Faculty Bibliography

OBJECTIVES: Missed and delayed breast cancer diagnoses are major sources of potential harm to patients and medical malpractice liability in the United States. Follow-up of abnormal mammogram results is an essential but challenging component of safe breast care. To explore the value of an inexpensive method to follow up abnormal test results, we examined a paper-based fail-safe system. METHODS: We examined a fail-safe system used to follow up abnormal mammograms at a primary care practice at an urban teaching hospital. We analyzed all abnormal mammogram reports and clinicians' responses to follow-up reminders. We characterized potential lapses identified in this system and used regression models to identify patient, provider, and test result characteristics associated with such lapses. RESULTS: Clinicians responded to fail-safe reminders for 92% of 948 abnormal mammograms. Clinicians reported that they were unaware of the abnormal result in 8% of cases and that there was no follow-up plan in place for 3% of cases. Clinicians with more years of experience were more likely to be aware of the abnormal result (odds of being unaware per incremental year in practice, 0.92; 95% confidence interval, 0.88-0.97) and were more likely to have a follow-up plan. CONCLUSIONS: A paper-based fail-safe system for abnormal mammograms is feasible in a primary care practice. However, special care is warranted to ensure full clinician adherence and address staff transitions and trainee-related issues

HawthoRNe [Television Program] -- The malformation is almost never life-threatening except in rare cases when it causes apnea (suspension of breathing), aspiration pneumonia (from breathing in foreign material) or a drop attack (sudden loss of muscle tone), says Dr. David Frim, chief of neurosurgery at Comer Children's Hospital of the University of Chicago

A community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strain known as pulsed-field type USA300 (USA300) is epidemic in the United States. Previous comparative whole-genome sequencing studies demonstrated that there has been recent clonal emergence of a subset of USA300 isolates, which comprise the epidemic clone. Although the core genomes of these isolates are closely related, the level of diversity among USA300 plasmids was not resolved. Inasmuch as these plasmids might contribute to significant gene diversity among otherwise closely related USA300 isolates, we performed de novo sequencing of endogenous plasmids from 10 previously characterized USA300 clinical isolates obtained from different geographic locations in the United States. All isolates tested contained small (2- to 3-kb) and/or large (27- to 30-kb) plasmids. The large plasmids encoded heavy metal and/or antimicrobial resistance elements, including those that confer resistance to cadmium, bacitracin, macrolides, penicillin, kanamycin, and streptothricin, although all isolates were sensitive to minocycline, doxycycline, trimethoprim-sulfamethoxazole, vancomycin, teicoplanin, and linezolid. One of the USA300 isolates contained an archaic plasmid that encoded staphylococcal enterotoxins R, J, and P. Notably, the large plasmids (27 to 28 kb) from 8 USA300 isolates--those that comprise the epidemic USA300 clone--were virtually identical (99% identity) and similar to a large plasmid from strain USA300_TCH1516 (a previously sequenced USA300 strain from Houston, TX). These plasmids are largely divergent from the 37-kb plasmid of FPR3757, the first sequenced USA300 strain. The high level of plasmid sequence identity among the majority of closely related USA300 isolates is consistent with the recent clonal emergence hypothesis for USA300

Background: Several studies have attempted to investigate the underlying mechanisms of cognitive deficits by different MRI techniques. In this respect, atrophy has been recognized to be one of the best correlates for cognitive changes whilst other MRI measures are less closely related. Since whole brain N-acetyl-aspartate (WBNAA) is used to quantify diffuse neuronal cell injury and has been described to precede brain atrophy in MS one intriguing question is whether WBNAA levels are associated with cognitive abnormalities. Objective: To study the relation between WBNAA, T1w and T2w lesion volume (LV) and cognitive core functions in MS. Methods: 82 MS-patients from our outpatient clinic (mean age 48.9 yrs; 56 female/26 male; CIS = 1; RRMS = 64; SPMS = 17) were prospectively studied. Besides application of different MRI measures (T1w and T2w LV, non-localized proton MR spectroscopy), participants were examined with a set of neuropsychological tests (MUSIC, SDMT). Spearman's rank correlation (one-sided) was used to analyze the associative strength between cognitive and MRI measures. Results: Significant correlations were found between WBNAA, short-term memory (STM) (p = 0.04) and executive functions (p = 0.04). In contrast, T1w and T2w LV did not show relations to these cognitive domains but were significantly correlated with SDMT (p < 0.001), speed (p<= 0.001), mental flexibility (p<= 0.034) and long-term memory (LTM) (p<= 0.041). There was no correlation between WBNAA and T1w and T2w LV, respectively. Discussion: This is one of the first studies on the relation between white matter lesion load, diffuse neuronal damage and cognitive parameters in MS. Interestingly, WBNAA correlated with measures of STM and executive functions but not with those of processing speed, mental flexibility and LTM. In contrast the three latter domains were exclusively related to T1w and T2w LVs. It is conceivable, that different neuropsychological domains are more strongly related to features of predominant neuronal vs. white matter damage. Thus, since WBNAA represents a non-regional parameter of neuronal destruction it can be concluded from the cognitive results that brain tissue alteration most probably occurs within frontal and prefrontal areas leading to functional disconnection. This study might also explain why results of MR correlative studies with cognitive performance need a careful consideration but also offer new means to understand the integration of pathology and clinical phenotypes

BACKGROUND: The second best conduit for coronary artery bypass graft surgery (CABG) is unclear. We sought to determine if the use of a second arterial conduit, the radial artery (RA), would improve long-term survival after CABG using the left internal thoracic artery (LITA) and saphenous vein (SV). METHODS: We compared the 14-year outcomes in propensity-matched patients undergoing isolated, primary CABG using the LITA, RA, and SV versus CABG using the LITA and only SV. In all, 826 patients from each group had similar propensity-matched demographics and multiple variables. The primary endpoint was all-cause mortality obtained using the Social Security Death Index. RESULTS: Perioperative outcomes including in hospital mortality (0.1% for the RA patients and 0.2% for the SV patients) were similar. Kaplan-Meier survival at 1, 5, and 10 years was 98.3%, 93.9%, and 83.1% for the RA group versus 97.2%, 88.7%, and 74.3% for the SV group (log rank, p = 0.0011). Cox proportional hazards models showed a lower all-cause mortality in the RA group (hazard ratio 0.72, confidence interval: 0.56 to 0.92, p = 0.0084). Ten-year survivals showed a 52% increased mortality for the SV patients (25.7%) versus the RA patients (16.9%; p = 0.0011). For symptomatic patients, RA patency was 80.7%, which was not different than the LITA patency rate of 86.4% but was superior to the SV patency rate of 46.7% (p < 0.001). CONCLUSIONS: Using the LITA, SV, and a RA conduit for CABG results in significantly improved long-term survival compared with using the LITA and SV. The use of two arterial conduits offers a clear and lasting survival advantage, likely due to the improved patency of RA grafts. We conclude that RA conduits should be more widely utilized during CABG

OBJECTIVE: Communication skills are crucial for high-risk behavior screening and counseling. Practicing physicians have limited opportunities to improve these skills. This paper assesses the impact of a continuing medical education (CME) program for Student Health Center clinicians that targeted communication skills, screening practices and patient satisfaction. METHODS: Program evaluation included pre- and post-objective structured clinical examinations (OSCE's), chart review, and provider and patient satisfaction surveys. Data were analyzed using paired t-tests and ranked sum tests. RESULTS: OSCE scores (n=15) revealed significant improvements in communication skills overall (p=0.004) and within specific domains (data gathering: p=0.003; rapport building: p=0.01; patient education: p=0.02), but no change in case-specific knowledge (p=0.1). Participants (n=14) reported high satisfaction with program methods (mean=4.6/5) and content (mean=4.7/5), 70% planning to alter their clinical practice. Chart audits (pre=96, post=103) showed increased screening for smoking (RR 1.65, p=0.03), depressed mood (RR 1.40, p=0.04), anhedonia (RR 1.47, p=0.01), sexual activity (RR 1.73, p=0.002) and drinking (RR 1.77, p=0.04). Sampling of satisfaction among participants' patients (pre n=689, post n=383) detected no increase in already high baseline satisfaction. CONCLUSION: This curriculum improved clinicians' relevant skills and screening behavior. PRACTICE IMPLICATIONS: Skills-oriented CME can improve clinicians' communication skills and screening and counseling practices

The Health Maintenance Organization Research Network (HMORN), a consortium of 16 health care delivery systems with integrated research divisions, held its annual meeting in Danville, Pennsylvania in April of 2009 and was attended by more than 260 researchers and operational leaders from HMORN organizations, pharmaceutical companies, the National Cancer Institute, and the Agency for Healthcare Research and Quality. The 2009 meeting was held from April 26(th) to April 29(th) at the Henry Hood Center for Health Research, and was hosted by Geisinger Health System. The conference theme was 'Clinical Effectiveness: Leadership in Comparative Effectiveness and Translational Research.' This article provides some background on the network, its research activities, and the annual conference. This issue of Clinical Medicine & Research also includes selected scientific abstracts presented at the meeting

BACKGROUND: It is uncertain whether training improves physicians' obesity counseling. OBJECTIVE: To assess the impact of an obesity counseling curriculum for residents. DESIGN: A non-randomized, wait-list/control design. PARTICIPANTS: Twenty-three primary care internal medicine residents; 12 were assigned to the curriculum group, and 11 were assigned to the no-curriculum group. Over a 7-month period (1-8 months post-intervention) 163 of the residents' obese patients were interviewed after their medical visits. INTERVENTION: A 5-hour, multi-modal obesity counseling curriculum based on the 5As (Assess, Advise, Agree, Assist, Arrange) using didactics, role-playing, and standardized patients. MAIN MEASURES: Patient-report of physicians' use of the 5As was assessed using a structured interview survey. Main outcomes were whether obese patients were counseled about diet, exercise, or weight loss (rate of counseling) and the quality of counseling provided (percentage of 5As skills performed during the visit). Univariate statistics (t-tests) were used to compare the rate and quality of counseling in the two resident groups. Logistic and linear regression was used to isolate the impact of the curriculum after controlling for patient, physician, and visit characteristics. KEY RESULTS: A large percentage of patients seen by both groups of residents received counseling about their weight, diet, and/or exercise (over 70%), but the quality of counseling was low in both the curriculum and no curriculum groups (mean 36.6% vs. 31.2% of 19 possible 5As counseling strategies, p = 0.21). This difference was not significant. However, after controlling for patient, physician and visit characteristics, residents in the curriculum group appeared to provide significantly higher quality counseling than those in the control group (std beta = 0.18; R(2) change = 2.9%, P < 0.05). CONCLUSIONS: Residents who received an obesity counseling curriculum were not more likely to counsel obese patients than residents who did not. Training, however, is associated with higher quality of counseling when patient, physician, and visit characteristics are taken into account

Language barriers may contribute to the under-detection of depression in Latinos and Asians. A total of 782 English, Spanish, and Chinese-speaking primary care patients were enrolled in a randomized controlled trial. Language discordant patients were randomized to Remote Simultaneous Medical Interpreting (RSMI) or usual and customary (U&C) interpreting. The Beck Depression Inventory-Fast Screen (BDI-FS) was administered. Patients were tracked for 1 year. A total of 462 patients completed the BDI-FS. Thirty-three percent had a positive (>/=4) screen. Twenty-seven percent of BDI-FS positive patients were diagnosed with depression. Among BDI-FS positive patients, Chinese-speakers were less likely to be diagnosed compared with English speakers (31% vs. 10%, P < 0.05). There was a trend towards greater diagnosis with RSMI (27% detection with RSMI vs. 20% U&C, P = 0.41). The diagnosis of depression among BDI-FS positive patients in our population was low, particularly among Chinese-speakers. RSMI could be an important part of a multi-faceted approach to improving the detection of depression