Current Doctors News Results

An outsider's perspective on a provocative proposal: What would Flexner think?

Anat Sci Educ. 2010 Mar 8;
Anderson MB

This viewpoint commentary focuses on a proposal for integrated anatomy education in undergraduate college from Dr. Darda published in the Anatomical Sciences Education. Although the proposal is for college level education, the proposal echoes some ideas proposed a century ago by Abraham Flexner when he wrote his report titled "Medical Education in the United States and Canada." It begins with an acknowledgement of the author's status as an outsider. There have been numerous calls for change in basic science education, particularly in medical education. Interestingly, however, the monumental reforms of the "Flexner Report" were impelled largely from outside the specific discipline of medical education. The commentary discussion then moves to observations about the proposal for Integrative Anatomy and support for the proposal from both the Flexner Report and the 2009 report from the Association of American Medical Colleges and the Howard Hughes Medical Institute, "Scientific Foundations for Future Physicians." The essay considers the benefits of the research on the learning sciences that now inform our work in education; the influence of competency-based education that frees education from a lock-step approach of course completion to a student-focused integrative approach to learning; and the availability of online resources for anatomy education through repositories, such as MedEdPORTAL. The final observation is that the changes underway in education and in the sciences basic to medicine, in particular, are substantial and will require the dialogue that Dr. Darda is promoting with his provocative proposal. Anat Sci Educ, 2010. (c) 2010 American Association of Anatomists.

The effect of alcohol on radiographic progression in rheumatoid arthritis.

Arthritis Rheum. 2010 Mar 8;
Nissen MJ, Gabay C, Scherer A, Finckh A,

BACKGROUND:: Alcohol consumption reduces the risk of development of Rheumatoid Arthritis (RA) and significantly attenuates the development of erosive arthritis in animal models. It remains unknown whether alcohol consumption influences joint damage progression in RA. OBJECTIVE:: To compare the rates of radiographic damage progression in alcohol drinkers (D) and non-drinkers (ND) in a large prospective RA cohort. METHODS:: All patients in the population-based SCQM-RA registry database with at least 2 sequential radiographs were included. Joint erosions were assessed in 38 hand and feet joints with a validated scoring method. The rate of erosive progression (DeltaERO) was analysed using multivariate regression models for longitudinal data and adjusted for potential confounders. RESULTS:: 2908 RA patients with a mean of 4 sequential radiographs and 3.9 years of follow-up were included. A trend towards reduced radiographic progression existed in D compared to ND, with DeltaERO of 0.99% (0.89-1.09) and 1.13% (1.00-1.26) at one year respectively. Alcohol consumption displayed a "J-shaped" dose response effect, with a more favorable evolution in "occasional consumers" (p=0.01) and "daily consumers" (p=0.001), compared to non-drinkers, while "heavy-drinkers" demonstrated worse radiographic evolution (p=0.0001). We found significant effect modification by sex, with male D displaying significantly less DeltaERO compared to male ND (0.86% (0.70-1.03) versus 1.35% (1.02-1.67), p=0.007). CONCLUSION:: A trend towards reduced radiographic progression was observed in alcohol drinkers compared to non-drinkers, specifically in occasional and daily alcohol consumers, and in particular, male RA patients who consume alcohol demonstrate less radiographic progression than male non-drinkers.

Patient-based continuum of care in nephrology: why read Thomas Addis' "Glomerular Nephritis" in 2010?

J Nephrol. 2010 Mar 1; 23(2): 164-167
Piccoli GB

The name of Thomas Addis (1881-1949) is linked to several aspects of nephrological practice: from the "Addis count" of urinary elements, to the history of diet in chronic kidney diseases. He was accustomed to working with limited funds, and developed his theories with relatively simple means, combined with the careful, long-term observation of single cases. His political ideas were progressive; his outlook on life was optimistic. This is deeply reflected in his Glomerular Nephritis: Diagnosis and Treatment, a book worth reading in the era of chronic kidney disease (CKD), as it contains sharp analyses of the organizational aspects, and accurate comments on the role of the physician - all subjects of interest for the present times and challenges. One of Addis' ingenious ideas was to follow his patients throughout their lifelong disease, thus anticipating the theories of continuum of care and of therapeutic alliance between patients and physicians. He used to tailor his prescriptions and frequency of controls to each patient and phase of the disease, thus anticipating the tailored therapies and the patient empowerment presently considered as fundamental in chronic diseases. Furthermore, he suggested that physicians should work outside the hospital in small coordinated teams, in which volunteers, dietitians and laboratory technicians would play a crucial role. Patient-centered care and the importance of nonmedical team members are clear from the first lines of his book. As far as we know, he was the first physician to stress the role of volunteers in CKD, anticipating by decades nonprofit organizations such as the National Kidney Foundation.

30th Anniversary of the "Kuratorium Tuberkulose in der Welt"

Pneumologie. 2010 Mar 8;
Siemon G

The "Kuratorium Tuberkulose in der Welt" is a non-profit association to fight tuberculosis (TB) in the world. It was founded by a group of idealist physicians 30 years ago. Its tasks are to fight against TB, especially in developing countries, to propagate the knowledge of TB prevention and therapy, and to promote research in the field of TB. The "Kuratorium" has set up projects in Santa Cruz (Bolivia), Kathmandu (Nepal), Lomé (Togo), Kiev (Ukraine), and Stavropol (Russia). In cooperation with the WHO, the International Union against Tuberculosis and Lung Disease (IUATLD), and local anti-tb-organisations microbiologic laboratories were established for case detection and therapeutic monitoring. Local staffs were trained and strategies to combat TB were implemented. For more than 30 years the "Kuratorium Tuberkulose in der Welt" has worked successfully and beneficially, despite of often difficult political situations. It has received great appreciation for its achievements.

Treatment of migraine and tension-type headache in Croatia.

J Headache Pain. 2010 Mar 6;
Vuković V, Plavec D, Lovrenčić Huzjan A, Budišić M, Demarin V

The aim of this study was to assess the treatment patterns of migraine and tension-type headache in the Croatian population. Analysis included the proportion of patients who were taking specific antimigraine therapy and the number of tablets per attack per month, the proportion of patients who were taking prophylactic therapy or using alternative treatment methods and their satisfaction with the treatment. The design of the study was a cross-sectional survey. Self-completed questionnaires were randomly distributed to adults >18 years of age in the Croatian population. A total of 616 questionnaires were analyzed: 115 patients with migraine (M), 327 patients with tension-type headache (TTH), and 174 patients with probable migraine (PM) and TTH. Specific antimigraine therapy was taken by half of patients with migraine: 35.7% of patients used triptans and 21.7% ergotamines. Prophylactic treatment had been used by 13.9% of M, 1.2% of TTH, and 6.9% of PM patients. Alternative methods of treatment were tried by 27% of M and TTH patients. Only 16.8% of patients with M pay regular visits to physicians, while 36.3% never visited a physician. More than half of TTH patients have never visited a physician. The majority of patients are only partially satisfied with their current treatment, and almost one-third are not satisfied. Results of this study indicate that the treatment of primary headaches in Croatia should be improved.

A guideline to fill the gap between endoscopists and physicians who prescribe anticoagulant and/or antiplatelet agents.

J Gastroenterol. 2010 Mar 9;
Lee SY

Reply: A guideline to fill the gap between endoscopists and physicians who prescribe anticoagulant and/or antiplatelet agents : Comment on the letter to the editor of Dr. Sun-Young Lee.

J Gastroenterol. 2010 Mar 9;
Ono S, Fujishiro M, Koike K

A Randomized Controlled Trial of a Multilevel Intervention to Increase Colorectal Cancer Screening among Latino Immigrants in a Primary Care Facility.

J Gen Intern Med. 2010 Mar 6;
Aragones A, Schwartz MD, Shah NR, Gany FM

BACKGROUND: Latino immigrants face a higher burden of colorectal cancer (CRC) and screening rates are low. OBJECTIVE: To assess the effectiveness of a multilevel intervention in increasing the rate of CRC screening among Latino immigrants. DESIGN: A randomized controlled trial, with randomization at the physician level. PARTICIPANTS: Pairs of 65 primary care physicians and 65 Latino immigrant patients participated, 31 in the intervention and 34 in the control group. INTERVENTION: CRC educational video in Spanish on a portable personal digital video display device accompanied by a brochure with key information for the patient, and a patient-delivered paper-based reminder for their physician. MEASUREMENTS: Completed CRC screening, physician recommendation for CRC screening, and patient adherence to physician recommended CRC screening. RESULTS: The overall rate of completed screening for CRC was 55% for the intervention and 18% for the control group (p = 0.002). Physicians recommended CRC screening for 61% of patients in the intervention group versus 41% in the control group (p = 0.08). Of those that received a recommendation, 90% in the intervention group adhered to it versus 26% in the control group (p = 0.007). CONCLUSIONS: The intervention was successful in increasing rates of completed CRC screening primarily through increasing adherence after screening was recommended. Additional efforts should focus on developing new strategies to increase physician recommendation for CRC screening, while employing effective patient adherence interventions.

A staff questionnaire study of MRSA infection on ENT and general surgical wards.

Eur Arch Otorhinolaryngol. 2010 Mar 7;
Phillips PS, Golagani AK, Malik A, Payne FB

Methicillin-resistant Staphyloccocus aureus (MRSA) infection has received much attention in both the medical and non-medical press. However, it is not widely encountered on ENT wards, given the profile of short-stay, relatively well patients, although its impact seems to be increasing. We wished to explore the knowledge and attitudes towards MRSA on general surgical and ENT wards, and see if there were any significant differences between specialties, or between doctors and nurses. A 13-item questionnaire with a Likert scale response with six knowledge questions and seven attitude questions was prepared. It was completed anonymously by all nursing and medical staffs on the ENT and general surgical wards of a large District General Hospital. ENT doctors displayed the lowest knowledge and attitude scores; however, this only attained significance in terms of the knowledge of the difference between infection and colonization. Overall, nurses displayed significantly more positive attitudes towards MRSA patients than doctors, but knowledge scores were not significantly different between professions. The study suggests a lack of knowledge about and preponderance of negative attitudes towards MRSA amongst ENT doctors. The difference between colonization and infection is not well understood. Reasons for this may include the relative rarity of MRSA cases on ENT wards.

Clinical investigation of malignant mesothelioma in Japan.

J Cancer Res Clin Oncol. 2010 Mar 6;
Fujimoto N, Aoe K, Gemba K, Kato K, Yamazaki K, Kishimoto T

PURPOSE: The asbestos-related problems caused much social concern; however, no large-scale study was conducted about clinical features of MM in Japan. Patients with MM who have a history of occupational asbestos exposure (AE) are provided worker's compensation in Japan. However, only about 10% of MM cases were actually claimed and compensated. So there is still controversy over the association between MM and AE. The aim of this study is to investigate the clinical features of MM. We also aimed to clarify the association between MM and occupational AE in Japan. METHODS: We examined the clinical features of MM cases. Clinical information was obtained including gender, age, site of origin, pathological subtype, radiological findings, and treatment outcome. To investigate the association between MM and AE, investigators interviewed all patients regarding work and residential history. RESULTS: Between January 2005 and December 2007, 105 cases (median age: 63 years, range 35-80, male/female: 88/17) were diagnosed with MM in the Rosai Hospital group and related facilities. Among them, 94(89.5%) cases originated in the pleura, 7(6.7%) in the peritoneum, 2(1.9%) in the pericardium, and 1(0.9%) in the tunica vaginalis testis. There were 69(65.7%) epithelioid, 19(18.1%) biphasic, 16(15.2%) sarcomatoid, and 1 unclassified pathological subtypes of MM. A favorable survival rate was indicated in the patient group of MPM that underwent surgery compared to others, though it was not statistically significant (P = 0.1743). The occupational AE was indicated in 89 cases (84.8%). Three patients had no history of occupational AE, but lived with someone who was in an occupation that handled asbestos. There were two patients in which AE was indicated in their life environment. Altogether, AE was indicated in 93(88.6%) patients. CONCLUSIONS: This study stresses the urgent need for physicians to acknowledge the association between MM and AE, and to inquire thoroughly regarding AE to the patients with MM.

Hand decontamination practices and the appropriate use of gloves in two adult intensive care units in Malaysia.

J Infect Dev Ctries. 2010; 4(2): 118-23
Katherason SG, Naing L, Jaalam K, Nik Mohamad NA, Bhojwani K, Harussani ND, Ismail A

BACKGROUND: Hand decontamination is a critical infection control practice in the prevention of nosocomial infection. This study was conducted to observe the hand hygiene practices of nurses and doctors in two intensive care units (ICUs) in Malaysia. METHODOLOGY: Staff members were observed during patient contacts, and their hand washing techniques and hand hygiene practices were monitored. Five contact periods were observed for staff members while they cared for their assigned patients. Hand hygiene practices before and after patient contacts were categorized as clean uncontaminated, clean recontaminated, new gloves, and unchanged contaminated gloves. Compliance to hand-washing steps and time taken for hand washing were analyzed. Appropriate use of gloves based on CDC criteria also was assessed. RESULTS: Compliance to hand hygiene practices was 70% before each patient contact. Staff members did not completely adhere to the hand-washing steps. The average time taken to wash hands was 20 seconds, and the necessary steps (rubbing palm over dorsum; rubbing fingers interlaced, and rotational rubbing of thumbs) were practiced minimally by all staff. Hand washing protocol was generally followed by all staff (100%). Alcohol hand rubs were available but were used moderately (60%); when used, staff members did not wait for the alcohol to dry. Only 4% of staff changed contaminated gloves between patients. CONCLUSIONS: Hand hygiene compliance by ICU staff members needs to be improved. Improving adherence to correct hand hygiene techniques will require effective education programs and behavioral modification techniques. Moreover, hand hygiene guidelines must be incorporated into new staff orientation programs and the continuing education curriculum in the two hospitals studied.

Patients' Question-Asking Behavior During Primary Care Visits: A Report From the AAFP National Research Network.

Ann Fam Med. 2010 Mar-Apr; 8(2): 151-9
Galliher JM, Post DM, Weiss BD, Dickinson LM, Manning BK, Staton EW, Brown JB, Hickner JM, Bonham AJ, Ryan BL, Pace WD

PURPOSE: The Ask Me 3 (AM3) health communication program encourages patients to ask specific questions during office visits with the intention of improving understanding of their health conditions and adherence to treatment recommendations. This study evaluated whether implementing AM3 improves patients' question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. METHODS: This randomized trial involved 20 practices from the American Academy of Family Physicians National Research Network that were assigned to an AM3 intervention group or a control group. Forty-one physicians in the practices were each asked to enroll at least 20 patients. The patients' visits were audio recorded, and recordings were reviewed to determine whether patients asked questions and which questions they asked. Patients were interviewed 1 to 3 weeks after the visit to assess their recall of physicians' recommendations, rates of prescription filling and taking, and attempts at complying with lifestyle recommendations. RESULTS: The study enrolled 834 eligible patients in 20 practices. There were no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. There also were no differences in rates of either filling or taking prescriptions, although rates of these outcomes were fairly high, too. Control patients were more likely to recall that their physician recommended a lifestyle change, however (68% vs 59%, P=.04). CONCLUSIONS: In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.

Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A Randomized Controlled Trial.

Ann Fam Med. 2010 Mar-Apr; 8(2): 124-33
Cals JW, Schot MJ, de Jong SA, Dinant GJ, Hopstaken RM

PURPOSE: Antibiotics are only beneficial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common. C-reactive protein (CRP) point-of-care testing and delayed prescribing are useful strategies to reduce antibiotic prescribing, but both have limitations. We evaluated the effect of CRP assistance in antibiotic prescribing strategies-including delayed prescribing-in the management of LRTI and rhinosinusitis. METHODS: We conducted a randomized controlled trial in which 258 patients were enrolled (107 LRTI and 151 rhinosinusitis) by 32 family physicians. Patients were individually randomized to CRP assistance or routine care (control). Primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery. RESULTS: Patients in the CRP-assisted group used fewer antibiotics (43.4%) than control patients (56.6%) after the index consultation (relative risk [RR] = 0.77; 95% confidence interval [CI], 0.56-0.98). This difference remained significant during follow-up (52.7% vs 65.1%; RR = 0.81; 95% CI, 0.62-0.99). Delayed prescriptions in the CRP-assisted group were filled only in a minority of cases (23% vs 72% in control group, P <.001). Recovery was similar across groups. Satisfaction with care was higher in patients managed with CRP assistance (P = .03). CONCLUSIONS: CRP point-of-care testing to assist in prescribing decisions, including delayed prescribing, for LRTI and rhinosinusitis may be a useful strategy to decrease antibiotic use and increase patient satisfaction without compromising patient recovery.

Experiences and Attitudes of Patients With Terminal Cancer and Their Family Caregivers Toward the Disclosure of Terminal Illness.

J Clin Oncol. 2010 Mar 8;
Yun YH, Kwon YC, Lee MK, Lee WJ, Jung KH, Do YR, Kim S, Heo DS, Choi JS, Park SY

PURPOSE: We investigated the experiences of cancer patients and their family caregivers who became aware that the cancer was terminal, how they became aware, and how they felt about disclosure of the information. PATIENTS AND METHODS: In this cohort study, we administered questionnaires to 619 consecutive patients determined by physicians to be terminally ill and to their family caregivers. RESULTS: A total of 481 patients and 381 family caregivers completed the questionnaire. A majority of patients (58.0%) and caregivers (83.4%) were aware of the patient's terminal status. Approximately 28% of patients and 23% of caregivers reported that they guessed it from the patient's worsening condition. The patient group was more likely than the caregiver group (78.6% v 69.6%) to prefer that patients be informed of their terminal status. Patients informed of their terminal diagnosis had a significantly better quality of life and fewer symptoms and had a lower rate of emotional distress than patients who guessed it from their worsening condition. Younger patients and patients who paid the treatment costs themselves were significantly more likely to want to be told when their illness was terminal. If the patient paid the treatment cost and was employed at the time of the cancer diagnosis, the family caregivers were more likely to prefer disclosure of terminal illness. CONCLUSION: Most patients with terminal cancer and their family caregivers preferred disclosure, and patients who knew of their terminal diagnosis had a lower rate of emotional distress and a higher health-related quality of life.

Rapid expansion of intravitreal drug injection procedures, 2000 to 2008: a population-based analysis.

Arch Ophthalmol. 2010 Mar; 128(3): 359-62
Campbell RJ, Bronskill SE, Bell CM, Paterson JM, Whitehead M, Gill SS

OBJECTIVE: To evaluate patterns of care for age-related macular degeneration following the introduction of vascular endothelial growth factor inhibitors. METHODS: Using a population-based retrospective design, we studied monthly fee claims for intravitreal injections submitted to the Ontario Health Insurance Plan between January 1, 2000, and March 30, 2008, and linked procedures to the physicians who performed them. This database records physician services provided as part of universal health care insurance coverage in Ontario, Canada. This program covers all residents of Ontario, which had an average population of 12.1 million during the study period. RESULTS: Following regulatory approval of bevacizumab for colorectal cancer in 2005, off-label use of this drug for the treatment of retinal disease, particularly age-related macular degeneration, became increasingly common. The rate of intravitreal injections in Ontario rapidly grew 8-fold, and this growth preceded the availability of ranibizumab by more than a year. Moreover, in 2007, more than 50% of intravitreal injections in Ontario were performed by 3% of ophthalmologists. CONCLUSIONS: The development of vascular endothelial growth factor inhibitors has revolutionized the treatment of age-related macular degeneration. To our knowledge, this study is the first to quantify the dramatic uptake of these treatments at a population level. Our findings also suggest that off-label injection of bevacizumab was highly prevalent in Ontario. Serial intravitreal injections requiring direct physician administration and the concentration of injection procedures in the hands of a small number of ophthalmologists have the potential to affect services for other vision-threatening conditions.

Potential use of 10-year and lifetime coronary risk information for preventive cardiology prescribing decisions: a primary care physician survey.

Arch Intern Med. 2010 Mar 8; 170(5): 470-7
Persell SD, Zei C, Cameron KA, Zielinski M, Lloyd-Jones DM

BACKGROUND: Data are sparse regarding how physicians use coronary risk information for prescribing decisions. METHODS: We presented 5 primary prevention scenarios to primary care physicians affiliated with an academic center and surveyed their responses after they were provided with (1) patient risk factor information, (2) 10-year estimated coronary disease risk information, and (3) 10-year and lifetime risk estimates. We asked about aspirin prescribing, lipid testing, and lipid-lowering drug prescribing. RESULTS: Of 202 physicians surveyed, 99 (49%) responded. The physicians made guideline-concordant aspirin decisions 51% to 91% of the time using risk factor information alone. Providing 10-year risk estimates increased concordant aspirin prescribing when the 10-year coronary risk was moderately high (15%) and decreased guideline-discordant prescribing when the 10-year risk was low (2 of 4 cases). Providing the lifetime risk information sometimes increased guideline-discordant aspirin prescribing. The physicians selected guideline-concordant thresholds for initiating treatment with lipid-lowering drugs 44% to 75% of the time using risk factor information alone. Selecting too low or too high low-density lipoprotein cholesterol thresholds was common. Ten-year risk information improved concordance when the 10-year risk was moderately high. Providing lifetime risk information increased willingness to initiate pharmacotherapy at low-density lipoprotein cholesterol levels that were lower than those recommended by guidelines when the 10-year risk was low but the lifetime risk was high. CONCLUSIONS: Providing 10-year coronary risk information improved some hypothetical aspirin-prescribing decisions and improved lipid management when the short-term risk was moderately high. High lifetime risk sometimes led to more intensive prescription of aspirin or lipid-lowering medication. This outcome suggests that, to maximize the benefits of risk-calculating tools, specific guideline recommendations should be provided along with risk estimates.

Statistical Numeracy for Health: A Cross-cultural Comparison With Probabilistic National Samples.

Arch Intern Med. 2010 Mar 8; 170(5): 462-8
Galesic M, Garcia-Retamero R

BACKGROUND: Statistical numeracy is essential for understanding health-related risks and making informed medical decisions. However, this concept has not been investigated with probabilistic national samples or compared cross-culturally. We sought (1) to investigate differences in the level of statistical numeracy between 2 countries with different educational and medical systems-the United States and Germany; (2) to study the relationship between statistical numeracy and demographic characteristics such as age, sex, and education; and (3) to test whether a subjective measure of numeracy is a valid indicator of objective measures. METHODS: In a survey of probabilistic, representative national samples in Germany and the United States, conducted in July and August 2008, we asked questions testing objective and subjective statistical numeracy. RESULTS: German participants had higher numeracy skills than did US participants. On average, 68.5% (SE, 1.1%) and 64.5% (SE, 1.3%), respectively, of items testing objective numeracy were answered correctly. Subjective estimates of numeracy were a good indicator of the objective measures. There is a large gap in numeracy skills between persons with lower and higher educational levels, particularly in the United States. CONCLUSIONS: Physicians should be aware that many patients may not understand all information relevant to making an informed decision. Fortunately, they can identify such patients and use nonnumerical presentation formats, such as graphical displays and analogies, to communicate important statistical information.

Physician visits prior to treatment for clinically localized prostate cancer.

Arch Intern Med. 2010 Mar 8; 170(5): 440-50
Jang TL, Bekelman JE, Liu Y, Bach PB, Basch EM, Elkin EB, Zelefsky MJ, Scardino PT, Begg CB, Schrag D

BACKGROUND: The 2 primary therapeutic interventions for localized prostate cancer are delivered by different types of physicians, urologists, and radiation oncologists. We evaluated how visits to specialists and primary care physicians (PCPs) by men with localized prostate cancer are related to treatment choice. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we identified 85 088 men with clinically localized prostate cancer diagnosed at age 65 years or older, between 1994 and 2002. Men were categorized by primary treatment received within 9 months of diagnosis: radical prostatectomy (n = 18 201 [21%]), radiotherapy (n = 35 925 [42%]), androgen deprivation (n = 14 021 [17%]), or expectant management (n = 16 941 [20%]). Visits to specialists and PCPs were analyzed by patient characteristics and primary therapies received and were identified using Medicare claims and the American Medical Association Physician Masterfile. RESULTS: Overall, 42 309 men (50%) were seen exclusively by urologists, 37 540 (44%) by urologists and radiation oncologists, 2329 (3%) by urologists and medical oncologists, and 2910 (3%) by all 3 specialists. There was a strong association between the type of specialist seen and primary therapy received. Visits to PCPs were infrequent between diagnosis and receipt of therapy (22% of patients visited any PCP and 17% visited an established PCP) and were not associated with a greater likelihood of specialist visits. Irrespective of age, comorbidity status, or specialist visits, men seen by PCPs were more likely to be treated expectantly. CONCLUSIONS: Specialist visits relate strongly to prostate cancer treatment choices. In light of these findings, prior evidence that specialists prefer the modality they themselves deliver and the lack of conclusive comparative studies demonstrating superiority of one modality over another, it is essential to ensure that men have access to balanced information before choosing a particular therapy for prostate cancer.

microRNA-29a induces aberrant self-renewal capacity in hematopoietic progenitors, biased myeloid development, and acute myeloid leukemia.

J Exp Med. 2010 Mar 8;
Han YC, Park CY, Bhagat G, Zhang J, Wang Y, Fan JB, Liu M, Zou Y, Weissman IL, Gu H

The function of microRNAs (miRNAs) in hematopoietic stem cells (HSCs), committed progenitors, and leukemia stem cells (LSCs) is poorly understood. We show that miR-29a is highly expressed in HSC and down-regulated in hematopoietic progenitors. Ectopic expression of miR-29a in mouse HSC/progenitors results in acquisition of self-renewal capacity by myeloid progenitors, biased myeloid differentiation, and the development of a myeloproliferative disorder that progresses to acute myeloid leukemia (AML). miR-29a promotes progenitor proliferation by expediting G1 to S/G2 cell cycle transitions. miR-29a is overexpressed in human AML and, like human LSC, miR-29a-expressing myeloid progenitors serially transplant AML. Our data indicate that miR-29a regulates early hematopoiesis and suggest that miR-29a initiates AML by converting myeloid progenitors into self-renewing LSC.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study.

CMAJ. 2010 Mar 8;
Villeneuve J, Genest J, Blais L, Vanier MC, Lamarre D, Fredette M, Lussier MT, Perreault S, Hudon E, Berbiche D, Lalonde L

BACKGROUND: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. METHODS: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients' adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in lowdensity lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. RESULTS: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was -0.2 mmol/L (95% confidence interval [CI] -0.3 to -0.1), and the adjusted reduction was -0.05 (95% CI -0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). INTERPRETATION: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.