Duration of anticoagulation after venous thromboembolism in real world clinical practice.

INTRODUCTION: Venous thromboembolism (VTE) carries a considerable risk of recurrence and anticoagulants should be administered for a minimum of three months. Since little is known about real life management of VTE, we aimed to describe current practice in the secondary prevention of VTE. MATERIALS AND METHODS: Using the database of an international, prospective registry on patients treated for VTE, RIETE, information was collected on risk factors for VTE and bleeding, anticoagulant treatment, and clinical outcomes during follow up. Multivariate analysis using logistic regression was performed to identify predictors of treatment duration. RESULTS: Of 6944 patients with a first episode of VTE 41.1% had unprovoked VTE, 31.8% had transient risk factors, 27.1% had cancer. After the exclusion of patients who died during the first year of observation, the rate of patients treated for >12 months was 55.1%, 41.9%, and 43.2%, respectively (p<0.001). Pulmonary embolism at presentation, recurrence while on treatment, chronic heart failure and age >65 years were independently associated with treatment for >12 months. Body weight <75 kg, anemia, cancer, and the presence of transient risk factors were associated with treatment for 12 months or less. Major bleeding occurred more frequently than recurrent VTE in patients with VTE secondary to transient risk factors and cancer; fatal bleeding was more frequent than fatal recurrent PE in all subgroups. CONCLUSIONS: We observed heterogeneous duration of anticoagulant treatment for the secondary prevention of VTE. A substantial proportion of patients, in particular those with VTE secondary to transient risk factors, may be exposed to a possibly unnecessary risk of bleeding.

Construction of an index of information from clinical practice in Radiology and Imaging Diagnosis based on text mining and thesaurus

Objective To construct a Portuguese language index of information on the practice of diagnostic radiology in order to improve the standardization of the medical language and terminology. Materials and Methods A total of 61,461 definitive reports were collected from the database of the Radiology Information System at Hospital das Clínicas – Faculdade de Medicina de Ribeirão Preto (RIS/HCFMRP) as follows: 30,000 chest x-ray reports; 27,000 mammography reports; and 4,461 thyroid ultrasonography reports. The text mining technique was applied for the selection of terms, and the ANSI/NISO Z39.19-2005 standard was utilized to construct the index based on a thesaurus structure. The system was created in *html. Results The text mining resulted in a set of 358,236 (n = 100%) words. Out of this total, 76,347 (n = 21%) terms were selected to form the index. Such terms refer to anatomical pathology description, imaging techniques, equipment, type of study and some other composite terms. The index system was developed with 78,538 *html web pages. Conclusion The utilization of text mining on a radiological reports database has allowed the construction of a lexical system in Portuguese language consistent with the clinical practice in Radiology.

Cardiac magnetic resonance imaging in clinical practice

Objective To evaluate and describe indications, mainly diagnoses and cardiac magnetic resonance imaging findings observed in clinical practice. Materials and Methods Retrospective and descriptive study of cardiac magnetic resonance performed at a private hospital and clinic in the city of Niterói, RJ, Brazil, in the period from May 2007 to April 2011. Results The sample included a total of 1000 studies performed in patients with a mean age of 53.7 ± 16.2 years and predominance for male gender (57.2%). The majority of indications were related to assessment of myocardial perfusion at rest and under pharmacological stress (507/1000; 51%), with positive results in 36.2% of them. Suspected myocarditis was the second most frequent indication (140/1000; 14%), with positive results in 63.4% of cases. These two indications were followed by study of arrhythmias (116/1000; 12%), myocardial viability (69/1000; 7%) and evaluation of cardiomyopathies (47/1000; 5%). In a subanalysis, it was possible to identify that most patients were assessed on an outpatient basis (58.42%). Conclusion Cardiac magnetic resonance has been routinely performed in clinical practice, either on an outpatient or emergency/inpatient basis, and myocardial ischemia represented the main indication, followed by investigation of myocarditis, arrhythmogenic right ventricular dysplasia and myocardial viability.

« How to Teach Evidence-Based Clinical Practice 2002 » : Rapport de la semaine de formation

Rapport de la semaine de formation "How to teach Evidence-Based Clinical Practice 2002" tenue à McMaster University du 9 au 14 juin 2002. Le rapport présente le déroulement de la semaine, les apprentissages et les applications au travail.

« How to Teach Evidence-Based Clinical Practice 2002 » à l'Université McMaster : 3 bibliothécaires participantes

Article en anglais et en français.

IT support for administrative planning of clinical practice.

The administration of clinical practice placements for nursing students is a highly complex and information driven task. This demonstration is intended to give insight into the web based system KliPP (a Swedish acronym for Clinical Practice Planning) and to discuss the possibilities for further development and use.

Usual clinical practice for early supported discharge after stroke with continued rehabilitation at home : an observational comparative study

Introduction: Based on randomised controlled trials, evidence exists that early supported discharge (ESD) from the hospital with continued rehabilitation at home has beneficial effects after stroke; however, the effects of ESD service in regular clinical practice have not been investigated. The purpose of the current study was to compare ESD service with conventional rehabilitation in terms of patient outcomes, caregiver burden at 3 and 12 months and the use and costs of healthcare during the first year after stroke. Material and methods: This study was a subgroup analysis of a longitudinal observational study of patients who received care in the stroke unit at Karolinska University Hospital in Sweden. Patients who met the inclusion criteria for ESD in previous experimental studies were included. The patients were referred to available rehabilitation services at discharge, and comparisons between those who received ESD service (the ESD group, n = 40) and those who received conventional rehabilitation (the NoESD group, n = 110) were performed with regard to independence in activities of daily living (ADL), the frequency of social activities, life satisfaction, and caregiver burden and the use and costs of healthcare during the first year after stroke. Results: At 3 and 12 months, no differences were observed with regard to patient outcomes; however, ESD was associated with a lower caregiver burden (p = 0.01) at 12 months. The initial length of stay (LOS) at the hospital was 8 days for the ESD group and 15 days for the NoESD group (p = 0.02). The median number of outpatient rehabilitation contacts was 20.5 for the ESD group (81% constituting ESD service) and 3 for the NoESD group (p<0.001). There was no difference between the groups with regard to overall healthcare costs. Conclusions: ESD service in usual clinical practice renders similar health benefits as conventional rehabilitation but a different pattern of resource use and with released capacity in acute stroke care.

Systematic reviews showed insufficient evidence for clinical practice in 2004: What about in 2011? the next appeal for the evidence-based medicine age

Rationale and aim The aims of the Cochrane systematic reviews are to make readily available and up-to-date information for clinical practice, offering consistent evidence and straightforward recommendations. In 2004, we evaluated the conclusions from Cochrane systematic reviews of randomized controlled trials in terms of their recommendations for clinical practice and found that 47.83% of them had insufficient evidence for use in clinical practice. We proposed to reanalyze the reviews to evaluate whether this percentage had significantly decreased. Methods A cross-sectional study of systematic reviews published in the Cochrane Library (Issue 7, 2011) was conducted. We randomly selected reviews across all 52 Cochrane Collaborative Review Groups. Results We analyzed 1128 completed systematic reviews. Of these, 45.30% concluded that the interventions studied were likely to be beneficial, of which only 2.04% recommended no further research. In total, 45.04% of the reviews reported that the evidence did not support either benefit or harm, of which 0.8% did not recommend further studies and 44.24% recommended additional studies; the latter has decreased from our previous study with a difference of 3.59%. Conclusion Only a small number of the Cochrane collaboration's systematic reviews support clinical interventions with no need for additional research. A larger number of high-quality randomized clinical trials are necessary to change the 'insufficient evidence' scenario for clinical practice illustrated by the Cochrane database. It is recommended that we should produce higher-quality primary studies in active collaboration and consultation with global scholars and societies so that this can represent a major component of methodological advance in this context. © 2012 John Wiley & Sons Ltd.

Clinical Practice: Vocal nodules in dysphonic children

Common among children, vocal symptoms are a cause of concern for parents who seek elucidation of their diagnosis and treatment. Vocal nodules are the major cause of dysphonias in children and are related to vocal abuse. We conducted a literature review considering clinical, physiopathological, epidemiological, and histological aspects of vocal nodules, as well as diagnostic methods, highlighting the main studies addressing this issue. The controversial points of treatments were also discussed.

Evaluation of dentists' knowledge of the use of oral exfoliative cytology in clinical practice

Oral exfoliative cytology (EC) is a rapid and practical complementary test that can be used in the diagnosis of various diseases. The objectives of this study were to assess dentists'knowledge of EC and to disseminate information on the technique. The study included 240 dentists from the city of Anapolis (Goias, Brazil) who answered a questionnaire regarding demographic data and data relating to EC and who then received information on the technique. The data revealed that 26.92% of the dentists did not know about EC. Among those who reported knowledge of EC, 33.91% did not know the procedures for performing the technique, and 85.38% had no experience with EC. In addition, 54.09% of the answers regarding the instrument used to collect the material and 56.82% of the answers concerning suitable fixatives were inappropriate. Although 73.02% of the dentists adequately identified the pathologies for which EC is recommended, it was concluded that the respondents had poor knowledge of EC. There is a need to increase dentists'awareness of this subject and of EC's use in diagnostic practices.

Anti-dementia medications: current prescriptions in clinical practice and new agents in progress

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Comparison of pattern VEP results acquired using CRT and TFT stimulators in the clinical practice

There are several electrophysiological systems available commercially. Usually, control groups are required to compare their results, due to the differences between display types. Our aim was to examine the differences between CRT and LCD/TFT stimulators used in pattern VEP responses performed according to the ISCEV standards. We also aimed to check different contrast values toward thresholds. In order to obtain more precise results, we intended to measure the intensity and temporal response characteristics of the monitors with photometric methods. To record VEP signals, a Roland RetiPort electrophysiological system was used. The pattern VEP tests were carried out according to ISCEV protocols on a CRT and a TFT monitor consecutively. Achromatic checkerboard pattern was used at three different contrast levels (maximal, 75, 25%) using 1A degrees and 15` check sizes. Both CRT and TFT displays were luminance and contrast matched, according to the gamma functions based on measurements at several DAC values. Monitor-specific luminance parameters were measured by means of spectroradiometric instruments. Temporal differences between the displays` electronic and radiometric signals were measured with a device specifically built for the purpose. We tested six healthy control subjects with visual acuity of at least 20/20. The tests were performed on each subject three times on different days. We found significant temporal differences between the CRT and the LCD monitors at all contrast levels and spatial frequencies. In average, the latency times were 9.0 ms (+/- 3.3 ms) longer with the TFT stimulator. This value is in accordance with the average of the measured TFT input-output temporal difference values (10.1 +/- A 2.2 ms). According to our findings, measuring the temporal parameters of the TFT monitor with an adequately calibrated measurement setup and correcting the VEP data with the resulting values, the VEP signals obtained with different display types can be transformed to be comparable.

Noninvasive positive-pressure ventilation in clinical practice at a large university-affiliated Brazilian hospital

OBJECTIVES: To describe noninvasive positive-pressure ventilation use in intensive care unit clinical practice, factors associated with NPPV failure and the associated prognosis. METHODS: A prospective cohort study. RESULTS: Medical disorders (59%) and elective surgery (21%) were the main causes for admission to the intensive care unit. The main indications for the initiation of noninvasive positive-pressure ventilation were the following: post-extubation, acute respiratory failure and use as an adjunctive technique to chest physiotherapy. The noninvasive positive-pressure ventilation failure group was older and had a higher Simplified Acute Physiology Score II score. The noninvasive positive-pressure ventilation failure rate was 35%. The main reasons for intubation were acute respiratory failure (55%) and a decreased level of consciousness (20%). The noninvasive positive-pressure ventilation failure group presented a shorter period of noninvasive positive-pressure ventilation use than the successful group [three (2-5) versus four (3-7) days]; they had lower levels of pH, HCO3 and base excess, and the FiO(2) level was higher. These patients also presented lower PaO2:FiO2 ratios; on the last day of support, the inspiratory positive airway pressure and expiratory positive airway pressure were higher. The failure group also had a longer average duration of stay in the intensive care unit [17 (10-26) days vs. 8 (5-14) days], as well as a higher mortality rate (9 vs. 51%). There was an association between failure and mortality, which had an odds ratio (95% CI) of 10.6 (5.93 - 19.07). The multiple logistic regression analysis using noninvasive positive pressure ventilation failure as a dependent variable found that treatment tended to fail in patients with a Simplified Acute Physiology Score II >= 34, an inspiratory positive airway pressure level >= 15 cmH2O and pH<7.40. CONCLUSION: The indications for noninvasive positive-pressure ventilation were quite varied. The failure group had a longer intensive care unit stay and higher mortality. Simplified Acute Physiology Score II >= 34, pH<7.40 and higher inspiratory positive airway pressure levels were associated with failure.