Experimental and clinical studies have shown the beneficial effects of triiodothyronine (T3) following myocardial revascularization on cardiopulmonary bypass (CPB). In this study, open-label T3 was administered to 68 high-risk patients undergoing open heart surgery. The New Jersey Risk Assessment was used to calculate the preoperative estimated surgical mortality. A loading dose of T3 was administered: (a) at release of the aortic cross-clamp, (b) whenever the patient became CPB dependent, (c) if the patient exhibited low cardiac output after discontinuing CPB and (d) as pretreatment before initiating CPB. All therapeutic modalities were followed by a continuous T3 infusion. Following T3 therapy, CPB was discontinued in all patients. Based upon discriminant analysis, a total of 26 deaths were expected from the entire group, but only 7 patients died, therefore, the observed mortality was reduced by 72% (p < 0.007). The use of T3 had a major impact on reducing surgical mortality, and may be advocated as a new therapeutic modality in patients with high estimated mortality undergoing open heart surgery.
A data warehouse was used to monitor therapeutic outcomes for a simvastatin tablet-splitting initiative. The data included prescription and laboratory information for all patients taking simvastatin between October 1, 1998 and February 28, 2003. Among 44,038 patients receiving simvastatin, the low-density lipoprotein (LDL) levels of 194,213 patients were reported. The tablet-splitting initiative was started in April 1999 and 5,683 patients were converted from whole to half tablets. The average LDL for these patients decreased by 15 mg/dL. A subset of patients (464 or 8.1%) had an increase in LDL greater than 10% and were above levels established in therapeutic guidelines. Based on the findings, concern about tablet splitting is most warranted during the initial period, when patients are switched from whole to split tablets. The economic benefit was more than $300,000 per year at our facility. Simvastatin tablet splitting appears to be an effective cost savings measure with little associated risk.
We trace the transformation in the behavior of our resident physicians from frequent hostility toward the computer (when first introduced to clinical computing by physician order entry) to their current facility and eagerness in using it, which were recently heightened even further by 1) Web page techniques for the easy and quick implementation of evidence-based clinical practice guidelines and 2) rapid online access to full-text articles from current key medical journals at the point of patient care. This striking transformation was fostered by our recurrent customization of the computer-human interface in response to clinical needs and to continuous feedback from the physician users.
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