide confirmation of previously reported positive findings. Next, we assessed the relationship between rs4680 and headache response to triptans in 2 independent cohorts of migraine patients. In patients with chronic low back pain (n = 74), logistic stepwise regression analysis showed that age (odds ratio [OR]: .90, 95% confidence interval [CI]: .85–.96, P = .002) and the presence of the COMT Met allele (vs Val/Val, OR: .21, 95% CI: .04–.98, P = .048) were predictive factors for lower risk of poor analgesic response to intrathecal morphine. Intriguingly, in migraine patients, the COMT rs4680 polymorphism influenced headache response to triptans in the opposite direction. Indeed, in an exploratory cohort of migraine patients without aura (n = 75), homozygous carriers of the COMT 158Met allele were found at increased risk to be poor responders to frovatriptan when compared to homozygous patients for the Val allele (OR: 5.20, 95% CI: 1.25–21.57, P = .023). In the validation cohort of migraine patients treated with triptans other than frovatriptan (n = 123), logistic stepwise regression analysis showed that use of prophylactic medications (OR: .43, 95% CI: .19–.99, P = .048) and COMT Met/Met genotype (vs Val/Val, OR: 4.29, 95% CI: 1.10–16.71, P = .036) were independent risk factors for poor response to triptans.     

Hemodilution is not the only reason of difference: Comparison of fasting and non-fasting lipoproteins in paired samples

IntroductionLow-density lipoprotein cholesterol (LDL) is an important risk factor for cardiovascular disease (CVD) and generally measured after 8–12 h fasting. However, some recent studies have pointed that non-fasting lipoproteins, especially LDL concentrations, are better indicators for demonstrating CVD risk and atherosclerosis. They asserted that nutrition is a negligible factor on changes in lipoprotein concentrations and claimed this difference as a result of hemodilution effect, caused from fluid intake and can be eliminated by applying some adjustments. We aimed to compare the fasting and non-fasting LDL values of the same individuals and discuss whether non-fasting and fasting LDL results can be used in place of each other, directly or after applying hemodilution correction models.Material and methodsFasting and non-fasting blood samples of 248 apparently healthy participants were collected. Lipid panel tests, albumin and hemoglobin levels were studied in each sample. Results were evaluated in seven different models which were recommended to correct the hemodilution effect on fasting and non-fasting lipid concentrations of the same individual. Concordance of fasting and non-fasting risk group of the individual were calculated according to the National Cholesterol Education Program classification.ResultsFasting and non-fasting LDL and non-high density lipoprotein cholesterol (non-HDL) concentrations were significantly different in every model (p < 0.001). Concordance results of fasting and non-fasting LDL and non-HDL risk groups were 63.8% and 77.9% respectively.ConclusionsOur results demonstrated that fasting and non-fasting LDL and non-HDL concentrations could not be used in place of each other even when the results were adjusted for elimination of the hemodilution effect.     

Effects of Kinesio Taping on Venous Symptoms,Bioelectrical Activity of the Gastrocnemius Muscle,Range of Ankle Motion,and Quality of Life in Postmenopausal Women With Chronic Venous Insufficiency: A Randomized Controlled Trial

Objective

To assess the efficacy of Kinesio taping (KT) on venous symptoms, quality of life, severity, pain, edema, range of ankle motion (ROAM), and peripheral muscle myoelectrical activity in lower limbs of postmenopausal women with mild chronic venous insufficiency (CVI).

Design

Double-blinded randomized controlled trial with concealed allocation.

Setting

Clinical setting.

Participants

Consecutive postmenopausal women (N=123; age range, 62–67y) with early-stage CVI. None of the participants withdrew because of adverse effects.

Intervention

Participants were randomly assigned to an experimental group for standardized KT application for external gastrocnemius (EG) and internal gastrocnemius (IG) muscle enhancement and ankle function correction or a placebo control group for sham KT application. Both interventions were performed 3 times a week during a 4-week period.

Main Outcome Measures

Venous symptoms, CVI severity, pain, leg volume, gastrocnemius electromyographic data, ROAM, and quality of life were recorded at baseline and after treatment.

Results

The experimental group evidenced significant improvements in pain distribution, venous claudication, swelling, heaviness, muscle cramps, pruritus, and CVI severity score (P≤.042). Both groups reported significant reductions in pain (experimental group: 95% confidence interval [CI], 1.6 to 2.1; control group: 95% CI, −0.2 to 0.3). There were no significant changes in either group in quality of life, leg volume, or ROAM. The experimental group showed significant improvements in root mean square signals (right leg: EG 95% CI, 2.99–5.84; IG 95% CI, 1.02–3.42; left leg: EG 95% CI, 3.00–6.25; IG 95% CI, 3.29–5.3) and peak maximum contraction (right leg: EG 95% CI, 4.8–22.7; IG 95% CI, 2.67–24.62; left leg: EG 95% CI, 2.37–20.44; IG 95% CI, 2.55–25.53), which were not changed in controls.

Conclusions

KT may reduce venous symptoms, pain, and their severity and enhance gastrocnemius muscle activity, but its effects on quality of life, edema, and ROAM remain uncertain. KT may have a placebo effect on venous pain.     

The correlation between TG vs remnant lipoproteins in the fasting and postprandial plasma of 23 volunteers

Background

Two recent publications report that non-fasting triglycerides concentrations in plasma are more predictive of cardiovascular events than conventional measurements of fasting triglycerides. While these observations are consistent with the previous studies, direct correlations between remnant lipoprotein triglyceride (RLP-TG) and remnant lipoprotein cholesterol (RLP-C), which are also considered to be risk factors for cardiovascular disease, and fasting and postprandial TG have not been investigated.

Methods

On four different days, both fasting and postprandial blood samples were collected from twenty-three overweight to obese men and women at UC Davis and analyzed for plasma concentrations of TG, RLP-C and RLP-TG.

Results

Significantly higher correlations between plasma TG and RLPs were observed in the postprandial state (RLP-C r² = 0.85; RLP-TG r² = 0.92) than in the fasting state (RLP-C r² = 0.61; RLP-TG r² = 0.73). The differences in the correlations between the fasting and postprandial TG and RLPs were statistically significant (p < 0.001). The increase of RLP-TG (postprandial RLP-TG minus fasting RLP-TG) consisted of approximately 80% of the total increase of TG (postprandial TG minus fasting TG).

Conclusion

Postprandial TG vs remnant lipoprotein concentrations were significantly more correlated when compared with fasting TG vs RLP concentrations. The increased TG in the postprandial state mainly consisted of TG in remnant lipoproteins. Therefore, the increased sensitivity of non-fasting TG in predicting the risk for cardiovascular events may be directly explained by the increase of remnant lipoproteins in the postprandial state.     

Risk factors for hospital-acquired pneumonia caused by carbapenem-resistant Gram-negative bacteria in critically ill patients: a multicenter study in Korea

We performed a case–control study to identify risk factors of carbapenem-resistant Gram-negative bacteria (CRGNB) as an increasing cause of hospital-acquired pneumonia (HAP). The study included critically ill adult patients with HAP whose microbial etiology was identified at eight tertiary centers in Korea between June 2008 and December 2009. Eighty two patients with 86 isolates of CRGNB (62 Acinetobacter baumannii, 14 Pseudomonas aeruginosa, and 10 Stenotrophomonas maltophilia) were included in the case group, and 122 patients with carbapenem-susceptible Gram-negative bacteria were included in the control group. Diabetes mellitus (adjusted odds ratio [aOR] 2.82, 95% confidence interval [95% CI] 1.25–6.38), radiologic score ≥ 5 (aOR 4.56, 95% CI 2.36–8.81), prior fluoroquinolone (aOR 2.39. 95% CI = 1.07–5.35), or carbapenem usage (aOR 2.82, 95% CI 1.75–17.83) were found to be independent risk factors. Fluoroquinolone and carbapenem should be cautiously used to avoid HAP caused by CRGNB.