Mount Sinai School Of Medicine Research Articles

Perioperative Assessment of Patients With Cardiac Implantable Electronic Devices

Worldwide, nearly 4 million patients currently have cardiac implantable electronic devices. Due to the increasing number of candidates to receive either pacemakers or implantable cardiac defibrillators, there is no doubt that primary care physicians or anesthesiologists are very likely to interact and deal with this particular patient population. However, besides technologic advancements, several factors have been frequently reported to cause confusion regarding their perioperative care. Therefore, it has become extremely valuable to understand the basic functions and operation of these devices, as well as their functional limitations, to prevent iatrogenic complications and detect potential failure in an early stage.

Integrating Perioperative Information From Divergent Sources

The enormous diversity of physician practices, including specialists, and patient requirements and comorbidities make integration of appropriate perioperative information difficult. Lack of communicating computer systems adds to the difficulty of assembling data. Meta analysis and evidence-based studies indicate that far too many tests are performed perioperatively. Guidelines for appropriate perioperative management have been formulated by several specialties. Education as to current findings and requirements should be better communicated to surgeons, consultants, and patients to improve healthcare needs and at the same time decrease costs. Means to better communication by interpersonal collaboration are outlined.

Déjà Flu—Scientists Continue To Debate Modified H5N1 Risks

“If it's the worst-case scenario, half the people you know who acquire the pandemic H5N1 influenza virus will die, and half the infected people you don't know will die,” says Arturo Casadevall from Albert Einstein College of Medicine in New York, N.Y. “If it's two orders of magnitude lower, there will be 70 million deaths.” Peter Palese at Mount Sinai School of Medicine, also in New York, disagrees, arguing that H5N1 lethality is vastly overestimated and that “what happens in ferrets doesn't really say anything about the disease in humans.” They and others spoke during a recent conference focused on strains of H5N1 influenza that, when modified, infect ferrets and possibly other mammals. It was convened by the New York Academy of Sciences (NYAS) last February.

Value of Specialized Preanesthetic Clinic for Cardiac and Major Vascular Surgery Patients

In a complicated and specialized population, such as patients undergoing cardiac and major vascular procedures, patients, clinicians, and hospitals may be best served and resources conserved with a specialized preanesthesia clinic. A specialized preanesthesia clinic for cardiac and major vascular procedures has a focused staff usually consisting of practitioners with cardiac and major vascular surgical care experience designed to address the patient evaluation, the information gathering, the necessary consultations, the required testing, and specific needs for the day of cardiac and major vascular surgery. Specialized preanesthesia clinics increase patient satisfaction and may also provide cost containment by decreasing the amount of indiscriminate ordering of expensive preoperative tests and potentially may decrease patient litigation. Resident trainee education can also be enhanced by a specialized preanesthesia clinic for cardiac and major vascular rotations. The ultimate goal of a specialized preanesthesia clinic is to ensure a safe and efficient perioperative cardiac and major vascular surgical experience in complicated patients undergoing complex procedures.

Preventing Post‐Thoracotomy Pain Syndrome

This article provides a concise overview of post-thoracotomy pain syndrome, describes anesthetic and surgical factors that have been investigated to reduce the incidence of the syndrome, and explores the effectiveness of various treatments for this condition. Although some interventions (both procedural and pharmacologic) have been investigated in both preventing and treating post-thoracotomy pain syndrome, definitive studies are lacking and firm conclusions regarding the benefit of any intervention cannot be drawn. The problem is compounded further by our lack of understanding of the pathophysiologic mechanisms underlying the development of chronic pain after surgery. Going forward, it will be important to elucidate these mechanisms and conduct well-designed trials involving novel therapeutic agents for both prevention and treatment of post-thoracotomy pain syndrome.

Impact of Red Blood Cell Transfusion on Global and Regional Measures of Oxygenation

Anemia is common in critically ill patients. Although the goal of transfusion of red blood cells is to increase oxygen-carrying capacity, there are contradictory results about whether red blood cell transfusion to treat moderate anemia (e.g., hemoglobin 7-10 g/dL) improves tissue oxygenation or changes outcomes. Whereas increasing levels of anemia eventually lead to a level of critical oxygen delivery, increased cardiac output and oxygen extraction are homeostatic mechanisms the body uses to prevent a state of dysoxia in the setting of diminished oxygen delivery due to anemia. In order for cardiac output to increase in the face of anemia, normovolemia must be maintained. Transfusion of red blood cells increases blood viscosity, which may actually decrease cardiac output (barring a state of hypovolemia prior to transfusion). Studies have generally shown that transfusion of red blood cells fails to increase oxygen uptake unless oxygen uptake/oxygen delivery dependency exists (e.g., severe anemia or strenuous exercise). Recently, near-infrared spectroscopy, which approximates the hemoglobin saturation of venous blood, has been used to investigate whether transfusion of red blood cells increases tissue oxygenation in regional tissue beds (e.g., brain, peripheral skeletal muscle). These studies have generally shown increases in near-infrared spectroscopy derived measurements of tissue oxygenation following transfusion. Studies evaluating the effect of transfusion on the microcirculation have shown that transfusion increases the functional capillary density. This article will review fundamental aspects of oxygen delivery and extraction, and the effects of red blood cell transfusion on tissue oxygenation as well as the microcirculation.

From Bloodless Surgery to Patient Blood Management

Safety and efficacy concerns of allogeneic blood transfusions and their impact on patient outcomes and associated staggering costs and restricted supply have fueled the quest for other modalities and strategies to reduce use of blood components. Patient blood management focuses on multidisciplinary and multimodal preventive measures to reduce or obviate the need for transfusions and ultimately to improve the clinical outcomes of patients. Patient blood management strategies can be applied at every stage of care to surgical and nonsurgical patients, and they generally fall under one of these three categories (the so-called pillars of blood management): optimizing hematopoiesis and appropriate management of anemia, minimizing bleeding and blood loss, and harnessing and optimizing physiological tolerance of anemia through employing all available modalities while treatment is initiated. Several tools and modalities are available to address each of these pillars. Examples include hematinic agents, systemic and topical hemostatic agents, autotransfusion, and blood-sparing perfusion and surgical techniques. Additionally, changes in practice of clinicians (e.g., adherence to restrictive, evidence-based transfusion strategies with emphasis on physiologic indications for transfusion, minimization of iatrogenic blood loss, and adequate planning) play an important role in patient blood management. Emerging evidence supports that appropriate use of these strategies as part of a multimodal program is a safe and effective way of reducing allogeneic transfusions and improving patient outcomes.

705: Polymorphisms of the glucocorticoid receptor gene NR3C1 and the association with birth weight and gestational age at delivery

gene NR3C1 and the association with birth weight and gestational age at delivery Jennifer Wong, Yula Ma, Luca Lambertini, Andrea Weintraub, Joanne Stone Mount Sinai School of Medicine, Maternal Fetal Medicine, New York, NY, Mount Sinai School of Medicine, Department of Preventive Medicine, New York, NY, Mount Sinai School of Medicine, Pediatrics, New York, NY OBJECTIVE: To determine the association of glucocorticoid receptor gene NR3C1 single nucleotide polymorphisms (SNPs) with birth weight and prematurity. STUDY DESIGN: This was a single center, pilot study of 80 umbilical cord blood samples collected prospectively from singleton pregnancies. DNA was isolated from each blood sample. SNPs were genotyped by Taqman assay (rs6193, rs6194, rs6195, rs6196, rs6198, rs258751) and sequencing (rs6189, rs6190). Linear regression models were calculated for birth weight (BW) and gestational age at delivery (GAd). RESULTS: The rs6195 SNP was not polymorphic in our sample, and was therefore excluded from further statistical analysis. The average BW was 3330g [1930-4660g]. The average GAd was 39.5 weeks [3241.6] with only 3 deliveries occurring prior to 37 weeks. The BW linear regression model showed a significant correlation with preterm labor, vaginal delivery, maternal Asian ethnicity, and the rs6196 variant (p 0.01; r2 0.270). The rs6196 GG genotype was associated with a 761g reduction in BW (95% CI 125-1398; p 0.02). The GAd linear regression model of gestational age at delivery also showed a significant correlation with preterm labor, betamethasone administration, neonatal intensive care unit admission, as well as the rs6196 GG genotype (p 0.01; r2 0.476). In this regression, the GG genotype was associated with an earlier GAd (95% CI 0.92-0.99; p 0.01). None of the other SNPs analyzed showed any significant correlation with either outcome. CONCLUSION: The GG genotype of the rs6196 SNP of the glucocorticoid receptor gene NR3C1 is associated with both lower birth weight and earlier gestational age at delivery. These data are consistent with existing scientific literature that correlates this and other SNP phenotypes to lower weight, BMI, waist/hip ratio, and decreased insulin resistance. This glucocorticoid-resistant phenotype may ultimately be protective postnatally among hypercortisolemic premature infants. Given the results from this interim analysis, our investigation will continue with a focus on umbilical cord blood collections from premature infants.

348: The accuracy of prenatal ultrasound in the diagnosis of true microcephaly

in the diagnosis of true microcephaly Jennifer Wong, Casey Howe, Angela Bianco, Robert Green, Joanne Stone Mount Sinai School of Medicine, Maternal Fetal Medicine, New York, NY, Mount Sinai School of Medicine, Department of Obstetrics and Gynecology, New York, NY, Department of Pediatrics, New York, NY OBJECTIVE: To determine the accuracy of prenatal ultrasound in detection of microcephaly, defined as birth head circumference (HCbirth) 10%ile. STUDY DESIGN: This was a retrospective chart review of fetuses identified prenatally with a head circumference (HCfetal) of 3%ile. HCbirth were abstracted from the newborn medical chart, and Z-scores calculated for both. Sensitivity, specificity, false positive (FP) and false negative (FN) rates were calculated for HCfetal. An ROC curve was calculated to determine the accuracy of HCfetal in the detection of microcephaly. RESULTS: An ultrasound database search from Jan 2005 to July 2011 for HC 3% identified 730 ultrasounds of 455 fetuses in 433 patients. There were 375 live births in this group. Median Z-scores were similar between fetal and neonatal groups ( 1.16 [ 1.6, 0.9] and 1.2 [ 1.8, 0.7], respectively). The overall prevalence of microcephaly was similar in both groups using an HCfetal Z-score cutoff of 1.3 (40.1% and 49.6% respectively). A Z-score of 1.3 had 44.6% sensitivity, 35.1% specificity, 44.9% FP rate, and 45.9% FN rate for detection of microcephaly (p 0.08). Using a HCfetal Z-score cutoff of 1.7 yielded 28.8% sensitivity, 21% specificity, 62.6% FP and 28.2% FN rate (p 0.09). The area under the ROC curve was 0.6, indicating that HCfetal is an inaccurate test for microcephaly. Gestational age at time of ultrasound was not significantly associated with microcephaly (95% CI 0.27-0.01). CONCLUSION: Prenatal ultrasound was able to detect a population at risk for microcephaly as evidenced by the high prevalence in this group at birth; however, the ability of prenatal ultrasound to predict a specific HCbirth for an individual is poor. Sensitivity and specificity for prenatal ultrasound are low, and FP and FN rates are high. Factors which contribute to the inaccuracy of prenatal ultrasound include the variability of the microcephaly phenotype, heterogeneous etiologies, lack of consensus regarding the definition of microcephaly, high rate of concurrent growth restriction, and lack of genderor race-specific fetal growth curves. 349 Antenatal ultrasonographic findings to predict esophageal atresia in cases with visible stomach bubble Jeong Woo Park, Yeo rang Kim, Seung Mi Lee, Chan-Wook Park, Joong Shin Park, Jong Kwan Jun, Hee Chul Shin Seoul National University College of Medicine, Deptartment of Obstetrics and Gynecology, Seoul, Korea, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Obstetrics and Gynecology, Seoul, Korea, Seoul National University College of Medicine, Department of Obstetrics and Gynecology, Seoul, Korea OBJECTIVE: Becauses fetuses with esophageal atresia need an early postnatal surgery, they should be delivered in a tertiary center. However, prenatal diagnosis of esophageal atresia sometimes challenging. The aim of this study was to determine the antenatal ultrasonographic findings which offer the best diagnostic accuracy in fetal esophageal atresia with or without tracheoesophageal fistula (EA/TEF) with moderate to severe polyhydramnios and visible stomach bubble. STUDY DESIGN: We performed a retrospective analysis of 121 pregnant women who presented polyhydramnios (AFI 24) between March 1996 and April 2011. Of these, 3 cases in whom EA was suspicious but delivered stillbirth without autopsy, and those who were diagnosed as having other fetal gastrointestinal obstructions (e.g. duodenal atresia, jejunal atresia, or ileal atresia), hydrops fetalis, or congenital diaphragmatic hernia were excluded. A total of 87 cases were enrolled. Ultrasonographic findings evaluated were (1) small abdominal circumference (AC) less than 10 percentile for gestational age, (2) upper pouch sign, and (3) tiny stomach bubble. Predictive value of an individual sonographic marker was calculated. RESULTS: Of a total of 87 cases with polyhydramnios, 2 cases had upper neck pouch sign. Of these 85 cases, 8 cases showed absent stomach bubble. The remaining 77 cases were analysed. In the setting of polyhydramnios and visible stomach bubble (77 cases), the prevalence of EA/TEF was 6.5% (5/77). Small AC had higher sensitivity compared to tiny stomach bubble. Small AC and tiny stomach bubble were statistically significant sonographic findings for diagnosing esophageal atresia antenatally. After adjusting possible confounders, only small AC was remained significant (P 0.05). CONCLUSION: In polyhydramnios and visible fetal stomach bubble, small AC as an antenatal sonographic finding suggests that the fetus has EA/TEF. Clinicians should measure AC in this setting. Poster Session II Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging www.AJOG.org

630: Comparing international guidelines on hypertensive disorders in pregnancy

630 Comparing international guidelines on hypertensive disorders in pregnancy Melanie Wiegerinck, Sigrid Huigen, Teus van Barneveld, Ben Willem Mol, Hans Duvekot Academic Medical Centre, Obstetrics and Gynaecology, Amsterdam, Netherlands, Erasmus Medical Center, Obstetrics and Gynaecology, Rotterdam, Netherlands, Netherlands Association of Medical specialists, Department of guideline development, Utrecht, Netherlands, Dutch consortium AMPHIA trial, Netherlands, Erasmus Medical Center, Department of Obstetrics and Gynaecology, Rotterdam, Netherlands OBJECTIVE: To compare international guidelines on Hypertensive disorders in pregnancy in order to assess the quality of guideline development in this field. STUDY DESIGN: We contacted the official Obstetric Societies of all European countries, the US, Canada and Australia, regarding the availability of a guideline on Hypertensive disorders in pregnancy. All retrieved guidelines were systematically reviewed on 7 topics that were identified as important by professionals: definitions of hypertensive disorders, methods for assessing proteinuria, top 3 antihypertensive agents, criteria for starting treatment (antihypertensive, anticonvulsive, termination of pregnancy), and target blood pressure after delivery. In addition, the methodologic quality of the guidelines was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE-II) Instrument. RESULTS: We approached professional societies in 41 European countries, and obtained guidelines from the US, Canada, and Australia (figure 1). Since 21 European countries did not reply and 4 had no guidelines, we analyzed a total of 19 guidelines. Nearly all countries had developed these guidelines themselves, and 17 dated from the last 4 years. Even though most guidelines refer to the same references, only 6 (32%) use the exact same definition for hypertension. All guidelines use the same cut-off values for proteinuria (0.3g/24 hours), but the accepted methods for assessing proteinuria differ (3 quantative 24 hour measure, 1 automated dipstick, 5 also accept protein/kreatinin ratio and visual dipstick, and in 10 it was not stated). Five guidelines agreed on initiation of antihypertensive treatment when the bloodpressure exceeds 160/110 mmHg, whereas 14 used other criteria. The remaining topics were comparable among the included guidelines. Methodological rigour and transparency of the guidelines also differed significantly. CONCLUSION: We found a wide variation in used definitions, clinical recommendations and methodology. This study emphasizes the need for international collaboration in the field of guideline development. 631 The impact of postpartum hemorrhage drill training at a single institution Noel Strong, Angela Bianco, Joanne Stone, Pozharny Zhenya, Luca Lambertini Mount Sinai Medical Center, Maternal Fetal Medicine, New York, NY, Mount Sinai School of Medicine, Maternal Fetal Medicine, New York, NY, North Shore-Long Island Jewish Health System, Maternal Fetal Medince, Manhasset, NY, Mount Sinai School of Medicine, Department of Preventive Medicine, New York, NY OBJECTIVE: To evaluate the impact of standardized postpartum hemorrhage drill training. STUDY DESIGN: In June of 2009 our institution mandated that all obstetrical providers participate in standardized postpartum hemorrhage training drills. The purpose of these drills was to improve recognition and management of post partum hemorrhage (PPH). Each drill consisted of a didactic session which emphasized accurate estimation of blood loss, early intervention, use of misoprostol as a first line agent and increased use of the Bakri Balloon and B-lynch suture. Each didactic session was followed by a simulated postpartum hemorrhage utilizing a female anthropomorphic robotic simulator. A retrospective chart review was preformed comparing all cases of PPH identified by the Labor & Delivery Quality Assurance Committee in the year preceding this mandate to all cases of PPH identified by the same committee in the year following this mandate. RESULTS: 160 patients with PPH were identified over the 2 year study period: 57 cases in the year preceding the PPH drills and 103 cases in the year following the PPH drills. The demographics of these two groups did not differ statistically, nor did their labor courses or etiologies of hemorrhage. In the first six months following the PPH training drills a trend toward increased use of misoprostol (26 %v 33% p 0.069) and Bakri Balloon (7% v 17% p 0.087) was noted. Although the rate of c-hysterectomy appeared to be reduced during this time period no trend toward significance was seen (19% v 8% p 0.220). At 6-12 months following the mandated drills these findings were no longer seen. No significant differences were noted in mean estimated blood loss, change in hemoglobin or rate of transfusion between any of the studied time periods. CONCLUSION: Training appears to improve recognition and reporting of PPH. While no statistically significant changes were noted, a trend towards increased use of misoprostol and Bakri Balloon was initially seen following the PPH training drills. This trend dissipated after 6 months. These findings seem to support a need for re-education.

Hospital Palliative Care Programs Raise Grade to B in New Report Card on Access

ARECENT SURVEY THAT GRADED THE 50 states on access to palliative care bumped the United States up a grade, to a B from a C in 2008. Despite the rapid growth of hospitalbased palliative care programs, the survey nonetheless reports ongoing barriers to access: too few trained professionals, knowledge gaps in symptom relief, and the need for new reimbursement models. The 2011 survey, carried out by the Center to Advance Palliative Care (CAPC) and the National Palliative Care Research Center (NPCRC) at the Mount Sinai School of Medicine, both in New York City, examined data taken primarily from the American Hospital Association Annual Survey Database for 2009. Of the 2489 hospitals with 50 or more beds surveyed, 63% had palliative care programs. Of hospitals with more than 300 beds, 85% had palliative care teams (http://www.capc.org /reportcard/). Seven states and the District of Columbia received an A grade, meaning that more than 80% of hospitals surveyed in those states reported having palliative care programs. Twenty-five states received B grades, indicating that 61% to 80% of hospitals had such programs. C’s went to 12 states where 42% to 60% of hospitals had programs; 4 states received D’s, with programs in 28% to 38% of hospitals; and F’s went to Delaware and Mississippi, each with 20% of hospitals surveyed having programs. States that made substantial gains since 2008 included Nevada, where the percentage increased from 23% to 69%; Mississippi, up from 10% to 20%; and Alabama, up from 16% to 28%. Hospitals with 300 or more beds were the most likely to have palliative care programs, while for-profit, public, and sole community provider hospitals were the least likely. Access to palliative care also varied widely among various regions of the country. For example, 73% of hospitals with 50 or more beds in the Northeast reported having programs, compared with 51% in the South. Lead author R. Sean Morrison, MD, director of the NPCRC, said that just as every hospital has an emergency department and intensive care units or beds, so should they have palliative care services for adults and children with serious illnesses. “I think that by 2020, we will be at a point where 100% of our 300-plusbed hospitals will have a palliative care team, and [more than] 80% of our smaller hospitals will have a palliative care [program],” said Morrison. He said data show that palliative care can cut hospital costs and improve the quality of care. In a study of Medicaid patients in 4 New York hospitals, Morrison and his colleagues showed that patients who received palliative care incurred $6900 less in a given admission than those who received usual care (Morrison RS et al. Health Aff [Millwood]. 2011;30[3]:454-463). If every New York hospital with 150 or more beds had properly trained teams that provided palliative services within routine patient care, the study estimated statewide Medicaid savings between $84 million and $252 million annually within 5 years. A study of 151 patients with metastatic non–small cell lung cancer, which usually has a prognosis of less than 1 year, showed that those who received palliative care had less depression and better scores on a quality-of-life scale than those who received usual care. Patients who were given palliative care early in their illness received less aggressive end-of-life care, but their median survival was 2.7 months longer than patients receiving usual care (Temel JS et al. N Engl J Med. 2010; 363[8]:733-742). According to the CAPC, an estimated 90 million Americans have serious or life-threatening illnesses. That number is expected to double in 25 years as baby boomers age. About 6 million people in the United States currently could benefit from receiving palliative care. Since 2000, the prevalence of palliative care teams in US hospitals with at least 50 beds has increased by 138%, according to the survey. That growth is among the factors that prompted the Joint Commission, which accredits about 4500 US hospitals, to launch a new cer-

Hepatic Steatosis, Fibrosis, and Cancer in Elderly Cadavers

The incidence of hepatic steatosis, fibrosis, and cancer in the elderly population remains unknown. Human cadavers used in anatomy teaching, which come largely from older adults, may provide liver tissue for examining their pathologies. Livers were obtained from 68 cadavers (mean age 82.1 ± 10.4 years) with diverse causes of death in the Anatomy course at Mount Sinai School of Medicine. Paraffin sections were stained with hematoxylin and eosin and Sirius red and evaluated for steatosis, fibrosis, cancer, and lipofuscin. Tissue preservation was graded as good in 38.2% of the embalmed livers, fair in 36.7%, and poor in 25.0%. Steatosis was observed in 35.3% of the livers, central vein fibrosis in 49.2%, perisinusoidal fibrosis in 63.2%, portal tract (PT) fibrosis in 47.0%, septa formation in 44.1%, bridging fibrosis in 30.8%, and cirrhosis in 4.4%. One hepatocellular carcinoma (HCC) and six metastatic tumors were detected. Lobular inflammation occurred in 20.8% of the livers and PT inflammation in 38.8%. Nine livers showed minimal change. Lipofuscin was detected in 60.2% of the livers. Steatosis, fibrosis, and cancer are highly prevalent in elderly cadavers with diverse causes of death. The prevalence of steatosis and fibrosis is consistent with the data in patients with specific liver diseases. Steatosis alongside fibrosis can accelerate the progression of fibrosis to cirrhosis and ultimately HCC. Though not indicated as the primary cause of death, the liver injury may have compromised hepatic functions and enhanced disease susceptibility, thereby exacerbating the health conditions in this elderly population.

Yoga as an Intervention for Low Back Pain

Dr. Danesh is Fellow, Department of Anesthesiology, Mount Sinai Medical Center, Dr. Serban is Assistant Professor of Anesthesiology and Pain Management, Mount Sinai School of Medicine, and Dr. Herrera is Assistant Professor of Rehabilitation Medicine, Mount Sinai School of Medicine, Box 1010, 1 Gustave Levy Plaza, New York, NY 10029; E-mail: [email protected]. All faculty and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This activity expires on November 30, 2012.

Factors Influencing Urinary Symptoms 10 Years After Permanent Prostate Seed Implantation

We investigated the factors that influenced urinary symptoms in the first 10 years after prostate brachytherapy. A total of 1,932 men were treated with prostate brachytherapy alone or with external beam irradiation and followed a mean of 6.8 years. The influence of pretreatment American Urological Association symptom score (7 or less, 8 to 19, 20 or greater), external beam radiotherapy, (125)I or (103)Pd, biological effective dose, age, prostate size and hormone therapy on the change in American Urological Association symptom score (11,491) was compared. The mean change from initial score (7.4) was 11.4, 5.5, 3.3, 2.7, 1.5, 1.2, 1, 1, 1, 1, 1.3 and 1.4 points at 3, 6 months and 1 to 10 years, respectively (p <0.001). Factors that resulted in a greater increase in urinary symptoms at year 1 were low pretreatment score (p <0.001), no hormonal therapy (p <0.001), younger age (p = 0.046) and higher biological effective dose (p = 0.025). At 10 years patients with an initial score of 20 or greater had an average decrease of 11 points compared to a decrease of 0.9 for an initial score of 8 to 19 and an increase of 2.7 for an initial score of 7 or less (p <0.001). On linear regression the scores at 1 year were influenced by initial score (p <0.001), biological effective dose (p = 0.022), prostate size (p <0.001) and hormonal therapy (p = 0.009). At 10 years only the pretreatment score remained significant (p <0.001). There is minimal change in mean American Urological Association symptom score (1.4 points) 10 years after prostate brachytherapy. Patients presenting with high initial scores have the greatest improvement from baseline. Biological effective dose, external beam radiotherapy, hormonal therapy, isotope, patient age and prostate size do not appear to influence long-term urinary symptoms.

Reforming Way Medical Students and Physicians Are Taught About Quality and Safety

The purpose of this article is to briefly review the history of how quality and safety have been addressed in the United States by those who have been teaching medical students and residents, and then discuss why and how this training must change in the future to more effectively address the problems of improving healthcare quality and safety. Although it has become clear that the curriculum in medical schools should encompass quality and safety training, medical schools have been very slow to implement the reforms that are necessary to accomplish such a goal. These changes, although desirable from a rational perspective, involve basic changes in the culture of medical schools and teaching hospitals. Moreover, the cost of implementing these changes would be very large, and, if imposed by outside agencies, would likely constitute an unfunded mandate. It should also be noted that at the present time there are very few people who are well trained to develop and teach these classes. In order to accomplish the goal of improving patient safety, it is essential that we provide much more training and knowledge regarding patient safety to medical students, including knowledge of interventions known to be effective in preventing errors; education in technical performance; information about organizational and team issues; and training in disclosing errors to patients. This training should occur early in the training of professionals, preferably while they are still in school, if such training is to change the culture of medicine. Some suggestions and plans for implementation are discussed, using some innovative programs as examples.

Effect of E‐Prescribing Systems on Patient Safety

E-prescribing systems enable electronic transmissions of prescriptions to pharmacies from the provider's office. The promise of e-prescribing in regard to patient safety is reduction in the time gap between point of care and point of service, reduction in medication errors, and improved quality of care. This article will give a brief overview of e-prescribing systems, what is known about these systems and their impact on patient safety, and what challenges remain. For purposes of this article, the term "patient safety" will be used interchangeably with medication errors and adverse drug events. Although there is some evidence that e-prescribing alone and e-prescribing with medication decision support can reduce medication errors, there is also evidence that e-prescribing can be a source of medication errors. The need for more study is particularly relevant and timely, as the Centers for Medicare and Medicaid Services is strongly incentivizing providers to use e-prescribing with medication decision support. Despite concerns about efficiency and dissatisfaction, the majority of providers believe e-prescribing provides for improved patient safety. Limited evidence suggests that e-prescribing with medication decision support can improve patient safety.

Who Do Global Health Missions Benefit More: Trainees or the Communities They Target?

Jonathan A. Ripp, MD, MPH, is an assistant professor of medicine at the Mount Sinai School of Medicine in New York City, where he sees patients with the Mount Sinai Visiting Doctors program. He is also the associate director of the School of Medicine's Global Health Center, co-chair of the American Society of Tropical Medicine and Hygiene's sub-section on Global Health, and an external reviewer on the selection committee for the Yale/Stanford Johnson & Johnson International Health Scholarship Program.

Improving Quality in Healthcare: Start With the Patient

In the decade since the Institute of Medicine released To Err Is Human, patient harm from medical errors is still widespread. Healthcare has not undergone the transformative change that is needed to reduce medical errors and improve quality. This article discusses patient-centeredness as an organizing principle for transforming healthcare. We also describe important efforts that depict the shift from a provider-focused system to one that is more patient-centered. Finally, the article discusses challenges for the future and the importance of involving patients in the quest to deliver safe, quality care.

Use of In Vivo Real‐Time Optical Imaging for Esophageal Neoplasia

Esophageal adenocarcinoma carries a poor prognosis, as it typically presents at a late stage. Thus, a major research priority is the development of novel diagnostic-imaging strategies that can detect neoplastic lesions earlier and more accurately than current techniques. Advances in optical imaging allow clinicians to obtain real-time histopathologic information with instant visualization of cellular architecture and the potential to identify neoplastic tissue. The various endoscopic imaging modalities for esophageal neoplasia can be grouped into 2 major categories: (1) wide-field imaging, a comparatively lower-resolution view for imaging larger surface areas, and (2) high-resolution imaging, which allows individual cells to be visualized. This review will provide an overview of the various forms of real-time optical imaging in the diagnosis and management of Barrett's esophagus and esophageal adenocarcinoma.

Prevention of Retained Surgical Items

Reduction in retained surgical items is an important part of any operating room patient-safety effort. Any item used in an operation can result in a retained surgical item, but sponges are the most frequent and the abdomen is the most common location. Retained sponges can cause significant morbidity, and the costs associated with both prevention and treatment of retained surgical items, including legal costs, can be considerable. This review will examine counting, teamwork, radiography, and new technology as methods used to prevent retained surgical items. Even though none of these techniques individually is likely to completely prevent retained surgical items, when used together the numbers can be reduced.