A summary of the "must-read" articles from the journals in that pile on your desk.
MRSA Review Warns of Potentially Explosive Outbreak
Surveillance, rapid screening, hygiene key to containment
Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) strains that are sufficient to maintain endemic levels in the community "could potentially become explosive," according to a review in the Sept. 2 issue of The Lancet.
In their review, Hajo Grundmann, M.D., of the National Institute for Public Health and the Environment in Bilthoven, the Netherlands, and colleagues outline the origin and future impact of MRSA.
The authors state that S. aureus gains resistance to multiple antibiotics through two main mechanisms: mutations in an existing gene and horizontal transfer of a mobile genetic element. Methicillin-resistance remains the most clinically important resistant trait since a single mutation confers resistance to most commonly prescribed antimicrobials. Recent work suggests that clones are becoming fitter through genomic variation.
"The onus is therefore on health-care authorities to develop not only surveillance systems that are able to monitor the clonal dynamics of MRSA over wide geographical areas, but also to provide the resources for early recognition of MRSA carriers through rapid screening," the authors write. "Hospital staff have a responsibility to implement, maintain, and adhere to strict contact precautions, should hospitals remain places where citizens can aspire to positive health-care outcomes with confidence.
Sudden Cardiac Death Usually Occurs at Home
Arrest often occurs in the presence of witnesses in patients with a known cardiac disease
Sudden cardiac death usually occurs at home and in the presence of witnesses, with most patients having a known cardiac disease or symptoms of coronary heart disease, according to a study published online Sept. 4 in Circulation: Journal of the American Heart Association.
Dirk Muller, M.D., Ph.D., and colleagues from Universitatsmedizin Berlin in Germany, examined 406 cases of out-of-hospital sudden cardiac death. This was defined as an arrest occurring within 24 hours after the onset of symptoms of cardiac origin and was determined through interviews with bystanders and witnesses, which were conducted by the emergency physician.
The team found that 66 percent of patients had a known cardiac disease. The arrest occurred at home in 72 percent of cases and was witnessed in 67 percent of cases. In 80 percent of all cases, there was information available about symptoms prior to the arrest. The symptoms were identical in these cases and in the witnessed arrests, with angina pectoris for a median of 120 minutes being most common (25 percent of witnessed arrests).
"Sudden cardiac death occurs most often at home in the presence of relatives and after a longer period of typical warning symptoms," Muller and colleagues conclude. "Although the much-hailed use of public access defibrillation is supported by several studies, the present results raise the question of whether educational measures and targeted educational programs tailored for patients at risk and their relatives should have a higher priority."
Doctors Get Poor Grades in Self-Assessment
External observations better measures of physicians' competence
Physicians are limited in their ability to accurately self-assess their own learning needs and to choose educational activities to meet those needs, according to a study in the Sept. 6 issue of the Journal of the American Medical Association.
David A. Davis, M.D., of the University of Toronto in Ontario, Canada, and colleagues examined 17 studies that compared physicians' self-reports on their need for continuing medical education with external observations.
Of 20 comparisons made between self-assessment and external observations, 13 had little, no, or an inverse relationship, while seven had positive associations. Several studies found that the worst self-assessment accuracy came from the least-skilled physicians and from those who expressed the most confidence. These findings, the authors note, are consistent with those seen in other professions.
Even though evidence is "suboptimal in quality," the preponderance of evidence suggests physicians do poorly in self-assessment and that "new initiatives and formats are needed to assist the self-assessment process and to more accurately promote and assess broader domains of competence such as professionalism and lifelong learning," the authors state. "Ultimately, a more useful approach may be to focus on externally determined self-assessments to guide the clinician in the use of educational and other activities designed to improve performance."
Residents' Errors Cause Them Significant Distress
Perceived medical errors and resultant distress may be reciprocal
Self-perceived medical errors are common among internal medicine residents, can cause them significant personal distress and decreased empathy, and can lead to more self-perceived errors and distress in the future, according to a report in the Sept. 6 issue of the Journal of the American Medical Association.
Colin P. West, M.D., Ph.D., of the Mayo Clinic College of Medicine in Rochester, Minn., and colleagues analyzed survey data provided by 184 residents who began their training during the 2003 through 2006 academic years. The residents completed quarterly self-assessments of their perceived medical errors and linear analog scale quality-of-life assessments. Twice a year, they completed the Maslach Burnout Inventory, Interpersonal Reactivity Index and a validated depression tool.
During the overall study period, 34 percent of residents reported at least one major medical error, while during each quarter, a mean of 14.7 percent reported making an error. These errors were significantly associated with a subsequent decrease in quality of life and significantly worse measures in all areas of burnout (depersonalization, emotional exhaustion and personal accomplishment). Those reporting such errors were also 3.29 times more likely to test positive for depression and those with increased burnout and reduced empathy had an increased odds of a self-perceived error in the following three months.
"Formal programs to provide additional support for physicians who make errors appear warranted," the authors write.
Medical School Enrollment Efforts Boost Minority Students
Nearly 70 percent of postbaccalaureate program participants in medical school by 2005
The University of California's efforts to boost medical school enrollment of minority and disadvantaged students by using postbaccalaureate premedical programs is increasing participation by these groups, researchers report in the Sept. 6 issue of the Journal of the American Medical Association.
Kevin Grumbach, M.D., of the University of California San Francisco, and a colleague compared 265 participants in five postbaccalaureate programs from 1999 through 2002 with 396 college graduates who did not enroll. Sixty-six percent of participants were from minority groups.
The researchers found 67.6 percent of participants and 22.5 percent of controls were in medical school by 2005. Students taking postgraduate courses had a 6.3 times greater chance of enrolling than students who did not. "Postbaccalaureate premedical programs appear to be an effective intervention to increase the number of medical school matriculants from disadvantaged and underrepresented groups," the authors write.
In an editorial, Jordan J. Cohen, M.D., of the Association of American Medical Colleges in Washington, D.C., and a colleague write that these "findings are timely, because the medical profession in the United States is in great need of documented ways to achieve substantially more racial and ethnic diversity."
Long Work Hours Linked to Injuries in Residents
More than 80 percent in violation of ACGME work-hour limits a year after implementation
Medical residents continue to work long hours in the clinic and the practice often results in serious mistakes that affect both resident and patient health, according to two reports the Sept. 6 issue of the Journal of the American Medical Association.
In a study of 2,737 residents in programs during 2002 and 2003, Charles A. Czeisler, Ph.D., M.D., of Brigham and Women's Hospital, Harvard Medical School in Boston, and colleagues found that longer hours and night-shift work increased the risk for percutaneous injuries during their first year of clinical training. Injuries occurred more often when residents worked extended shifts -- day to overnight -- and nearly doubled during night work compared with day work.
In a second study by Czeisler and colleagues, residents reported little change in their work schedules a year after work-hour limits imposed by the Accreditation Council for Graduate Medical Education (ACGME) went into effect in 2003. The investigators found that 83.6 percent of 1,278 residents surveyed reported work hours in violation of ACGME limits, including working longer than 30 hours in one shift and over 80 hours a week.
Work hour limits are just one variable in a complex system controlling resident training and quality patient care, adds ACGME member Ingrid Philibert, M.H.A., M.B.A. in an accompanying editorial. "High-quality learning is impossible in the absence of high-quality patient care; likewise, high-quality patient care is impossible without high-quality learning. Attention to both is needed."
Oncogene-Induced Cell Senescence Key to Cancer
Research into phenomenon could lead to better understanding of tumor growth
Understanding the mechanism of oncogene-induced cell senescence could provide vital insight into cancer risk, kinetics and treatment, according to an article published in the Sept. 7 issue of the New England Journal of Medicine.
Wolter J. Mooi, M.D., of the Vrije University Medical Center in Amsterdam, the Netherlands, and a colleague write that several factors could explain why small neoplastic lesions fail to grow into overt cancers, such as the rarity of multiple oncogenic mutations and the absence of the ability to produce vascular stroma.
"Moreover, apoptotic cell death may be triggered by oncogene-driven cellular proliferation, either directly, or by means of the activation of nearby natural killer cells and other immune cells," they write. Susceptibility to cancer is likely caused by faults in the anti-proliferation mechanism that usually blocks the growth of early neoplastic cells. This phenomenon has been noted even in malignant tumors, in which many cells fail to multiply.
"Investigations of the effects of oncogene-driven mitogenic signaling may have diagnostic and prognostic applications, may lead to a better understanding of the mechanisms halting neoplastic growth, and may identify targets for new strategies of cancer prevention and treatment," the authors write.
Tumor Protein Affects Cisplatin Outcome in Lung Cancer
Patients with completely resected non-small-cell lung cancer who are negative for ERCC1 get better results
Patients with completely resected non-small-cell lung cancer who have tumors that do not express the excision repair cross-complementation group 1 (ERCC1) protein have better outcomes from treatment with cisplatin-based adjuvant chemotherapy than those with ERCC1-positive tumors, according to a report published in the Sept. 7 issue of the New England Journal of Medicine.
Jean-Charles Soria, M.D., Ph.D., of the Institut Gustave Roussy in Villejuif, France, and colleagues analyzed 761 tumors, and found ERCC1 expression in 335 tumors (44 percent) and no expression in the remainder.
In patients with ERCC1-negative tumors, cisplatin-based adjuvant therapy decreased death by 35 percent compared with expected observations, while having no impact on those with ERCC1-positive tumors. Among those who did not receive any adjuvant therapy, patients with ERCC1-positive tumors survived 34 percent longer than their ERCC1-negative counterparts.
"Our results suggest that determination of ERCC1 expression in non-small-cell lung cancer cells before chemotherapy can make a contribution as an independent predictor of the effect of adjuvant therapy," the authors conclude. "Since the type of immunohistochemical analysis we used can be applied in almost every pathology laboratory, our findings could be widely applicable if confirmed by independent studies."
Increase in Circulating Endoglin a Marker for Preeclampsia
Combined with other antiangiogenic factors, endoglin strongly predictive for preeclampsia
Circulating levels of soluble endoglin increase in women two to three months prior to the development of preeclampsia and the increase occurs along with alterations in soluble antiangiogenic proteins and growth factor ratios, according to a report in the Sept. 7 issue of the New England Journal of Medicine.
Richard J. Levine, M.D., of the National Institute of Child Health and Human Development in Bethesda, Md., and colleagues performed a nested case-control study of healthy nulliparous women enrolled in the Calcium for Preeclampsia Prevention trial. The study included 72 women with preterm preeclampsia and 480 other women (120 with preeclampsia at term, 120 with gestational hypertension, 120 normotensive women who delivered small-for-gestational-age infants, and 120 normotensive controls who delivered infants not small for their gestational age).
The authors report that circulating soluble endoglin increased markedly starting two to three months before preeclampsia; after disease onset, a difference was seen in the mean serum levels between women with preterm preeclampsia (46.4 ng/mL) compared with controls (9.8 ng/mL). The mean serum level in women with preeclampsia was 31.0 ng/mL compared with 13.3 ng/mL in controls. An increased ratio of soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor usually accompanied increased levels of endoglin.
"Taken together with experimental evidence in rodents, these data suggest that circulating soluble endoglin and sFlt1, each of which causes endothelial dysfunction by a different mechanism, may both contribute to the syndrome of preeclampsia. Prospective longitudinal studies are needed to assess whether these biomarkers can predict the imminent onset of clinical disease," the authors conclude.
Social Phobia Common But Under-Recognized
Patients may respond to cognitive-behavioral therapy or pharmacotherapy
Social anxiety disorder is a common psychiatric condition with a lifetime prevalence of 12 percent, but many people don't get the treatment because clinicians simply don't recognize it, a New York physician reports in the Sept. 7 issue of the New England Journal of Medicine.
Franklin R. Schneier, M.D., of the Anxiety Disorders Clinic, New York State Psychiatric Institute in New York City, reviewed social anxiety disorder treatment strategies including cognitive-behavioral therapy and pharmacotherapy. The disorder is diagnosed on clinical presentation including marked persistent fear of one or more social or performance situations with exposure to unfamiliar people or possible scrutiny; the recognition that the fear is excessive or unreasonable; the fear interferes with normal routines; and the social fear is unrelated to an existing general medical condition or another mental disorder.
Cognitive-behavioral therapy addresses the cycle of anticipatory negative thoughts and maladaptive behavior and negative self-appraisals that increase avoidance behavior, Schneier writes. Cognitive restructuring techniques identify and question maladaptive thoughts, then provide alternatives. Therapeutic exposure eases the patient into feared situations while the patient simultaneously uses cognitive strategies to manage anxiety.
For most patients, cognitive-behavioral therapy is appropriate initially, given the data supporting its potential long-term benefit. "Selective serotonin-reuptake inhibitors or venlafaxine are alternative first-line treatments for patients who prefer medication, have prominent coexisting depression, or lack access to a trained therapist," Schneier writes. "Patients should be encouraged to try to increase their social activities gradually, and they may benefit from adjunctive use of self-help literature oriented toward a cognitive-behavioral approach," he concludes.
Prepared jointly by the editors of Medical Economics and HealthDay's Physicians Briefing (www.physiciansbriefing.com).