The frequency of initial misdiagnosis of acute aortic dissection in the emergency department and its impact on outcome.

We determine the frequency of initial misdiagnosis and inappropriate treatment with antiplatelets/anticoagulants in the emergency department (ED) and the resultant clinical outcomes in patients with acute type A aortic dissection (AAOD). Medical records of patients with a final diagnosis of AAOD admitted from March 2004 through October 2015 to our tertiary-level heart hospital were evaluated. Patients with suspected dissection in ED were compared to those with initial misdiagnosis regarding demographics and clinical presentation, laboratory and echocardiographic findings. Our primary outcome was hospital mortality in two groups. Long-term mortality after discharge was our secondary outcome. Among 189 patients, 47 (24.8 %) were initially misdiagnosed and received antiplatelets/anticoagulants in ED (Group F), and 142 (75.1 %) were appropriately diagnosed in ED (Group T). The mean age in group F was 60.4 ± 15.0 vs. 57.4 ± 16.0 years in group T (p = 0.260). In group F, 70.2 % were male vs. 60.6 % in group T (p = 0.311). Hospital mortality was 48.9 % in group F vs. 43.7 % in group T (p = 0.645). Long-term mortality was significantly higher in group F (55.6 vs. 21.2 %, p = 0.007). Univariate hazard ratio (HR) of initial misdiagnosis for long-term mortality was 2.56 (95 % CI 1.08-6.06, p = 0.031). In multivariate Cox regression analysis with adjustment for age and type of management (surgical/medical), initial misdiagnosis lost its significance for predicting long-term mortality (HR 2.14, 95 % CI 0.89-5.13, p = 0.086). Initial misdiagnosis of AAOD is a common problem. Hospital mortality is not significantly affected by receiving antiplatelets/anticoagulants. Although long-term mortality is higher in patients with initial misdiagnosis, it is not an independent predictor for long-term mortality.

Predictors of hospital mortality and serious complications in patients admitted with excessive warfarin anticoagulation.

INTRODUCTION: Warfarin is the most commonly used oral anticoagulant and serious bleeding remains the most feared complication. Excessive warfarin anticoagulation (EWA) can be associated with adverse outcome. We aimed to identify the predictors of adverse clinical outcomes in patients admitted with EWA. METHODS AND MATERIALS: Medical records of patients admitted with EWA from March-2004 through Feb-2015 were reviewed. EWA was defined as international normalized ratio (INR)>3.5 in patients who have been receiving warfarin. Primary outcome was death within hospital and secondary outcome was major composite complications (MCC) defined as intracranial hemorrhage (ICH), a need for transfusing ≥ 4 units packed red blood cell (PRBC), a need for surgical intervention for hemostasis or death within hospital. RESULTS: 267 patients (153 females and 114 male) were enrolled. 25 patients (9.4%) died during hospitalization. ICH, upper gastrointestinal bleeding and hemoptysis were more common in patients who did not survive (P-value: <0.001, 0.033 and 0.028; respectively). There was no correlation between indication for anticoagulation and death within hospital or development of MCC. In multivariate analysis, O blood group, ICH and the number of transfused PRBC and fresh frozen plasma units were identified as independent predictors of death within hospital. Lower hemoglobin concentrations and higher pulmonary pressures on admission were independent predictors of MCC, which occurred in 47 patients (17.6%). CONCLUSION: Hospital mortality correlated with the severity of bleeding (requiring ≥ 4 units PRBC), intracranial hemorrhage and O blood group, while MCC associated with lower hemoglobin and pulmonary hypertension at the time of admission.

Developing an instrument to measure the influential factors on career choice among Iranian nursing students.

BACKGROUND: Understanding why the graduates from the high schools choose nursing is essential for the health policy makers in each country and Iran is not an exception. The aim of this study was to develop an instrument measuring the influential factors on career choice among Iranian nursing students. MATERIALS AND METHODS: This methodological study employed both qualitative and quantitative approaches. In the first phase of the study, the items were generated for the instrument. These items were drawn from a relevant literature review along with taking a poll of experts' opinions. Then the psychometric properties of instrument were measured using content validity, face validity, and construct (exploratory factor analysis) validity as well as its reliability. RESULTS: Initially, a 35-item instrument was developed. In the second phase, a scale-level content validity index of 0.90 was obtained for the instrument. The factor structure of the inventory was identified by undertaking a principal component analysis in a sample of 139 nursing students. Three factors were extracted with a total variance account of 42.03%. Reliability was demonstrated with Cronbach's alpha coefficient of 0.77 for the entire scale. Consistency of the instrument was established with test - retest reliability with an interval of 2 weeks (intra-cluster correlation = 0.94, P < 0.001). Wilcoxon signed-rank test demonstrated no significant differences between the test - retest scores (P > 0.05). CONCLUSION: It seems a culturally sensitive instrument with a satisfactory level of validity and reliability has some implications for policy makers in nursing education.

The effect of supportive counseling program on the academic performance of nursing and midwifery students.

INTRODUCTION: Poor academic performance in universities is a worrying issue, imposing extra finance on the government. This study was conducted to discover if supportive counseling program (SCP) has any effects on the academic performance of students. METHODS: Sixty nursing and midwifery Iranian students with poor academic performance participated in this quasi-experimental semester-long study. They were balanced by gender, major, years of study, and grade average. They were divided into intervention and control groups, the former attended the SCP. Finally the grade averages of the groups before and after the intervention were calculated. RESULTS: An independent t-test revealed a significant difference between the grade averages of the two groups (p = 0.01); similar results were obtained for theoretical courses' grade averages (p = 0.03). Also, a paired t-test indicated a significant difference between the grade averages of the intervention group pre and post-intervention (p < 0.0001). CONCLUSION: Findings favored designing and carrying out SCP for students, especially for those with poor academic performance. The effect of SCP on the academic performance of nursing and midwifery students.