Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety

OBJECTIVE

To mitigate the risks of fatigue-related medical errors, the Accreditation Council for Graduate Medical Education introduced work hour limits for resident physicians in 2003. Our goal was to determine whether work hours, sleep, and safety changed after implementation of the Accreditation Council for Graduate Medical Education standards.

METHODS

We conducted a prospective cohort study in which residents from 3 large pediatric training programs provided daily reports of work hours and sleep. In addition, they completed reports of near-miss and actual motor vehicle crashes, occupational exposures, self-reported medical errors, and ratings of educational experience. They were screened for depression and burnout. Concurrently, at 2 of the centers, data on medication errors were collected prospectively by using an established active surveillance method.

RESULTS

A total of 220 residents provided 6007 daily reports of their work hours and sleep, and 16 158 medication orders were reviewed. Although scheduling changes were made in each program to accommodate the standards, 24- to 30-hour shifts remained common, and the frequency of residents' call remained largely unchanged. There was no change in residents' measured total work hours or sleep hours. There was no change in the overall rate of medication errors, and there was a borderline increase in the rate of resident physician ordering errors, from 1.06 to 1.38 errors per 100 patient-days. Rates of motor vehicle crashes, occupational exposures, depression, and self-reported medical errors and overall ratings of work and educational experiences did not change. The mean length of extended-duration (on-call) shifts decreased 2.7% to 28.5 hours, and rates of resident burnout decreased significantly (from 75.4% to 57.0%).

CONCLUSIONS

Total hours of work and sleep did not change after implementation of the duty hour standards. Although fewer residents were burned out, rates of medication errors, resident depression, and resident injuries and educational ratings did not improve.

Rates of medication errors among depressed and burnt out residents: prospective cohort study

OBJECTIVE

To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors.

DESIGN

Prospective cohort study.

SETTING

Three urban freestanding children's hospitals in the United States.

PARTICIPANTS

123 residents in three paediatric residency programmes.

MAIN OUTCOME MEASURES

Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month.

RESULTS

24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001). Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 0.45 (0.20 to 0.98) compared with 0.53 (0.21 to 1.33, P=0.2).

CONCLUSIONS

Depression and burnout are major problems among residents in paediatrics. Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors.

The Ets transcription factor Esx regulates expression of metastasis-associated genes in non-small cell lung cancer (NSCLC)

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Background: The overall 5-yr survival for the treatment of lung cancer patients is less than 20% due to the inability to control metastatic disease. Methods: To identify genes that promote the development of metastases in NSCLC and other solid tumors, we first performed three separate microarray analyses using Affymetrix U133A chips whereby expression values of a pool of normal lymph nodes was compared to: lung cancer cell lines (n = 4), and metastatic lymph nodes from breast (n = 3) and pancreatic (n = 3) cancer patients. Separate lists of the 35 most highly overexpressed genes for each cancer type were compiled. Results: We observed that each list contained EpCAM, XAG, CK19, and CK8 (p = 1.1E-18). To search for genes that might regulate expression of these four genes, we queried the CGAP NCI60 gene expression database with the 87 genes contained on the three lists and constructed a connectivity map such that the presence of a gene on the map required: 1) high correlation (p < 8.0E-6) with at least two other genes, and 2), direct or indirect contact to EpCAM or XAG. The map contained two gene clusters (XAG cluster = 6 genes; EpCAM/CK19/CK8 cluster = 7 genes) that were connected to, and potentially regulated by, the Ets transcriptional factor Esx. Genes from both clusters, as well as Esx, were highly overexpressed in metastatic mediastianal lymph nodes obtained from NSCLC patients. To investigate whether Esx might regulate expression of one or more genes in the two clusters, we transfected an NSCLC cell line derived from lymph node metastases with siRNA to Esx and observed: 1) a reduction in expression of EpCAM (4-fold), XAG (7-fold), and the orphan nuclear receptor ESRRα (1,000-fold), and 2), an inhibition of cell growth. Conclusions: Based on our ability to simultaneously inhibit cell growth and expression of multiple metastasis-associated genes with a single siRNA, we conclude that Esx is a major regulator of lymph node metastasis.

No significant financial relationships to disclose.

Sleep in Overweight Adolescents: Shorter Sleep, Poorer Sleep Quality, Sleepiness, and Sleep-Disordered Breathing

OBJECTIVE

To document the sleep of overweight adolescents and to explore the degree to which weight-related sleep pathology might account for diminished psychosocial outcome.

METHODS

Sixty children aged 10-16.9 from a weight-management clinic were compared to 22 healthy controls using comprehensive actigraphic, polysomnographic, and parent- and self-report questionnaire assessments.

RESULTS

Overweight participants averaged more symptoms of sleep-disordered breathing, later sleep onset, shorter sleep time, and more disrupted sleep than controls. Although the groups did not differ in self-reported sleep habits, multiple concerns were reported by parents of overweight participants, including daytime sleepiness, parasomnias, and inadequate sleep. Group differences in academic grades and depressive symptoms were at least partially accounted for by short sleep and daytime sleepiness.

CONCLUSIONS

Excessive weight is associated with an increased risk of sleep problems. There is a need for further research in this area and for clinicians who work with overweight children to evaluate their sleep.

Pediatric Sleep Disorders

Pediatric sleep disorders represent a heterogeneous collection of disturbances that require varied intervention strategies. The diagnosis of some sleep disorders (eg, OSAS, narcolepsy, PLMD) require PSG, whereas others can be diagnosed during an office visit with a thorough medical,psychiatric, and sleep history. Sleep disorders place children at risk for school failure, accidents, and social problems, and can place a significant burden on families and the parent-child relationship.

Psychological comorbidity and stress reactivity in children and adolescents with recurrent abdominal pain and anxiety disorders

OBJECTIVE

To compare clinical symptoms, diagnoses, and physiological measures in children and adolescents with recurrent abdominal pain (RAP) (n = 14), to a group with anxiety disorders (ANX) (n = 14) and a physically and psychiatrically healthy control group (HC) (n = 14).

METHOD

The cross-sectional study examined group differences in clinical symptoms of anxiety, somatic complaints, depression, and behavior problems. Physiological measures included heart rate, systolic and diastolic blood pressure, and salivary cortisol in response to the Trier Social Stress Test for Children (TSST-C). Subjects were between the ages of 8 and 16 years.

RESULTS

RAP and ANX subjects had comparable scores on most psychological measures, and their scores were higher (n < .05) than those of the HC. The ANX and RAP groups exhibited physiological findings that had more shared similarities than either group with the HC group. Few statistically significant group differences were noted in physiological measures, yet the pattern of findings in blood pressure and cortisol supported the use of the TSST-C and the direction of the findings was consistent with expectations.

CONCLUSIONS

Understanding more about comorbidity between RAP and anxiety could have important management implications, with observed congruities between the disorders suggesting treatments already demonstrated to be efficacious for pediatric anxiety and depression might be applied productively to RAP.

Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy

BACKGROUND

EUS-guided fine needle aspiration (EUS-FNA) is a highly accurate method of detecting malignant lymphadenopathy. The optimal methods for performing EUS-FNA to maximize sensitivity and to minimize the number of needle passes necessary are unknown. This is a report of the results of a prospective randomized controlled trial to determine the effect of suction, the site of FNA (edge or center of lymph node), and the method of preparation of cytologic specimens on accuracy, number of needle passes needed, and specimen quality.

METHODS

Consecutive patients with lymphadenopathy detected by EUS underwent FNA. Each lymph node was sampled with or without suction and from the edge or center in a 2 x 2 factorial design. The samples were expressed onto slides for cytology, and the residual material in the needle was analyzed by the cytospin-cellblock technique. Each aspirate was individually characterized for a diagnosis of malignancy, cellularity, and bloodiness.

RESULTS

Forty-three patients with a total of 46 lymph nodes were evaluated. The final lymph node diagnosis was benign in 22 (48%), "suspicious for malignancy" in 6 (13%), and malignant in 18 (39%). The use of suction was associated with an increase in the cellularity of the specimen, but did not improve the likelihood of obtaining a correct diagnosis (OR 1.52: 95% CI [0.81, 2.85]). Samples obtained with suction were of worse quality because of excessive bloodiness (OR 4.7: 95% CI [1.99, 11.24]). Aspiration from the edge of the lymph node (compared with the center) did not increase the likelihood of a correct diagnosis (OR 1.16: 95% CI [0.42, 3.21]). For 78% of malignant lymph nodes, the correct diagnosis was obtained on the first needle pass and for 100% by the third pass. Cytospin-cellblock methods did not add any additional diagnostic information compared with direct smear cytology.

CONCLUSIONS

The traditional method of applying suction during EUS-FNA does not improve diagnostic accuracy and worsens specimen bloodiness compared with FNA without suction. The site of FNA within the lymph node does not affect accuracy. When EUS-FNA is necessary, our recommendation is up to 3 FNAs without suction from the most convenient and safe location within abnormal-appearing lymph nodes.

Primary hepatic B-cell lymphoma of mucosa-associated lymphoid tissue

Mucosa-associated lymphoid tissue (MALT) lymphomas are low-grade B-cell lymphomas that occur in a variety of extranodal sites but rarely as a primary hepatic lymphoma. We describe the histological findings, immunophenotype, and immunohistochemistry of one such lymphoma found incidentally in a 69-year-old woman. The lymphoid infiltrate invaded the liver in a serpiginous configuration with entrapment of nodules of normal liver. Reactive follicles were surrounded by intermediate-sized lymphoid cells with slightly irregular nuclei and pale cytoplasm. Only a few scattered lymphoepithelial lesions were identified since most of the bile ducts were destroyed. The immunophenotype determined by flow cytometry identified the lymphoid cells as being CD19, CD20 positive and exhibiting lambda light chain restriction. CD5, CD10, and CD23 were negative. Immunohistochemistry showed the neoplastic cells to be positive for CD20 (L-26) and bcl-2. The reactive follicles were negative for bcl-2. CD3 showed only a few scattered T cells. Cyclin D1 did not stain the neoplastic cells. Cytokeratin (AE1/AE3) highlighted the lymphoepithelial lesions and residual bile ducts. MALT lymphomas need to be recognized and distinguished from other B-cell lymphomas, particularly mantle cell lymphomas, because of the difference in behavior and treatment.

Evaluation of gastric biopsies for neoplasia: differences between Japanese and Western pathologists

Cited variations in the evaluation of gastric endoscopic biopsies for neoplasms between pathologists in Japan and those in the United States and Europe (the West) may have stemmed from several causes. The five-tiered group classification of the Japanese Research Society for Gastric Cancer (JRSGC) for interpretation of biopsies is not used in the West. Some differences may also exist in the morphologic criteria to reach a diagnosis of dysplasia or carcinoma. The goals of this study were to test the Western and Japanese classifications of gastric dysplasia and adenocarcinoma and to assess the differences between four Japanese and seven Western pathologists. One hundred biopsies, 20 from each of the five categories of the JRSGC scheme as determined by one observer, were collected. The Japanese observers used the JRSGC system, expressed in Roman numerals, whereas Western pathologists used a five- or six-tiered scheme expressed in diagnostic terms. Pairwise agreement was evaluated using k statistics within both groups. Consensus diagnosis on each biopsy was accepted as the opinion of the majority. The sensitivity and specificity of each reviewer for a certain diagnosis were also assessed. The intragroup agreements were moderate for both the Japanese (mean k = 0.663) and the Westerners (mean k = 0.652). The pairwise agreements between Japanese and Western observers were low (mean k = 0.542). Overall, the sensitivity was low for all Japanese observers for the diagnosis of dysplasia (38.7% vs 92.5%), and the sensitivity for the diagnosis of adenocarcinoma was high in both groups but higher among the Japanese observers (93.9% and 85.2%, respectively). Overall, the Japanese-Western interobserver agreement was moderate. The JRSCG scheme did not translate into higher interobserver agreement among Japanese observers. The sensitivity for the diagnosis of gastric adenocarcinoma was high for both groups, but the specificity was low among the Japanese. The cause seemed to be centered around the diagnosis of dysplasia in the Western system, which was a lesion frequently interpreted as carcinoma in Japan because of the different definitions of carcinoma in each system. Such a discrepancy might be important because it may explain some of the differences in the prevalence and prognosis of early gastric cancer between Japan and the West. An international effort is needed to harmonize morphologic criteria and analyze whether therapeutic consequences may stem from such discrepancies.

Vaginal ligature of uterine arteries during postpartum hemorrhage

Immediate postpartum hemorrhage due to uterine inertia is usually treated by injection of oxytocics. In some situations, bleeding continues and distends the uterine cavity, in turn disturbing the hemostasis that accompanies uterine retraction. Uterine bleeding must be rapidly reduced while the coagulation defect is corrected. The authors propose the vaginal ligature of uterine arteries, which can be performed in the delivery room, as an alternative to hysterectomy.

Prospective comparison of commercially available rapid urease tests for the diagnosis of Helicobacter pylori

BACKGROUND

Rapid urease testing is the initial endoscopic test of choice for the diagnosis of Helicobacter pylori. Determination of the relative diagnostic yields and times to a positive test for the different rapid urease tests is important for endoscopists. We compared three commercially available tests using histologic examination and culture as a gold standard.

METHODS

Patients undergoing upper endoscopy had six biopsy specimens taken from the antrum and six from the body with a large-channel biopsy forceps. Each set of six specimens was divided as follows: one each for CLOtest, Hpfast, and Pyloritek rapid urease tests; one for culture; and two for histologic examination (H&E, Genta). All tests were read every 15 minutes for 1 hour; the final reading for Pyloritek was at 1 hour. CLOtest and Hpfast were also read at 4 hours and 24 hours.

RESULTS

One hundred seventy-three sets of biopsy specimens from 87 patients were evaluated; 98 (57%) of the 173 sets were positive for H. pylori by histologic examination and/or culture. The mean and median times to a positive test were significantly less for Pyloritek (0.5 +/- 0.02 hour and 0.5 hour) than for CLOtest (2.0 +/- 0.6 hour and 0.75 hour) or Hpfast (2.2 +/- 0.6 hour and 0.5 hour). The sensitivities at the final readings were similar among the three tests (CLOtest: 93%; Hpfast: 88%; Pyloritek: 89%), but sensitivities at 1 hour were significantly better for Pyloritek (89%) than for CLOtest (71%) or Hpfast (66%). At 4 hours, sensitivities for CLOtest and Hpfast improved significantly and were not significantly different from those of Pyloritek. Specificities were 99% to 100% at all times for all three tests.

CONCLUSION

The three rapid urease tests, CLOtest, Hpfast, and Pyloritek, provide comparable results, with sensitivities around 90% and specificities around 100%. The Pyloritek becomes positive more rapidly than the CLOtest or Hpfast. If a reading is desired within 1 hour, the Pyloritek provides a greater sensitivity than the CLOtest or Hpfast without any sacrifice in specificity.

Bereavement care: relationships between the intensive care unit and the general practitioner

This study examines relationships between an intensive care unit and the general practitioners within a local health authority in respect of bereavement care. A questionnaire to all 113 local general practitioners generated a response from 67 (59.3%). While about two-fifths of respondents reported at least one of their patients dying on the intensive care unit, half said that they were often first informed by relatives. Although four-fifths of inner city general practitioners offered some form of bereavement service, it ranked lowest in terms of priority on time, and a further one-seventh provided no service at all. Half the respondents thought that hospital staff could do more to help. The implications for practice are discussed.

[Antenatal diagnosis and management of congenital chylothorax]

A case of congenital chylothorax diagnosed with prenatal ultrasonography is described. Thoracocentesis was performed at 33 weeks of gestational age but recurrence of chylothorax, increasing hydramnios and subcutaneous oedema made cesarean section necessary at 37 weeks. Mechanisms of chylothorax during the fetal life and its management before and after delivery are discussed.

[The value of a large obstetrical database]

The author presents his views on the advantage of a large database in obstetrics. The objectives and methods, as well as the main previously encountered difficulties, are analyzed.

Clinical experience in student nurse training

This paper presents some results on the range of clinical responsibilities undertaken by three cohorts of student nurses in basic training. It concentrates on the quantity and variety of a student's clinical experience. Seventy-seven important items in nurse training, classified into three groups (general nursing, responsibility situations and interpersonal situations) are discussed.