Health Changes in Fishermen 2 Years After Clean-up of the Prestige Oil Spill.

Ann Intern Med. 2010 Aug 23;

Authors: Rodríguez-Trigo G, Zock JP, Pozo-Rodríguez F, Gómez FP, Monyarch G, Bouso L, Coll MD, Verea H, Antó JM, Fuster C, Barberà JA,

Background: In 2002, the oil tanker Prestige spilled more than 67 000 tons of bunker oil, heavily contaminating the coast of northwestern Spain. Objective: To assess respiratory effects and chromosomal damage in clean-up workers of the oil spill 2 years after the exposure. Design: Cross-sectional study. Setting: Fishermen cooperatives in coastal villages. Participants: Local fishermen who were highly exposed (n = 501) or not exposed (n = 177) to oil 2 years after the spill. Measurements: Respiratory symptoms; forced spirometry; methacholine challenge; markers of oxidative stress (8-isoprostane), airway inflammation (interleukins, tumor necrosis factor-alpha, and interferon-gamma), and growth factor activity in exhaled breath condensate; and chromosomal lesions and structural alterations in circulating lymphocytes. Results: Compared with nonexposed participants, persons exposed to oil were at increased risk for lower respiratory tract symptoms (risk difference, 8.0 [95% CI, 1.1 to 14.8]). Lung function did not significantly differ between the groups. Among nonsmoking participants, exposed individuals had higher exhaled 8-isoprostane levels than nonexposed individuals (geometric mean ratio, 2.5 [CI, 1.7 to 3.7]), and exposed individuals with lower respiratory tract symptoms had higher 8-isoprostane levels than exposed individuals without symptoms. Exposed nonsmoking participants also had higher levels of exhaled vascular endothelial growth factor (risk difference, 44.8 [CI, 27.9 to 61.6]) and basic fibroblast growth factor (risk difference, 16.0 [CI, 3.5 to 28.6]). A higher proportion of exposed participants had structural chromosomal alterations (risk difference, 27.4 [CI, 10.0 to 44.8]), predominantly unbalanced alterations. The risk for elevated levels of exhaled 8-isoprostane, vascular endothelial growth factor, basic fibroblast growth factor and structural chromosomal alterations seemed to increase with intensity of exposure to clean-up work. Limitations: The clinical significance of exhaled biomarkers and chromosomal findings are uncertain. The association between oil exposure and the observed changes may not be causal. The findings may not apply to spills involving other types of oil or to different populations of oil spill workers. Conclusion: Participation in clean-up of a major oil spill was associated with persistent respiratory symptoms, elevated markers of airway injury in breath condensate, and chromosomal damage. Primary Funding Source: Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation.

PMID: 20733177 [PubMed - as supplied by publisher]

The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges.

Ann Intern Med. 2010 Aug 23;

Authors: Kocher R, Emanuel EJ, Deparle NA

Reader Survey: Which objectives will the Affordable Care Act succeed in achieving? The Affordable Care Act is a once-in-a-generation change to the U.S. health system. It guarantees access to health care for all Americans, creates new incentives to change clinical practice to foster better coordination and quality, gives physicians more information to make them better clinicians and patients more information to make them more value-conscious consumers, and changes the payment system to reward value. The Act and the health information technology provisions in the American Recovery and Reinvestment Act removes many barriers to delivering high-quality care, such as unnecessary administrative complexity, inaccessible clinical data, and insufficient access to primary care and allied health providers. To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change. The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups. The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience.

PMID: 20733178 [PubMed - as supplied by publisher]

Health Effects in Fisherman 2 Years After Assisting With Oil Spill Clean-up.

Ann Intern Med. 2010 Aug 23;

Authors:

PMID: 20733180 [PubMed - as supplied by publisher]

Lessons for Study of the Health Effects of Oil Spills.

Ann Intern Med. 2010 Aug 23;

Authors: Savitz DA, Engel LS

PMID: 20733179 [PubMed - as supplied by publisher]

The Vulnerable Atherosclerotic Plaque: Scope of the Literature.

Ann Intern Med. 2010 Aug 16;

Authors: Alsheikh-Ali AA, Kitsios GD, Balk EM, Lau J, Ip S

The scope of recent literature on the concept of "vulnerable plaque" was reviewed by examining 463 abstracts of primary and review articles identified through MEDLINE (2003 to April 2010). Proposed definition criteria of vulnerable plaque included active inflammation, a thin cap with a large lipid core, endothelial denudation, fissured cap, severe stenosis, or combinations of these findings. In 242 primary studies, histopathology, biomarkers and imaging of carotid and coronary artery plaques were evaluated for features suggestive of vulnerability. Notably, 89% of these studies were cross-sectional in design and exclusively conducted in patients with known cardiovascular disease. None of the imaging studies documented whether the identified lesions were responsible for cardiovascular events. Cross-sectional design precludes evaluation of the predictive utility of biomarkers. Because vulnerable plaque is not an established medical diagnosis, no studies have been done that explicitly evaluate the treatment of vulnerable plaques per se. Few studies examined potential systemic treatments (for example, statins) to modify vulnerability features. Large prospective studies in patients with and without previous cardiovascular events during long follow-up are required to validate this concept.

PMID: 20713770 [PubMed - as supplied by publisher]

Does admitting mistakes to patients lead to more lawsuits?

Ann Intern Med. 2010 Aug 17;153(4):I28

Authors:

PMID: 20713776 [PubMed - in process]

Dexamethasone did not reduce mortality or neurologic sequelae in bacterial meningitis.

Ann Intern Med. 2010 Aug 17;153(4):JC210

Authors:

PMID: 20713777 [PubMed - in process]

HbA1c levels <= 5.5% ruled out, and levels >= 7.0% ruled in, type 2 diabetes in clinical and community populations.

Ann Intern Med. 2010 Aug 17;153(4):JC211

Authors:

PMID: 20713778 [PubMed - in process]

Review: Clinical pathways reduce in-hospital complications but not in-hospital mortality or readmissions.

Ann Intern Med. 2010 Aug 17;153(4):JC212

Authors:

PMID: 20713779 [PubMed - in process]

Review: Some instruments predict development of persistent, disabling low back pain.

Ann Intern Med. 2010 Aug 17;153(4):JC213

Authors:

PMID: 20713780 [PubMed - in process]

Review: Joint lavage does not reduce pain or improve function in knee osteoarthritis.

Ann Intern Med. 2010 Aug 17;153(4):JC22

Authors:

PMID: 20713781 [PubMed - in process]

Review: Therapy guided by B-type natriuretic peptide levels reduces mortality in chronic heart failure.

Ann Intern Med. 2010 Aug 17;153(4):JC23

Authors:

PMID: 20713782 [PubMed - in process]

Lenient rate control is as effective as strict rate control for preventing cardiovascular events in AF.

Ann Intern Med. 2010 Aug 17;153(4):JC24

Authors:

PMID: 20713783 [PubMed - in process]

Low-dose computed tomography was associated with higher risk for false-positive lung cancer screening than chest radiography.

Ann Intern Med. 2010 Aug 17;153(4):JC25

Authors:

PMID: 20713784 [PubMed - in process]

Amylmetacresol and 2, 4-dichlorobenzyl alcohol lozenges were better than placebo lozenges for relief of acute sore throat.

Ann Intern Med. 2010 Aug 17;153(4):JC26

Authors:

PMID: 20713785 [PubMed - in process]

Telaprevir combination therapy induced a sustained virologic response in nonresponsive chronic HCV infection.

Ann Intern Med. 2010 Aug 17;153(4):JC27

Authors:

PMID: 20713786 [PubMed - in process]

Rifaximin maintained remission from hepatic encephalopathy longer than placebo in patients with cirrhosis.

Ann Intern Med. 2010 Aug 17;153(4):JC28

Authors:

PMID: 20713787 [PubMed - in process]

Early tracheotomy did not reduce ventilator-associated pneumonia in adults ventilated for acute respiratory failure.

Ann Intern Med. 2010 Aug 17;153(4):JC29

Authors:

PMID: 20713788 [PubMed - in process]

Liability claims and costs before and after implementation of a medical error disclosure program.

Ann Intern Med. 2010 Aug 17;153(4):213-21

Authors: Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, Rogers MA

Background: Since 2001, the University of Michigan Health System (UMHS) has fully disclosed and offered compensation to patients for medical errors. Objective: To compare liability claims and costs before and after implementation of the UMHS disclosure-with-offer program. Design: Retrospective before-after analysis from 1995 to 2007. Setting: Public academic medical center and health system. Patients: Inpatients and outpatients involved in claims made to UMHS. Measurements: Number of new claims for compensation, number of claims compensated, time to claim resolution, and claims-related costs. Results: After full implementation of a disclosure-with-offer program, the average monthly rate of new claims decreased from 7.03 to 4.52 per 100 000 patient encounters (rate ratio [RR], 0.64 [95% CI, 0.44 to 0.95]). The average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100 000 patient encounters (RR, 0.35 [CI, 0.22 to 0.58]). Median time from claim reporting to resolution decreased from 1.36 to 0.95 years. Average monthly cost rates decreased for total liability (RR, 0.41 [CI, 0.26 to 0.66]), patient compensation (RR, 0.41 [CI, 0.26 to 0.67]), and non-compensation-related legal costs (RR, 0.39 [CI, 0.22 to 0.67]). Limitations: The study design cannot establish causality. Malpractice claims generally declined in Michigan during the latter part of the study period. The findings might not apply to other health systems, given that UMHS has a closed staff model covered by a captive insurance company and often assumes legal responsibility. Conclusion: The UMHS implemented a program of full disclosure of medical errors with offers of compensation without increasing its total claims and liability costs. Primary Funding Source: Blue Cross Blue Shield of Michigan Foundation.

PMID: 20713789 [PubMed - in process]

Steroid pretreatment of organ donors to prevent postischemic renal allograft failure: a randomized, controlled trial.

Ann Intern Med. 2010 Aug 17;153(4):222-30

Authors: Kainz A, Wilflingseder J, Mitterbauer C, Haller M, Burghuber C, Perco P, Langer RM, Heinze G, Oberbauer R

Background: Posttransplantation acute renal failure (ARF) occurs in roughly 25% of recipients of organs from deceased donors. Inflammation in the donor organ is associated with risk for ARF. Objective: To determine whether administering corticosteroids to deceased organ donors reduces the incidence and duration of ARF in organ recipients more than placebo. Design: Parallel, blocked randomized trial, performed between February 2006 and November 2008, with computer-generated randomization and centralized allocation. Investigators were masked to group assignment. (Controlled-trials.com registration number: ISRCTN78828338) Setting: 3 renal transplantation centers in Austria and Hungary. Patients: 306 deceased heart-beating donors and 455 renal transplant recipients. Interventions: Organ donors were administered an intravenous infusion of either 1000 mg of methylprednisolone (136 donors) or placebo (0.9% saline) (133 donors) at least 3 hours before organ harvesting. Measurements: Incidence of ARF, defined as more than 1 dialysis session in the first week after transplantation, was the primary end point. Secondary and other end points included duration of ARF and trajectories of serum creatinine level. The suppression of immune response and inflammation by the intervention was assessed in the donor organ on a genome-wide basis. Results: 52 of 238 recipients (22%) of kidneys from steroid-treated donors and 54 of 217 recipients (25%) of kidneys from placebo-treated donors had ARF (difference, 3 percentage points [95% CI, -11 to 5 percentage points]). One graft was lost on day 1 in each group, and 1 recipient in the placebo group died of cardiac arrest on day 2. The median duration of ARF was 5 days (interquartile range, 2 days) in the steroid group and 4 days (interquartile range, 2 days) in the placebo group (P = 0.31). The groups had similar trajectories of serum creatinine level in the first week (P = 0.72). Genomic analysis showed suppressed inflammation and immune response in kidney biopsies from deceased donors who received corticosteroids. Limitation: Donors and recipients were mainly white, and all were from 3 transplantation centers in central Europe, which may limit generalizability. Conclusion: Systemic suppression of inflammation in deceased donors by corticosteroids did not reduce the incidence or duration of posttransplantation ARF in allograft recipients. Primary Funding Source: Austrian Science Fund and Austrian Academy of Science.

PMID: 20713790 [PubMed - in process]

Quality of care in patients with chronic hepatitis C virus infection: a cohort study.

Ann Intern Med. 2010 Aug 17;153(4):231-9

Authors: Kanwal F, Schnitzler MS, Bacon BR, Hoang T, Buchanan PM, Asch SM

Background: Medicare has proposed quality-of-care indicators for chronic hepatitis C virus (HCV) infection. The extent to which these standards are met in practice is largely unknown. Objective: To evaluate the quality of health care that patients with HCV receive and the factors associated with receipt of quality care. Design: Retrospective cohort study. Setting: Nationwide U.S. health insurance company research database. Participants: 10 385 patients with HCV enrolled in the database between 2003 and 2006. Patients were included if they were eligible for at least 1 quality indicator. Measurements: Quality of HCV care received by patients, as measured by 7 explicit quality indicators included in Medicare's 2009 Physician Quality Reporting Initiative. Results: Proportions of patients meeting quality indicators varied, ranging from 21.5% for vaccination to 79% for the HCV genotype testing indicator. Overall, 18.5% of patients (95% CI, 18% to 19%) received all recommended care. Older age and presence of comorbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. Patients who saw both generalists and specialists received the best care (odds ratio of receiving care for which a patient is eligible: specialists alone, 0.79 [CI, 0.66 to 0.95]; primary care physician alone, 0.44 [CI, 0.40 to 0.48]). Limitations: The study had an observational retrospective design, used a convenience sample, and had no information on patient ethnicity. It may be that the indicators or the reporting of the indicators of HCV care-and not the care itself-is suboptimum. Conclusion: Health care quality, based on Medicare criteria, is suboptimum for HCV. Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care. Primary Funding Source: Saint Louis University Liver Center.

PMID: 20713791 [PubMed - in process]

Narrative review: ventilator-induced respiratory muscle weakness.

Ann Intern Med. 2010 Aug 17;153(4):240-5

Authors: Tobin MJ, Laghi F, Jubran A

Clinicians have long been aware that substantial lung injury results when mechanical ventilation imposes too much stress on the pulmonary parenchyma. Evidence is accruing that substantial injury may also result when the ventilator imposes too little stress on the respiratory muscles. Through adjustment of ventilator settings and administration of pharmacotherapy, the respiratory muscles may be rendered almost (or completely) inactive. Research in animals has shown that diaphragmatic inactivity produces severe injury and atrophy of muscle fibers. Human data have recently revealed that 18 to 69 hours of complete diaphragmatic inactivity associated with mechanical ventilation decreased the cross-sectional areas of diaphragmatic fibers by half or more. The atrophic injury seems to result from increased oxidative stress leading to activation of protein-degradation pathways. Scientific understanding of ventilator-induced respiratory muscle injury has not reached the stage where meaningful controlled trials can be done, and thus, it is not possible to give concrete recommendations for patient management. In the meantime, clinicians are advised to select ventilator settings that avoid both excessive patient effort and excessive respiratory muscle rest. The contour of the airway pressure waveform on a ventilator screen provides the most practical indication of patient effort, and clinicians are advised to pay close attention to the waveform as they titrate ventilator settings. Research on ventilator-induced respiratory muscle injury is in its infancy and portends to be an exciting area to follow.

PMID: 20713792 [PubMed - in process]

Redefining the "Planning" in Advance Care Planning: Preparing for End-of-Life Decision Making.

Ann Intern Med. 2010 Aug 17;153(4):256-61

Authors: Sudore RL, Fried TR

The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.

PMID: 20713793 [PubMed - in process]

Patient compensation without litigation: a promising development.

Ann Intern Med. 2010 Aug 17;153(4):266-7

Authors: Localio AR

PMID: 20713794 [PubMed - in process]

My moment.

Ann Intern Med. 2010 Aug 17;153(4):270-1

Authors: Bove RM

PMID: 20713795 [PubMed - in process]

Fresh eyes.

Ann Intern Med. 2010 Aug 17;153(4):272

Authors: Glod SA

PMID: 20713796 [PubMed - in process]

Further perspectives on concierge medicine.

Ann Intern Med. 2010 Aug 17;153(4):274-5

Authors: Harter C

PMID: 20713797 [PubMed - in process]

Further perspectives on concierge medicine.

Ann Intern Med. 2010 Aug 17;153(4):274

Authors: Fields RP

PMID: 20713798 [PubMed - in process]

Further perspectives on concierge medicine.

Ann Intern Med. 2010 Aug 17;153(4):274

Authors: Swerlick RA

PMID: 20713799 [PubMed - in process]

Further perspectives on concierge medicine.

Ann Intern Med. 2010 Aug 17;153(4):275-6

Authors: Zwelling-Aamot M

PMID: 20713800 [PubMed - in process]

Further perspectives on concierge medicine.

Ann Intern Med. 2010 Aug 17;153(4):275

Authors: Walen HM

PMID: 20713801 [PubMed - in process]

Further perspectives on concierge medicine.

Ann Intern Med. 2010 Aug 17;153(4):275

Authors: Bowers J

PMID: 20713802 [PubMed - in process]

Population strategies to decrease sodium intake.

Ann Intern Med. 2010 Aug 17;153(4):276

Authors: Narayan P, Kumar A

PMID: 20713803 [PubMed - in process]

Population strategies to decrease sodium intake.

Ann Intern Med. 2010 Aug 17;153(4):276

Authors: Tapolyai M

PMID: 20713804 [PubMed - in process]

Errors in Meta-analysis Regarding the 3CPO Trial.

Ann Intern Med. 2010 Aug 17;153(4):277-8

Authors: Goodacre SW, Gray A, Newby D

PMID: 20713805 [PubMed - in process]

Population strategies to decrease sodium intake.

Ann Intern Med. 2010 Aug 17;153(4):277

Authors: Smith-Spangler CM, Owens DK, Garber AM

PMID: 20713806 [PubMed - in process]

Delayed complications from exposure to improvised explosive devices.

Ann Intern Med. 2010 Aug 17;153(4):278-9

Authors: Cawley PJ, Mokadam NA

PMID: 20713807 [PubMed - in process]

Errors in Meta-analysis Regarding 3CPO Trial.

Ann Intern Med. 2010 Aug 17;153(4):278

Authors: Zhao YT

PMID: 20713808 [PubMed - in process]

The ice diet.

Ann Intern Med. 2010 Aug 17;153(4):279

Authors: Weiner BC, Weiner AC

PMID: 20713809 [PubMed - in process]

Correction: noninvasive ventilation in acute cardiogenic pulmonary edema.

Ann Intern Med. 2010 Aug 17;153(4):280

Authors:

PMID: 20713810 [PubMed - in process]

Health Care for Prisoners in Haiti.

Ann Intern Med. 2010 Aug 2;

Authors: May JP, Joseph P, Pape JW, Binswanger IA

Prisoners have disproportionate health care needs. Meeting those needs in a prison environment is challenging, especially in resource-poor countries such as Haiti. Even so, prior to the January 2010 earthquake, local and international organizations in collaboration with the Haitian government had been making significant progress to provide for the health needs of prisoners. The effort screened and identified prisoners for infectious disease, initiated appropriate care and treatment, and prepared prisoners for release to the community. Not only is it possible to establish an adequate prison health care program in a resource-poor country, it is necessary. Without adequate management of prisoners' health needs, especially infectious diseases such as HIV and tuberculosis, disease burden increases. Infectious disease can spread among prisoners and impact the public's health. Recovery for post-earthquake Haiti, as any nation rebuilding following natural disaster or conflict, requires respect for rule of law. This includes humane detention, and the delivery of justice and adequate health care for prisoners.

PMID: 20679542 [PubMed - as supplied by publisher]

Narrative Review: Percutaneous Heart Valve Replacement for Aortic Stenosis: State of the Evidence.

Ann Intern Med. 2010 Aug 2;

Authors: Coeytaux RR, Williams JW, Gray RN, Wang A

Surgical aortic valve replacement (SAVR) is the only treatment known to improve symptoms and survival in patients with severe, symptomatic aortic stenosis. Perioperative mortality, however, is high among many patients for whom SAVR may be indicated. Percutaneous heart valve replacement (PHV) is an emerging, catheter-based technology that allows for implantation of a prosthetic valve without open heart surgery. This review describes the available literature on PHV replacement for aortic stenosis, which comprised 84 published reports representing 76 distinct studies and 2375 unique patients. Successful implantation was achieved in 94% of patients; 30-day survival was 89%. Differences between patients undergoing PHV replacement and those typically selected for SAVR make full interpretation of these results difficult. A large, multicenter, randomized, controlled trial comparing PHV to SAVR or medical management has recently been completed, with initial results expected in September 2010. Pending publication of findings from that trial, the available evidence is inadequate to determine the most appropriate clinical role for PHVs or the specific patient populations for whom they might eventually be indicated.

PMID: 20679543 [PubMed - as supplied by publisher]

Comparative Effectiveness Research: A Progress Report.

Ann Intern Med. 2010 Aug 2;

Authors: Sox HC

PMID: 20679544 [PubMed - as supplied by publisher]

Are abnormal lipid levels harmful in young adults?

Ann Intern Med. 2010 Aug 3;153(3):I25

Authors:

PMID: 20679554 [PubMed - in process]

Comparison of weight loss at 2 years on a low-carbohydrate versus low-fat diet.

Ann Intern Med. 2010 Aug 3;153(3):I35

Authors:

PMID: 20679555 [PubMed - in process]

What happens to people who need a breathing machine for more than a few days?

Ann Intern Med. 2010 Aug 3;153(3):I56

Authors:

PMID: 20679556 [PubMed - in process]

Dyslipidemia.

Ann Intern Med. 2010 Aug 3;153(3):ITC21

Authors: Kopin L, Lowenstein C

This issue provides a clinical overview of dyslipidemia focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View." Subscribers can receive 1.5 category 1 CME credits by completing the CME quiz that accompanies this issue of In the Clinic. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

PMID: 20679557 [PubMed - in process]

Nonoptimal Lipids Commonly Present in Young Adults and Coronary Calcium Later in Life: The CARDIA (Coronary Artery Risk Development in Young Adults) Study.

Ann Intern Med. 2010 Aug 3;153(3):137-46

Authors: Pletcher MJ, Bibbins-Domingo K, Liu K, Sidney S, Lin F, Vittinghoff E, Hulley SB

Background: Dyslipidemia causes coronary heart disease in middle-aged and elderly adults, but the consequences of lipid exposure during young adulthood are unclear. Objective: To assess whether nonoptimal lipid levels during young adulthood cause atherosclerotic changes that persist into middle age. Design: Prospective cohort study. Setting: 4 cities in the United States. Participants: 3258 participants from the 5115 black and white men and women recruited at age 18 to 30 years in 1985 to 1986 for the CARDIA (Coronary Artery Risk Development in Young Adults) study. Measurements: Low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglycerides, and coronary calcium. Time-averaged cumulative exposures to lipids between age 20 and 35 years were estimated by using repeated serum lipid measurements over 20 years in the CARDIA study; these measurements were then related to coronary calcium scores assessed later in life (45 years [SD, 4]). Results: 2824 participants (87%) had nonoptimal levels of LDL cholesterol (>/=2.59 mmol/L [>/=100 mg/dL]), HDL cholesterol (<1.55 mmol/L [<60 mg/dL]), or triglycerides (>/=1.70 mmol/L [>/=150 mg/dL]) during young adulthood. Coronary calcium prevalence 2 decades later was 8% in participants who maintained optimal LDL levels (<1.81 mmol/L [<70 mg/dL]), and 44% in participants with LDL cholesterol levels of 4.14 mmol/L (160 mg/dL) or greater (P < 0.001). The association was similar across race and sex and strongly graded, with odds ratios for coronary calcium of 1.5 (95% CI, 0.7 to 3.3) for LDL cholesterol levels of 1.81 to 2.56 mmol/L (70 to 99 mg/dL), 2.4 (CI, 1.1 to 5.3) for levels of 2.59 to 3.34 mmol/L (100 to 129 mg/dL), 3.3 (CI, 1.3 to 7.8) for levels of 3.37 to 4.12 mmol/L (130 to 159 mg/dL), and 5.6 (CI, 2.0 to 16) for levels of 4.14 mmol/L (160 mg/dL) or greater, compared with levels less than 1.81 mmol/L (<70 mg/dL), after adjustment for lipid exposure after age 35 years and other coronary risk factors. Both LDL and HDL cholesterol levels were independently associated with coronary calcium after participants who were receiving lipid-lowering medications or had clinically abnormal lipid levels were excluded. Limitation: Coronary calcium, although a strong predictor of future coronary heart disease, is not a clinical outcome. Conclusion: Nonoptimal levels of LDL and HDL cholesterol during young adulthood are independently associated with coronary atherosclerosis 2 decades later. Primary Funding Source: National Heart, Lung, and Blood Institute.

PMID: 20679558 [PubMed - in process]

Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat diet: a randomized trial.

Ann Intern Med. 2010 Aug 3;153(3):147-57

Authors: Foster GD, Wyatt HR, Hill JO, Makris AP, Rosenbaum DL, Brill C, Stein RI, Mohammed BS, Miller B, Rader DJ, Zemel B, Wadden TA, Tenhave T, Newcomb CW, Klein S

Background: Previous studies comparing low-carbohydrate and low-fat diets have not included a comprehensive behavioral treatment, resulting in suboptimal weight loss. Objective: To evaluate the effects of 2-year treatment with a low-carbohydrate or low-fat diet, each of which was combined with a comprehensive lifestyle modification program. Design: Randomized parallel-group trial. (ClinicalTrials.gov registration number: NCT00143936) Setting: 3 academic medical centers. Patients: 307 participants with a mean age of 45.5 years (SD, 9.7 years) and mean body mass index of 36.1 kg/m(2) (SD, 3.5 kg/m(2)). Intervention: A low-carbohydrate diet, which consisted of limited carbohydrate intake (20 g/d for 3 months) in the form of low-glycemic index vegetables with unrestricted consumption of fat and protein. After 3 months, participants in the low-carbohydrate diet group increased their carbohydrate intake (5 g/d per wk) until a stable and desired weight was achieved. A low-fat diet consisted of limited energy intake (1200 to 1800 kcal/d; </=30% calories from fat). Both diets were combined with comprehensive behavioral treatment. Measurements: Weight at 2 years was the primary outcome. Secondary measures included weight at 3, 6, and 12 months and serum lipid concentrations, blood pressure, urinary ketones, symptoms, bone mineral density, and body composition throughout the study. Results: Weight loss was approximately 11 kg (11%) at 1 year and 7 kg (7%) at 2 years. There were no differences in weight, body composition, or bone mineral density between the groups at any time point. During the first 6 months, the low-carbohydrate diet group had greater reductions in diastolic blood pressure, triglyceride levels, and very-low-density lipoprotein cholesterol levels, lesser reductions in low-density lipoprotein cholesterol levels, and more adverse symptoms than did the low-fat diet group. The low-carbohydrate diet group had greater increases in high-density lipoprotein cholesterol levels at all time points, approximating a 23% increase at 2 years. Limitation: Intensive behavioral treatment was provided, patients with dyslipidemia and diabetes were excluded, and attrition at 2 years was high. Conclusion: Successful weight loss can be achieved with either a low-fat or low-carbohydrate diet when coupled with behavioral treatment. A low-carbohydrate diet is associated with favorable changes in cardiovascular disease risk factors at 2 years. Primary Funding Source: National Institutes of Health.

PMID: 20679559 [PubMed - in process]

Outcome Reporting Among Drug Trials Registered in ClinicalTrials.gov.

Ann Intern Med. 2010 Aug 3;153(3):158-66

Authors: Bourgeois FT, Murthy S, Mandl KD

Background: Clinical trial registries are in widespread use to promote transparency around trials and their results. Objective: To describe characteristics of drug trials listed in ClinicalTrials.gov and examine whether the funding source of these trials is associated with favorable published outcomes. Design: An observational study of safety and efficacy trials for anticholesteremics, antidepressants, antipsychotics, proton-pump inhibitors, and vasodilators conducted between 2000 and 2006. Setting: ClinicalTrials.gov, a Web-based registry of clinical trials launched in 1999. Measurements: Publications resulting from the trials for the 5 drug categories of interest were identified, and data were abstracted on the trial record and publication, including timing of registration, elements of the study design, funding source, publication date, and study outcomes. Assessments were based on the primary funding categories of industry, government agencies, and nonprofit or nonfederal organizations. Results: Among 546 drug trials, 346 (63%) were primarily funded by industry, 74 (14%) by government sources, and 126 (23%) by nonprofit or nonfederal organizations. Trials funded by industry were more likely to be phase 3 or 4 trials (88.7%; P < 0.001 across groups), to use an active comparator in controlled trials (36.8%; P = 0.010 across groups), to be multicenter (89.0%; P < 0.001 across groups), and to enroll more participants (median sample size, 306 participants; P < 0.001 across groups). Overall, 362 (66.3%) trials had published results. Industry-funded trials reported positive outcomes in 85.4% of publications, compared with 50.0% for government-funded trials and 71.9% for nonprofit or nonfederal organization-funded trials (P < 0.001). Trials funded by nonprofit or nonfederal sources with industry contributions were also more likely to report positive outcomes than those without industry funding (85.0% vs. 61.2%; P = 0.013). Rates of trial publication within 24 months of study completion ranged from 32.4% among industry-funded trials to 56.2% among nonprofit or nonfederal organization-funded trials without industry contributions (P = 0.005 across groups). Limitations: The publication status of a trial could not always be confirmed, which could result in misclassification. Additional information on study protocols and comprehensive trial results were not available to further explore underlying factors for the association between funding source and outcome reporting. Conclusion: In this sample of registered drug trials, those funded by industry were less likely to be published within 2 years of study completion and were more likely to report positive outcomes than were trials funded by other sources. Primary Funding Source: National Library of Medicine and National Institute of Child Health and Human Development, National Institutes of Health.

PMID: 20679560 [PubMed - in process]

One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study.

Ann Intern Med. 2010 Aug 3;153(3):167-75

Authors: Unroe M, Kahn JM, Carson SS, Govert JA, Martinu T, Sathy SJ, Clay AS, Chia J, Gray A, Tulsky JA, Cox CE

Background: Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization. Objective: To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation. Design: 1-year prospective cohort study. Setting: 5 intensive care units at Duke University Medical Center, Durham, North Carolina. Participants: 126 patients receiving prolonged mechanical ventilation (defined as ventilation for >/=4 days with tracheostomy placement or ventilation for >/=21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year. Measurements: Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. Physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for postacute care. Results: 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency [4 patients; 21%] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was $306 135 (SD, $285 467), and total cohort cost was $38.1 million, for an estimated $3.5 million per independently functioning survivor at 1 year. Limitation: The results of this single-center study may not be applicable to other centers. Conclusion: Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support. Primary Funding Source: None.

PMID: 20679561 [PubMed - in process]

The Development of Clinical Practice Guidelines and Guidance Statements of the American College of Physicians: Summary of Methods.

Ann Intern Med. 2010 Aug 3;153(3):194-199

Authors: Qaseem A, Snow V, Owens DK, Shekelle P,

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP's Guidelines Committee and the staff of the Clinical Programs and Quality of Care Department develop the clinical recommendations. The ACP develops 2 different types of clinical recommendations: clinical practice guidelines and clinical guidance statements. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading. All ACP clinical practice guidelines and clinical guidance statements, if not updated, are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

PMID: 20679562 [PubMed - as supplied by publisher]

On humility.

Ann Intern Med. 2010 Aug 3;153(3):200-1

Authors: Coulehan J

The new professionalism movement in medical education takes seriously the old medical virtues. Perhaps the most difficult virtue to understand and practice is humility, which seems out of place in a medical culture characterized by arrogance, assertiveness, and a sense of entitlement. Countercultural though it is, humility need not suggest weakness or lack of self-confidence. On the contrary, humility requires toughness and emotional resilience. Humility in medicine manifests itself as unflinching self-awareness; empathic openness to others; and a keen appreciation of, and gratitude for, the privilege of caring for sick persons. Justified pride in medicine's accomplishments should neither rule out nor diminish our humility as healers.

PMID: 20679563 [PubMed - in process]

Cardiovascular risk in young persons: secondary or primordial prevention?

Ann Intern Med. 2010 Aug 3;153(3):202-3

Authors: Berenson GS, Srinivasan SR

PMID: 20679564 [PubMed - in process]

Survivorship will be the defining challenge of critical care in the 21st century.

Ann Intern Med. 2010 Aug 3;153(3):204-5

Authors: Iwashyna TJ

PMID: 20679565 [PubMed - in process]

The scent of cancer.

Ann Intern Med. 2010 Aug 3;153(3):206-7

Authors: Steensma DP

PMID: 20679566 [PubMed - in process]

Does inconclusive evidence for vitamin d supplementation to reduce risk for cardiovascular disease warrant pessimism?

Ann Intern Med. 2010 Aug 3;153(3):208-9

Authors: Heaney RP

PMID: 20679567 [PubMed - in process]

Does inconclusive evidence for vitamin d supplementation to reduce risk for cardiovascular disease warrant pessimism?

Ann Intern Med. 2010 Aug 3;153(3):208

Authors: Plotnikoff GA

PMID: 20679568 [PubMed - in process]

Does inconclusive evidence for vitamin d supplementation to reduce risk for cardiovascular disease warrant pessimism?

Ann Intern Med. 2010 Aug 3;153(3):209-10

Authors: Guallar E, Miller ER, Ordovas JM, Stranges S

PMID: 20679569 [PubMed - in process]

Does inconclusive evidence for vitamin d supplementation to reduce risk for cardiovascular disease warrant pessimism?

Ann Intern Med. 2010 Aug 3;153(3):209

Authors: Grant WB

PMID: 20679570 [PubMed - in process]

Herpes zoster vaccine in nursing facility residents: safety questions remain.

Ann Intern Med. 2010 Aug 3;153(3):210-1

Authors: Nace DA, Drinka PJ, Crnich CJ

PMID: 20679571 [PubMed - in process]

Misleading statement in trial on false-positive results in lung cancer screening.

Ann Intern Med. 2010 Aug 3;153(3):210

Authors: Croswell JM, Kramer BS

PMID: 20679572 [PubMed - in process]

Misleading statement in trial on false-positive results in lung cancer screening.

Ann Intern Med. 2010 Aug 3;153(3):210

Authors: Sokol HN

PMID: 20679573 [PubMed - in process]

Herpes Zoster Vaccine in Nursing Facility Residents: Safety Questions Remain.

Ann Intern Med. 2010 Aug 3;153(3):211-212

Authors: Simberkoff MS, Arbeit RD, Johnson G, Oxman MN,

PMID: 20679574 [PubMed - as supplied by publisher]

Correction: the social mission of medical education.

Ann Intern Med. 2010 Aug 3;153(3):212

Authors:

PMID: 20679575 [PubMed - in process]

An Academic Center's Delivery of Care After the Haitian Earthquake.

Ann Intern Med. 2010 Jul 19;

Authors: Jaffer AK, Campo RE, Gaski G, Reyes M, Gebhard R, Ginzburg E, Kolber MA, Macdonald J, Falcone S, Green BA, Barreras-Pagan L, O'Neill WW

The Miller School of Medicine of the University of Miami and Project Medishare, an affiliated not-for-profit organization, provided a large-scale relief effort in Haiti after the earthquake of 12 January 2010. Their experience demonstrates that academic medical centers in close geographic proximity to natural disasters can help deliver effective medical care through a coordinated process involving mobilization of their own resources, establishment of focused management teams at home and on the ground with formal organizational oversight, and partnership with governmental and nongovernmental relief agencies. Geographic proximity to the disaster area allows for prompt arrival of medical personnel and equipment. The recruitment and organized deployment of large numbers of local and national volunteers are indispensable parts of this effort. Multidisciplinary teams on short rotations can form the core of the medical response.

PMID: 20643974 [PubMed - as supplied by publisher]

End-of-Life Planning Intervention and the Completion of Advance Directives in Homeless Persons.

Ann Intern Med. 2010 Jul 20;153(2):I38

Authors:

PMID: 20643975 [PubMed - in process]

Influenza vaccination of children and adolescents decreased influenza infection in nonvaccinated community members.

Ann Intern Med. 2010 Jul 20;153(2):JC110

Authors:

PMID: 20643976 [PubMed - in process]

Lasofoxifene reduced vertebral fractures in postmenopausal women with osteoporosis.

Ann Intern Med. 2010 Jul 20;153(2):JC111

Authors:

PMID: 20643977 [PubMed - in process]

Magnetic resonance angiography and venography were sensitive but had poor technical adequacy for diagnosing pulmonary embolism.

Ann Intern Med. 2010 Jul 20;153(2):JC112

Authors:

PMID: 20643978 [PubMed - in process]

Higher "normal" glycated hemoglobin levels were associated with increased risk for diabetes, CVD, stroke, and mortality in adults.

Ann Intern Med. 2010 Jul 20;153(2):JC113

Authors:

PMID: 20643979 [PubMed - in process]

Review: Tiotropium does not increase risk for cardiovascular events in chronic obstructive pulmonary disease.

Ann Intern Med. 2010 Jul 20;153(2):JC12

Authors:

PMID: 20643980 [PubMed - in process]

Recent use of ipratropium bromide increased risk for cardiovascular events in chronic obstructive pulmonary disease.

Ann Intern Med. 2010 Jul 20;153(2):JC13

Authors:

PMID: 20643981 [PubMed - in process]

Intensive blood pressure control did not prevent major CV events more than standard control in type 2 diabetes.

Ann Intern Med. 2010 Jul 20;153(2):JC14

Authors:

PMID: 20643982 [PubMed - in process]

Fenofibrate plus simvastatin did not prevent major CV events more than simvastatin alone in type 2 diabetes.

Ann Intern Med. 2010 Jul 20;153(2):JC15

Authors:

PMID: 20643983 [PubMed - in process]

Review: Enteral nutrition reduces mortality, multiple organ failure, and systemic infection more than TPN in acute pancreatitis.

Ann Intern Med. 2010 Jul 20;153(2):JC16

Authors:

PMID: 20643984 [PubMed - in process]

Review: Heparin and mechanical compression are similar in reducing postsurgical VTE risk, but heparin increases bleeding.

Ann Intern Med. 2010 Jul 20;153(2):JC17

Authors:

PMID: 20643985 [PubMed - in process]

Adding NT-proBNP-guided management to multidisciplinary care reduced heart failure rehospitalization days.

Ann Intern Med. 2010 Jul 20;153(2):JC18

Authors:

PMID: 20643986 [PubMed - in process]

Review: Metformin does not increase risk for lactic acidosis in type 2 diabetes.

Ann Intern Med. 2010 Jul 20;153(2):JC19

Authors:

PMID: 20643987 [PubMed - in process]

Contextual errors and failures in individualizing patient care: a multicenter study.

Ann Intern Med. 2010 Jul 20;153(2):69-75

Authors: Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, M Schapira M, Persell SD, Jacobs E, Abrams RI

Background: A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care. Objective: To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes. Design: An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. Setting: 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities. Measurements: Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans. Results: Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters. Limitations: Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context. Conclusion: Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance. Primary Funding Source: U.S. Department of Veterans Affairs Health Services Research and Development Service.

PMID: 20643988 [PubMed - in process]

Effect of an End-of-Life Planning Intervention on the Completion of Advance Directives in Homeless Persons: A Randomized Trial.

Ann Intern Med. 2010 Jul 20;153(2):76-84

Authors: Song J, Ratner ER, Wall MM, Bartels DM, Ulvestad N, Petroskas D, West M, Weber-Main AM, Grengs L, Gelberg L

Background: Few interventions have focused on improving end-of-life care for underserved populations, such as homeless persons. Objective: To determine whether homeless persons will complete a counseling session on advance care planning and fill out a legal advance directive designed to assess care preferences and preserve the dignity of marginalized persons. Design: Prospective, single-blind, randomized trial comparing self-guided completion of an advance directive with professionally assisted advance care planning. (ClinicalTrials.gov registration number: NCT00546884) Setting: 8 sites serving homeless persons in Minneapolis, Minnesota. Participants: 262 homeless persons recruited between November 2007 and August 2008. Intervention: Minimal, self-guided intervention consisting of advance directive forms and written educational information versus a one-on-one advance planning intervention consisting of counseling and completing an advance directive with a social worker. Measurements: Rate of advance directive completion, assessed by inspection of completed documents. Results: The overall completion rate for advance directives was 26.7% (95% CI, 21.5% to 32.5%), with a higher rate in the counselor-guided group (37.9%) than in the self-guided group (12.8%) (CI of adjusted difference, 15.3 to 34.3 percentage points). This difference persisted across all sites and most subgroups. The advance directive's 4 clinical scenarios found a preference for surrogate decision making in 29% to 34% of written responses. Limitations: Sampling was limited to a more stable subset of the homeless population in Minneapolis and may have been subject to selection bias. Modest compensation to complete the preintervention survey could have influenced participants to complete advance directives. Conclusion: Both a simple and complex intervention successfully engaged a diverse sample of homeless persons in advance care planning. One-on-one assistance significantly increased the completion rate. Homeless persons can respond to an intervention to plan for end-of-life care and can express specific preferences for care or a surrogate decision maker, but additional studies are needed to assess the effect of these directives on subsequent care. Primary Funding Source: National Institute for Nursing Research and National Center on Minority Health and Health Disparities.

PMID: 20643989 [PubMed - in process]

Narrative review: the systemic capillary leak syndrome.

Ann Intern Med. 2010 Jul 20;153(2):90-8

Authors: Druey KM, Greipp PR

The systemic capillary leak syndrome (SCLS) is a rare disease of reversible plasma extravasation and vascular collapse accompanied by hemoconcentration and hypoalbuminemia. Its cause is unknown, although it is believed to be a manifestation of transient endothelial dysfunction due to endothelial contraction, apoptosis, injury, or a combination of these. Fewer than 150 cases of SCLS have been reported, but the condition is probably underrecognized because of its nonspecific symptoms and signs and high mortality rate. Patients experience shock and massive edema, often after a nonspecific prodrome of weakness, fatigue, and myalgias, and are at risk for ischemia-induced organ failure, rhabdomyolysis and muscle compartment syndromes, and venous thromboembolism. Shock and edema reverse almost as quickly as they begin, at which time patients are at risk for death from flash pulmonary edema during rapid fluid remobilization. Diagnosis is made clinically and by exclusion of other diseases that cause similar symptoms and signs, most notably sepsis, anaphylaxis, and angioedema. Acute episodes are treated with vasopressor therapy and judicious fluid replacement, possibly with colloid solutions for their osmotic effects, to prevent the sequelae of underperfusion. Between episodes, patients may be treated with theophylline and terbutaline, which clinical experience suggests may reduce the severity and frequency of acute episodes. Prognosis is uncertain, but patients who survive an initial severe SCLS episode are estimated to have a 10-year survival rate greater than 70%. Much remains to be learned about SCLS, and clinicians should consider the diagnosis in patients with unexplained edema, increased hematocrit, and hypotension.

PMID: 20643990 [PubMed - in process]

Plagiarism in residency application essays.

Ann Intern Med. 2010 Jul 20;153(2):112-20

Authors: Segal S, Gelfand BJ, Hurwitz S, Berkowitz L, Ashley SW, Nadel ES, Katz JT

Background: Anecdotal reports suggest that some residency application essays contain plagiarized content. Objective: To determine the prevalence of plagiarism in a large cohort of residency application essays. Design: Retrospective cohort study. Setting: 4975 application essays submitted to residency programs at a single large academic medical center between 1 September 2005 and 22 March 2007. Measurements: Specialized software was used to compare residency application essays with a database of Internet pages, published works, and previously submitted essays and the percentage of the submission matching another source was calculated. A match of more than 10% to an existing work was defined as evidence of plagiarism. Results: Evidence of plagiarism was found in 5.2% (95% CI, 4.6% to 5.9%) of essays. The essays of non-U.S. citizens were more likely to demonstrate evidence of plagiarism. Other characteristics associated with the prevalence of plagiarism included medical school location outside the United States and Canada; previous residency or fellowship; lack of research experience, volunteer experience, or publications; a low United States Medical Licensing Examination Step 1 score; and nonmembership in the Alpha Omega Alpha Honor Medical Society. Limitations: The software database is probably incomplete, the 10%-match threshold for defining plagiarism has not been statistically validated, and the study was confined to applicants to 1 institution. Evidence of matching content in an essay cannot be used to infer the applicant's intent and is not sensitive to variations in the cultural context of copying in some societies. Conclusion: Evidence of plagiarism in residency application essays is more common in international applicants but was found in those by applicants to all specialty programs, from all medical school types, and even among applicants with significant academic honors. Primary Funding Source: No external funding.

PMID: 20643991 [PubMed - in process]

Open notes: doctors and patients signing on.

Ann Intern Med. 2010 Jul 20;153(2):121-5

Authors: Delbanco T, Walker J, Darer JD, Elmore JG, Feldman HJ, Leveille SG, Ralston JD, Ross SE, Vodicka E, Weber VD

Few patients read their doctors' notes, despite having the legal right to do so. As information technology makes medical records more accessible and society calls for greater transparency, patients' interest in reading their doctors' notes may increase. Inviting patients to review these notes could improve understanding of their health, foster productive communication, stimulate shared decision making, and ultimately lead to better outcomes. Yet, easy access to doctors' notes could have negative consequences, such as confusing or worrying patients and complicating rather than improving patient-doctor communication. To gain evidence about the feasibility, benefits, and harms of providing patients ready access to electronic doctors' notes, a team of physicians and nurses have embarked on a demonstration and evaluation of a project called OpenNotes. The authors describe the intervention and share what they learned from conversations with doctors and patients during the planning stages. The team anticipates that "open notes" will spread and suggests that over time, if drafted collaboratively and signed by both doctors and patients, they might evolve to become contracts for care.

PMID: 20643992 [PubMed - in process]

Contextual errors.

Ann Intern Med. 2010 Jul 20;153(2):126-7

Authors: Lacombe MA

PMID: 20643993 [PubMed - in process]

Plagiarism on personal statements: a disturbing symptom of a broader trend.

Ann Intern Med. 2010 Jul 20;153(2):128-9

Authors: Papadakis MA, Wofsy D

PMID: 20643994 [PubMed - in process]

An exchange.

Ann Intern Med. 2010 Jul 20;153(2):130

Authors: Holman RP

PMID: 20643995 [PubMed - in process]

Electrocardiography and preparticipation screening of competitive high school athletes.

Ann Intern Med. 2010 Jul 20;153(2):131-2

Authors: Marek JC

PMID: 20643996 [PubMed - in process]

Will evidence be enough to promote interactive communication for the benefit of patients?

Ann Intern Med. 2010 Jul 20;153(2):131

Authors: Foy R

PMID: 20643997 [PubMed - in process]

Will evidence be enough to promote interactive communication for the benefit of patients?

Ann Intern Med. 2010 Jul 20;153(2):131

Authors: Braillon A, Bernardy-Prud'homme A, Dubois G

PMID: 20643998 [PubMed - in process]

Electrocardiography and preparticipation screening of competitive high school athletes.

Ann Intern Med. 2010 Jul 20;153(2):132-3

Authors: Maron BJ

PMID: 20643999 [PubMed - in process]

Electrocardiography and preparticipation screening of competitive high school athletes.

Ann Intern Med. 2010 Jul 20;153(2):132

Authors: Pelliccia A, Corrado D

PMID: 20644000 [PubMed - in process]

Complexities of Defibrillator Deactivation.

Ann Intern Med. 2010 Jul 20;153(2):133-134

Authors: Dev S, Galanos AN,

PMID: 20644001 [PubMed - as supplied by publisher]

Possible stereotyping in a personal essay.

Ann Intern Med. 2010 Jul 20;153(2):134-5

Authors: Scully JM

PMID: 20644002 [PubMed - in process]

Complexities of defibrillator deactivation.

Ann Intern Med. 2010 Jul 20;153(2):134

Authors: Goldstein NE, Carlson M, Kutner JS

PMID: 20644003 [PubMed - in process]

Possible stereotyping in a personal essay.

Ann Intern Med. 2010 Jul 20;153(2):135

Authors: Smythe WR

PMID: 20644004 [PubMed - in process]

Screening for Osteoporosis: An Update for the U.S. Preventive Services Task Force.

Ann Intern Med. 2010 Jul 5;

Authors: Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R

Background: This review updates evidence since the 2002 U.S. Preventive Services Task Force recommendation on osteoporosis screening. Purpose: To determine the effectiveness and harms of osteoporosis screening in reducing fractures for men and postmenopausal women without known previous fractures; the performance of risk-assessment instruments and bone measurement tests in identifying persons with osteoporosis; optimal screening intervals; and the efficacy and harms of medications to reduce primary fractures. Data Sources: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth quarter of 2009), MEDLINE (January 2001 to December 2009), reference lists, and Web of Science. Study Selection: Randomized, controlled trials of screening or medications with fracture outcomes published in English; performance studies of validated risk-assessment instruments; and systematic reviews and population-based studies of bone measurement tests or medication harms. Data Extraction: Data on patient populations, study design, analysis, follow-up, and results were abstracted, and study quality was rated by using established criteria. Data Synthesis: Risk-assessment instruments are modest predictors of low bone density (area under the curve, 0.13 to 0.87; 14 instruments) and fractures (area under the curve, 0.48 to 0.89; 11 instruments); simple and complex instruments perform similarly. Dual-energy x-ray absorptiometry predicts fractures similarly for men and women; calcaneal quantitative ultrasonography also predicts fractures, but correlation with dual-energy x-ray absorptiometry is low. For postmenopausal women, bisphosphonates, parathyroid hormone, raloxifene, and estrogen reduce primary vertebral fractures. Trials are lacking for men. Bisphosphonates are not consistently associated with serious adverse events; raloxifene and estrogen increase thromboembolic events; and estrogen causes additional adverse events. Limitation: Trials of screening with fracture outcomes, screening intervals, and medications to reduce primary fractures, particularly those enrolling men, are lacking. Conclusion: Although methods to identify risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms, and intervals. Primary Funding Source: Agency for Healthcare Research and Quality.

PMID: 20621892 [PubMed - as supplied by publisher]

Systematic Review: Nonoperative and Operative Treatments for Rotator Cuff Tears: A Comparative Effectiveness Review.

Ann Intern Med. 2010 Jul 5;

Authors: Seida JC, Leblanc C, Schouten JR, Mousavi SS, Hartling L, Vandermeer B, Tjosvold L, Sheps DM

Background: Many approaches exist for managing rotator cuff tears. Purpose: To compare the benefits and harms of nonoperative and operative interventions on clinically important outcomes in adults with rotator cuff tears. Data Sources: 12 electronic databases (1990 to September 2009), grey literature, trial registries, and reference lists were searched. Study Selection: Controlled and uncontrolled studies that assessed nonoperative or operative treatments or postoperative rehabilitation for adults with confirmed rotator cuff tears were included. Operative studies in English-language publications and nonoperative and postoperative rehabilitation studies in English, French, or German were considered. Studies were assessed in duplicate. Data Extraction: 2 reviewers assessed risk for bias by using the Cochrane tool and the Newcastle-Ottawa scale. One reviewer rated the evidence by using a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Data were extracted by one reviewer and verified by another. Data Synthesis: 137 studies met eligibility criteria. All trials had high risk for bias. Cohort and uncontrolled studies were of moderate quality. Reported functional outcomes did not differ between open versus mini-open repair, mini-open versus arthroscopic repairs, arthroscopic repairs with versus without acromioplasty, or single-row versus double-row fixation. Earlier return to work was reported for mini-open repair versus open repair and for continuous passive motion with physical therapy versus physical therapy alone. Open repairs showed greater improvement in function when compared with arthroscopic debridement. Complication rates were low across all interventions. Limitations: Limited evidence, which was often of low quality, precluded conclusions for most comparisons. Language restrictions may have excluded some relevant studies, and selective outcome reporting may have introduced bias. Conclusion: Evidence on the comparative effectiveness and the harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive. Primary Funding Source: Agency for Healthcare Research and Quality.

PMID: 20621893 [PubMed - as supplied by publisher]

Do the benefits of prolonged low-molecular-weight heparin treatment outweigh the harms in hospitalized patients who are bedbound?

Ann Intern Med. 2010 Jul 6;153(1):I50

Authors:

PMID: 20621897 [PubMed - in process]

Sexually transmitted diseases among men who use erectile dysfunction drugs.

Ann Intern Med. 2010 Jul 6;153(1):I44

Authors:

PMID: 20621896 [PubMed - in process]