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Cds, Ux, And System Redesign - Promising Techniques And Tools To Bridge The Evidence Gap, T. Mcginn

Journal Articles

INTRODUCTION: In this special issue of eGEMs, we explore the struggles related to bringing evidence into day-to-day practice, what I define as the "evidence gap." We are all aware of high quality evidence in the form of guidelines, randomized clinical trials for treatments and diagnostic tests, and clinical prediction rules, which are all readily available online. We also know that electronic health records (EHRs) are now ubiquitous in health care and in most practices across the country. How we marry this high quality evidence and the practice of medicine through effective decision support is a major challenge. ABOUT THE ISSUE: …

Use And Outcomes Associated With Bridging During Anticoagulation Interruptions In Patients With Atrial Fibrillation: Findings From The Outcomes Registry For Better Informed Treatment Of Atrial Fibrillation (Orbit-Af), B. A. Steinberg, E. D. Peterson, S. Kim, L. Thomas, B. J. Gersh, G. C. Fonarow, P. R. Kowey, K. W. Mahaffey, M. W. Sherwood, J. Ansell, +2 Additional Authors

Journal Articles

BACKGROUND: Temporary interruption of oral anticoagulation for procedures is often required, and some propose using bridging anticoagulation. However, the use and outcomes of bridging during oral anticoagulation interruptions in clinical practice are unknown. METHODS AND RESULTS: The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry is a prospective, observational registry study of US outpatients with atrial fibrillation. We recorded incident temporary interruptions of oral anticoagulation for a procedure, including the use and type of bridging therapy. Outcomes included multivariable-adjusted rates of myocardial infarction, stroke or systemic embolism, major bleeding, cause-specific hospitalization, and death within 30 days. Of …

Malignancies, Particularly B-Cell Lymphomas, Are A Frequent Cause Of Mortality In Human Immunodeficiency Virus-1 Patients Despite Highly Active Antiretroviral Therapy, D. O. Griffin, M. Metzger, K. Poeth, K. Deng, A. Dharsee, J. C. Rico, J. Mcgowan

Journal Articles

Human immunodeficiency virus (HIV)-1-infected individuals are affected by diseases at rates above those of their HIV-negative peers despite the increased life expectancy of the highly active antiretroviral therapy era. We followed a cohort of approximately 2000 HIV-1-infected patients for 5 years. The most frequent cause of death in this HIV-1-infected cohort was malignancy, with 39% of all classified deaths due to cancer. Among the cancer deaths, B-cell lymphomas were the most commonly seen malignancy, representing 34% of all cancer deaths. These lymphomas were very aggressive with a median survival ofdiagnosis.

Perioperative Bridging Anticoagulation In Patients With Atrial Fibrillation, J. D. Douketis, A. C. Spyropoulos, S. Kaatz, R. C. Becker, J. A. Caprini, A. S. Dunn, D. A. Garcia, A. Jacobson, A. K. Jaffer, T. L. Ortel, +4 Additional Authors

Journal Articles

BACKGROUND: It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding. METHODS: We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or …

A Randomized, Phase 2 Trial Of Docetaxel With Or Without Px-866, An Irreversible Oral Phosphatidylinositol 3-Kinase Inhibitor, In Patients With Relapsed Or Metastatic Head And Neck Squamous Cell Cancer, A. Jimeno, J. E. Bauman, C. Weissman, D. Adkins, I. Schnadig, P. Beauregard, D. W. Bowles, A. Spira, B. Levy, N. Seetharamu, D. Hausman, L. Walker, C. M. Rudin, K. Shirai

Journal Articles

INTRODUCTION: The phosphotidylinositol-3 kinase (PI3K)/serine-threonine kinase (AKT)/mammalian target of rapamycin (mTOR) signaling pathway is frequently altered in head and neck squamous cell cancer (HNSCC). PX-866 is an oral, irreversible, pan-isoform inhibitor of PI3K. Preclinical models revealed synergy with docetaxel and a phase 1 trial demonstrated tolerability of this combination. This randomized phase 2 study evaluated PX-866 combined with docetaxel in patients with advanced, refractory HNSCC. METHODS: Patients with locally advanced, recurrent or metastatic HNSCC who had received at least one and no more than two prior systemic treatment regimens were randomized (1:1) to a combination of docetaxel (75mg/m(2) IV every …

A Framework For Usable And Effective Clinical Decision Support: Experience From The Icpr Randomized Clinical Trial, J. Kannry, L. Mccullagh, A. Kushniruk, D. Mann, D. Edonyabo, T. Mcginn

Journal Articles

INTRODUCTION: The promise of Clinical Decision Support (CDS) has always been to transform patient care and improve patient outcomes through the delivery of timely and appropriate recommendations that are patient specific and, more often than not, are appropriately actionable. However, the users of CDS-providers-are frequently bombarded with inappropriate and inapplicable CDS that often are not informational, not integrated into the workflow, not patient specific, and that may present out of date and irrelevant recommendations. METHODS: The integrated clinical prediction rule (iCPR) project was a randomized clinical trial (RCT) conducted to determine if a novel form of CDS, i.e., clinical prediction …

Healthcare Provider Perceptions Of Clinical Prediction Rules, S. Richardson, S. Khan, L. Mccullagh, M. Kline, D. Mann, T. Mcginn

Journal Articles

Objectives: To examine internal medicine and emergency medicine healthcare provider perceptions of usefulness of specific clinical prediction rules. Setting: The study took place in two academic medical centres. A web-based survey was distributed and completed by participants between 1 January and 31 May 2013. Participants: Medical doctors, doctors of osteopathy or nurse practitioners employed in the internal medicine or emergency medicine departments at either institution. Primary and secondary outcome measures: The primary outcome was to identify the clinical prediction rules perceived as most useful by healthcare providers specialising in internal medicine and emergency medicine. Secondary outcomes included comparing usefulness scores …

Comparison Of Cytologic Accuracy Of Endobronchial Ultrasound Transbronchial Needle Aspiration Using Needle Suction Versus No Suction, K. Harris, R. Maroun, K. Attwood, M. Chalhoub

Journal Articles

BACKGROUND AND OBJECTIVES: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new procedure initially used for lung cancer diagnosis, staging and re-staging and extended to benign diseases such as sarcoidosis and other mediastinal lesions. Previously, multiple studies evaluated the use of needle biopsy with no aspiration that did not change the diagnostic accuracy compared with needle biopsy aspiration. MATERIALS AND METHODS: All adult subjects who were scheduled to undergo EBUS-TBNA to sample mediastinal lesions were eligible. We evaluated two methods of sampling mediastinal lesions. The first method was the application of negative pressure syringe for needle suction aspiration. The …

Comparison Of An Extended-Release Formulation Of Granisetron (Apf530) Versus Palonosetron For The Prevention Of Chemotherapy-Induced Nausea And Vomiting Associated With Moderately Or Highly Emetogenic Chemotherapy: Results Of A Prospective, Randomized, Double-Blind, Noninferiority Phase 3 Trial, H. Raftopoulos, W. Cooper, E. O'Boyle, N. Gabrail, R. Boccia, R. J. Gralla

Journal Articles

PURPOSE: Subcutaneous APF530 provides controlled sustained release of granisetron to prevent acute (0-24 h) and delayed (24-120 h) chemotherapy-induced nausea and vomiting (CINV). This randomized, double-blind phase 3 trial compared APF530 and palonosetron in preventing acute and delayed CINV after moderately (MEC) or highly emetogenic chemotherapy (HEC). METHODS: Patients receiving single-day MEC or HEC received single-dose APF530 250 or 500 mg subcutaneously (SC) (granisetron 5 or 10 mg) or intravenous palonosetron 0.25 mg. Primary objectives were to establish APF530 noninferiority to palonosetron for preventing acute CINV following MEC or HEC and delayed CINV following MEC and to determine APF530 superiority …

Xanomeline Suppresses Excessive Pro-Inflammatory Cytokine Responses Through Neural Signal-Mediated Pathways And Improves Survival In Lethal Inflammation, M. Rosas-Ballina, S. I. Valdes-Ferrer, M. E. Dancho, M. Ochani, D. Katz, K. F. Cheng, P. S. Olofsson, S. S. Chavan, Y. Al-Abed, K. J. Tracey, V. A. Pavlov

Journal Articles

Inflammatory conditions characterized by excessive immune cell activation and cytokine release, are associated with bidirectional immune system-brain communication, underlying sickness behavior and other physiological responses. The vagus nerve has an important role in this communication by conveying sensory information to the brain, and brain-derived immunoregulatory signals that suppress peripheral cytokine levels and inflammation. Brain muscarinic acetylcholine receptor (mAChR)-mediated cholinergic signaling has been implicated in this regulation. However, the possibility of controlling inflammation by peripheral administration of centrally-acting mAChR agonists is unexplored. To provide insight we used the centrally-acting M1 mAChR agonist xanomeline, previously developed in the context of Alzheimer's disease …

Immune Dysregulation In Patients Persistently Infected With Human Papillomaviruses 6 And 11, A. V. Lucs, J. A. Devoti, L. Hatam, A. Afzal, A. L. Abramson, B. M. Steinberg, V. R. Bonagura

Journal Articles

Human Papillomaviruses (HPVs) 6 and 11 are part of a large family of small DNA viruses, some of which are commensal. Although much of the population can contain or clear infection with these viruses, there is a subset of individuals who develop persistent infection that can cause significant morbidity and on occasion mortality. Depending on the site of infection, patients chronically infected with these viruses develop either recurrent, and on occasion, severe genital warts or recurrent respiratory papillomas that can obstruct the upper airway. The HPV-induced diseases described are likely the result of a complex and localized immune suppressive milieu …

Primary Extranodal Marginal Zone Lymphoma Of The Endometrium: Report Of Four Cases And Review Of Literature, F. C. Tahmasebi, S. Roy, J. E. Kolitz, F. Sen, J. Laser, X. Zhang

Journal Articles

Primary extranodal marginal zone lymphoma of the endometrium (PEMZL-EM) is exceedingly rare and has not been well characterized. Herein, we study the clinicopathological, cytogenetic and molecular features of four cases, the largest case series reported to date. The median age of the four patients was 59 years. Clinical presentations included abnormal vaginal bleeding (three cases) and incidental finding (one case). There were no constitutional symptoms in any of the cases. None of the patients had evidence of lymphoma in any other anatomic sites including bone marrow. Histologically, the lymphoma was characterized by a nodular proliferation of small lymphocytes admixed with …

Successful Treatment Of Peritoneal Dialysis Catheter-Related Polymicrobial Peritonitis Involving Clostridium Difficile, A Case Report And Review Of The Literature, S. Bharti, P. Malhotra, S. Juretschko

Journal Articles

Clostridium difficile is one of the most common nosocomial pathogens and the cause of pseudomembranous colitis in cases of prior antimicrobial exposure. Extra intestinal manifestations of C. difficile are uncommon and rarely reported. We report the first successfully treated case of catheter-related C. difficile peritonitis in a patient undergoing peritoneal dialysis.

Anti-C1q Antibodies In Systemic Lupus Erythematosus, A. M. Orbai, L. Truedsson, G. Sturfelt, O. Nived, H. Fang, G. S. Alarcon, C. Gordon, J. Merrill, C. Aranow, M. Petri, +43 Additional Authors

Journal Articles

OBJECTIVE: Anti-C1q has been associated with systemic lupus erythematosus (SLE) and lupus nephritis in previous studies. We studied anti-C1q specificity for SLE (vs rheumatic disease controls) and the association with SLE manifestations in an international multicenter study. METHODS: Information and blood samples were obtained in a cross-sectional study from patients with SLE (n = 308) and other rheumatologic diseases (n = 389) from 25 clinical sites (84% female, 68% Caucasian, 17% African descent, 8% Asian, 7% other). IgG anti-C1q against the collagen-like region was measured by ELISA. RESULTS: Prevalence of anti-C1q was 28% (86/308) in patients with SLE and 13% …

Target-Specific Oral Anticoagulants-New Approaches In The Field Of Oral Anticoagulation, H. Mani, J. Douxfils, J. Ansell

Journal Articles

No abstract provided.

A Novel Engineered Vegf Blocker With An Excellent Pharmacokinetic Profile And Robust Anti-Tumor Activity, L. Liu, H. Yu, X. Huang, H. Tan, S. Li, Y. Luo, L. Zhang, S. Jiang, C. C. Chu, W. Tian, +4 Additional Authors

Journal Articles

BACKGROUND: Relatively poor penetration and retention in tumor tissue has been documented for large molecule drugs including therapeutic antibodies and recombinant immunoglobulin constant region (Fc)-fusion proteins due to their large size, positive charge, and strong target binding affinity. Therefore, when designing a large molecular drug candidate, smaller size, neutral charge, and optimal affinity should be considered. METHODS: We engineered a recombinant protein by molecular engineering the second domain of VEGFR1 and a few flanking residues fused with the Fc fragment of human IgG1, which we named HB-002.1. This recombinant protein was extensively characterized both in vitro and in vivo for …

Reply To: Nasal Endoscopy To Characterize Sinonasal Disease, A. E. Dixon, M. Castro, R. I. Cohen, L. B. Gerald, J. T. Holbrook, C. G. Irvin, S. Mohapatra, S. P. Peters, S. Rayapudi, R. A. Wise, +1 Additional Author

Journal Articles

No abstract provided.

Treatment Of Sigmoid Volvulus By Deflation Versus Surgery: A Single Site Report, Yonas Raru, Patricia Messmer, Arthur Williams, Dawood Sultan, Ashenafi Adale, Yalelet Shiferaw, Paul Hart, Hugh Pettigrew

Internal Medicine

Background: Although very common in developing regions like Africa, sigmoid volvulus (SV) has a much lower incidence in the West. There is a dearth of literature on the treatment of SV in countries with limited resources. This paper reports study results using a cohort of 200 SV patients in a low-income developing country. Objectives: The aim of this study was to identify the characteristics associated with length of hospital stay (LOS) in the largest sample of sigmoid volvulus patients drawn from a single site within a single year and to examine the effects of treatment complications and previous attacks of …

Clinical Predictors Of Mortality In Hospitalized Patients With Infective Endocarditis At A Tertiary Care Center In Pakistan, Sadia Arshad, Safia Awan, Syedah Saira Bokhari, M. Tariq

Department of Medicine

Objective: To evaluate the clinical characteristics and predictors of in-hospital mortality in patients with infective endocarditis at a tertiary care centre in Pakistan.
Methods: The cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from January 1, 2002, to December 31, 2006, and comprised 84 consecutive patients hospitalised with infective endocarditis,. All patients underwent verification of the diagnosis according to the Modified Duke criterion. Data was collected through a questionnaire and analysed using Student's t test, Chi square and Fisher's exact test. Univariate and multivariate logistic regression analysis was performed to assess predictors of mortality.
Results: Of the …

Initial Impressions And Review Of Literature Concerning Factors Affecting The Use Of Palliative Care Assessment Tools In An African Setting, John Weru

Internal Medicine, East Africa

Introduction: Quality palliative care encompasses early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Despite the importance of symptom assessment in palliative care, use of assessment tools in practice is limited. The aim of this study was to assess factors that influence use of symptom assessment tools.

Methodology: 1:1 interviews were conducted using a guideline developed by the researcher. Ten participants who met the inclusion criteria were interviewed. The data was recorded and then transcribed with topics and issues being isolated and grouped together into themes.

Findings: The themes were perception of palliative …

Gender Differences In Clinical Characteristics And Outcome Of Acute Heart Failure In Sub-Saharan Africa: Results Of The Thesus-Hf Study, Okechukwu S. Ogah, Beth A. Davison, Karen Sliwa, Bongani M. Mayosi, Albertino Damasceno, Mahmoud U. Sani, Charles Mondo, Anastase Dzudie, Dike B. Ojji, Charles Kouam, Ahmed Suliman, Neshaad Schrueder, Gerald Yonga, Sergine Abdou Ba, Fikru Maru, Bekele Alemayehu, Christopher Edwards, Gad Cotter

Internal Medicine, East Africa

Background: The impact of gender on the clinical characteristics, risk factors, co-morbidities, etiology, treatment and outcome of acute heart failure in sub-Saharan Africa has not been described before. The aim of this study was to evaluate the sex diffe rences in acute heart failure in sub-Saharan Africa using the data from The sub-Saharan Africa Survey of Heart Failure (THESUS-HF).

Methods and results: 1,006 subjects were recruited into this prospective multicenter, international observational heart failure survey. The mean age of total population was 52.4 years (54.0 years for men and 50.7 years for women). The men were significantly older (p …

Cutaneous Ulcers As Initial Presentation Of Localized Granulomatosis With Polyangiitis: A Case Report And Review Of The Literature, Noreen Nasir, Syed Ahsan Ali, Hafiz Mohammed Mehmood Riaz

Section of Internal Medicine

Background. Granulomatosis with polyangiitis (GPA) is an ANCA associated small vessel vasculitis characterized by necrotizing granulomatous inflammation involving the upper and the lower respiratory tract and the kidneys. The disease has a broad clinical spectrum that ranges from limited/localized involvement of a single organ system to a generalized systemic vasculitis that affects several organs with evidence of end organ damage. Atypical forms of the disease have been recognized with or without respiratory tract involvement with a long protracted course before manifesting as generalized disease.

Case Presentation. We describe a 57-year-old woman who presented with recurrent fever and cutaneous ulcers on …

Primary Cutaneous Peripheral T-Cell Lymphoma Not Otherwise Specified: A Rapidly Progressive Variant Of Cutaneous T-Cell Lymphoma., Kimberly Aderhold, Lisa Carpenter, Krysta Brown, Anthony Donato

Reading Hospital Internal Medicine Residency

Primary Cutaneous Peripheral T-Cell Lymphoma NOS (PTL-NOS) is a rare, progressive, fatal dermatologic disease that presents with features similar to many common benign plaque-like skin conditions, making recognition of its distinguishing features critical for early diagnosis and treatment (Bolognia et al., 2008). A 78-year-old woman presented to ambulatory care with a single 5 cm nodule on her shoulder that had developed rapidly over 1-2 weeks. Examination was suspicious for malignancy and a biopsy was performed. Biopsy results demonstrated CD4 positivity, consistent with Mycosis Fungoides with coexpression of CD5, CD47, and CD7. Within three months her cancer had progressed into diffuse …

Optimum Number Of Procedures Required To Achieve Procedural Skills Competency In Internal Medicine Residents, M. Tariq, Nizar Bhulani, Asif Jafferani, Quratulain Naeem, Syed Ahsan Ali, Afaq Motiwala, Jan Van Dalen, Saeed Hamid

Section of Internal Medicine

Background: Procedural skills training forms an essential, yet difficult to assess, component of an Internal Medicine Residency Program. We report the development of process of documentation and assessment of procedural skills training.
Method: An explanatory sequential mixed methods design was adopted where both quantitative and qualitative information was collected sequentially. A survey was conducted within the Department of Internal Medicine at The Aga Khan University Hospital, Karachi, Pakistan to determine the optimum number of procedures needed to be performed by residents at each year of residency. Respondents included both faculty and the residents in the Department. Thereafter, all responses …

Factors Supporting And Inhibiting Adherence To Hiv Medication Regimen In Women: A Qualitative Analysis Of Patient Interviews., Oluwakemi Fagbami, Adetokunbo Oluwasanjo, Carrie Fitzpatrick, Rebecca Fairchild, Ann Shin, Anthony Donato

Reading Hospital Internal Medicine Residency

Adherence to antiretroviral therapy reduces morbidity and mortality; however rates of non-adherence are variable among women for unclear reasons. This study was a single-center qualitative analysis of interviews with 18 female HIV-positive non-adherent patients (defined by virologic failure) to explore psychosocial factors impacting adherence. Factors identified were categorized as promoting, inhibiting or having no effect on adherence. Three themes, characterized as social factors, illness factors and other societal pressures, were identified. Medical systems support, family support and compliance for children were most commonly identified as promoting adherence, while psychiatric comorbidities, lack of medical systems support and side effects were identified …

New Onset Refractory Status Epilepticus As An Unusual Presentation Of A Suspected Organophosphate Poisoning, Shahan Waheed, Amber Sabeen, Nadeem Ullah Khan

Department of Medicine

New onset refractory status epilepticus (NORSE) is a new entity in medical literature. It has different infectious and noninfectious etiologies showing a devastating impact onto the clinical outcome of patients. Therapy with anaesthetic and antiepileptic agents often fails to improve the condition, unless the primary cause is rectified. Here is presented the case of a young female with a history of depression who after a recent bereavement came to the Emergency Department of Aga Khan University Hospital with complaints of drowsiness that lasted for few hours. Though she had no history of organophosphate poisoning, her physical examination and further investigations …

Interventions To Promote Adherence To Antiretroviral Therapy In Africa: A Network Meta-Analysis, Edward J. Mills, Richard Lester, Kristian Thorlund, Maria Lorenzi, Katherine Muldoon, Steve Kanters, Sebastian Linnemayr, Robert Gross, Yvette Calderon, K Rivet Amico, Harsha Thirumurthy, Cynthia Pearson, Robert H. Remien, Lawrence Mbuagbaw, Lehana Thabane, Michael Chung, Ira B. Wilson, Albert Liu, Olalekan A. Uthman, Jane Simoni, David Bangsberg, Sanni Yaya, Till Bärnighausen, Nathan Ford, Jean B. Nachega

Internal Medicine, East Africa

Background: Adherence to antiretroviral therapy (ART) is necessary for the improvement of the health of patients and for public health. We sought to determine the comparative effectiveness of different interventions for improving ART adherence in HIV-infected people living in Africa.

Methods: We searched for randomised trials of interventions to promote antiretroviral adherence within adults in Africa. We searched AMED, CINAHL, Embase, Medline (via PubMed), and ClinicalTrials.gov from inception to Oct 31, 2014, with the terms “HIV”, “ART”, “adherence”, and “Africa”. We created a network of the interventions by pooling the published and individual patients' data for comparable treatments and comparing …

Emerging Antiretroviral Drug Resistance In Sub-Saharan Africa: Novel Affordable Technologies Are Needed To Provide Resistance Testing For Individual And Public Health Benefits, Gert U. Van Zyl, Lisa M. Frenkel, Michael Chung, Wolfgang Preiser, John W. Mellors, Jean B. Nachega

Internal Medicine, East Africa

In industrialized countries, viral load monitoring and genotypic antiretroviral drug resistance testing (GART) play an important role in the selection of initial and subsequent combination antiretroviral therapy (cART) regimens. In contrast, resource constraints in Africa limit access to assays that could detect virologic failure, transmitted drug resistance (TDR) and acquired drug resistance to cART. This has adverse consequences for both individual and public health. Although the further roll-out of antiretrovirals for prevention, including preexposure prophylaxis (PrEP) and universal test and treat (UTT) strategies, could reduce HIV-1 incidence, these strategies may increase TDR [1,2]. Here, we present arguments that the scale …

Current Perspectives On Primary Care Workforce, Kathleen Klink

Health Workforce Speaker Series

No abstract provided.

Effects Of Polypharmacy On Adverse Drug Reactions Among Geriatric Outpatients At A Tertiary Care Hospital In Karachi: A Prospective Cohort Study., Bilal Ahmed, Kashmira Nanji, Rakshinda Mujeeb, Muhammad Junaid Patel

Department of Medicine

Background: Adverse drug reactions (ADRs) present a challenging and expensive public health problem. Polypharmacy is defined according to the WHO criteria as the, ‘‘concurrent use of five or more different prescription medication’’. Elderly are more prone to adverse reactions due to comorbid conditions, longer lists of medications and sensitivity to drug effects. The aim of the study is to estimate the incidence and strength of association of ADRs due to polypharmacy among the geriatric cohort attending outpatient clinics at a tertiary care center.

Methods: A hospital based prospective cohort study was conducted at ambulatory care clinics of Aga Khan University …