Management and outcomes of superficial vein thrombosis: a single-center retrospective study.

Background: Guidelines suggest but cannot recommend the optimal management of superficial vein thrombosis (SVT). Objectives: To identify the prevalence of asymptomatic deep vein thrombosis (DVT) at the time of SVT diagnosis, and to report the treatment and 3-month complications of patients with only SVT more than 3 cm from deep vein junction (or unknown distance). Methods: We performed a single-center retrospective review of patients referred to the Ottawa Hospital thrombosis unit with ultrasound (US)-diagnosed SVT, and followed patients with only SVT for 3 months. Results: Three hundred sixteen patients with SVT were included. Of the 218 patients without DVT symptoms at presentation, 19 (8.7%; 95% CI, 5.7%-13.2%) were found to have asymptomatic concomitant DVT (11 proximal and 8 distal), and 45 (20.6%) had SVT within 3 cm of the saphenofemoral or saphenopopliteal junctions. Among the 192 patients diagnosed with SVT only, we observed 3-month thrombotic complications in 56 (29.2%; 95% CI, 23.2%-36.0%) patients, with a total of 69 events: 11 (5.7%) DVTs, 2 (1.0%) pulmonary embolisms, 37 (19.2%) SVT extensions, and 19 (9.8%) SVT recurrences. Eighty-two percent (9/11) of the 3-month DVT and pulmonary embolism events occurred in patients who initially received conservative management. Therapeutic treatment doses were most effective. Conclusion: At the time of SVT diagnosis, many patients had asymptomatic DVT and SVT near the deep venous system, supporting the systematic use of initial US in patients clinically diagnosed with SVT. The observed differences in 3-month complication rates, according to the treatment provided, highlight the need for large-scale randomized controlled trials to establish optimal management.

Transitioning towards senior medical resident: identification of the required competencies using consensus methodology.

BACKGROUND: Residency programs are facing significant restructuring through the "Competence by Design" (CBD) framework proposed by the Royal College of Physicians and Surgeons of Canada (RCPSC). Our goal was to establish the competencies to be acquired during the transition to a senior role within Internal Medicine (IM) training. METHODS: Using a modified Delphi technique, practicing IM physicians and recent graduates were polled to develop consensus on the required competencies to effectively transition from junior to senior medical resident. Participants rated each competency on a three-point Likert scale. Each competency was linked to an Entrustable Professional Activity (EPA) identified by the RCPSC IM Specialty Committee. RESULTS: A total of eighteen participants took part in item generation (16% response rate) and nineteen in the initial ranking with seventeen completing all three iterations (89% completion rate). Eighty-three competencies were identified during questionnaire development. A final list of seventy-seven competencies reached consensus after three rounds. Most competencies matched to core of discipline EPAs. CONCLUSION: This consensus-based list of competencies will help create a framework and tools for the assessment of junior residents as they prepare to transition to the role of senior in the new CBD curricula for IM trainees at our institution.

Time is of the essence: an observational time-motion study of internal medicine residents while they are on duty.

BACKGROUND: The effects of changes to resident physician duty hours need to be measureable. This time-motion study was done to record internal medicine residents' workflow while on duty and to determine the feasibility of capturing detailed data using a mobile electronic tool. METHODS: Junior and senior residents were shadowed by a single observer during six-hour blocks of time, covering all seven days. Activities were recorded in real-time. Eighty-nine activities grouped into nine categories were determined a priori. RESULTS: A total of 17,714 events were recorded, encompassing 516 hours of observation. Time was apportioned in the following categories: Direct Patient Care (22%), Communication (19%), Personal tasks (15%), Documentation (14%), Education (13%), Indirect care (11%), Transit (6%), Administration (0.6%), and Non-physician tasks (0.4%). Nineteen percent of the education time was spent in self-directed learning activities. Only 9% of the total on duty time was spent in the presence of patients. Sixty-five percent of communication time was devoted to information transfer. A total of 968 interruptions were recorded which took on average 93.5 seconds each to service. CONCLUSION: Detailed recording of residents' workflow is feasible and can now lead to the measurement of the effects of future changes to residency training. Education activities accounted for 13% of on-duty time.

Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis.

BACKGROUND: Since the mid-1980s, medical residents' long duty hours have been under scrutiny as a factor affecting patient safety and the work environment for the residents. After several mandated changes in duty hours, it is important to understand how residents spend their time before proposing and implementing future changes. Time-motion methodology may provide reliable information on what residents do while on duty. PURPOSE: The purpose of this study is to review all available literature pertaining to time-motion studies of internal medicine residents while on a medicine service and to understand how much of their time is apportioned to various categories of tasks, and also to determine the effects of the Accreditation Council for Graduate Medical Education (ACGME)-mandated duty hour changes on resident workflow in North America. METHODS: Electronic bibliographic databases were searched for articles in English between 1941 and April 2013 reporting time-motion studies of internal medicine residents rotating through a general medicine service. RESULTS: Eight articles were included. Residents spent 41.8% of time in patient care activities, 18.1% communicating, 13.8% in educational activities, 19.7% in personal/other, and 6.6% in transit. North American data showed the following changes after the implementation of the ACGME 2003 duty hours standard: patient care activities from 41.8% to 40.8%, communication activities from 19.0% to 22.3%, educational activities from 17.7% to 11.6%, and personal/other activities from 21.5% to 17.1%. CONCLUSION: There was a paucity of time-motion data. There was great variability in the operational definitions of task categories reported in the studies. Implementation of the ACGME duty hour standards did not have a significant effect on the percentage of time spent in particular tasks. There are conflicting reports on how duty hour changes have affected patient safety. A low proportion of time spent in educational activities deserves further study and may point to a review of the educational models used.

The feasibility of e-learning as a quality improvement tool.

RATIONAL, AIMS AND OBJECTIVES: Many quality problems exist in health care. We aim to investigate the feasibility and acceptability of using e-learning (defined as computer-based learning modules) to address gaps in quality of care. METHODS: We performed a qualitative evaluation of participants in a pilot e-learning program. Physician members of six medical teaching units (MTUs) at a multi-site tertiary care teaching hospital were asked to complete two e-learning modules addressing hand hygiene practices and management of community-acquired pneumonia (CAP). An e-learning design team created online modules that were made available to members of the six MTUs for 4 weeks using a password secured website. Use of the modules was voluntary. Participants' perceptions of module content, mode of delivery, and suggestions for improvement were determined through focus groups. We then performed content analysis on the transcripts. We used system data to define patterns of module access. RESULTS: Out of 55 eligible users, 30 (55%) logged onto the system at least once. Residents (14/30, 47%) were less likely to use the system than medical students (9/14, 64%) and attending staff (7/11, 64%). Learners at all levels thought the modules were easy to use. Participants liked the knowledge-based material in the CAP module because it directly applied to their work. There were less favourable opinions of the hand hygiene module CONCLUSIONS: Generating e-learning modules targeted at gaps in quality of care is feasible and acceptable to learners. Future studies should assess whether these approaches lead to desired changes in behavior.

The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force.

BACKGROUND: Aspirin for prevention of colorectal cancer is controversial. PURPOSE: To examine the benefits and harms of aspirin chemoprevention. DATA SOURCES: MEDLINE, 1966 to December 2006; EMBASE, 1980 to April 2005; CENTRAL, Cochrane Collaboration's registry of clinical trials; Cochrane Database of Systematic Reviews. STUDY SELECTION: Two independent reviewers conducted multilevel screening to identify randomized, controlled trials (RCTs), case-control studies, and cohort studies of aspirin chemoprophylaxis. For harms, systematic reviews were sought. DATA EXTRACTION: In duplicate, data were abstracted and checked and quality was assessed. DATA SYNTHESIS: Regular use of aspirin reduced the incidence of colonic adenomas in RCTs (relative risk [RR], 0.82 [95% CI, 0.7 to 0.95]), case-control studies (RR, 0.87 [CI, 0.77 to 0.98]), and cohort studies (RR, 0.72 [CI, 0.61 to 0.85]). In cohort studies, regular use of aspirin was associated with RR reductions of 22% for incidence of colorectal cancer. Two RCTs of low-dose aspirin failed to show a protective effect. Data for colorectal cancer mortality were limited. Benefits from chemoprevention were more evident when aspirin was used at a high dose and for periods longer than 10 years. Aspirin use was associated with a dose-related increase in incidence of gastrointestinal complications. LIMITATIONS: Important clinical and methodological heterogeneity in the definitions of regular use, dose, and duration of use of aspirin necessitated careful grouping for analysis. CONCLUSIONS: Aspirin appears to be effective at reducing the incidence of colonic adenoma and colorectal cancer, especially if used in high doses for more than 10 years. However, the possible harms of such a practice require careful consideration. Further evaluation of the cost-effectiveness of chemoprevention compared with, and in combination with, a screening strategy is required.

Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force.

PURPOSE: To examine the benefits and harms of nonaspirin (non-ASA) nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX-2) inhibitors for the prevention of colorectal cancer (CRC) and adenoma. DATA SOURCES: MEDLINE (1966 to 2006), EMBASE (1980 to 2006), Cochrane Central Register of Controlled Trials, Cochrane Collaboration's registry of clinical trials, Cochrane Database of Systematic Reviews. STUDY SELECTION: Randomized, controlled trials and case-control and cohort studies of the effectiveness of NSAIDs for the prevention of CRC and colorectal adenoma were identified by multilevel screening by 2 independent reviewers. Systematic reviews of harms were sought. DATA EXTRACTION: Data abstraction, checking, and quality assessment were completed in duplicate. DATA SYNTHESIS: A single cohort study showed no effect of non-ASA NSAIDs on death due to CRC. Colorectal cancer incidence was reduced with non-ASA NSAIDs in cohort studies (relative risk, 0.61 [95% CI, 0.48 to 0.77]) and case-control studies (relative risk, 0.70 [CI, 0.63 to 0.78]). Colorectal adenoma incidence was also reduced with non-ASA NSAID use in cohort studies (relative risk, 0.64 [CI, 0.48 to 0.85]) and case-control studies (relative risk, 0.54 [CI, 0.4 to 0.74]) and by COX-2 inhibitors in randomized, controlled trials (relative risk, 0.72 [CI, 0.68 to 0.77]). The ulcer complication rate associated with non-ASA NSAIDs is 1.5% per year. Compared with non-ASA NSAIDs, COX-2 inhibitors reduce this risk but, in multiyear use, have a higher ulcer complication rate than placebo. Cyclooxygenase-2 inhibitors and nonnaproxen NSAIDs increase the risk for serious cardiovascular events (relative risk, 1.86 [CI, 1.33 to 2.59] for COX-2 inhibitors vs. placebo). LIMITATIONS: Heterogeneity in the dose, duration and frequency of use necessitated careful grouping for analysis. CONCLUSIONS: Cyclooxygenase-2 inhibitors and NSAIDs reduce the incidence of colonic adenomas. Nonsteroidal anti-inflammatory drugs also reduce the incidence of CRC. However, these agents are associated with important cardiovascular events and gastrointestinal harms. The balance of benefits to risk does not favor chemoprevention in average-risk individuals.

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

BACKGROUND: Adverse events are poor patient outcomes that are due to medical care. Studies of hospital patients have demonstrated that adverse events are common, but few data describe the timing of them in relation to hospital admission. We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing. METHODS: We randomly selected 502 adults admitted to the Ottawa Hospital for acute care of nonpsychiatric illnesses over a 1-year period. Charts were reviewed in 2 stages. If an adverse event was judged to have occurred, a physician determined whether it occurred before or during the index hospitalization. The reviewer also rated the preventability, severity and type of each adverse event. RESULTS: Of the 64 patients with an adverse event (incidence 12.7%, 95% confidence interval [CI] 10.1%-16.0%), 24 had a preventable event (4.8%, 95% CI 3.2%-7.0%), and 3 (0.6%, 95% CI 0.2%-1.7%) died because of an adverse event. Most adverse events were due to drug treatment, operative complications or nosocomial infections. Of the 64 patients, 39 (61%, 95% CI 49%-72%) experienced the adverse event before the index hospitalization. INTERPRETATION: Adverse events were common in this study. However, only one-third were deemed avoidable, and most occurred before the hospitalization. Interventions to improve safety must address ambulatory care as well as hospital-based care.

The reporting of theoretical health risks by the media: Canadian newspaper reporting of potential blood transmission of Creutzfeldt-Jakob disease.

BACKGROUND: The media play an important role at the interface of science and policy by communicating scientific information to the public and policy makers. In issues of theoretical risk, in which there is scientific uncertainty, the media's role as disseminators of information is particularly important due to the potential to influence public perception of the severity of the risk. In this article we describe how the Canadian print media reported the theoretical risk of blood transmission of Creutzfeldt-Jakob disease (CJD). METHODS: We searched 3 newspaper databases for articles published by 6 major Canadian daily newspapers between January 1990 and December 1999. We identified all articles relating to blood transmission of CJD. In duplicate we extracted information from the articles and entered the information into a qualitative software program. We compared the observations obtained from this content analysis with information obtained from a previous policy analysis examining the Canadian blood system's decision-making concerning the potential transfusion transmission of CJD. RESULTS: Our search identified 245 relevant articles. We observed that newspapers in one instance accelerated a policy decision, which had important resource and health implication, by communicating information on risk to the public. We also observed that newspapers primarily relied upon expert opinion (47 articles) as opposed to published medical evidence (28 articles) when communicating risk information. Journalists we interviewed described the challenges of balancing their responsibility to raise awareness of potential health threats with not unnecessarily arousing fear amongst the public. CONCLUSIONS: Based on our findings we recommend that journalists report information from both expert opinion sources and from published studies when communicating information on risk. We also recommend researchers work more closely with journalists to assist them in identifying and appraising relevant scientific information on risk.