Effectiveness of thrombophilia testing: testing to a fault?

Introduction. Thrombophilias can occur from a variety of inherited and acquired abnormalities. Patients with these abnormalities of the coagulation pathway often have a higher propensity to develop venous thromboemboli (VTE), although the risk for developing a VTE is not dependent on the existence of an acquired or genetic abnormality. The question then remains, in the event of a VTE, when is testing indicated for a potential thrombophilic pre-disposition? The standard reasons to consider testing are to: a) Look for an underlying cause of an unprovoked VTE; b) Assess the probability of a repeat event thereby guiding duration of anticoagulation therapy; and c) Identify asymptomatic family members with an underlying predisposition to thrombophilia who might benefit from thromboprophylaxis or genetic counseling. In an effort to improve testing efficiency, the hypercoagulable panel order set (HCPAN), a set of 8 tests indicated for inherited thrombophilia, was instituted at the University of New Mexico at the outset of induction of the electronic medical record. However, we hypothesize that the HCPAN is being utilized outside of guideline-directed diagnostic utility. Methods: A list of 600 HCPAN tests from October 2012 to November 2013 was generated from the TriCore historical database. This included all adult inpatient and outpatient instances. The investigators conducted manual chart review of each patient, evaluating risk factors for VTE, the rationale for ordering the HCPAN, and the level and service of the ordering provider. The protocol was approved by the Institutional Review Board for the UNM School of Medicine. Results: Preliminary data indicate minimal correlation with ordering the test and the status of the thrombophilic event. Out of the 50 patients that were analyzed, 42% of the charts surveyed ordered the HCPAN for a VTE that was clearly provoked, despite guidelines indicating the test for unprovoked cases only. It is well known that various tests for thrombophilia are invalidated when a patient is on anticoagulation, (e.g. unfractionated Heparin); however, of patients reviewed, 71% of the panels were drawn while on one or more of these agents were present. Furthermore, 62% of HCPAN tests were ordered in the presence of an active thrombus, invalidating the results of the test. Conclusion: The data indicates that the majority of HCPAN tests are being ordered outside of recommended guidelines, either because they are being ordered for a provoked clot, in the presence of anticoagulant, or in the presence of an active clot. Furthermore, our preliminary results also indicate that the HCPAN at UNM Hospital encompasses a variety of tests which appear to have been ordered in their entirety when only a small number of tests were indicated, and that the reason for this testing was often not documented in the chart. This, along with the evidence that the majority of testing is not in accordance with current guidelines, establishes that hypercoagulability testing is an area which may benefit from a quality improvement intervention

Assessing Communities of Practice in health policy : A conceptual framework as a first step towards empirical research

Peer reviewe

Uterine Torsion Dystocia Complicated by Perosomus Elumbis in an Angus Calf Associated with a Consanguineous Mating

A six-year-old multiparous Angus cow was presented for dystocia. Vaginal and rectal examinations revealed an approximately 360° counterclockwise uterine torsion. The torsion was corrected by rolling the cow counterclockwise (three episodes) with the aid of a plank coupled with manual detorsion via the vagina. The placement of obstetric chains followed by manual traction ultimately delivered a stillborn male calf with evidence of vertebral aplasia, arthrogryposis, and abdominal organ herniation. Patient history and subsequent parentage verification revealed that the calf was the result of a consanguineous (mother to son) mating. Tissue samples from the affected calf and blood samples from the dam, sire, and ten half siblings were collected for genetic testing and parentage verification. Necropsy, radiographic, and computed tomography examinations all supported a diagnosis of perosomus elumbis. Perosomus elumbis is a congenital abnormality of unknown origin(s), and this is the first report of a case associated with a consanguineous mating

Limits and barriers to adaptation to climate variability and change in Bangladeshi coastal fishing communities

Limits and barriers to adaptation restrict people’s ability to address the negative impacts of climate change or manage risks in a way that maximises their wellbeing. There is a lack of evidence of this on small-scale fishing communities in developing countries. This study identifies and characterises limits and barriers to adaptation of fishing activities to cyclones and examines interactions between them in two fishing communities in Bangladesh, using household questionnaires, oral history interviews, vulnerability matrices and focus group discussions. The limits include physical characteristics of climate and sea like higher frequency and duration of cyclones, and hidden sandbars. Barriers include technologically poor boats, inaccurate weather forecast, poor radio signal, lack of access to credit, low incomes, underestimation of cyclone occurrence, coercion of fishermen by the boat owners and captains, lack of education, skills and livelihood alternatives, unfavourable credit schemes, lack of enforcement of fishing regulations and maritime laws, and lack of access to fish markets. These local and wider scale factors interact in complex ways and constrain completion of fishing trips, coping with cyclones at sea, safe return of boats from sea, timely responses to cyclones and livelihood diversification. The findings indicate a need for further detailed research into the determinants and implications of such limits and barriers, in order to move towards an improved characterisation of adaptation and to identify most suitable means to overcome the limits and barriers

Understanding Gender Inequality in Poverty and Social Exclusion through a Psychological Lens:Scarcities, Stereotypes and Suggestions

Poverty and social exclusion are a gendered phenomenon. They are rooted deeply in the stereotypes, biases, prejudices, and discriminations against women, especially those suffering from poor living conditions. Unfortunately, gender inequality is manifested in most, if not all, major life domains. It is therefore important to understand the gender aspect of poverty and social exclusion through a psychological lens. We begin this chapter by introducing the concepts of multi-dimensional poverty and social exclusion with a sketch of the gender disparities displayed in these areas. We turn next to several mainstream psychological theories which have attempted to investigate and interpret the relationship between poverty and gender inequality from the dispositional, motivational, cognitive, and behavioural perspectives. Finally, we evaluate the reliability, objectivity, and generalisability of the reviewed theories and studies and offer suggestions for future research.</p