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Biomedical subjects

Arthur T Evans

Publications and source records attributed to Arthur T Evans.

At least 19 recordsLinked to original sources
PubMed2007

Obesity hypoventilation syndrome: prevalence and predictors in patients with obstructive sleep apnea.

Patients with obesity hypoventilation syndrome (OHS) have a lower quality of life, more healthcare expenses, a greater risk of pulmonary hypertension, and a higher mortality compared to eucapnic patients with obstructive sleep apnea (OSA). Despite significant morbidity and mortality associated with OHS, it is often unrecognized and treatment is frequently delayed. The objective of this observational study was to determine the prevalence of OHS in patients with OSA seen at the sleep disorders clinic of a large public urban hospital serving predominantly minority population and to identify clinical--not mechanistic--predictors that should prompt clinicians to measure arterial blood gases. In the first stage, we randomly selected 180 patients referred to our sleep disorders clinic between 2000 and 2004 for suspicion of OSA. From this retrospective random sample we calculated the prevalence of OHS in patients with OSA and identified independent clinical predictors using logistic regression. In the second stage, we prospectively validated these predictors in a sample of 410 consecutive patients referred to the sleep disorders clinic for suspicion of OSA between 2005 and 2006. The prevalence of OHS in patients with OSA was 30% in the retrospective random sample and 20% in the prospective sample. Three variables independently predicted OHS in both samples: serum bicarbonate level (p < 0.001), apnea-hypopnea index (p = 0.006), and lowest oxygen saturation during sleep (p < 0.001). Due to the serious morbidity associated with OHS, we selected a highly sensitive threshold of serum bicarbonate level. A threshold of 27 mEq/l had a sensitivity of 92% and a specificity of 50%. Only 3% of patients with a serum bicarbonate level <27 mEq/l had hypercapnia compared to 50% with a serum bicarbonate > or =27 mEq/l. In conclusion, OHS is common in severe OSA. A normal serum bicarbonate level excludes hypercapnia and an elevated serum bicarbonate level should prompt clinicians to measure arterial blood gases.

Adult↗
PubMed2006

Translating clinical research into clinical practice: impact of using prediction rules to make decisions.

Clinical prediction rules, sometimes called clinical decision rules, have proliferated in recent years. However, very few have undergone formal impact analysis, the standard of evidence to assess their impact on patient care. Without impact analysis, clinicians cannot know whether using a prediction rule will be beneficial or harmful. This paper reviews standards of evidence for developing and evaluating prediction rules; important differences between prediction rules and decision rules; how to assess the potential clinical impact of a prediction rule before translating it into a decision rule; methodologic issues critical to successful impact analysis, including defining outcome measures and estimating sample size; the importance of close collaboration between clinical investigators and practicing clinicians before, during, and after impact analysis; and the need to measure both efficacy and effectiveness when analyzing a decision rule's clinical impact. These considerations should inform future development, evaluation, and use of all clinical prediction or decision rules.

Biomedical Research↗
PubMed2006

Prospective cohort study of central venous catheters among internal medicine ward patients.

BACKGROUND: Central venous catheter (CVC) use is less well described for patients outside the intensive care unit. We evaluated CVCs and the associated bloodstream infection rate among patients admitted to the general medical service. METHODS: We performed a prospective cohort study of patients who had a CVC on admission or inserted during their stay on the general medical service in a public teaching hospital, November 15, 2004, to March 31, 2005. RESULTS: We identified 106 CVCs, 52 were present on admission and 54 were inserted; there were 682 catheter-days. The primary bloodstream infection rate was 4.4 per 1000 catheter-days (95% CI: 0.9-13): highest for catheters inserted in the emergency department compared with those inserted on other units (24 vs 1.7 per 1000 catheter-days), P = .045. By multivariable analysis, inadequate dressings were more likely among patients with a body mass index > or =30 kg/m(2), adjusted odds ratio, 3.4 (95% CI: 1.4-8.0). CONCLUSIONS: Many CVCs had previously been inserted in the emergency department or intensive care unit; therefore, strategies to reduce bloodstream infections that focus on ward insertion practices may not dramatically reduce bloodstream infection rates. Intervention strategies should target improved dressing care and consideration of early removal or replacement of catheters inserted in the emergency department.

Adult↗
PubMed2006

Learning by doing: developing fellows' academic skills through collaborative research.

Physicians in postgraduate training are expected to learn research methods but how best to achieve that curricular goal is unclear. This article describes a novel educational approach to develop research skills among infectious disease fellows. Five infectious disease fellows and two faculty members participated in a collaborative research project as a vehicle for active, problem-based learning. During the learning experience several tasks with specific learning objectives were achieved. The authors evaluated the weaknesses and strengths of the collaborative research project as an educational program. This problem-based approach for learning research methods seems more effective than traditional methods and may be applicable to a broad range of training programs.

Cohort Studies↗
PubMed2006

Teaching cardiac examination skills. A controlled trial of two methods.

OBJECTIVE: To determine if structured teaching of bedside cardiac examination skills improves medical residents' examination technique and their identification of key clinical findings. DESIGN: Firm-based single-blinded controlled trial. SETTING: Inpatient service at a university-affiliated public teaching hospital. PARTICIPANTS: Eighty Internal Medicine residents. METHODS: The study assessed 2 intervention groups that received 3-hour bedside teaching sessions during their 4-week rotation using either: (1) a traditional teaching method, "demonstration and practice" (DP) (n=26) or (2) an innovative method, "collaborative discovery" (CD) (n=24). The control group received their usual ward teaching sessions (n=25). The main outcome measures were scores on examination technique and correct identification of key clinical findings on an objective structured clinical examination (OSCE). RESULTS: All 3 groups had similar scores for both their examination technique and identification of key findings in the preintervention OSCE. After teaching, both intervention groups significantly improved their technical examination skills compared with the control group. The increase was 10% (95% confidence interval [CI] 4% to 17%) for CD versus control and 12% (95% CI 6% to 19%) for DP versus control (both P<.005) equivalent to an additional 3 to 4 examination skills being correctly performed. Improvement in key findings was limited to a 5% (95% CI 2% to 9%) increase for the CD teaching method, CD versus control P=.046, equivalent to the identification of an additional 2 key clinical findings. CONCLUSIONS: Both programs of bedside teaching increase the technical examination skills of residents but improvements in the identification of key clinical findings were modest and only demonstrated with a new method of teaching.

Cardiology↗
PubMed2006

Correlation of abnormal rapid FISH and chromosome results from amniocytes for prenatal diagnosis.

Rapid fluorescence in situ hybridization (FISH) performed on 1,788 amniocenteses, using Aneuvision (Vysis) probes for chromosomes 13, 18, 21, X, and Y, over several years, yielded 115 cases with percentages of aneuploidy between 4 and 100%. All cases above 60% were confirmed to be positive by chromosome analysis. Fifteen of forty-one cases that would be considered inconclusive by generally accepted criteria (i.e. with less than 60% of cells with an abnormal signal pattern) revealed lower cutoffs to be positive when confirmed by chromosome analysis. For trisomy 21, 6 cases with percentages from 36 to 57% were positive; 4 of 7 cases with percentages from 22.5 to 33% were positive; 11 cases with percentages of 13% or less were negative. Similar trends were found for aneuploidies of 13, 18, X, and Y. However, the number of abnormal cases is still too small to determine definitive cutoffs in the <60% gray zone. An average of 57 metaphases was analyzed for cases with FISH percentages below 60%. Despite the wide range of abnormal FISH percentages for chromosomally positive cases, we found no examples of autosomal mosaicism in this series. Although sex chromosome mosaicism was cytogenetically evident in several cases, there was little direct correlation between cytogenetic and rapid FISH results. FISH results involving sex chromosomes were more frequently confounded by maternal cell contamination and other technical factors.

Amniocentesis↗
PubMed2005

Thyroid hormone levels improve the prediction of mortality among patients admitted to the intensive care unit.

OBJECTIVE: As hormones are strongly associated with mortality in critically ill patients, we investigated whether mortality prediction based on the Acute Physiology and Chronic Health Evaluation (APACHE) is improved by combining this score with hormone measurements. DESIGN AND SETTING: Intensive care units in three hospitals. PATIENTS AND PARTICIPANTS: 113 patients admitted to. MEASUREMENTS: Within the first hour after ICU admission we measured total triiodothyronine, total thyroxine, free thyroxine, thyrotropin, cortisol, growth hormone, dehydroepiandrosterone, and prolactin levels and administered the APACHE. Patients were followed until they died or were discharged from the ICU. RESULTS: The best logistic regression model for ICU mortality included the APACHE score and thyroid-stimulating hormone and triiodothyronine levels. This model had an area under the receiver operating characteristic curve of 0.88, significantly higher than the APACHE score alone with 0.75. The model with hormone levels and APACHE score was also significantly better calibrated than the model with only the APACHE score. CONCLUSIONS: The addition of thyroid hormones to the APACHE score improves the prediction of mortality for ICU patients.

APACHE↗
PubMed2005

A prospective randomized trial of magnesium sulfate in severe preeclampsia: use of diuresis as a clinical parameter to determine the duration of postpartum therapy.

OBJECTIVE: The purpose of this study was to assess the use of the onset of diuresis in the determination of the duration of postpartum magnesium sulfate therapy among patients with severe preeclampsia. STUDY DESIGN: A prospective randomized trial of postpartum therapy with magnesium sulfate was conducted. The control group received 24 hours of therapy, and the study group received therapy until the onset of diuresis (urine output >100 mL/hr for 2 consecutive hours). The Student t test, chi 2 test, and Fisher's exact test were used for analysis of data; a probability value of <.05 was considered statistically significant. RESULTS: There were 50 patients in the control group and 48 patients in the study group. There was no difference in maternal demographic data, severe disease criteria, blood pressure, 24-hour postpartum urine output, or need for antihypertensive therapy. The study group had a significantly shorter duration of therapy, and no patient had eclampsia or required the re-initiation of therapy. CONCLUSION: The use of the onset of diuresis in the postpartum period as the determinant clinical parameter for the discontinuation of magnesium sulfate in patients with severe preeclampsia was associated with no untoward outcomes or need for the re-initiation of treatment.

Adult↗
PubMed2005

Abruptio placentae associated with misoprostol use in women with preeclampsia.

OBJECTIVE: To evaluate complications associated with cervical ripening with vaginal administration of misoprostol and dinoprostone vaginal inserts in women with preeclampsia. preeclampsia. STUDY DESIGN: Retrospective study of patients with preeclampsia undergoing cervical ripening with vaginal misoprostol and dinoprostone vaginal inserts prior to labor induction. RESULTS: Among 203 patients with preeclampsia undergoing cervical ripening prior to induction, 95 received vaginal misoprostol, and 108 received dinoprostone. The incidence of uterine hyperstimulation requiring medical therapy and the need for emergency cesarean section due tofetal heart rate abnormalities were significantly higher among patients receiving misoprostol (22.1% versus 12.0%, p = 0.04, and 17.9% versus 8.3%, p = 0.03, respectively). The overall incidence of abruptio placentae was 7.4%, with a significantly higher incidence among those receiving misoprostol as compared to dinoprostone (13.7% versus 1.9%, p = 0.001). CONCLUSION: Among patients with preeclampsia undergoing cervical ripening prior to labor induction, there is a higher incidence of acute intrapartum complications (uterine hyperstimulation, cesarean section for fetal heart rate abnormalities and abruptio placentae) with vaginal misoprostol, as compared to dinoprostone, vaginal insert.

Abruptio Placentae↗
PubMed2004

Why don't they listen? Adherence to recommendations of infectious disease consultations.

The effectiveness of an infectious diseases (ID) consultation is dependent on adherence to the recommendations. To delineate the factors that affect adherence, we conducted a prospective cohort study of 465 consultations at 2 academic institutions in which we evaluated the consultation process, patient and consultant characteristics, types of recommendations, and compliance with recommendations. The overall compliance rate was 80%, with 85% adherence to crucial recommendations. Multivariate analysis revealed that adherence to ID recommendations was higher when the recommendations were therapeutic instead of diagnostic, when they related to a specific clinical question, when recommendations were deemed crucial by the ID service, if the primary service was medicine, and if the consultation note was legible and organized. Whether modification of consultant practice will lead to improved recommendation compliance and patient outcomes warrants further study.

Adolescent↗
PubMed2004

Evaluating the performance of inpatient attending physicians: a new instrument for today's teaching hospitals.

OBJECTIVE: Instruments available to evaluate attending physicians fail to address their diverse roles and responsibilities in current inpatient practice. We developed a new instrument to evaluate attending physicians on medical inpatient services and tested its reliability and validity. DESIGN: Analysis of 731 evaluations of 99 attending physicians over a 1-year period. SETTING: Internal medicine residency program at a university-affiliated public teaching hospital. PARTICIPANTS: All medical residents (N= 145) and internal medicine attending physicians (N= 99) on inpatient ward rotations for the study period. MEASUREMENTS: A 32-item questionnaire assessed attending physician performance in 9 domains: evidence-based medicine, bedside teaching, clinical reasoning, patient-based teaching, teaching sessions, patient care, rounding, professionalism, and feedback. A summary score was calculated by averaging scores on all items. RESULTS: Eighty-five percent of eligible evaluations were completed and analyzed. Internal consistency among items in the summary score was 0.95 (Cronbach's alpha). Interrater reliability, using an average of 8 evaluations, was 0.87. The instrument discriminated among attending physicians with statistically significant differences on mean summary score and all 9 domain-specific mean scores (all comparisons, P <.001). The summary score predicted winners of faculty teaching awards (odds ratio [OR], 17; 95% confidence interval [CI], 8 to 36) and was strongly correlated with residents' desire to work with the attending again (r =.79; 95% CI, 0.74 to 0.83). The single item that best predicted the summary score was how frequently the physician made explicit his or her clinical reasoning in making medical decisions (r(2)=.90). CONCLUSION: The new instrument provides a reliable and valid method to evaluate the performance of inpatient teaching attending physicians.

Clinical Competence↗
PubMed2004

The impact of evidence on physicians' inpatient treatment decisions.

OBJECTIVE: Previous studies have shown that most medical inpatients receive treatment supported by strong evidence (evidence-based treatment), but they have not assessed whether and how physicians actually use evidence when making their treatment decisions. We investigated whether physicians would change inpatient treatment if presented with the results of a literature search. DESIGN: Before-after study. SETTING: Large public teaching hospital. PARTICIPANTS: Random sample of 146 inpatients cared for by 33 internal medicine attending physicians. INTERVENTIONS: After physicians committed to a specific diagnosis and treatment plan, investigators performed standardized literature searches and provided the search results to the attending physicians. MEASUREMENTS AND MAIN RESULTS: The primary study outcome was the number of patients whose attending physicians would change treatment due to the literature searches. These changes were evaluated by blinded peer review. A secondary outcome was the proportion of patients who received evidence-based treatment before and after the literature searches. Attending physicians changed treatment for 23 (18%) of 130 eligible patients (95% confidence interval, 12% to 24%) as a result of the literature searches. Overall, 86% of patients (112 of 130) received evidence-based treatments before the searches and 87% (113 of 130) after the searches. Changes were not related to whether patients were receiving evidence-based treatment before the search (P =.6). Panels of peer reviewers judged the quality of patient care as improved or maintained for 18 (78%) of the 23 patients with treatment changes. CONCLUSIONS: Searching the literature could improve the treatment of many medical inpatients, including those already receiving evidence-based treatment.

Adult↗
PubMed2003

Antibiotic therapy in preterm premature rupture of membranes: Are seven days necessary? A preliminary, randomized clinical trial.

OBJECTIVE: The purpose of this study was to determine whether 3 days of broad-spectrum antibiotic therapy, which is intended to prolong latency in patients with preterm premature rupture of membranes, is comparable to 7 days of therapy. STUDY DESIGN: Patients with preterm premature rupture of membranes at three separate study sites were asked to participate in this intent-to-treat, prospective, randomized trial. They were assigned randomly to either 3 or 7 days of ampicillin-sulbactam (3 g intravenously every 6 hours). The primary outcome of interest was the latency period from membrane rupture to delivery. RESULTS: Forty-two individuals were enrolled in each group. No difference was noted in the latency interval between the two groups (3 days, 214 +/- 225 hours, vs 7 days, 229 +/- 218 hours). A significantly higher number of patients in the 3-day group completed therapy (80.1% vs 47.6%, P =.003). No other parameters were significantly different between the two groups. No adverse events or trends were noted in either group. CONCLUSION: There appears to be no difference in the latency period between 3 and 7 days of ampicillin-sulbactam antibiotic therapy. More patients are needed to exclude a type II error.

Adult↗