Association of Aspirin With Prevention of Venous Thromboembolism in Patients After Total Knee Arthroplasty Compared With Other Anticoagulants: A Noninferiority Analysis.

Importance: There has been significant debate in the surgical and medical communities regarding the appropriateness of using aspirin alone for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA).

Objective: To determine the acceptability of aspirin alone vs anticoagulant prophylaxis for reducing the risk of postoperative VTE in patients undergoing TKA.

Design, Setting, And Participants: Noninferiority study of a retrospective cohort of TKA cases submitted to the Michigan Arthroplasty Registry Collaborative Quality Initiative at 29 member hospitals, ranging from small community hospitals to large academic and nonacademic medical centers in Michigan.

Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates-A Multicenter Study Using the MARCQI Total Joint Registry Database.

Background: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines.

Data Sharing Between Providers and Quality Initiatives Eliminate Unnecessary Nursing Home Admissions.

Background: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) has monitored discharge disposition, after total hip and knee arthroplasties, since inception in 2012 and found the standardized risk of extended care facility (ECF) placement to be highly variable between hospitals.

Methods: The variation in standardized risks of ECF placement among MARCQI member sites was reported to the collaborative. At the May 2, 2014 quarterly meeting, a quality initiative was started, emphasizing the wide variability between hospitals, the contribution of hospital and surgeon to that variability using median odds ratios, and the need for outlier hospitals to initiate quality improvement (QI) processes.

The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty.

Background: The efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements in total hip and knee arthroplasty has been well established in small controlled clinical trials and meta-analyses. The purpose of the current study was to determine the risks and benefits of TXA use in routine orthopaedic surgical practice on the basis of data from a large, statewide arthroplasty registry.

Methods: From April 18, 2013, to September 30, 2014, there were 23,236 primary total knee arthroplasty cases and 11,489 primary total hip arthroplasty cases completed and registered in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI).

A Delphi Method Analysis to Create an Emergency Medicine Educational Patient Satisfaction Survey.

Introduction: Feedback on patient satisfaction (PS) as a means to monitor and improve performance in patient communication is lacking in residency training. A physician's promotion, compensation and job satisfaction may be impacted by his individual PS scores, once he is in practice. Many communication and satisfaction surveys exist but none focus on the emergency department setting for educational purposes.

Reference range for tissue oxygen saturation in pregnancy using near-infrared spectroscopy.

Objective: To estimate the reference range of tissue oxygen saturation (StO2) values in pregnancy. Near-infrared spectroscopy-derived StO2 is a noninvasive continuous measure used to predict hypoperfusion. Normal StO2 values have not been established in pregnant women.

Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections.

Background: A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone.

Methods: Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports.

You've got mail … and need follow-up: the effect and patient perception of e-mail follow-up reminders after emergency department discharge.

Objectives: The hypothesis was that a reminder about recommended primary care physician (PCP) follow-up, sent via e-mail to patients discharged from the emergency department (ED), would increase the proportion of patients who followed up with their PCPs within the recommended time frame. Patient receptiveness to e-mail follow-up reminders was also assessed.

Methods: This was a mixed methods clinical intervention study with subjects randomized either to receive the usual care discharge instructions only or to also receive a reminder e-mail message the day after the ED visit.

(1,3)-β-d-glucan in cerebrospinal fluid for diagnosis of fungal meningitis associated with contaminated methylprednisolone injections.

Prompt diagnosis and treatment of fungal meningitis are critical, but culture is insensitive. (1,3)-β-d-Glucan (BDG) testing is FDA approved for serological diagnosis of invasive fungal disease; however, BDG testing is not approved for cerebrospinal fluid (CSF), and the appropriate cutoff value is unknown. We aimed to validate the diagnostic accuracy of CSF BDG measurements for fungal meningitis among patients exposed to contaminated methylprednisolone acetate (MPA).

Mind the (knowledge) gap: the effect of a communication instrument on emergency department patients' comprehension of and satisfaction with care.

Objectives: We developed a communication instrument to be used in the Emergency Department (ED) and hypothesized that use of this guide would increase patient comprehension of and satisfaction with care.

Methods: This multi-site trial enrolled 643 patients in treatment and control groups. Comprehension of care was assessed by chart review and satisfaction measured via validated survey.

A multifactorial intervention for hospital opioid management.

Objective: To determine whether an educational intervention combined with a voluntary decision support system improves inpatient pain control.

Design: Retrospective serial cross-sectional study.

Setting: Community teaching hospital.

Alopecia and nail changes associated with voriconazole therapy.

Background: Voriconazole was 1 of 2 antifungal agents recommended for treatment of fungal infections associated with injection of contaminated methylprednisolone. Alopecia and nail changes are not commonly reported side effects of voriconazole. Having noted increasing hair loss among our patients treated with voriconazole, we sought to determine the prevalence and characteristics of alopecia associated with this agent.

Procalcitonin as a marker of serious bacterial infections in febrile children younger than 3 years old.

Objectives: There is no perfectly sensitive or specific test for identifying young, febrile infants and children with occult serious bacterial infections (SBIs). Studies of procalcitonin (PCT), a 116-amino-acid precursor of the hormone calcitonin, have demonstrated its potential as an acute-phase biomarker for SBI. The objective of this study was to compare performance of serum PCT with traditional screening tests for detecting SBIs in young febrile infants and children.

Impact of a new senior emergency department on emergency department recidivism, rate of hospital admission, and hospital length of stay.

Study Objective: Senior (geriatric) emergency departments (EDs) are an emerging phenomenon across the United States, designed to provide greater comfort for elders, screening for common morbidities, and selective contact with social workers. We hypothesize that the senior ED will reduce recidivism, rate of admission, and hospital length of stay.

Methods: This was a pre/postintervention observational study of seniors (≥65 years) before and after opening of a new senior ED in a large community hospital.

Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate.

Importance: Injection of contaminated methylprednisolone has resulted in an unprecedented nationwide outbreak of Exserohilum rostratum fungal infections, manifested initially as meningitis and/or basilar stroke. Insidious onset of spinal or paraspinal infection at the injection site has been increasingly reported and is occurring months after receipt of injection with the contaminated drug. The clinical findings are often subtle and similar to those that led the patient to undergo the methylprednisolone injection.

Implementation of a novel communication tool and its effect on patient comprehension of care and satisfaction.

Background: Emergency department (ED) communication has been demonstrated as requiring improvement and ED patients have repeatedly demonstrated poor comprehension of the care they receive. Through patient focus groups, the authors developed a novel tool designed to improve communication and patient comprehension.

Study Design: This is a prospective, randomised controlled clinical trial to test the efficacy of a novel, patient-centred communication tool.

Clinical and economic outcomes from a community hospital's antimicrobial stewardship program.

Background: Data from community antimicrobial stewardship programs (ASPs) are limited. We describe clinical and economic outcomes from the first year of our hospital's ASP.

Methods: The ASP team comprised 2 infectious disease physicians and 3 intensive care unit pharmacists.

Does intrathecal morphine sulfate provide preemptive analgesia for patients undergoing stapled hemorrhoidopexy?

Objective: Surgical excision of hemorrhoids is characterized by a prolonged and painful postoperative course. This double-blind, randomized, prospective, controlled trial was conducted to determine if morphine sulfate provides additional pain relief after stapled hemorrhoidopexy when added to a standard lidocaine spinal anesthetic. It was hypothesized that the addition of morphine sulfate to a spinal anesthetic would decrease postoperative pain.

Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children.

Objectives: We describe children's postconcussive symptoms (PCSs), neurocognitive function, and recovery during 4 to 5 weeks after mild traumatic brain injury (MTBI) and compare performance and recovery with those of injured control group participants without MTBIs.

Methods: A prospective, longitudinal, observational study was performed with a convenience sample from a tertiary care, pediatric emergency department. Participants were children 10 to 17 years of age who were treated in the emergency department and discharged.

The inability of B-type natriuretic protein to predict short-term risk of death or myocardial infarction in non-heart-failure patients with marginally increased troponin levels.

Study Objective: We want to know whether a low B-type natriuretic peptide (BNP) level, obtained shortly after presentation and independent of information provided by other clinical findings and laboratory tests, would affect management decisions for emergency department (ED) patients with nondiagnostic troponin levels. Previous studies have generally been retrospective or inclusive of patients with heart failure.

Methods: We prospectively studied patients evaluated for possible acute coronary syndromes who had nondiagnostic levels of serum troponin, nondiagnostic ECGs, and no clinical heart failure within 4 hours of presentation.

Is it possible to safely administer early a loading dose of clopidogrel before coronary angiography to patients who are candidates for percutaneous coronary intervention?

Current American College of Cardiology/American Heart Association guidelines recommend loading clopidogrel >or=6 hours before percutaneous coronary intervention. Other American College of Cardiology guidelines advise withholding clopidogrel for 5 days before coronary artery bypass grafting (CABG) to avoid excessive bleeding. Previously published rules for predicting early CABG after coronary angiography (CA) were developed in selected patients with non-ST-segment elevation-acute coronary syndrome and not tested in community practice settings.

The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction.

Although experimental evidence suggests that the preliminary surgical delay procedure physiologically improves the circulation of the TRAM flap, there are no published controlled studies evaluating the clinical outcomes associated with this procedure. The purpose of this study was to evaluate the efficacy of the surgical flap delay versus no delay in consecutive patients having pedicle TRAM breast reconstruction. This was a retrospective cohort study of breast cancer patients at the University of Michigan who had pedicle TRAM reconstruction between January 2004 and March 2008.