The ‘July effect’ has just ended in the United States and it is currently ‘August Killing season’ in the United Kingdom. These months not only signify the start of residency/internships for recent graduates, but the academic year-end for numerous medical trainees. It is a time when new physician trainees enter the workforce, others are promoted and the experienced depart. It has been suggested that this clinician turnover, which occurs at academic teaching hospitals, has a negative effect on the health and wellbeing of patients. Published in July in the Annals of Internal Medicine, a systematic review of 39 articles explored whether the ‘July Effect’ exists and how it impacts patient care. The study demonstrates increased mortality and decreased efficiency patterns during the changeover months. It also highlights the need for intervention to ensure that the ‘July Effect’ is minimized, ensuring optimal care year-round.

Summary: http://www.ncbi.nlm.nih.gov/pubmed/21747093
Full article (requires access to RCSI Library):
http://www.annals.org.proxy.library.rcsi.ie/content/early/2011/07/11/0003-4819-155-5-201109060-00354.full
PMID: 21747093

Title: July Effect: Impact of the Academic Year-End Changeover on Patient Outcomes
Authors: Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD
Journal Title: Annals of Internal Medicine

The sibling study conducted in this paper examined 664 infants between 18 and 36 months who had an older biological sibling with diagnosed autism spectrum disorder (ASD). Published earlier this month, the study found that nearly 19% of the infants developed ASD, with a three fold increase in risk for males. While previous studies had shown an increase in risk, the risk was estimated to be only 3-10%. Given the large scale of trial, the data accounted for many potential biases which may have influenced findings in previous studies. This insight emphasises the need for screening and close observation from birth, particularly in boys, as early identification and thus early intervention is currently considered the best method in improving the symptoms and reducing effects of ASD.

Full article: http://pediatrics.aappublications.org/content/early/2011/08/11/peds.2010-2825.full.pdf+html
Summary: http://pediatrics.aappublications.org/content/early/2011/08/11/peds.2010-2825
PMID: 21844053

Title: Recurrence Risk for Autism Spectrum Disorders: A Baby Siblings Research Consortium Study
Authors: Ozonoff S, Young G S, Carter A, Messinger D, Yimiya N, Zwaigenbaum L et al
Journal Title: Pediatrics

Cardiotocography (CTG) was introduced in the 1960s to monitor fetal cardiac activity in utero. Its use in the intrapartum period is an attempt to predict fetal acidosis, allowing clinicians to intervene before fetal asphyxia occurs. However, it tends to have poor sensitivity and specificity. When fetal blood sampling (FBS) is used in conjunction with CTG, it results in more accurate determination of fetal acidosis, but even then it does not adequately predict fetal outcome.

ST-analysis of the fetal electrocardiogram (STAN) was introduced in the 2000s. This method analyses fetal ST-segments and T-waves, which are said to change in response to hypoxia before the development of neurological damage. In this article by Becker et al in the September issue of the British Journal of Obstetrics and Gynaecology, they looked at when STAN recommended FBS and whether fetal acidosis was actually present. With continued fine-tuning of STAN criteria, it may redefine intrapartum monitoring.

Summary: http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03027.x/abstract
Full article (requires access to RCSI library):
http://onlinelibrary.wiley.com.proxy.library.rcsi.ie/doi/10.1111/j.1471-0528.2011.03027.x/full
PMID: 21668767

Based on the well-known concept that early interventions lead to improved clinical outcomes, rapid-response teams have been gaining popularity in many countries around the world. These hospital-based teams aim to improve early identification of patients at risk of rapid clinical deterioration, and subsequently to provide specialized critical care at their bedside.

While they have been applauded for improved outcomes in conditions such as acute respiratory failure, acute cardiac failure and sepsis, these medical emergency teams are not without controversy. A recent review published in the New England Journal of Medicine highlights the fact that the only studies which have demonstrated drastically improved outcomes attributable to rapid-response teams have been unblinded, non-randomized trials. Furthermore, meta-analyses failed to demonstrate significant decreases in adverse clinical endpoints when these teams were employed. While these controversies have thus far limited their worldwide implementation, rapid-response teams aspire to a goal too fundamental to ignore and merit further study.

Preview: http://www.nejm.org/doi/full/10.1056/NEJMra0910926
Full article (requires access to RCSI Library):
http://www.nejm.org.proxy.library.rcsi.ie/doi/full/10.1056/NEJMra0910926
PMID: 21751906

HLA-sensitisation is observed in 30% of patients on the kidney-transplant waiting list and has long been a problem in transplantation treatment of kidney failure. In this study conducted across the UK, Germany and the Netherlands, Montgomery et al investigate the possibility of overcoming this obstacle to successful lasting treatment of renal failure.

Published last month in the New England Journal of Medicine, the paper compares its method of overcoming the presence of donor-specific HLA antibody and subsequent transplantation (treatment group) to dialysis treatment (dialysis group). To achieve desensitisation, participants in the treatment arm underwent plasmapheresis at least twice after transplantation with non-HLA-compatible kidneys. Over a period of 8 years there was a significant increase in survival rate estimates of the treatment group as compared to the dialysis group (80.6% as compared to 30.5%). The study concludes that transplantation subsequent to HLA-desensitisation is associated with better outcomes, patients no longer requiring a completely negative cross-match for the treatment.

Summary: http://www.nejm.org/doi/full/10.1056/NEJMoa1012376
Full article (requires access to RCSI Library):
http://www.nejm.org.proxy.library.rcsi.ie/doi/pdf/10.1056/NEJMoa1012376
PMID: 21793744

In this article, published in the Journal of the Royal Society of Medicine (JRSM) Short Reports in May 2011, author Vishal Luther addresses the difficulties of choosing a specialization for medical students. Questionnaires were administered and filled out by 115 final year students from a medical school in London, UK. In the questionnaire, students ranked their preferences for specializations as well as their certainty in their decision and whether or not they felt prepared to make this career decision at the end of medical school. Results showed a large degree of uncertainty with students being most confident in a ‘maybe’ response. There was an overwhelming (95%) agreement among the students that the end of medical school was not the preferred time for choosing their career path. Luther suggests that the results of this study call for an improvement in career guidance throughout medical school.

Summary: http://www.ncbi.nlm.nih.gov/pubmed/21637400
Full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3105460/?tool=pubmed
PMID: 21637400

Osteoporosis is most prevalent in older women. If breast cancer treatment has caused women to go through menopause early, they may be at risk for osteoporosis at a younger age. Hormone deprivation therapy is one of several treatment options available to men with prostate cancer, and research shows that men who are given hormone deprivation therapy for prostate cancer have an increased risk of developing osteoporosis due to obstruction of hormone activity such as that of testosterone. This review article explains the side effects on skeletal bone due to cancer therapy experienced by older patients who suffer from either breast or prostate cancer and discusses how to identify the cause for bone loss and distinguish the various treatments which contribute to it. It is an interesting read as the occurrence of osteoporosis due to chemotherapy and various other cancer treatments has become more evident in recent years.

Summary: http://www.cacancerjournal.com/details/journalArticle/1065585/Aging_and_osteoporosis_in_breast_and_prostate_cancer_.html
Full article: http://onlinelibrary.wiley.com/doi/10.3322/caac.20103/pdf
PMID: 21543824

Tissue engineering is a rapidly expanding field which strives to develop viable organs. In this article, Petersen et al describe a novel technique for regenerating damaged lung tissue. Adult rat lungs were treated with a protocol which removed all cellular components from the lung, leaving behind an extracellular matrix which retained the airway and vascular structure of the original lung. Pulmonary and vascular cells were then seeded on the decellularized matrix, resulting in an engineered lung capable of gaseous exchange. The organ also demonstrated remarkably similar physiological properties to that of a normal lung. Although multiple issues remain to be addressed before tissue-engineered lungs can become a reality, this study nevertheless represents an important step in the in vitro development of lung tissue for clinical use.

Summary: http://www.sciencemag.org/content/329/5991/520
Full article (requires access to RCSI Library): http://www.sciencemag.org.proxy.library.rcsi.ie/content/329/5991/520.full
PMID: 20576850

This opinion piece from the latest issue of the BMJ is of particular relevance to RCSI students, who come from a variety of countries and backgrounds. In addition, RCSI holds its own membership exams abroad, particularly in the Middle East. The writers of this piece stress that countries should be encouraged to develop their own membership exams and postgraduate training exams that are tailored to local context. There are aspects of the British and Irish exams that are not relevant to medical practice in parts of Asia and Africa where foreign membership exams are popular. Also, many issues important in these areas are not covered by British and Irish exams. The existence of foreign membership exams, they argue, also acts as a disincentive to the development of local exams. This article provides food for thought, especially for students of such an international college.

Link: http://www.bmj.com/content/343/bmj.d4560.full
PMID: 21798971

As medical education has become more layered, the overlap of patient management in different specialities has increased. Such an overlap can create a difference in opinion regarding treatment course. This issue is highlighted in The University of Alabama’s recent publication in The World Journal of Emergency Surgery titled “Management of Blunt Extracranial Traumatic Cerebrovascular Injury: A Multidisciplinary Survey of Current Practice”.
The preferred methods of treating traumatic cerebrovascular injury (TCVI) are varied. Each speciality seems to have its own preference when it comes to imaging type and intervention strategy.  TCVI does not currently have a clear line of treatment as it is complicated by the variety of cerebrovascular injuries and the presence of further injuries. Thus, TCVI tends to involve numerous specialists including, but not limited to, neurologists, trauma surgeons and interventional neuroradiologists, each with differing views on patient management. Here, the authors provide data on different approaches utilised and highlight the need for further high-quality research to resolve this issue.

Summary: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097147/?report=abstract
Full article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097147/
PMID: 21477304