Gleason score predicts androgen independent progression after androgen deprivation therapy

OBJECTIVE: The Gleason system is the most widely utilized histologic grading system for prostate cancer and a powerful predictor of cancer behavior. In this study, we evaluated the prognostic value of the Gleason grading system in predicting progression to androgen independent prostate cancer (AIPC). METHODS: Records from 150 patients with advanced or metastatic prostate cancer treated with androgen deprivation therapy (ADT) were retrospectively reviewed. Androgen independent progression was defined as two consecutive elevations of serum prostate specific antigen (PSA) above the nadir value. Kaplan-Meier and the Cox proportional hazards methods were used to assess potential predictors of progression to AIPC. RESULTS: Patients with low and moderate Gleason scores experienced significantly longer remissions compared to those with Gleason score of 8-10 (p=0.0006, Log-Rank test). The cumulative hazard of progressing to AIPC increased by almost 70% for each unit increase in total Gleason score. CONCLUSION: In this patient cohort the Gleason score was the only independent predictor of progression to AIPC.     

Effectiveness of medical resident education in mechanical ventilation

Specific methods of mechanical ventilation management reduce mortality and lower health care costs. However, in the face of a predicted deficit of intensivists, it is unclear whether residency programs are training internists to provide effective care for patients who require mechanical ventilation. To evaluate these educational outcomes, we administered a validated 19-item case-based test and survey to resident physicians at 31 diverse U.S. internal medicine residency programs nationwide. Of 347 senior residents, 259 (75%) responded. The mean test score was 74% correct (SD, 14%; range, 37 to 100%). Important items representing evidence-based standards of critical care answered incorrectly were as follows: use of appropriate tidal volume in the acute respiratory distress syndrome (48% incorrect), identifying a patient ready for a weaning trial (38% incorrect), and recognizing indication for noninvasive ventilation (27% incorrect). Most accurately identified pneumothorax (86% correct) and increased intrathoracic positive end-expiratory pressure (93% correct). Better scores were associated with "closed" versus "open" intensive care unit organization (76 versus 71% correct, p = 0.001), resident perception of greater versus lesser ventilator knowledge (79 versus 71% correct, p = 0.001), and graduation from a U.S. versus international medical school (75 versus 69% correct, p = 0.033). Although overall training satisfaction correlated strongly with program use of learning objectives (r = 0.89, p < 0.0001), only 46% reported being satisfied with their mechanical ventilation training. We conclude that senior residents may not be gaining essential evidence-based knowledge needed to provide effective care for patients who require mechanical ventilation. Residency programs should emphasize evidence-based learning objectives to guide mechanical ventilation instruction.     

Whiplash injury--a retrospective study on patients seeking compensation

The purpose of this cohort study is to evaluate the objective long-term findings and the final outcome of a population suffering from whiplash-associated disorders (WAD) after rear-end car collision and claiming legal compensation. Eight hundred and sixty-six patients after whiplash injury were followed up on average 32 months post-trauma. All patients had clinical examination and radiographs performed on the day of the accident and at follow up. MRI, CT scan, bone scan, electromyographic (EMG) tests were performed upon request of the treating physician and correlated by the authors with the clinical findings. Cervical pain was the most common complaint (96%). Radiating pain to one side of the upper limbs or the shoulder was also very common (36 and 24%, respectively). Chin to chest test was found to be a strong indicator in differentiating between the less severe (grades 1 and 2) to more severe (grades 3 and 4) WAD patients. In 10% of the patients with normal radiographic findings, degenerative changes were found at follow up. CT scan and MRI did not add to patient diagnosis, except for those patients suffering from degenerative changes and decreased range of motion (RoM). Based on our findings the initial radiograph taken in the emergency room was the best imaging modality and probably the only one needed routinely following whiplash injury. Although this is a special subgroup of patient seeking compensation, the overall prognosis is favorable in all grades of WAD injury and there is no need for further diagnostic expenditures.     

Control of an outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus colonization and infection in an intensive care unit (ICU) without closing the ICU or placing patients in isolation.

OBJECTIVE: To describe the control of multidrug-resistant Acinetobacter baumannii-calcoaceticus (MDRABC) colonization and infection in an intensive care unit (ICU). SETTING: An 18-bed ICU in a large tertiary care teaching hospital in London. INTERVENTIONS: After recognition of the outbreak, a range of infection control measures were introduced over several months that were primarily aimed at reducing environmental contamination with the outbreak strain. Strategies included use of a closed tracheal suction system for all patients receiving mechanical ventilation, use of nebulized colistin for patients with evidence of mild to moderate ventilator-associated pneumonia, improved availability of alcohol for hand decontamination, and clearer designation of responsibilities and strategies for cleaning equipment and the environment in the proximity of patients colonized or infected with MDRABC. RESULTS: The outbreak lasted from June 2001 through November 2002 and involved 136 new cases of MDRABC infection or colonization. The number of newly diagnosed cases per month reached a maximum of 15 in February 2002, and the number of new cases slowly decreased over the next 9 months. CONCLUSION: This outbreak was controlled by emphasizing the control of environmental reservoirs and did not require recourse to ward closure or placement of affected patients in isolation.     

Concordance of Patient-Physician Obesity Diagnosis and Treatment Beliefs in Rural Practice Settings

CONTEXT: Although clinical guidelines recommend routine screening and treatment for obesity in primary care, lack of agreement between physicians and patients about the need for obesity treatment in the primary care setting may be an unexplored factor contributing to the obesity epidemic. PURPOSE AND METHODS: To better understand this dynamic, we surveyed 439 obese patients (body mass index >or=30) at the time of clinic visits in 2003 at diverse primary care settings in rural Kansas and conducted same-day interviews with their physicians (N = 28). We used Spearman's correlation to describe and compare patient and physician responses. FINDINGS: Most patients were women (66%). Their mean age was 55.8 years, and mean body mass index was 37.7. Half (51%) reported discussing their weight on that visit date. Overall, 51% of patients wanted to discuss weight more often with their physician and 54% wanted to discuss weight sooner. Patients and physicians gave similar assessments of the patient's preference for discussing weight loss, how often weight was discussed at visits, and the patient's motivation for weight loss. Spearman's correlations on these variables were .33, .54, and .25, respectively (all P < .001). CONCLUSIONS: These patients and their physicians demonstrated a weak to moderate agreement on several variables crucial to initiating and continuing obesity care. Understanding patient and provider beliefs and preferences regarding obesity diagnosis and treatment is essential in designing obesity interventions for primary care.