The American journal of medicine
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we examined the diagnostic performance of high sensitivity cardiac troponin T (cTnThs) measurement and its ability to predict risk in unselected patients presenting to the emergency department with acute chest pain. ⋯ the introduction of cTnThs assay displays an excellent diagnostic performance for the workup of patients with chest pain at the time of their initial presentation. Even small increases of cTnThs indicate increased risk for death or myocardial infarction during follow-up.
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years may elapse between the publication of results of rigorous randomized trials and changes in clinical practice. It is not often that a definitive time interval can be identified that shows the time taken for published clinical trials to affect clinical practice. In the present study, we track the timelines of evidence for home treatment of deep venous thrombosis and its eventual impact on hospitalizations and early discharge. ⋯ whether the slow implementation of home treatment reflects a cautious approach accompanied by a gradual testing of shortened hospitalization for deep venous thrombosis or other factors is uncertain.
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conflicting evidence regarding the association of vancomycin serum concentrations with efficacy and toxicity has resulted in controversy regarding optimal target concentrations. Recent publications recommend attaining higher vancomycin trough concentrations of 15 to 20 mg/L for target infections, yet limited research is available assessing the correlation of vancomycin serum concentrations with toxicity. The aim of this study was to evaluate the association between vancomycin serum trough concentrations and nephrotoxicity. ⋯ a higher vancomycin serum trough concentration and prolonged vancomycin therapy are associated with an increased risk of nephrotoxicity. The decision to target increased vancomycin trough concentrations should be based on an assessment of the severity of the infection and must consider the nephrotoxicity risk associated with increased vancomycin levels.
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Comparative effectiveness research (CER) holds the promise of improving patient-centered care and increasing value in the healthcare system. Achieving these goals, however, depends on effectively implementing the findings of CER. In this article, we draw on lessons from implementation research and our experience in the Veterans Administration (VA) healthcare system to offer recommendations about what is needed to support implementation of CER. ⋯ Implementation efforts must take into account the nature of the evidence, the type of change being implemented, the clinical context in which the findings are being applied, and the specific barriers and facilitators to implementing new practices. The experience of the VA illustrates the importance of taking a systems approach that aligns numerous elements of the healthcare system--guidelines, decision support, performance measures, financial incentives, coverage and benefits policy, and health information technology--to support implementation:. We illustrate these principles with an example of implementing a new model of evidence-based depression care.