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This study did not employ a control group, making it difficult to ascribe the improvement in compliance solely to the training given (some improvement in processes may have occurred independent of the training).

Bottom line: A national education effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality.

Citation: Ferrer R, Artigas A, Levy MM, et al. Improvement in process of care and outcomes after a multicenter severe sepsis educational program in Spain. JAMA 2008;299(19):2294-2303.

Can SSRI and problem-solving therapy reduce the incidence of depression in non-depressed patients with a recent stroke?

Background: Depression occurs in more than half of previously non-depressed patients after a stroke. Post-stroke depression is associated with impaired recovery and increased mortality.

Study design: A multicenter randomized controlled trial.

Setting: Two urban university-affiliated hospitals and a suburban rehabilitation hospital in the U.S.

Synopsis: 178 patients age 50 to 90 were enrolled within three months of an index stroke in a 12-month trial. The patients were randomized into three groups of a double-blind placebo control comparison of escitalopram with placebo, and non-blinded problem-solving therapy group.

During the period of the trial, patients on escitalopram experienced significant reductions in the incidence of depression versus placebo (23.1% vs. 34.5%). Problem-solving therapy did not result in significant benefit over the placebo.

The study results were limited by several factors. The study did not include all patients with acute stroke, employed a relatively small sample size, used a non-blinded psychological problem-solving therapy group, and had a high drop out rate.

Bottom line: Consider SSRI use to prevent depression in post-stroke patients.

Citation: Robinson RG, Jorge RE, Moser DJ, et. al. Escitalopram and problem-solving therapy for prevention of post stroke depression: a randomized controlled trial. JAMA 2008;299 (20):2391-2400

CLINICAL SHORTS

By Kenneth Epstein, MD, Brian Donovan, MD, Augustine Osagie, MD, Richard Otto, MD, Marium Steele, MD

SUBCUTANEOUS METHYLNALTREXONE RAPIDLY REVERSES THE EFFECT OF OPIOID-INDUCED CONSTIPATION

A double-blind randomized trial of patients with opioid-induced constipation demonstrated that methylnaltrexone was more successful than placebo in inducing defecation within four hours, without affecting analgesia or causing opioid withdrawal.

Citation: Thomas J, Karver S, Cooney GA, Chamberlain BH, Watt CK, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med. 2008;358:2332-43.

PRUCALOPRIDE IMPROVES BOWEL FUNCTION IN PATIENTS WITH SEVERE CONSTIPATION

Multicenter, randomized, placebo controlled, parallel-group phase 3 trial of prucalopride in patients with severe constipation demonstrated significant improvement in bowel function versus placebo.

Citation: Camilleri M, Kerstens R, Rykx A, Vandeplassche L. A placebo controlled trial of prucalopride for severe chronic constipation. N Engl J Med. 2008;358:2344-2354

SURVEILLANCE CULTURES FOR METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) IN ICU PATIENTS DO NOT IMPROVE OUTCOMES.

A systematic review of the literature on the use of surveillance cultures and control of MRSA infection found no high quality articles to support this strategy.

Citation: McGingle KL, Gourley ML, Buchanan IB. The use of active surveillance cultures in adult intensive care units to reduce methicillin-resistant Staphylococcus aureus-related morbidity, mortality, and costs: A systematic review. Clin Infect Dis 2008;46:1717-25.

OSTEOPOROSIS MEDICATION USE LOW IN OSTEOPOROTIC NURSING HOME PATIENTS

A 10-year observational study demonstrated that only 11.5% of patients admitted to a nursing home after suffering hip, wrist or humeral fracture received osteoporosis medications.

Citation: Parikh S, Mogun H, Avorn J, Solomon DH. Osteoporosis medication use in nursing home patients with fractures in 1 US state. Arch Intern Med. 2008;168(10):1111-1115

LOW DIABETIC NUMERACY SKILL ASSOCIATED WITH POOR GLYCEMIC CONTROL

A cross-sectional survey of diabetics showed that low diabetic numeracy skills were associated with possibly poorer glycemic control, including hemoglobin A1c levels of 7.65% versus 7.1%.

Citation: Cavanaugh K, Hulzinga MM, Wallston KA, et.al. Association of numeracy and diabetes control. Ann Intern Med. 2008;148(10):737-746.

INADEQUATE KNOWLEDGE OF ACS IN PATIENTS WITH CORONARY ARTERY DISEASE

A survey of patients with a history of acute myocardial infarction or invasive cardiac procedures for ischemic heart disease showed their knowledge of acute coronary syndrome symptoms and treatment options remained poor.

Citation: Dracup K, McKinley S, Doering LV, et.al. Acute coronary syndrome: What do patients know? Arch Intern Med. 2008;168(10):1049-1054.

POOR ACADEMIC AND BEHAVIORAL PERFORMANCE DURING RESIDENCY PREDICTS LICENSING BOARD ACTION

A retrospective cohort study found low ABIM test scores and poor professionalism ratings during internal medicine residency correlated on a continuum basis with future state licensing board actions.

Citation: Papadakis MA, Arnold GK, Blank LL. Holmboe ES, Lipner RS. Performance during internal medicine residency training and subsequent disciplinary action by state licensing boards. Ann Intern Med. 2008;148:869-876.

MEASUREMENT OF URINARY NEUTROPHIL GELATINASE-ASSOCIATED LIPOCALIN (NGAL) PREDICTS ACUTE KIDNEY INJURY

Prospective cohort study compared the measurement of NGAL with other proteins and serum creatinine and found the measurement of NGAL better predicts renal injury and poor patient outcomes.

Citation: Nickolas TL, O’Rourke MJ, Yang J, et al. Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury. Ann Intern Med. 2008;148:810-819

PATIENTS SEEM LESS CONCERNED ABOUT PHYSICIAN FATIGUE AND MEDICAL CONTINUITY OF CARE THAN THE MEDIA SUGGESTS

A survey revealed most patients did not worry about the fatigue of their doctors or the discontinuity of medical care as implied by ACGME requirement of resident work hours.

Citation: Fletcher K, Wiest F, Halasyamani L, et al. How do hospitalized patients feel about resident work hours fatigue, and discontinuity of care? J Gen Intern Med. 2008;23(5):623-8.

RAPID RESUSCITATION WITH ACTUAL PERFORMANCE INTEGRATED DEBRIEFING IMPROVES QUALITY OF CPR

Evaluating the quality of CPR by feedback defibrillators and performance debriefing improved the return of spontaneous circulation but did not result in a significant difference of survival at discharge.

Citation: Edelson D, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcome with performance debriefing. Arch Intern Med. 2008;168(10):1063-1069.

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