Answering questions at the point of care: do residents practice EBM or manage information sources?

PURPOSE

To determine the types of information sources that evidence-based medicine (EBM)-trained, family medicine residents use to answer clinical questions at the point of care, to assess whether the sources are evidence-based, and to provide suggestions for more effective information-management strategies in residency training.

METHOD

In 2005, trained medical students directly observed (for two half-days per physician) how 25 third-year family medicine residents retrieved information to answer clinical questions arising at the point of care and documented the type and name of each source, the retrieval location, and the estimated time spent consulting the source. An end-of-study questionnaire asked 37 full-time faculty and the participating residents about the best information sources available, subscriptions owned, why they use a personal digital assistant (PDA) to practice medicine, and their experience in preventing medical errors using a PDA.

RESULTS

Forty-four percent of questions were answered by attending physicians, 23% by consulting PDAs, and 20% from books. Seventy-two percent of questions were answered within two minutes. Residents rated UptoDate as the best source for evidence-based information, but they used this source only five times. PDAs were used because of ease of use, time factors, and accessibility. All examples of medical errors discovered or prevented with PDA programs were medication related. None of the participants' residencies required the use of a specific medical information resource.

CONCLUSIONS

The results support the Agency for Health Care Research and Quality's call for medical system improvements at the point of care. Additionally, it may be necessary to teach residents better information-management skills in addition to EBM skills.

Extracorporeal photochemotherapy in patients with cutaneous T-cell lymphoma: is clinical response predictable?

BACKGROUND

Extracorporeal photochemotherapy (ECP) has been accepted as a standard therapy in cutaneous T-cell lymphomas (CTCL), a category of lymphomas mainly resistant to conventional therapies. Approximately one half of patients demonstrate a reduction in skin affliction by at least 50% within 12 months of therapy and are categorized as responders to ECP. Predictive criteria for selecting patients who will respond to ECP are lacking. Such criteria would however, be of great benefit.

OBJECTIVES

This study compared T-cell clonality and serum levels of soluble interleukin-2 receptor (sIL-2R), lactate dehydrogenase (LD), neopterin, beta2-microglobulin (beta(2)-M) and granzyme B in CTCL patients in order to evaluate their potential usefulness as predictive markers.

PATIENTS/METHODS

Serum and T lymphocytes obtained from 16 patients with CTCL receiving ECP treatment were evaluated in an open retrospective study.

RESULTS

We found no evident correlation between detected T-cell clonality and response to ECP. The non-responding group had on average a higher level of serum sIL-2R. This difference was significant after 6 and 12 months of therapy, but not pretreatment. An individual reduction in serum sIL-2R, neopterin and beta(2)-M during a 6-month course of ECP was well correlated to clinical remission.

CONCLUSIONS

Seven out of 16 patients were classified as responders. Neither T-cell clonality nor any of the serum markers assessed pretreatment could reliably predict the response to ECP treatment. However, the individual relative changes in sIL-2R, neopterin and beta(2)-M during 6 months of ECP treatment coherently displayed correlation to the clinical response, as assessed after 12 months of ECP treatment.

Spontaneous rupture of the hepatic artery in a patient with type 1 neurofibromatosis treated by embolization: a case report

We report the case of a 48-year-old man with neurofibromatosis presenting with sudden-onset abdominal pain, profound hypotension, and a drop in hemoglobin. CT scan demonstrated a massive hematoma within the right lobe of the liver with rupture into the peritoneal cavity. Angiography demonstrated diffuse abnormalities of the hepatic circulation with fusifom, ectatic, and stenotic segments. Acute extravasation from a peripheral branch of the right hepatic artery was identified and successfully embolized with subsequent hemodynamic stabilization of the patient. To the best of our knowledge this is the first case report of this kind in a patient with type I neurofibromatosis.

mTOR inhibition induces endothelial progenitor cell death

Immunosuppressants are necessary to prevent graft rejection after solid organ transplantation. However, they are also known to have significant side effects, including endothelial toxicity. Endothelial progenitor cells originate in the bone marrow and are recognized by their angiogenic and endothelial reparative properties. The effects of the immunosuppressants cyclosporine A (CyA), tacrolimus and rapamycin were analyzed on endothelial progenitor-like cells. Rapamycin induced rapid cell death, even at concentrations much lower than those used clinically, in peripheral blood mononuclear cells (PBMC) cultured to favor outgrowth of endothelial progenitors. Cyclosporine A and tacrolimus had no significant effects at clinical concentrations. The effect of rapamycin was specific to endothelial progenitor cells, in particular to the early stages of differentiation, as a lesser effect was observed in late outgrowth endothelial progenitors, mature aortic endothelial cells, and macrophages derived from the same PBMCs. The mechanism of cell death appeared to be apoptosis; however, its induction was probably multifactorial and did not depend on caspase or cathepsin activation. In conclusion, rapamycin induces endothelial progenitor cell death, possibly because it blocks survival signals given by growth factors critically required by these cells.

An open-label study of escitalopram (Lexapro) for the treatment of 'Depression of Alzheimer's disease' (dAD)

BACKGROUND

Depression is a frequent neuropsychiatric complication of Alzheimer's Disease.

METHODS

This study investigated the safety and effectiveness of escitalopram (LEXAPRO) for depression in AD (dAD) as defined by the NIMH consensus criteria in an 8-week, open-label treatment study.

CONCLUSION

Escitalopram was efficacious and safe for the treatment of dAD in this study. Larger, controlled studies are warranted to further assess the efficacy for mood and behavioral disturbances in this medically fragile population.

Increased expression of Mycobacterium tuberculosis 19 kDa lipoprotein obliterates the protective efficacy of BCG by polarizing host immune responses to the Th2 subtype

Mycobacterium tuberculosis can not only neutralize immune effector functions, but also has the ability to modulate host-signalling cascades involved in the development of these responses. The 19 kDa antigen (Rv3763), a lipoprotein of M. tuberculosis, elicits high levels of interleukin (IL)-12 from macrophages in addition to its powerful immunomodulatory properties, leading to suppression of antigen-presentation signalling cascades. The present study was aimed at analysing the effect of overexpression of this antigen on the immunostimulatory properties of M. bovis Bacille Calmette-Guerin (BCG). We have constructed a recombinant BCG strain (rBCG19N) producing higher levels of the 19 kDa antigen in both the cytoplasmic (approximately eightfold) and extracellular (approximately fivefold) fractions as compared to the wildtype BCG. Immunization of mice with rBCG19N elicited high levels of interferon-gamma (IFN-gamma) and relatively low levels of IL-10 against the purified 19 kDa antigen. However, in response to total BCG sonicate, mice immunized with rBCG19N produced significantly high levels of IL-10 with relatively very low levels of IFN-gamma. This polarization of the host immune responses towards T-helper 2 subtype resulted in complete abrogation of the protective efficacy of BCG, when rBCG19N was used as a live vaccine against M. tuberculosis challenge in guinea pigs.

Genotoxicity of the Musi River (Hyderabad, India) investigated with the VITOTOX test

The bacterial VITOTOX genotoxicity test was used to screen water samples collected from three different stations along the banks of the river Musi, in Hyderabad, India. Water was collected at three stations that differed from each other in the nature of the surrounding industrial and other activities. A number of different pollutants were also measured in water, soil and air samples. The three stations were found highly polluted and different with regard to the genotoxicity and toxicity of their samples. These results demonstrate the need for further biological studies in this area to generate valuable data on genomic instability, risk assessment of cancer, and to provide avenues for risk management.

Deep vein thrombosis during rabbit antithymocyte globulin administration

INTRODUCTION

Rabbit antithymocyte globulin (RATG) is recommended for central administration, and no evidence justifies the common practice of adding heparin to the bag, but the evaluation of thrombocytopenia may be complicated by coadministration. We recently phased out the use of heparin in RATG in our kidney and kidney-pancreas transplant recipients but subsequently observed several episodes of deep vein thrombosis (DVT), so we sought to determine the factors linked to DVT during RATG therapy.

METHODS

A search of billing and diagnosis codes for RATG and DVT in one hospital revealed relevant admissions from January 2000 to April 2004.

RESULTS

Patients (n=288) received 330 courses of RATG (central or peripheral), and nine were diagnosed with DVT. Four patients were excluded because the diagnosis was not confirmed by Doppler ultrasound (n=1), DVT occurred more than 10 days after RATG discontinuation (n=2), or DVT occurred after switching to equine antithymocyte globulin (n=1). All patients (n=5) who developed DVT related to RATG exhibited prior infusion-related reactions, received peripherally administered RATG with premedication (methylprednisolone, diphenhydramine, and acetaminophen), and did not receive heparin. The DVT occurred near the site of the infusion in 60% of cases. Four of the patients were male, and 80% had diabetes (one developed posttransplant), and all included patients received infusions over at least 6 hours for the first dose, and at least 4 hours for subsequent doses.

CONCLUSIONS

These results provide justification for adding heparin to the RATG bag, especially when administered peripherally.

Dementia in hippocampal sclerosis resembles frontotemporal dementia more than Alzheimer disease

OBJECTIVE

To characterize the clinical course of pathologically diagnosed hippocampal sclerosis dementia (HSD).

BACKGROUND

Dementia associated with HSD is incompletely characterized. Previous studies suggest similarities to both Alzheimer disease (AD) and frontotemporal dementia (FTD).

METHODS

Case-control analysis of the clinical course of patients with HSD, FTD, and AD from a neuropathology autopsy series conducted by a university hospital. Case histories were reviewed. Cumulative prevalence of behavioral, cognitive, psychiatric, and language symptoms were compared between groups, as was time of symptom onset. Clinical diagnostic criteria for FTD and AD were applied to case histories. Sensitivity and specificity of clinical FTD diagnostic criteria (Report of the Work Group on FTD and Pick's disease) were computed.

RESULTS

Cumulative prevalence of symptoms in HSD was most similar to that of FTD and differed from AD. Behavioral abnormalities such as decreased grooming and inappropriate behavior were more prevalent in HSD and FTD than AD. Hyperorality, inappropriate behavior, and decreased interest had earlier onset in HSD and FTD. Cognitive symptoms of disorientation, dyscalculia, apraxia, and agnosia were more prevalent in AD, as were psychiatric symptoms of hallucinations, delusions, and aggression. Most HSD patients met diagnostic criteria for FTD. Criteria sensitivity was 64.0% and specificity was 73.7%.

CONCLUSIONS

FTD is a clinical syndrome associated with heterogeneous neuropathology. The clinical course of HSD is more similar to that of FTD than AD. These findings, together with the neuropathologic data presented in the accompanying article, support expanding the scope of FTD (Pick complex) to include HSD.