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The Centor score is a clinical tool for assessing the risk for group A streptococcal pharyngitis in individual patients. This study added biosurveillance data on the local incidence of group A streptococcal infection to the score for older adolescents and adults presenting to retail pharmacy clinics with sore throat. Modifying the Centor score by adding biosurveillance data improved its diagnostic accuracy and holds promise for improving clinical decision making for pharyngitis and reducing unnecessary antibiotic prescription.
The relationship between virologic response and adherence to ribavirin and interferon therapy in patients with hepatitis C virus (HCV) infection is not well-described. This study links registry data on dispensed drugs to electronic medical records for more than 5000 patients with HCV. Decline in adherence over time occurred for both drugs but was more pronounced for ribavirin. Greater adherence to therapy increased the likelihood of early and sustained virologic response.
Delays in reperfusion are associated with increased mortality in patients with ST-segment elevation myocardial infarction (STEMI). This study found that delays are also associated with increased hospital readmissions and outpatient visits for congestive heart failure. System delays of 60 minutes or less, 61 to 120 minutes, 121 to 180 minutes, and 181 to 360 minutes corresponded with long-term risks for readmission or outpatient contacts of 10.1%, 10.6%, 12.3%, and 14.1%, respectively. The benefits of timely reperfusion in STEMI seem to extend beyond reduced mortality.
Studies of the effects of bisphenol A (BPA) in humans have had conflicting results, but some evidence suggests associations between BPA levels and type 2 diabetes. In this cross-sectional study from China, researchers could not detect a clear association between urinary BPA concentrations and objective measures of impaired glucose regulation, including type 2 diabetes. Larger cohort studies accounting for diet and incident disease are needed to draw more definitive conclusions about the safety of BPA.
The U.S. Preventive Services Task Force solicited this systematic review to inform the update of its recommendations on screening asymptomatic adults for cardiovascular disease with resting or exercise electrocardiography (ECG). Included studies showed that some abnormalities on resting or exercise ECG were independent predictors of future cardiovascular events. However, no study compared clinical outcomes or use of risk-reducing therapies in individuals who did and did not receive screening ECGs, and no study assessed whether ECG findings classified patients into meaningful risk groups better than traditional risk factor assessment alone.
At present, the 6 general competencies that the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties use to drive residency training do not include responsible stewardship of health care resources. Because control of health care costs has reached crisis level, the author believes that it is essential to change the culture of the training environment with regard to cost-consciousness. He proposes that the accreditation organizations incorporate responsible stewardship of resources as a new, seventh general competency.
The current treatment paradigm for STEMI asserts superior reperfusion with primary percutaneous coronary intervention (PPCI) over fibrinolysis. However, most patients present to non-PPCI hospitals, and many end up not receiving the benefit of pharmacologic reperfusion. This article describes the treatment paradox in which efforts to promote PPCI for acute STEMI often lead to unnecessary avoidance and delay in the use of fibrinolysis. The authors believe that clinicians should embrace an integrated dual reperfusion strategy.
The potential role of BPA in the pathogenesis of human obesity and disease is deeply controversial, and there is little agreement on interpretation of laboratory and human data. The editorialists discuss why the cross-sectional study by Ning and colleagues in this issue is a welcome addition to the literature and propose future research to further clarify the relationship of BPA and disease.
The review by Chou and colleagues in this issue affirms the U.S. Preventive Services Task Force's 2004 judgment on the role of ECG abnormalities in predicting risk. The editorialist explains why no changes in the evidence have been found by discussing the role of clinical measurements in prediction and disease prevention and the complexity underlying ECG findings.
I go to my patients' funerals when possible, but nothing in these experiences prepared me for gravedigging. Digging a grave is like a funeral raised to the tenth power.
Shaun was only 14 years old. He had leukemia and aspergillosis, and no visitors. As the days passed, he slipped more and more into a depressive defiance of his caregivers. I lingered at Shaun's bedside and asked him why he was so down on that particular day.