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In this trial, patients with atrial fibrillation who required warfarin interruption for an elective procedure were assigned to either bridging anticoagulation or placebo. Forgoing bridging was noninferior to bridging for arterial thromboembolism and superior for major bleeding. For patients with atrial fibrillation who are receiving warfarin and require an elective operation or other elective invasive procedure, the need for bridging anticoagulation during perioperative interruption of warfarin treatment has long been uncertain. 1 – 3 Each year, this common clinical scenario affects approximately one in six warfarin-treated patients with atrial fibrillation. 4 , 5 Warfarin treatment is typically stopped 5 days before an elective procedure to allow its anticoagulant effect to wane; it is resumed after the procedure, when hemostasis is secured, at which point 5 to 10 days of treatment is required to attain therapeutic anticoagulation. 6 , 7 During the interruption of . . .

Background Educating medical trainees to practice high value care is a critical component to improving quality of care and should be introduced at the beginning of medical education. Aim To create a successful educational model that provides medical students and junior faculty with experiential learning in quality improvement and mentorship opportunities, and produce effective quality initiatives. Setting A tertiary medical center affiliated with a medical school in New York City. Participants First year medical students, junior faculty in hospital medicine, and a senior faculty course director. Program Description The Student High Value Care initiative is a longitudinal initiative comprised of six core elements: (1) project development, (2) value improvement curriculum, (3) mentorship, (4), Institutional support, (5) scholarship, and (6) student leadership. Program Evaluation During the first 3 years, 68 medical students and ten junior faculty participated in 10 quality improvement projects. Nine projects were successful in their measured outcomes, with statistically significant improvements. Nine had an abstract accepted to a regional or national meeting, and seven produced publications in peer-reviewed literature. Discussion In the first 3 years of the initiative, we successfully engaged medical students and junior faculty to create and support the implementation of successful quality improvement initiatives. Since that time, the program continues to offer meaningful mentorship and scholarship opportunities.

The Surviving Sepsis Campaign and Centers for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) recommend rapid crystalloid infusion (≥30 mL/kg) for patients with sepsis-induced hypoperfusion or septic shock. We aimed to assess compliance with this recommendation, factors associated with non-compliance, and how compliance relates to mortality. Retrospective, observational study. 1136-bed academic and 235-bed community hospital (January 2015–June 2016). Patients with septic shock. Crystalloid infusion (≥30 mL/kg) within 6 h of identification of septic shock as required by CMS. Associations with compliance and how compliance associates with mortality; odds ratios (OR) and 95% confidence intervals (CI) reported. Overall, 1027 septic shock patients were included. Of these, 486 (47.3%) met the 6-hour 30 ml/kg fluid requirement. Compliance was lower in patients with congestive heart failure (CHF) (40.9%), chronic kidney disease (CKD) (42.3%) or chronic liver disease (38.5%) and among those that were identified in the inpatient setting (35.4%) rather than in the emergency department (51.7%). When adjusting for relevant covariates, compliance (compared to non-compliance) was not associated with in-hospital mortality: OR 1.03 CI 0.76–1.41. These findings question a “one-size-fits-all” approach to fluid administration and performance measures for patients with sepsis. •Of the 1,027 patients identified as having septic shock, less than half met the CMS 6-hour 30 mL/kg fluid requirement.•Compliance was lower in patients with CHF, CKD and chronic liver disease, and sepsis identified in the inpatient setting.•Compliance with the fluid requirement, compared to non-compliance, was not associated with in-hospital mortality.

Problems with physician-physician communication and how this communication can be improved are examined. High-quality communication between inpatient and outpatient physicians is essential to ensure patient safety during transitions.

Back pain is the leading cause of global years lived with disability. This cross-sectional study assessed if a greater exposure to smoking cigarettes was associated with a greater prevalence of back pain.  This study examined data from 34,525 United States adults from the 2012 National Health Interview Survey. Analyses assessed the difference in back pain prevalence among current smokers, former smokers, and never smokers and the number of cigarettes smoked between current smokers with and without back pain. Back pain prevalence was 28%. There was a significant association between back pain and smoking, (2, 599, n = 34, 241) = 546.3, < .001. Back pain increased with increased smoking exposure; back pain was present in 23.5% of never-smokers, 33.1% of former smokers, and 36.9% of current smokers. The number of cigarettes smoked per day for current daily smokers was higher for those with back pain (Md = 13) than those without back pain (Md = 10), = 2701065, = -3.70, < .001, = .05. Our findings suggest that there may be a biological gradient associated with exposure to smoking cigarettes and back pain in adult Americans.

Escalating prevalence estimates of posttraumatic stress disorder (PTSD) among recently returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans highlight the need for early detection and management for reducing chronic mental illness and disability. Because PTSD and chronic pain are common comorbid conditions among veterans, PTSD screening within specialty clinic settings addressing musculoskeletal pain may be of value. This retrospective study evaluated measures of diagnostic value for the PTSD Checklist (PCL) for a sample (n = 79) of OIF/OEF veterans seeking care for neck or back pain within a Department of Veterans Affairs specialty clinic. Because published accounts of optimal PCL cutoff scores vary considerably, we used receiver operating characteristic curves to identify whether the optimal PCL cutoff score for the sample differed from a conventional cutoff score of 50. A clinical psychologist experienced in diagnosing and managing PTSD confirmed the diagnosis of PTSD for 37 veterans through a review of clinical records. The prevalence of diagnosed PTSD was 46.8%, with an optimal PCL cutoff score of 44. These findings may guide future research and influence clinical practice regarding PTSD screening for recently returning veterans with chronic pain.

This study was a cross-sectional analysis of clinical outcomes for 130 veteran patients with neck or low back complaints completing a course of care within the chiropractic clinic at the VA of Western New York in 2006. Multivariate analysis of variance (MANOVA) was utilized, comparing baseline and discharge scores for both the neck and low back regions and for those patients with and without post-traumatic stress disorder (PTSD). Patients with PTSD (n = 21) experienced significantly lower levels of score improvement than those without PTSD (n = 119) on self-reported outcome measures of neck and low back disability. These findings, coupled with the theorized relationships between PTSD and chronic pain, suggest that the success of conservative forms of management for veteran patients with musculoskeletal disorders may be limited by the presence of PTSD. Further research is warranted to examine the potential contributions of PTSD on chiropractic clinical outcomes with this unique patient population.

Musculoskeletal complaints, most notably low back pain (LBP), are prevalent among veterans. Despite a focus on LBP management by chiropractors within the Veterans Health Administration, limited published accounts detail clinical outcomes with chiropractic management of LBP among veterans. This was a retrospective case series of 171 veterans with a chief complaint of LBP who were managed with chiropractic care. Descriptive statistics and paired t-tests were used, with the Numeric Rating Scale (NRS) and the Back Bournemouth Questionnaire (BBQ) serving as the outcome measures. A minimum clinically important difference (MCID) was set as 30% improvement from baseline for both measures. The mean number of treatments was 8.7. For the NRS, the mean raw score improvement was 2.2 points, representing 37.4% change from baseline; 103 (60.2%) patients met or exceeded the MCID. For the BBQ, the mean raw score improvement was 13.6 points, representing 34.6% change from baseline; 92 patients (53.8%) met or exceeded the MCID. For this sample of veterans with LBP, the mean percentages of clinical improvement were statistically significant and clinically meaningful for both the NRS and BBQ.

A retrospective review of completed chiropractic consultations in 2006 (N = 354) was carried out to investigate consultation request patterns, patient characteristics, and the utilization of chiropractic services within the Department of Veterans Affairs of Western New York Health Care System. Primary care was the main source of patients with variation in the volume of consultation requests among providers. The average chiropractic patient was a 55-year-old male with low back pain who was overweight or obese with 27.43% service-connected disability. Post-traumatic stress disorder was diagnosed in 16.44%. The mean number of patient visits was minimized by following outcome-based practice parameters. Management consisted mainly of spinal manipulative therapy and mobilization techniques. Veteran chiropractic patients differed demographically from those in the general public who are predominantly female and younger. The implications of these differences on clinical outcomes and chiropractic clinical education are unclear and serve as the stimulus for additional research.

The in vitro degradation of biodegradable polymer/ceramic composites was assessed in two different environments under both static and pseudodynamic conditions. The blends, consisting of polycaprolactone, poly(lactic-co-glycolic acid), and hydroxyapatite, have potential use in bone tissue engineering applications, thus it is essential to establish a standardized method of characterizing the degradation of new biomaterials. In this study, the variation in polymer blend ratio was examined to observe a change in degradation rate. The porous blends were degraded in water and serum-containing media. A previous study examined in vitro degradation in serum-free buffer. Molecular weight loss, gravimetric weight loss, pH changes and morphological changes were evaluated. The changes in porosity were observed with scanning electron microscopy and quantitatively assessed using image analysis. There was a significant difference in molecular weight loss and gravimetric weight loss between the blends after 10 weeks in vitro. Blends containing the greatest amount of poly(lactic-co-glycolic acid) degraded most rapidly.