By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In ...2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used.
Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.
Summary Expression of GATA-3 in female breast cancers has been linked to estrogen receptor (ER) expression and, in turn, to improved outcomes. However, GATA-3 has not been studied in male breast ...cancers. Nineteen male breast carcinomas (average age: 63 years) and 164 female breast carcinomas (average age: 57 years) were immunostained for GATA-3. Results were compared to age, tumor size, tumor grade, lymph node status, distant metastases, survival, and positivity for ER, progesterone receptor (PR), and HER2/neu. Six of 19 (31.6%) male and 135 of 164 (82.3%) female breast carcinomas were GATA-3 positive ( P < .001). In women, 82.1% of GATA-3-positive cancers were grade 1 or 2, whereas 75.9% of GATA-3-negative cancers were grade 3 ( P < .001); no such significant correlation was seen in men. Unlike female cancers, male cancers showed no correlation between GATA-3 positivity and ER positivity, PR positivity, or distant metastases. Nodal metastasis and HER2 status were not linked to GATA-3 in either sex. Seventeen (89.5%) men were alive at follow-up (average: 61 months); only 1 died of disease. Most women (159/164, 97.0%) were also alive at follow-up (average: 41 months), with a higher proportion of GATA-3-negative women dead than GATA-3-positive women (3/29 10.3% vs. 2/135 1.5%, P = .039). GATA-3 is expressed less often in male than female breast cancers. Male cancers show no correlation between GATA-3 positivity and ER/PR positivity or distant metastases, unlike female cancers. There appears to be no link between GATA-3 positivity and survival in men, whereas in women, GATA-3-positive tumors are typically lower grade with a better prognosis.
Abstract Objective To estimate the reliability and validity of the Nutrition Literacy Assessment Instrument for Parents (NLit-P) and to investigate relationships among parental nutrition literacy, ...parental and child body mass index, and child diet quality (Healthy Eating Index). Methods Cross-sectional study of 101 parent–child dyads that collected measures of socioeconomic status, nutrition literacy, 2 24-hour child diet recalls, and body mass index. Reliability of NLit-P was assessed by confirmatory factor analysis. Pearson correlation and multiple linear regression were used. Results Fair to substantial reliability was seen across 5 NLit-P domains, whereas Pearson correlations support concurrent validity for the NLit-P related to child diet quality and parental income, age, and educational attainment ( P < .001). For every 1% increase in NLit-P, there was a 0.51 increase in child Healthy Eating Index (multivariate coefficient, 0.174; P < .001). Conclusions and Implications The NLit-P demonstrates potential for measuring parental nutrition literacy, which may be an important educational target for improving child diet quality.
Educational Strategies for Improving Clinical Reasoning Cutrer, William B., MD, MEd; Sullivan, William M., MD, MEd; Fleming, Amy E., MD
Current problems in pediatric and adolescent health care,
10/2013, Letnik:
43, Številka:
9
Journal Article
Recenzirano
Clinical reasoning serves as a crucial skill for all physicians regardless of their area of expertise. Helping trainees develop effective and appropriate clinical reasoning abilities is a central aim ...of medical education. Teaching clinical reasoning however can be a very difficult challenge for practicing physicians. Better understanding of the different cognitive processes involved in physician clinical reasoning provides a foundation from which to guide learner development of effective reasoning skills, while pairing assessment of learner reasoning abilities with understanding of different improvement strategies offers the opportunity to maximize educational efforts for learners. Clinical reasoning errors often can occur as a result of one of four problems in trainees as well as practicing physicians; inadequate knowledge, faulty data gathering, faulty data processing, or faulty metacognition. Educators are encouraged to consider at which point a given learner's reasoning is breaking down. Experimentation with different strategies for improving clinical reasoning can help address learner struggles in each of these domains. In this chapter, various strategies for improving reasoning related to knowledge acquisition, data gathering, data processing, and clinician metacognition will be discussed. Understanding and gaining experience using the different educational strategies will provide practicing physicians with a toolbox of techniques for helping learners improve their reasoning abilities.
On-site pharmacists in the ED improve medical errors Ernst, Amy A., MD; Weiss, Steven J., MD; Sullivan, Arthur, MD ...
The American journal of emergency medicine,
06/2012, Letnik:
30, Številka:
5
Journal Article
Recenzirano
Abstract Objective The objective of the study was to compare errors in the emergency department (ED) with pharmacists present (PPs) for resuscitations and traumas vs with pharmacists absent (PAs). ...Our hypothesis was that errors would be significantly fewer during PP than PA times. We also hypothesized that times with PP would affect patients greater when disposition was to more critical areas (intensive care unit, or ICUs). Methods The study was conducted during a 3-month period in 2009 in a level 1 trauma center with an emergency medicine residency. This was a cross-sectional cohort study comparing a prospective analysis of patients during the time (10 hour/day) with PP and a retrospective review of the time on the same days (14 hours/day) with PA. Demographics of age, race, and sex were recorded. Patient disposition was either ICU, operating room, non-ICU wards, observation unit, or discharge. Main outcome was errors recorded including medications given but not ordered, medication ordered but not given, and time delays for medications. For demographics and prevalence, descriptive statistics and percentages were used. Percent differences and 95% confidence intervals (CIs) and χ2 were derived. Logistic regression used predictor variables of age, race, sex, disposition, and presence or absence of pharmacists. An a priori power analysis was performed. The study was powered at 80% with 186 subjects per group (PP vs PA), to find a difference of 20% between the 2 groups in percent of medical errors. Results There were 694 patients included in the 3-month period. A total of 242 presented during PP times and 452 during PA times. There were 383 (55%) male, 301 (43%) female, and 10 (2%) unknown sex. Mean age was 45 ± 18 years in PP group and 48 ± 20 years in PA group ( P , nonsignificant). There was no difference in ethnicity between groups. There were 6 (3%) patients with errors recorded during PP times and 137 (30%) with errors recorded during PA times (difference, 27%; 95% CI, 23-32). Controlling for age, race, sex, and disposition, medical errors were 13.5 times more likely during PA than during PP times (adjusted odds ratio, 13.5; 95% CI, 5.7-31.9). Conclusion With pharmacists absent, over 13 times more errors are recorded in our ED than with pharmacists present. An on-site pharmacist in the ED may be helpful in reducing medical errors.
Objective We sought to estimate the optimal time to deliver uncomplicated monochorionic-diamnionic (MCDA) twins. Study Design Data were retrospectively obtained from twin pregnancies from 2000 ...through 2009. The gestational week–specific prospective perinatal mortality risk was calculated. A cohort of MCDA twins with nonindicated deliveries was analyzed separately. Neonatal outcomes and costs were compared between MCDA twins with nonindicated deliveries born at specific weeks of gestation, and those born the subsequent week. Results There were 5894 dichorionic-diamnionic twins and 1704 MCDA twins. After 28 weeks, the gestational week–specific prospective risk of perinatal mortality did not differ between groups. There were 948 MCDA twins with nonindicated deliveries. Until 37 weeks, the risk of severe neonatal morbidity, perinatal mortality, and hospital costs were greater for fetuses delivered compared to fetuses born in a subsequent week. Conclusion To optimize neonatal outcome and decrease hospital costs, MCDA twins should not be delivered <37 weeks unless medically indicated.
Abnormal anal cytology in HIV-infected women Tandon, Richa, MD; Baranoski, Amy S., MD; Huang, Faye, NP ...
American journal of obstetrics and gynecology,
07/2010, Letnik:
203, Številka:
1
Journal Article, Conference Proceeding
Recenzirano
Odprti dostop
Objective The purpose of this study was to assess the prevalence of and risk factors for abnormal anal cytology and human papillomavirus (HPV) infections in women who are human immunodeficiency virus ...(HIV) positive. Study Design We conducted an observational single center study of 100 HIV-infected women with cervical and anal specimens that were obtained for cytologic and high-risk HPV testing with Hybrid Capture 2. Results Seventeen women had abnormal anal cytology; 16 women had anal HPV; 21 women had abnormal cervical cytology, and 24 women had cervical HPV. Abnormal anal cytology was associated with cervical HPV infection, abnormal cervical cytology, and anal HPV infection in univariate analysis. In multivariate analysis, abnormal anal cytology was associated with a CD4 count <200 cells/mm3 , a history of sexually transmitted disease, and concurrent cervical cytologic abnormality. Conclusion HIV-infected women are at high risk for abnormal cytology and HPV infections of both the anus and cervix. Risk factors for abnormal anal cytology include abnormal cervical cytology, cervical and anal HPV infections, and low CD4 count.
We explore the impact of a host genetic factor on heterosexual HIV epidemics by using a deterministic mathematical model. A protective allele unequally distributed across populations is exemplified ...in our models by the 32-bp deletion in the host-cell chemokine receptor CCR5, CCR5Delta32.
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