Faculty Bibliography

Elevated troponin T is known to be a prognostic marker for long-term cardiac events and mortality in asymptomatic end-stage renal disease patients. There are conflicting data in this regard with respect to troponin I (TnI). We recently showed a high incidence of elevated TnI levels in asymptomatic hemodialysis (HD) patients using a new generation sensitive TnI assay. The aim of this pilot study was to explore the prognostic value of TnI, as measured with this new assay, as a marker for outcomes in HD patients over a 2-year follow-up period. Fifty-one asymptomatic HD patients were enrolled, and pre-dialysis TnI levels were checked once monthly over 3 consecutive months. Patients were considered to be in the TnI positive group if TnI level on any of the three draws was >/=0.035 ng/ml. All patients were followed for a period of 2 years. The primary end points were acute coronary syndrome, coronary revascularization, sudden death, or cardiac arrest. The secondary end point was all-cause mortality. Elevated TnI levels were found in 51% (26/51) of patients in our cohort. One TnI positive patient was subsequently lost to follow up. There were 6 cardiac events over 2 years, all of which were in the troponin positive group (6/25 or 24%). The presence of a positive TnI at baseline was significantly associated with future cardiac events (p = 0.022). A prior history of coronary artery disease (CAD) was also significantly related to future cardiac events (p = 0.010). No patient with negative TnI at baseline developed a cardiac event, while 45.5% of those with both a positive TnI and a history of CAD had an event. Fourteen deaths occurred over 2 years, 8 in TnI positive and 6 in the negative group. All-cause mortality was not associated with elevated TnI levels at baseline. We found a significant association between positive TnI and subsequent cardiac events in asymptomatic HD patients followed for 2 years. TnI levels, as measured with a sensitive assay, may be useful in assessing cardiac risk in asymptomatic HD patients. This needs further confirmation in a larger cohort.

Barriers to blood pressure control exist at the patient, physician, and system levels. We review the current evidence for interventions that target patient- and physician-related barriers, such as patient education, home blood pressure monitoring, and computerized decision-support systems for physicians, and we emphasize the need for more studies that address the effectiveness of these interventions in African American patients

ABSTRACT Primary care is understudied as a reentry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid-dependent adults seeking buprenorphine/naloxone maintenance in an urban primary care clinic following release from jail versus community referrals. Postrelease patients were either (a) induced to buprenorphine in-jail as part of a clinical trial, or (b) seeking buprenorphine induction post release. From 2007 to 2008, N = 142 patients were new to primary care buprenorphine: n = 32 postrelease; n = 110 induced after community referral and without recent incarceration. Jail-released patients were more likely African American or Hispanic and uninsured. Treatment retention rates for postrelease (37%) versus community (30%) referrals were similar at 48 weeks. Rates of opioid positive urines and self-reported opioid misuse were also similar between groups. Postrelease patients in primary care buprenorphine treatment had equal treatment retention and rates of opioid abstinence versus community-referred patients

BACKGROUND: To determine whether a 'lay' rater could assess clinical reasoning, interrater reliability was measured between physician and lay raters of patient notes written by medical students as part of an 8-station objective structured clinical examination. METHODS: Seventy-five notes were rated on core elements of clinical reasoning by physician and lay raters independently, using a scoring guide developed by physician consensus. Twenty-five notes were rerated by a 2nd physician rater as an expert control. Kappa statistics and simple percentage agreement were calculated in 3 areas: evidence for and against each diagnosis and diagnostic workup. RESULTS: Agreement between physician and lay raters for the top diagnosis was as follows: supporting evidence, 89% (kappa = .72); evidence against, 89% (kappa = .81); and diagnostic workup, 79% (kappa = .58). Physician rater agreement was 83% (kappa = .59), 92% (kappa = .87), and 96% (kappa = .87), respectively. CONCLUSIONS: Using a comprehensive scoring guide, interrater reliability for physician and lay raters was comparable with reliability between 2 expert physician raters

BACKGROUND: Teaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture. METHODS: The goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents' perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group. RESULTS: Study 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents' skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as 'slightly better' or 'much better' compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department's leadership view toward professionalism as 'much better' compared with 5 years ago. CONCLUSIONS: All 3 assessment methods suggest that residents feel increasingly prepared to effectively deal with the professionalism challenges they face. Although professionalism seminars may have seemed like an oddity several years ago, residents today recognize their importance and value their professionalism skills. As importantly, department chairpersons report that formal professionalism education for residents is viewed more favorably compared with 5 years ago