Utilization of serum D-dimer assays prior to computed tomography pulmonary angiography scans in the diagnosis of pulmonary embolism among emergency department physicians: a retrospective observational study.

Background: A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients.

Objective: To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA).

Methods: Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period.

Antiepileptic rufinamide and QTc interval shortening in a patient with long QT syndrome: case report.

Background: There is limited pharmacologic therapy to reduce the QT interval in hereditary long QT syndrome (LQTS).

Case Summary: We describe a child with Allan-Herndon-Dudley syndrome, Lennox-Gastaut epileptic syndrome (LGS), and LQTS Type 1 (LQTS1). Rufinamide was added to his antiepileptic medications to improve seizure control and was noted to be associated with a marked improvement in electrocardiogram QT interval.

Reanimating Patients After Traumatic Cardiac Arrest: A Practical Approach Informed by Best Evidence.

Resuscitation of traumatic cardiac arrest is typically considered futile. Recent evidence suggests that traumatic cardiac arrest is survivable. In this article key principles in managing traumatic cardiac arrest are discussed, including the importance of rapidly seeking prognostic information, such as signs of life and point-of-care ultrasonography evidence of cardiac contractility, to inform the decision to proceed with resuscitative efforts.

Educational interventions to train healthcare professionals in end-of-life communication: a systematic review and meta-analysis.

Background: Practicing healthcare professionals and graduates exiting training programs are often ill-equipped to facilitate important discussions about end-of-life care with patients and their families. We conducted a systematic review to evaluate the effectiveness of educational interventions aimed at providing healthcare professionals with training in end-of-life communication skills, compared to usual curriculum.

Methods: We searched MEDLINE, Embase, CINAHL, ERIC and the Cochrane Central Register of Controlled Trials from the date of inception to July 2014 for randomized control trials (RCT) and prospective observational studies of educational training interventions to train healthcare professionals in end-of-life communication skills.

Do research findings on schema-based instruction translate to the classroom?

Introduction: Schema-based instruction has been shown to improve diagnostic performance and reduce cognitive load. However, to date, this has only been studied in controlled research settings. More distractions in classrooms may limit generalizability to real-world settings.

The offering of family presence during resuscitation: a systematic review and meta-analysis.

Background: Family members may wish to be present during resuscitation of loved ones, despite concerns that they may interfere with the resuscitation or experience psychological harm.

Methods: We conducted a systematic review to determine whether offering family presence during resuscitation (FPDR) affected patient mortality, resuscitation quality, or family member psychological outcomes. We searched multiple databases up to January 2014 for studies comparing FPDR to usual care.

Real-world data confirm clinical trial outcomes for rivaroxaban in orthopaedic patients.

Venous thromboembolism (VTE) is a potential cause of morbidity and mortality in patients after major orthopaedic surgery. Based on the results of the international phase III RECORD (Regulation of Coagulation in Orthopaedic Surgery to Prevent Deep Vein Thrombosis and Pulmonary Embolism) program, the oral, direct Factor Xa inhibitor rivaroxaban has been approved in many countries for the prevention of VTE after elective hip arthroplasty or knee arthroplasty. However, study results of randomized controlled trials may have limited generalizability to routine clinical practice in unselected patients.

Virtuous laughter: we should teach medical learners the art of humor.

There is increasing recognition of the stress and burnout suffered by critical care workers. Physicians have a responsibility to teach learners the skills required not only to treat patients, but to cope with the demands of a stressful profession. Humor has been neglected as a strategy to help learners develop into virtuous and resilient physicians.

Benefit-risk assessment of rivaroxaban versus enoxaparin for the prevention of venous thromboembolism after total hip or knee arthroplasty.

Purpose: Venous thromboembolism is a common complication after major orthopedic surgery. When prescribing anticoagulant prophylaxis, clinicians weigh the benefits of thromboprophylaxis against bleeding risk and other adverse events. Previous benefit-risk analyses of the REgulation of Coagulation in ORthopaedic surgery to prevent Deep vein thrombosis and pulmonary embolism (RECORD) randomized clinical studies of rivaroxaban versus enoxaparin after total hip (THA) or knee (TKA) arthroplasty generally used pooled THA and TKA results, counted fatal bleeding as both an efficacy and a safety event, and included the active and placebo-controlled portions of RECORD2, which might confound benefit-risk assessments.

Advances in oral anticoagulation treatment: the safety and efficacy of rivaroxaban in the prevention and treatment of thromboembolism.

Arterial and venous thromboembolic diseases are a clinical and economic burden worldwide. In addition to traditional agents such as vitamin K antagonists and heparins, newer oral agents - such as the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, and the direct thrombin inhibitor dabigatran - have been shown to be effective across several indications. Rivaroxaban has been shown to have predictable pharmacokinetic and pharmacodynamic properties, including a rapid onset of action.

Fluids and diuretics for acute ureteric colic.

Background: Acute ureteric colic is commonly associated with severe and debilitating pain. Theoretically, increasing fluid flow through the affected kidney might expedite stone passage, thereby improving symptoms more quickly. The efficacy and safety of interventions such as high volume intravenous (IV) or oral fluids and diuretics aimed at expediting ureteric stone passage is, however, uncertain.

Are hemostatic agents effective in the treatment of acute spontaneous intracerebral hemorrhage?

Unlabelled: Methods

Data Sources: The investigators searched the Cochrane Stroke Group Trials and Central Register of Controlled Trials, MEDLINE (from 1966), EMBASE (from 1980), bibliographies of relevant articles, and clinical trial registries. Authors and pharmaceutical companies were contacted for clarification and to identify any additional studies.

Study Selection: Randomized controlled trials with clinical outcome measures evaluating all doses and administration routes of single or multiple hemostatic agents, including antifibrinolytics, blood coagulation factors, and platelet activators.

Warfarin after anterior myocardial infarction in current era of dual antiplatelet therapy: a randomized feasibility trial.

Unlabelled: In the current era of early revascularization and routine use of dual antiplatelet therapy, the incremental benefit of warfarin to reduce the incidence of left ventricular thrombus (LVT) in patients with impaired left ventricular ejection fraction post anterior ST-elevation myocardial infarction (aSTEMI), remains uncertain. The purpose of this study is to assess the feasibility of evaluating the added benefit and safety of triple therapy (TT-warfarin, ASA, and clopidogrel) versus dual therapy (DT-ASA and clopidogrel) in patients at risk of LVT post aSTEMI.

Design: Open-label randomized controlled trial.

Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes treated with glycoprotein IIb/IIIa inhibitors or thienopyridines: results from the OASIS 5 (Fifth Organization to Assess Strategies in Ischemic Syndromes) trial.

Objectives: This study sought to evaluate the relative safety and efficacy of fondaparinux and enoxaparin in patients with acute coronary syndromes (ACS) treated with glycoprotein (GP) IIb/IIIa inhibitors or thienopyridines.

Background: The OASIS 5 (Fifth Organization to Assess Strategies in Ischemic Syndromes) trial showed that fondaparinux reduced major bleeding by 50% compared with enoxaparin while preserving similar efficacy. Whether this benefit is consistent in the presence or absence of concurrent antiplatelet therapy with clopidogrel and GP IIb/IIIa inhibitors is unknown.

The absence of 'minor' risk factors for recurrent venous thromboembolism: a systematic review of negative predictive values and negative likelihood ratios.

Background: The decision to stop anticoagulation after an episode of venous thromboembolism (VTE) depends on the risk of recurrence. A number of recently discussed risk factors that are not routinely used in clinical practice might be useful for the identification of patients with a low risk of recurrence.

Objectives: The aim of this study was to determine the negative predictive value and likelihood ratio of the absence of each of these factors in patients with VTE.

Decreasing warfarin sensitivity during the first three months after heart valve surgery: implications for dosing.

Introduction: Vitamin K antagonists are prescribed to prevent thromboembolic complications after heart valve surgery. In our experience, patients often show a progressive decrease in sensitivity to warfarin after surgery making it difficult to reach and maintain a therapeutic International Normalized Ratio (INR). We sought to confirm our clinical impression and to gather data for the development of a guide to dosing these patients.

Determinants of bleeding risk in patients on antithrombotic and antifibrinolytic drugs.

The risk of bleeding associated with antithrombotic and fibrinolytic therapy depends on factors that are specific for the drugs and the patients. In this narrative review, we describe the most important risk factors for bleeding for each class of drugs. Pertinent examples are recent initiation of therapy with vitamin K antagonists, low-molecular-weight heparins, and renal dysfunction, and higher dose of aspirin.

Hemorrhagic complications of anticoagulant and thrombolytic treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

This article about hemorrhagic complications of anticoagulant and thrombolytic treatment is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Bleeding is the major complication of anticoagulant and fibrinolytic therapy. The criteria for defining the severity of bleeding vary considerably between studies, accounting in part for the variation in the rates of bleeding reported.

Prevention of venous thromboembolism in medically ill patients: a clinical update.

The risk of venous thromboembolism (VTE) in hospitalised medically ill patients is often underestimated, despite the fact that it remains a major cause of preventable morbidity and mortality in this group. It is not well recognised that the risk of VTE in many hospitalised medically ill patients is at least as high as in populations after surgery. This may partly be attributed to the clinically silent nature of VTE in many patients, and the difficulty in predicting which patients might develop symptoms or fatal pulmonary embolism.

Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial.

Context: Despite many therapeutic advances, mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) remains high. The role of additional antithrombotic agents is unclear, especially among patients not receiving reperfusion therapy.

Objective: To evaluate the effect of fondaparinux, a factor Xa inhibitor, when initiated early and given for up to 8 days vs usual care (placebo in those in whom unfractionated heparin [UFH] is not indicated [stratum 1] or unfractionated heparin for up to 48 hours followed by placebo for up to 8 days [stratum 2]) in patients with STEMI.