Major Specialties Research Articles

Lung Injury Prevention with Aspirin (LIPS-A): a protocol for a multicentre randomised clinical trial in medical patients at high risk of acute lung injury

IntroductionAcute lung injury (ALI) is a devastating condition that places a heavy burden on public health resources. Although the need for effective ALI prevention strategies is increasingly recognised, no effective...

1987年から20年間に日中笹川医学奨学金で来日した中国人医療従事者についての分析 －中国口腔科医師の受け入れ状況を中心に－

The present paper analyzed Chinese medical staff （including stomatologists, pharmacists, and nurses）, comprising a total 1782 persons who visited Japan from 1987 through 2006 and were sponsored by the Sasagawa Medical Fellowship. Chinese stomatologists accounted for 88 persons among the total of 1782. Among the 88 stomatologists, 15 were from the 4th Military Medical University, 9 from Jilin University, 8 from Beijing University, and 6 from China Medical University; a total of 25 were from North East China. The departments of Japanese universities attended by Chinese stomatologists included 17 departments of in periodontology and conservative dentistry, 16 departments of oral surgery, 12 departments of prosthetics, 11 departments of orthodontics, and 8 departments of pedodontics at dental and medical schools. Stomatologists who had learned major specialties in Chinese stomatological colleges also majored in similar specialties at the Japanese universities or hospitals.Chinese administrators have been investigating Japanese health science systems, including not only medical technology and clinical medicine, but also several administrative specialties such as medical law, public health, provention of infection diseases, cancer, population research, and budgets from both research and clinical perspectives.Medical staff from central administration in the Government of China have also learned considerably from his or her experience during investigations in Japan. No administration staff of stomatologists were supported by the Sasagawa Fund.

Genital herpes in Canada: Deciphering the hidden epidemic.

Genital herpes (GH) is the most common cause of genital ulceration, but is not reportable in Canada. Research in the United States has found that less than 10% of seropositive persons reported a diagnosis of GH. The present article investigates the rates of diagnosed cases of GH in Canada from 2002 to 2007. Primary case diagnosis data on GH for the period between 2002 and 2007 were obtained from the Canadian Disease and Therapeutic Index, a proprietary database maintained by Intercontinental Medical Statistics (IMS) Health Canada. Of the 45,000 to 49,000 office-based physicians in Canada, IMS Health collected diagnosis-specific prescription diaries from a sample of 652, stratified according to geographic region and representing all major specialties, during this period. Between 2002 and 2007, there were approximately 84,398 to 122,456 medically attended GH cases annually in Canada. Approximately 74% to 93% of these diagnosed cases made one physician visit per year. The annual rate of medically attended GH cases ranged from 261.2 per 100,000 population to 386.6 per 100,000 population. The present report is the first time that administrative data have been used to estimate the annual rate of medically attended GH cases in Canada. The data include both incident and prevalent cases and are likely an underestimate of the actual number of cases because they only represent diagnosed cases presenting for medical care. Further seroepidemiological and clinical research studies would be helpful to assess the burden of infection and to plan appropriate diagnostic, treatment and preventive counselling services. Genital herpes (GH) is the most common cause of genital ulceration, but is not reportable in Canada. Research in the United States has found that less than 10% of seropositive persons reported a diagnosis of GH. The present article investigates the rates of diagnosed cases of GH in Canada from 2002 to 2007. Primary case diagnosis data on GH for the period between 2002 and 2007 were obtained from the Canadian Disease and Therapeutic Index, a proprietary database maintained by Intercontinental Medical Statistics (IMS) Health Canada. Of the 45,000 to 49,000 office-based physicians in Canada, IMS Health collected diagnosis-specific prescription diaries from a sample of 652, stratified according to geographic region and representing all major specialties, during this period. Between 2002 and 2007, there were approximately 84,398 to 122,456 medically attended GH cases annually in Canada. Approximately 74% to 93% of these diagnosed cases made one physician visit per year. The annual rate of medically attended GH cases ranged from 261.2 per 100,000 population to 386.6 per 100,000 population. The present report is the first time that administrative data have been used to estimate the annual rate of medically attended GH cases in Canada. The data include both incident and prevalent cases and are likely an underestimate of the actual number of cases because they only represent diagnosed cases presenting for medical care. Further seroepidemiological and clinical research studies would be helpful to assess the burden of infection and to plan appropriate diagnostic, treatment and preventive counselling services.

Noncardiac Point-of-Care Ultrasound by Nonradiologist Physicians: How Widespread Is It?

The use of point-of-care (POC) ultrasound by nonradiologist physicians has recently been advocated. The aim of this study was to see how widespread this practice is. The Medicare Part B databases for 2004 to 2009 were used. Global and professional component claims for noncardiac ultrasound were tabulated, and utilization rates per 1,000 beneficiaries were calculated. Provider specialty was determined. Utilization rates of ultrasound by radiologists and other specialists were compared, and changes over the years were studied. In 2009, 425.3 Medicare noncardiac ultrasound examinations per 1,000 beneficiaries were performed (+21% since 2004). Of these, radiologists performed 233.7 (55%), and another 15.6 (4%) were done at independent diagnostic testing facilities, for which provider specialty could not be determined. The remaining 175.7 (41%) constituted POC ultrasound by nonradiologists. Between 2004 and 2009, radiologists' utilization rate increased by 17%, compared with 28% for nonradiologists. Radiologists' market share of noncardiac ultrasound was 56.6% in 2004 and 54.9% in 2009. Other major specialties involved in POC ultrasound and their 2009 rates per 1,000 and percentage increases since 2004 were cardiology (39.7 [+60%]), vascular surgery (34.9 [+36%]), primary care (27.2 [+11%]), general surgery (24.2 [+8%]), and urology (22.3 [+12%]). Between 2004 and 2009, there was a 21% increase in the overall utilization rate of noncardiac ultrasound. Point-of-care ultrasound by nonradiologists amounted to 41% of all studies done in 2009. Multiple nonradiologic specialties are involved, but radiologists' involvement is far higher than any other single specialty. Radiologists' ultrasound market share remained relatively stable between 2004 and 2009.

Semiotics for University: Semiosis Makes the World Locally Plural

Abstract The position of semiotics in university can be discovered by the study of the position of semiosis in the universe. Sign action is what constitutes knowing of all kinds, including both propositional and non-propositional knowing. Contemporary semiotic studies have well proved that semiotics belongs to the core of knowledge, which means that semiotics should be one of the main domains, one of the core disciplines in university teaching in parallel to the natural sciences. At several universities in the world this is already happening. One of these-the University of Tartu-can be used as an example worthy of a case study, as it is where semiotics is taught as a major specialty in undergraduate, graduate, and postgraduate levels, and where a course in semiotics is also provided as a core ( methodological) course for students of many specialties. The proper place for semiotics in university entails the cooperation between biosemiotics and cultural semiotics.

Present and Future of Korean Geriatrics

Worldwide, aged population has been rising since the Second World War. Developed countries have already taken measures to confront various problems brought by the phenomenon. Korea, with its population aging faster than any other countries, is developing national plans of action as well. The Korean government developed several strategies comprising long-term care insurance policies. In 2004, it attempted to newly recognize geriatric medicine as a specialty, but the efforts were futile in the face of medical societies seeking interests. Established in 1968, the Korean Geriatric Society reached 6,000 members in 2010. It has been decided that the 20th International Association of Gerontology and Geriatrics World Congress of Gerontology and Geriatrics in 2013 will be held in Seoul. Despite the circumstances, medical colleges are still failing to provide enough education on geriatric medicine, and geriatricians are not playing critical roles in caring elderly individuals in Korea. As the population is aging more rapidly, we will be facing numerous obstacles in maintaining the present society. It is imperative that the government recognize geriatric medicine as a major specialty to meet the demands of our future society. We hope that geriatricians will eventually take major actions to confront the health problems of the aged population and contribute not only to education of medical students but also to training of medical doctors in preparation for the near coming future.

Reporting of Research Quality Characteristics of Studies Published in 6 Major Clinical Dental Specialty Journals

The objective of this article was to record reporting characteristics related to study quality of research published in major specialty dental journals with the highest impact factor (Journal of Endodontics, Journal of Oral and Maxillofacial Surgery, American Journal of Orthodontics and Dentofacial Orthopedics; Pediatric Dentistry, Journal of Clinical Periodontology, and International Journal of Prosthetic Dentistry). The included articles were classified into the following 3 broad subject categories: (1) cross-sectional (snap-shot), (2) observational, and (3) interventional. Multinomial logistic regression was conducted for effect estimation using the journal as the response and randomization, sample calculation, confounding discussed, multivariate analysis, effect measurement, and confidence intervals as the explanatory variables. The results showed that cross-sectional studies were the dominant design (55%), whereas observational investigations accounted for 13%, and interventions/clinical trials for 32%. Reporting on quality characteristics was low for all variables: random allocation (15%), sample size calculation (7%), confounding issues/possible confounders (38%), effect measurements (16%), and multivariate analysis (21%). Eighty-four percent of the published articles reported a statistically significant main finding and only 13% presented confidence intervals. The Journal of Clinical Periodontology showed the highest probability of including quality characteristics in reporting results among all dental journals.

Clinical Trials in Orthopaedics Research. Part II. Prioritization for Randomized Controlled Clinical Trials *

The American Academy of Orthopaedic Surgeons (AAOS) and Orthopaedic Research Society (ORS) Clinical Trials in Orthopaedics Research Symposium had three major themes including barriers to performing clinical trials, methodology of clinical trials, and prioritization of clinical questions in orthopaedics to address in randomized controlled trials. This paper addresses the latter theme. Clinical experts from the major orthopaedic specialties provided presentations on key issues in their respective fields that had been addressed with clinical trials and the clinical questions that were most appropriate and pressing for clinical trials. Clinicians caring for patients with musculoskeletal disorders must make treatment decisions daily. While the number of clinical trials has increased dramatically in the last two decades, many clinical decisions remain guided by a weak evidence base. The most rigorous evidence for evaluating the efficacy of interventions comes from randomized controlled trials. While it is tempting to envision filling each gap in the clinical evidence base with a randomized controlled trial, trials are resource intensive. The scientific community cannot perform a randomized controlled trial to answer every clinical question. How, then, do clinical scientists prioritize potential trials to select those that yield the most favorable balance between the resources required to conduct the trial and the value of the information a trial would yield? We suggest approaching these critical questions through three complementary lines of inquiry. The first is evaluation of the information that would be gained if the trial were executed successfully. The second is the feasibility of the trial. The final consideration is the resource cost of performing the trial. We ask: What would be gained from the trial? What would it take for the trial to succeed in answering the study question? What would it cost? The first goal of this paper is to articulate a framework for prioritizing clinical trials …

Increasing interest in PK and PD studies has many advantages for anesthesiologists

In this issue of the Korean journal of anesthesiology, Bae and colleagues [1] studied the induction and maintenance dose of propofol for anesthesia in major burn patients. They reported that an induction dose of 1.5 mg/kg is appropriate and a slow infusion rate of 20 mg/kg/hr is safe for maintaining the desirable hypnotic condition and this causes no significant hemodynamic problems. Many pathophysiologic alterations in patients with major burn can cause changes in the response of propofol. Many other diseases can change the of anesthetic drugs in patients. The study of Bae and colleagues [1] would seem to reflect the increasing interest of anesthesiologists in clinical pharmacologic study. Korean anesthesiologists have recently focused on the clinical pharmacologic studies including pharmacokinetic/pharmacodynamic (PK/PD) modeling. The Korean Society for Intravenous Anesthesia changed its formal name to the Korean Society for Anesthetic Pharmacology in May 2008. Microemulsion propofol was developed in Korea and its induction and recovery characteristics have been evaluated [2]. Historically, modern anesthesia has slowly developed as a medical discipline since William Morton first administered ether to a patient. But anesthesia today stands out as the major primary medical specialty that routinely incorporates clinical pharmacology principles into patient care. Anesthesiologists have made major contributions to clinical pharmacology in the areas of physiological pharmacokinetics, PK-PD modeling and pharmacogenetics [3]. Physiologic pharmacokinetic models describe the time sequences of the measured blood and tissue drug concentrations by apportioning the cardiac output and hence the drug distribution, among the tissues with similar perfusion and drug solubility characteristics [4]. Brodie et al. [5] demonstrated that the effects of small doses of thiopental were terminated by redistribution from the site of action to other body tissues and not by metabolism. The physiologic pharmacokinetic model provides the first understanding of factors that contribute the variability in response to rapidly acting drugs. PK/PD modeling is the process of constructing a mathematical model to relate the time course of the dose to the concentration (PK) and the concentration to the (PD). Minto and Schnider [6] well summarized the enormous contribution of PK/PD modeling to advances in intravenous anesthesia. They said that PK/PD models have provided us with insight into the factors affecting the onset and offset of drugs' effects. The PK/PD model was postulated from the most important concept of the effect compartment model and this concept was developed from the data obtained from experiments where a neuromuscular-blocking agent was administered [7,8]. The data was modeled to integrate and characterized the lag time between the time course of the concentration of a drug and the time course of its measured effect. This concept was developed under the circumstances that patients are routinely and exhaustively monitored during anesthesia. This makes it easy to observe and quantify the effects of anesthetic drugs. Anesthesia has been the benchmark for the development of new concepts and principles in clinical pharmacology. Using PK/PD modeling techniques from the early phases of clinical development has helped to define the characteristics of most drugs and specially those drugs that are intravenously administered. With the appropriate statistical methodology, the effects of covariate factors have been identified and based on all this, rational dosing guidelines have been defined and later validated in routine clinical use [9]. For the point of view of the clinical pharmacologist, intravenously administered anesthetic drugs have concepts and lessons that are valuable for drug development. The intravenously administered hypnotic and opiate drugs that are used for producing anesthesia have fundamental characteristics that are applicable to all drug development. These characteristics include the 100% bioavailability and a precise knowledge of the administered drug dose, easy access to blood sampling, linear PKs, relatively rapid onset and offset, a profound degree of drug from awake to completely unconscious and the ability to directly record the drug effects as shown on an electroencephalogram [10]. Anesthesiologists have many advantages to gain knowledge and data for drug discovery, development, regulation, and utilization.

Changes in Resident Work and Sleep Hours 1999 to 2009: Results From a Survey of 4 Specialties

Resident work hours have been a recurring source of concern and controversy for many years. From the Spartan origins of the Halsted generic model of the surgical service at Johns Hopkins in 1897 to the present, there have been major tensions between the educational needs of learners and the workload demands of patient care, resulting, at times, in classic labor-management confrontations about work hours and conditions.

Perceived practice change in Australian doctors as a result of medicolegal concerns

To explore the perceived impact of medicolegal concerns on how Australian doctors practise medicine and to compare doctors who have experienced a medicolegal matter with those who have not. Cross-sectional survey (posted in September 2007, with reminder 4 weeks later) of Australian doctors from all major specialty groups, trainees and a sample of general practitioners who were insured with a medical insurance company. 2999 respondents of 8360 who were sent the survey. Perceived practice changes due to concerns about medicolegal issues, beliefs about medicolegal issues, and the influence of medicolegal issues on both career choices and how doctors relate to their patients. Respondents reported changes in practice behaviour due to medicolegal concerns, with 43% of doctors stating that they referred patients more than usual, 55% stating that they ordered tests more than usual, and 11% stating that they prescribed medications more than usual. Respondents also reported improved communication of risk (66%), increased disclosure of uncertainty (44%), developed better systems for tracking results (48%) and better methods for identifying non-attenders (39%) and for auditing clinical practice (35%). Concerns about medicolegal issues led to 33% considering giving up medicine, 32% considering reducing their working hours and 40% considering retiring early. These proportions were all significantly greater for doctors who had previously experienced a medicolegal matter compared with those who had not. This Australian study, like international studies, confirms that doctors' concerns about medicolegal issues impact on their practice in a variety of ways. There is a greater perceived impact on those doctors who have previously experienced a medicolegal matter.

Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors

To identify factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors. Cross-sectional postal survey of 2999 doctors (including all major specialty groups, trainees and general practitioners) insured with an Australian medical insurance company. The potential for psychiatric morbidity was measured by the General Health Questionnaire (GHQ), and the potential for hazardous alcohol use by the Alcohol Use Disorders Identification Test (AUDIT). The survey was conducted in 2007. Demographic, work-related and personality factors associated with a GHQ score > 4 and an AUDIT score > or = 8. Factors significantly associated with psychiatric morbidity in doctors were: having a current medicolegal matter, not taking a holiday in the previous year, working long hours, type of specialty, and having personality traits of neuroticism and introversion. Factors significantly associated with potentially hazardous alcohol use were being male, being Australian-trained, being between 40 and 49 years of age, having personality traits of neuroticism and extroversion, failing to meet Continuing Medical Education requirements, and being a solo practitioner. The mental health of medical practitioners is crucial to the quality of care their patients receive. Doctors should reflect on their hours of work and need for holidays. Involvement with medicolegal processes, such as lawsuits, complaints and inquiries, is a stressful part of medical practice today. Doctors need to be educated about these processes and understand how the experience may affect their health, work and loved ones.

The Value of Anesthesiology in Undergraduate Medical Education as Assessed by Medical School Faculty

Unlike Europe and Canada, the majority of American medical schools do not require an anesthesiology rotation. Yet the skill set and knowledge base of anesthesiologists includes many topics of importance to all physicians. Furthermore, the clinical environment offers more procedural experience and real-time physiology and pharmacology for teaching than that available elsewhere. Medical schools, however, often focus on "general medical education" and discount the value of a required anesthesiology clerkship. This begs the question, of the topics anesthesiologists excel at teaching, which are considered important by faculty across the spectrum of medical specialties? Two-hundred-three senior medical students rated the importance to their career of 14 topics currently taught by lecture, simulation or reading assignment in the required anesthesiology curriculum at the University of Florida. Specialty faculty in each of the major specialties similarly rated the topics. The authors compared these with the opinion of 20 anesthesiology faculty who rated the importance of each topic for each major specialty. Overall, acute pain management and acute decompensation management were rated "somewhat" or "very important" by the highest proportion of respondents; followed closely by vascular access and fluid management, non-invasive monitoring and conscious sedation. The topics of interest to surgeons most closely aligned with those offered (12/14 rated somewhat or very important by >75% of faculty polled, 14/14: students), followed by emergency medicine physicians (10/14: faculty, 11/14: students). Significant differences of opinion existed between all three groups on several topics. Anesthesiologists excel in topics important to all future physicians; as many schools enter a new phase of curricular redesign, a rotation in anesthesiology should receive serious consideration. The input of students and physicians in major medical specialties may help define an appropriate curriculum. Including the flexibility for students to adapt that curriculum to individual goals may increase the rotation's value.

An assessment of quality characteristics of randomised control trials published in dental journals

Objectives The purpose of this study was to investigate the quality of reporting of randomised clinical trials (RCTs) published in dental specialty journals. Methods The journals possessing the highest impact factor (2008 data) in the six major dental specialties were included in the study. The contents of the 24 most recent issues of each journal were hand-searched and research articles identified as randomised controlled trials (RCTs) were selected. Quality evaluation was performed using the modified Consolidated Standards of Reporting Trials (CONSORT) statement checklist. The data were analysed using descriptive statistics followed by univariate and multivariate examination of statistical associations ( α = 0.05). Results Ninety-five RCTs were identified with generally suboptimal scores on quality reporting on key CONSORT areas. Significant differences were found among journals with the Journal of Clinical Periodontology achieving the highest score, followed by the American Journal of Orthodontics and Dentofacial Orthopedics. There was a positive association between quality score and number of authors, involvement of statistician/epidemiologist, and multicentre trials. Conclusions The quality scores of RCTs in major dental journals are considered suboptimal in key CONSORT areas. This receives critical importance considering that improved quality of RCTs is a fundamental prerequisite for improved dental care.

Interest in neurology during medical clerkship in three Nigerian medical schools

BackgroundThis study sought to ascertain perception of Nigerian medical students of neurology in comparison with 7 other major medical specialties. To also determine whether neurology was the specialty students consider most difficult and the reasons for this and to appraise their opinion on how neurosciences and neurology were taught in their different universities.MethodsSelf-administered questionnaires were used to obtain information from randomly selected clinical students from 3 medical colleges in Nigeria (University of Ibadan, Ibadan; University of Ilorin, Ilorin; Ladoke Akintola University of Technology, Osogbo).ResultsOf 320 questionnaires sent out, 302 were returned given 94% response rate. Students felt they knew neurology least of all the 8 medical specialties, and were not confident of making neurological diagnoses. About 82% of the students indicated they learnt neurology best from bedside teaching, followed by use of medical textbooks. Close to 15% found online resources very useful for learning neurology and 6% indicated that group discussion was quite useful in the acquisition of knowledge on neurology. Histology and biochemistry were the preclinical subjects participants opined were least useful in learning neurology. The most frequent reasons students felt neurology was difficult were problems with understanding neuroanatomy (49%), insufficient exposure to neurological cases (41%), too many complex diagnoses (32%) and inadequate neurology teachers (32%).ConclusionsNigerian medical students perceived neurology as the most difficult medical specialty and are not interested in specializing in it. Neurology education could be improved upon by provision of more bedside tutorials and increased availability of online resources to enhance learning. There is need to emphasize increased frequency of small group discussions amongst students so that they will be used to teamwork after graduation.

Research and training

How important is it for today’s trainees to acquire research experience? Stephen Bradley and Dan Carradice have sought the opinion of leaders from eight major specialties

Panton-Valentine Leukocidin–Positive MRSA, Shanghai

To the Editor: The development of methicillin resistance in community strains of Staphylococcus aureus is a notable step in the evolution of this pathogen. Unlike their equivalents in the hospital environment, community-associated methicillin-resistant S. aureus (CA-MRSA) strains tend to cause infections in children and young adults who have few known healthcare risks (1). CA-MRSA strains usually possess the Panton-Valentine leukocidin (PVL) genes and staphylococcal cassette chromosome (SCC) mec type IV or V (1,2). We studied 72 S. aureus isolates (49 MRSA and 23 methicillin-susceptible [MSSA]) by pulsed-field gel electrophoresis and by SCCmec, staphylococcal protein A (spa), and multilocus sequence typing (1,3). These isolates were recovered from clinical specimens (52 respiratory specimens, 9 wound, 4 urine, 2 blood, and 5 other body fluids) from 72 patients treated in 5 district hospitals in Shanghai, People’s Republic of China, during October 2005 through January 2007. The isolates were randomly chosen. In the hospitals, ≈1,000 S. aureus isolates were recovered annually during the time period of our study. The 5 hospitals are estimated to serve a population of 3.4 million, equivalent to one fourth of the total population in Shanghai. Hospital D is a children’s hospital. The other 4 hospitals (A, B, C, and E) have all the major clinical specialties, emergency departments, and outpatient clinics. The isolates were identified as S. aureus by Gram stain, latex agglutination (Slide StaphPlus; bioMerieux, Marcy l’Etoile, France), and tube coagulase, mannitol, ornithine, and deoxyribonuclease reactions (1,4). Methicillin resistance in the isolates was detected by cefoxitin disc screening and confirmed by mecA PCR (1,4). For patients with PVL-positive MRSA, the computerized discharge records in the hospitals were retrospectively reviewed to ascertain demographic and clinical information. A MRSA case was considered to be community associated if it was isolated from an outpatient or within 2 days of a patient’s hospitalization. Exclusion criteria included a history of hospitalization for illness (except birth), surgery, or dialysis in the previous year or the presence of indwelling catheters or other medical devices (1). Conversely, healthcare-associated MRSA was defined by isolation >2 days after hospitalization or presence of any of the aforementioned healthcare risks. PVL genes were detected in 9 (18.4%) of the 49 MRSA isolates (Table) and 4 (17.3%) of the 23 MSSA isolates. The 9 MRSA case-patients included 8 infants with pneumonia and 1 adult with prostatitis. Pulsed-field gel electrophoresis clustered 8 of the 9 PVL-positive MRSA isolates into 2 groups: 6 isolates as SH100 and 2 isolates as SH200. Strains of SH100 were spa type/MLST-SCCmec type t318/ST30-IV or t318/ST1114-V, and SH200 strains had t1376/ST88-V. Similar to the PVL-positive MRSA isolates, a limited number of spa types were found among the 40 PVL-negative MRSA isolates. These were t037/ST239-III (n = 19), t002/ST5-II (n = 14), t030/ST239-III (n = 5), t459/ST239-III (n = 1), and t1764/ST88-IV (n = 1). Table Epidemiologic and microbiologic characteristics for Panton-Valentine leukocidin–positive MRSA infections in 9 case-patients, Shanghai, People’s Republic of China, 2006* In contrast, spa and sequence types (STs) among the 23 MSSA isolates were highly diverse. There were 20 spa types and 14 STs, giving a total of 20 distinct patterns. Three patterns (t091/ST7, t3388/ST630, t3389/ST15) had 2 isolates, and 17 patterns (t002/ST5, t1077/ST121, t127/ST1, t1376/ST88, t189/ST188, t2024/ST30, t2092/ST121, t2207/ST1206, t2471/ST25, t258/ST25, t3383/ST20, t3386/ST630, t377/ST630, t437/ST1205, t548/ST5, t701/ST6, t796/ST7) had 1 isolate only. The 4 PVL-positive MSSA isolates were t1376/ST88, t2471/ST25, t258/ST25, and t3383/ST20. Mupirocin resistance rates among the PVL-positive and PVL-negative MRSA isolates were 33.3% (3/9) and 7.5% (3/40), respectively (p = 0.07). All MSSA isolates were susceptible to mupirocin. It is notable that of the 9 PVL-positive MRSA isolates, 8 of them came from hospital D and all were from children 1–4 months of age. Others have noted that the epidemiology of MRSA differs for children and adults (1,2,7,8). Molecular typing showed that the PVL-positive CA-MRSA isolates were attributed to 2 clones with genotypes t318/ST30-IV (or t318/ST1114-V) and t1376/ST88-V. Detection of t318/ST30 strains in 4 patients with healthcare-associated infections suggested hospital transmission of this CA-MRSA clone, corroborating reports elsewhere (9). Worldwide, ST30 is a common CA-MRSA genetic lineage (1,2). Besides t318, strains related to the ST30 clone have been reported to be spa types t019, t021, and t1273 (2). ST88 PVL-positive MRSA is relatively less common but has been found in Wenzhou (People’s Republic of China), Bangladesh, Belgium, and Nigeria (2,7,8,10). Because the number of isolates tested in this study is relatively small, no firm conclusion could be drawn on the prevalence of PVL-positive CA-MRSA among S. aureus isolates. Nonetheless, our findings agree with previous reports that the genotypes of MSSA isolates are more diverse than are those for PVL-positive and -negative MRSA isolates and that genotypes for some CA-MRSA strains are shared by a few of the MSSA strains (1).

Psychiatry is alive and well

More than 30 years ago, E. Fuller Torrey published “The death of psychiatry” 1. He predicted psychiatry’s demise on the basis that disorders of the brain would be subsumed under the neurological specialty and problems of the mind would be taken over by the psychology professions. As we enter the 21st century, the specialty of psychiatry is not only alive but is thriving. It is thriving because of the excitement generated by scientific discoveries of the brain, the practical and growing applications for psycho- pharmacology, the emerging new science on genetics and mental health, as well as a renewed interest in psychosocial interventions and psychotherapies. The most profound reason for the survival and success of the profession of psychiatry, however, relates to the continuing mysteries of mental illness and the fear of mental illness in individuals and the community at large. Stigma, the pervasive issue that affects patients and providers alike, paradoxically benefits psychiatry and helps the survival of this medical specialty. Essentially, no one wants our patients except us. The acutely psychotic, the demented, the morbidly and suicidally depressed, the paranoid and manic, the personality disordered are not welcomed by other medical specialties or even other mental health disciplines, which compete with us but prefer to treat less disturbed or ill individuals. The issues for a successful psychiatric practice and the survival of the profession have much less to do with referrals than with adequacy of reimbursement for the difficult work entailed in diagnosis and treatment for the seriously mentally ill. Paying for quality psychiatric treatment is a challenge everywhere, especially since the majority of our patients are poor (or eventually become poor). The epidemiology and need clearly are present but the financing is inadequate. In response to this economic challenge, subspecialization is growing. The new subspecializations in psychiatry that, I believe, are a strength and a source of optimism for the future of the field underscore the adaptive nature of psychiatric practice. A decade ago, I wrote a small article on the future of the profession, entitled “In the year 2099” 2. I made a number of predictions, including a projection that psychiatry itself would become an expanded specialty, certified in one of four major specialties of practice – neuroscience, medical psychiatry, psychotherapy, and social psychiatry – with subspecialties in geriatrics, adult, substance abuse, developmental disabilities, and forensics. And, since the brain would be a continuing frontier of learning and research in 2099, many more physicians would consider themselves psychiatric specialists than today. Another example of coping and adaptation by psychiatrists is the experience in Washington, DC, of the federal employees’ health benefits program in the early 1980s. For many years, psychiatrists enjoyed excellent insurance coverage through the insurance held by federal employees and dependents, but in 1980, because of budgetary constraints, these benefits were cut back. Inpatient care was limited to 60 days per year and outpatient visits to 30 per year. The unlimited benefit and large number of federal employees who availed themselves of it had made Washington, DC, a destination for psychiatric practice and the highest proportion of psychiatrists per population in the United States in private practice. As a result of this cutback, I made the prediction that 100-200 psychiatrists in the Washington, DC, area would have to move to find enough patients to continue their practice. At the end of the first year we studied, there was a net gain of ten psychiatrists despite these dire predictions. A survey of the membership of the Washington Psychiatric Society 3 illuminated the reasons for survival (even growth) of the profession despite a financial recession due to the cutback in insurance. What we found was the psychiatrists rapidly found other work in community, forensic, and health care settings; they lowered their fees and were able to receive payment out of pocket from patients where insurance had paid before; and managed to survive by taking on part-time salaried positions and adjusting their private clinical practice. The prediction of the death of psychiatry in Washington, DC, was greatly exaggerated. This is not to make light of the challenges on which H. Katschnig elaborates in his excellent essay, but we need not despair. Our technologies may be “halfway”, that is, we help individuals and communities be better but not well, and most of our illnesses are chronic and relapsing. Our successes, however, increase the demand for our specialty services and now we just have to find a way to get paid adequately for the quality that we bring to the task.

100 Jahre DGP – 100 Jahre deutsche Pneumologie

During the first half of its 100-year history, tuberculosis was predominant in the German Society of Pneumology (DGP). This led largely to the separation of pneumology from internal medicine, particularly in the universities. Since the 1960s, the spectrum of respiratory diseases has changed considerably. Asthma, COPD, lung cancer, and pneumonia today rank among the most widespread diseases. Numerous new diagnostic and therapeutic methods have induced dramatic changes in the field of pneumology. Today, pneumology, together with cardiology and gastroenterology, belongs to the major specialties of internal medicine. One of the most urgent tasks of the DGP is to improve the insufficient representation at German universities, and thus promote teaching and research in respiratory medicine.

Gerald Nepom puts the FOCIS on immunology

Gerald Nepom puts the FOCIS on immunology