The search-inference framework: a proposed strategy for novice clinical problem solving.

CONTEXT: Medical education in the clinical clerkship years emphasises the systematic collection and organisation of patient information to be combined with domain-specific knowledge of disease processes. Eventually, novice clinical problem solvers will learn to recognise patterns within the patient data ('illness scripts') which suggest the main diagnostic possibilities. Before novice problem solvers develop these illness scripts, pattern recognition may not be effective for solving clinical problems. METHODS: This discussion paper describes the application of a decision framework adapted from cognitive psychology (the search-inference framework) to basic medical problem solving. Emphasis is placed on problem solving by novices who have not yet developed a full compliment of illness scripts. CONCLUSIONS: The search-inference framework is similar to the approach taken by laypersons to diagnose their own symptoms or solve other problems. It may be especially useful for students who have not yet developed a sizeable repertoire of illness scripts, and the principles described may also be invoked by experienced clinicians confronting difficult clinical problems.

Thromboembolic events during continuous vasopressin infusions: a retrospective evaluation.

BACKGROUND: Published guidelines suggest that vasopressin has a role in shock treatment, although its safety has not been adequately evaluated in a clinical setting. Vasopressin causes platelet aggregation and has been associated with the release of factor VIII coagulant and von Willebrand factor. OBJECTIVE: To compare the incidence of venous thromboembolism (VTE) in patients with a diagnosis of shock who received vasopressin with those who did not receive vasopressin for hemodynamic support. METHODS: A retrospective, single-center, cohort study was conducted at an academic, tertiary care center with 350 patients with a diagnosis of shock. Patients from the intensive care unit were randomly selected and separated into 2 groups for comparison of those receiving only catecholamines with those receiving vasopressin with or without catecholamines for hypotension. Patients with diabetes insipidus or variceal hemorrhage and those with any documented history of VTE were excluded. The primary outcome, VTE occurrence, was defined as a positive Doppler ultrasound, spiral computed tomography, or documented diagnosis in the discharge records. Frequency and type of risk factors for VTE were compared between the 2 study arms. A risk factor modeling approach was performed, using logistic regression to identify potential confounders and effect modifiers in the relationship between vasopressin and VTE. RESULTS: There were 175 patients in each arm of the study. The crude incidence of VTE was 7.4% and 8% in the vasopressin and catecholamine groups, respectively (p = 0.84). No significant difference in the incidence of deep venous thrombosis (vasopressin 5.1%, control 7.4%; p = 0.51) or pulmonary embolism (vasopressin 2.3%, control 0.6%; p = 0.37) was found between groups. After adjusting for covariates, there was no statistically significant difference in the incidence of VTE between the 2 arms (p = 0.72). CONCLUSIONS: This investigation provides initial evidence that vasopressin infusions do not increase the risk of VTE in patients with shock.

Survey of current practices in fellowship orientation.

BACKGROUND: The transition from medical resident to subspecialty fellow is a critical time period in fellowship training that has not been well described. The current practices of fellow orientation in pulmonary and critical care training programs are not known. OBJECTIVES: The aim of this study was to describe orientation practices for training programs in the United States. METHODS: A 10-question survey was sent via e-mail to program directors of pulmonary/critical care fellowship programs identified on the American Thoracic Society (ATS) web-page of current programs. RESULTS: Eighty-seven programs responded (61.7%), of which 86% had a formal orientation program. The mean time spent in fellow orientation was 5-10 h in didactic sessions and 0-5 h in wet labs. The most frequent didactic sessions were bronchoscopy in 69 programs (80.2%), pulmonary function testing in 63 programs (73.3%) and orientation to hospital services in 63 programs (73.3%). The most frequent use of wet labs was in bronchoscopy training in 60 programs (81.1%) and ventilators in 45 programs (60.8%). Simulators were used in 37 programs (43%). The majority reported that these areas were covered with on the job training, without a formal designated orientation. CONCLUSION: This survey demonstrated that early fellow training differs across programs in both time spent and clinical and procedural topics covered. An early, standardized approach to clinical and procedural training can assure appropriate exposure that cannot be guaranteed by on the job training. To provide justification for such an approach, clinical outcomes need to be correlated with training methods.

Differences in the evaluation and management of exercise-induced bronchospasm between family physicians and pulmonologists.

Previous studies have demonstrated that specialists and generalists differ in the evaluation and management of asthma especially in terms of use of objective testing. We speculated that there also may be differences in the diagnosis and management of exercise-induced respiratory complaints. An Internet survey was sent to samples of pulmonologists and family physicians. Our data suggests that pulmonologists are much more likely to order bronchoprovocation testing than family physicians, and family physicians are more likely to start any empiric therapy than perform bronchoprovocation testing when exercise-induced bronchospasm is suspected. These differences may lead to inaccurate or missed diagnoses and unnecessary morbidity.

Body mass index is independently associated with hospital mortality in mechanically ventilated adults with acute lung injury.

OBJECTIVE: To determine the association between body mass index (BMI) and hospital mortality for critically ill adults. DESIGN: Retrospective cohort study. SETTING: One-hundred six intensive care units (ICUs) in 84 hospitals. PATIENTS: Mechanically ventilated adults (n=1,488) with acute lung injury (ALI) included in the Project IMPACT database between December 1995 and September 2001. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over half of the cohort had a BMI above the normal range. Unadjusted analyses showed that BMI was higher among subjects who survived to hospital discharge vs. those who did not (p<.0001). ICU and hospital mortality rates were lower in higher BMI categories. After risk-adjustment, BMI was independently associated with hospital mortality (p<.0001) when modeled as a continuous variable. The adjusted odds were highest at the lowest BMIs and then declined to a minimum between 35 and 40 kg/m2. Odds increased after the nadir but remained below those seen at low BMIs. With use of a categorical designation, BMI was also independently associated with hospital mortality (p=.0055). The adjusted odds were highest for the underweight BMI group (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.05-3.60) relative to the normal BMI group. As in the analysis using the continuous BMI variable, the odds of hospital mortality were decreased for the groups with higher BMIs (overweight adjusted OR, 0.72; 95% CI, 0.51-1.02; obese adjusted OR, 0.67; 95% CI, 0.46-0.97; severely obese adjusted OR, 0.78; 95% CI, 0.44-1.38). Differences in the use of heparin prophylaxis mediated some of the protective effect of severe obesity. CONCLUSIONS: BMI was associated with risk-adjusted hospital mortality among mechanically ventilated adults with ALI. Lower BMIs were associated with higher odds of death, whereas overweight and obese BMIs were associated with lower odds.

Toxicity of Food Drug and Cosmetic Blue No. 1 dye in critically ill patients.

Food Drug and Cosmetic Blue No. 1 dye (FD&C Blue No. 1) is commonly added to enteral nutrition formulations in order to facilitate the detection of gastric aspirate in tracheal secretions of critically ill patients. However, reports of systemic blue dye absorption and associated adverse outcomes are emerging. We report two cases of abnormal systemic absorption of FD&C Blue No. 1 in critically ill patients who subsequently died of refractory shock and metabolic acidosis. Risk factors and mechanisms of FD&C Blue No. 1 toxicity are discussed, and alternate approaches to gastric aspiration detection in critically ill patients are considered.

Validaçäo do inventário de sintomas de stress infantil - ISS -I / Validity of the child stress symptons inventory - ISS - I

Este trabalho teve por objetivo submeter o Inventário de Sintomas de Stress Infantil a um estudo de validaçäo. Foram sujeitos 255 crianças entre 6 e 14 anos de idade, de ambos os sexos, alunos de escolas públicas, e 9 profissionais. Foi feita a aplicaçäo do ISS-I nas crianças e de um questionário nos profissionais. Os resultados culminaram em um novo instrumento: Escala de Stress Infantil. A análise de precisäo evidenciou elevada consistência interna, alfa de Cronbach. Extraíram-se quatro fatores com a análise fatorial exploratória relacionados às reaçöes do stress: físicas, psicológicas, psicológicas com componente depressivo e psicofisiológicas. A análise fatorial confirmatória evindeciou alta correlaçäo entre os fatores, supondo que exista um único constructo. O estudo revelou ainda alta correlaçäo entre aplicaçäo individual e coletiva. Concluiu-se que a ESI pode ser considerada como um bom e válido instrumento de avaliaçäo do stress para crianças de 6 a 14 anos de idade de ambos os sexos

Validacao do inventario de sintomas de stress infantil -ISS-I

Este trabalho teve por objetivo submeter o Inventario de Sintomas de Stress Infantil a um estudo da validacao. Foram sujeitos 255 criancas entre 6 e 14 anos de idade, de ambos os sexos, alunos de escolas publicas, e 9 profissionais. Foi feita a aplicacao do ISS-I nas criancas e de um questionario nos profissionais. Os resultados culminaram em um novo instrumento: Escala de Stress Infantil. A analise de precisao evidenciou elevada consistencia interna, alfa de Cronbach. Extrairam-se quatro fatores com a analise fatorial exploratoria relacionados as reacoes do stress: fisicas, psicologicas, psicologicas com componente depressivo e psicofisiologicas. A analise fatorial confirmatoria evidenciou alta correlacao entre os fatores, supondo que exista um unico constructo. O estudo revelou ainda alta correlacao entre aplicacao individual e coletiva. Concluiu-se que a ESI pode ser considerada como um bom e valido instrumento de avaliacao do stress para criancas de 6 a 14 anos de idade de ambos os sexos.