JAMA network open
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Laboratory data are frequently collected throughout the care of critically ill patients. Currently, these data are interpreted by comparison with values from healthy outpatient volunteers. Whether this is the most useful comparison has yet to be demonstrated. ⋯ The standard reference ranges obtained from healthy volunteers differ from the analogous range generated from data from patients in intensive care. Laboratory data interpretation may benefit from greater consideration of clinically contextual and outcomes-related factors.
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Renin angiotensin aldosterone system inhibitors (RAASIs) benefit individuals with chronic kidney disease (CKD). Elevations in serum creatinine and potassium levels are common reasons for discontinuation of this therapy, but their incidence and risks are not well characterized in community practice. ⋯ Acute creatinine and potassium level disturbances after initiation of RAASI therapy in individuals with CKD appear to be sustained often often not sustained and not associated with ED visits or hospitalizations, despite therapy continuation. Findings from this study suggest that increases in creatinine level were independently associated with mortality among individuals prescribed diuretics but not RAASIs. Structured laboratory monitoring during RAASI therapy initiation may guide appropriate continuation of therapy in the outpatient setting.
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Observational Study
Association of a Competency-Based Assessment System With Identification of and Support for Medical Residents in Difficulty.
Competency-based medical education is now established in health professions training. However, critics stress that there is a lack of published outcomes for competency-based medical education or competency-based assessment tools. ⋯ The CBAS approach to assessment appeared to be associated with better identification of residents in difficulty, facilitating the program's ability to address learners' deficiencies in competence. After implementation of CBAS, residents experiencing challenges were better supported and their deficiencies did not recur on later rotations. A key argument for shifting to competency-based medical education is to change assessment approaches; these findings suggest that competency-based assessment may be useful.