Primecuts: This Week in the Journals

April 12, 2010

120px-golfballRobert Gianotti, MD

Faculty Peer Reviewed

Welcome back to this week’s edition of prime cuts. For all you sports fans out there it has been filled with some exciting comebacks and breaking news. Earlier in the week, Duke was restored as the number one team in the nation as they edged out the Butler Bulldogs (61-59) to return to their former glory as the best in the NCAA. This week also marks the 74th Masters Golf Tournament featuring none other than Tiger Woods making his comeback following a 5-month golf hiatus taken amidst scandal. We can all only hope that the focus will be on golf and with a field full of potential green jackets, it is sure to be an exciting tournament. Lastly, the baseball season has gone into full swing this week and the world champion Yankees look toward number 28 (and the Mets to number 3-ed.). In addition to the wide world of sports we’ve had some exciting comebacks and big hitters in the medical news this week. Let’s see who’s on deck from the leading journals.

Medical residency training is again in the news and in this weeks’ New England Journal of Medicine (NEJM) we find a study from Brigham and Women’s Hospital by Mcmahon et al.(1) looking at an attempt to redesign training programs to increase resident satisfaction and time for education. In this study, resident and intern teams were divided into two working models. First, the experimental or Integrated Teaching Unit (ITU) team was comprised of two attending physicians hand selected for their teaching prowess, two residents, and three interns with a service cap of 15 patients. This team held daily multidisciplinary rounds, had dedicated rounding time with both attendings together, and reduced intern and resident on call time. This ITU team was compared to a general medical service team (GMS) that acted as a standard control comprised of one resident and two interns with a teaching attending that met with each team for 5 hours per week but was not the attending of record for service patients. The GMS teams had more on call time and also had a service cap of 15 albeit with 2 less house officers. Not unexpectedly, satisfaction among residents and interns with the ITU model far exceeded that of the GMS model with 41.4 % vs. 6.4% (p<0.001) stating that the ITU was closest to their ideal training experience. In addition, attendance at educational conferences and peer-to-peer teaching activities were significantly increased on the ITU teams over the GMS teams. Patient care outcomes and satisfaction were not significantly different between teams. Interestingly, and which may come as a surprise to those residents training at large urban medical centers, intern censes were only 3.5 and 6.6 patients on the ITU and GMS teams, respectively. In the end, this study suggests that decreasing intern census, decreasing on call duty, and increasing educational activities and dedicated attending time leads to greater resident satisfaction and teaching. Nevertheless, the study suffers from obvious flaws.  Comparing handpicked attendings with a group of general voluntary faculty would easily bias the satisfaction results.  Limiting census numbers by definition would increase teaching time but how does the subsequent decrease in clinical exposure to cases during training affect outcomes?  Our surgical colleagues have recently shown that less experience may lead to worse outcomes.(2)  The debate is growing louder, as programs struggle to balance work hours with clinical and educational experiences.  One hopes that a balance can be struck that can successfully turn out large numbers of superior physicians…only time will tell.

 Making the turn from residency training we now look to JAMA and this week’s major article that evaluates the complex and often debated issue of treatment for lumbar spinal stenosis.(3)  In this article, Deyo et al. look at the subtypes of surgical intervention for symptomatic lumbar stenosis in Medicare patients 65 and older between the years 2002 and 2007. Due to the lack of randomized consensus data as to the best approach for these patients, the authors sought to examine the complication rates and financial burden of three surgical methods: decompression alone, simple fusion, and complex fusion with more than 2 disk levels involved or both anterior and posterior approach. It should be noted that not one of these three procedures has been shown reliably to lead to better symptomatic or functional outcome.  Choice of which procedure to perform is largely surgeon dependent. Although the data showed a trend toward decreased overall surgical intervention it was noted that the complex fusion procedures increased 15-fold from 1.3 per 100,000 to 19.9 per 100,000. It’s important to realize that decompression still is the most commonly performed surgery with 21,474 procedures vs. 4,596 complex fusion procedures over the time period examined. Strikingly, major cardiopulmonary complications and stroke were significantly increased in those patients undergoing complex fusions vs. decompression (5.2% vs.  2.1%, p<0 .05). The data also shows that complex fusion is far more expensive ($80,868 vs. $23, 724,p<0.05) and leads to a significant increase in re-hospitalization for any cause over thirty days (13.0% vs. 7.8%, p<0.05). This article comes at a time when our health care system is under great scrutiny, and sheds light on one area that needs to be addressed, and that is how we as a medical community should decide how taxpayer dollars are spent. It seems clear that an evidence based approach should be implemented to address the ever increasing cost in both dollars and lives of newer, complex procedures that may yield no clinical benefit and may in fact do more harm than good. Perhaps our government’s investment in comparative effectiveness studies will lead to answers to these and similar questions.  I hope that Fred Couples (PGA golfer) seeks a second opinion for his back woes so that he may continue to shoot below par well into his 80′s.

 In the news again is our old foe, hepatitis C.  Researchers from Duke are now trying to gain the upper hand in the fight against non-responders to initial treatment.(4)  In this week’s edition of NEJM, McHutchinson et al. evaluate combination peginterferon alfa-2a/ribavirin and telaprevir (a specific inhibitor of HCV protease) in those patients who failed to show a sustained viral response (SVR-undetectable HCV RNA at 24 weeks) to initial treatment with IFN alfa 2a/ribavirin alone. The results are hopeful as they demonstrate a 53% SVR in those patients receiving 24 weeks of telaprevir in combination with 48 weeks of INF alfa 2a/ribavirin compared to a 14% SVR in those patients receiving INF alfa 2a/ribavirin alone for 48 weeks (p<0.001). The rate of SVR was similar (51%) in those patients receiving 12 weeks of telaprevir and only 24 weeks of INF alfa 2a/ribavirin as compared to the longer triple drug regimen. Seeing that the rates of discontinuation due to adverse effects of treatment such as rash and flu-like illness were less in the shorter treatment arm, it can be concluded that with similar response rates and higher compliance the shorter regimen of the triple therapy may prove to be a very effective regimen in both new and relapse cases. This data is promising and a definite victory for those infected with HCV.

 Coming into the home stretch we are again confronted with the challenge of diagnosing pulmonary embolism.  Making a big comeback this week is the third edition of PIOPED (Prospective Investigation of Pulmonary Embolism III) looking at using contrast enhanced MRA for the diagnosis of pulmonary embolism. In this paper from the most recent Annals of Internal Medicine(5), Stein et al. look at the sensitivity and specificity of gadolinium enhanced MRA combined with MR venography compared to  standard reference tests such as CT angiography, VQ scan, venous ultrasound, and d-dimer. By far the most commonly used method to diagnose PE was by CT angiogram (90% of PE) and the most commonly used method to exclude PE were negative CT angiogram (49%) and negative d-dimer (36%). Of the 13,390 patients screened, 2273 were deemed eligible (patients were excluded for many reasons, the most common being that they had a contraindication to gadolinium or MRI or a GFR < 60mL/min). 818 patients were enrolled and of those 450 completed both the local reference standard and the MRA. Overall, MRA had a sensitivity of 92% in patients with confirmed PE by the reference test and a specificity of 96% in patients with a negative reference study. All in all it seems pretty good, but only when adequate images are obtained and only if you are not excluded. Overall, 25% of the MRA images were thought inadequate due to poor quality. In the end, I believe we are still left with one fact….MRI is not a great test for diagnosing PE. This is not due to poor sensitivity or specificity when done right, but simply that most people in whom we are trying to diagnose PE (a) will have a contraindication to MRI or (b) will not have the benefit of a center experienced in MRA for the diagnosis of PE. For now, MRI should be reserved only to the few centers that perform the test well for the minority of patients who cannot tolerate standard testing.

 It’s been yet another great week in sports and medical literature. I hope you found this week’s highlight reel full of the instant replays you were looking for. Enjoy the spring weather and as always… Go Yanks (better yet, Go Mets-ed.)!

Dr. Gianotti is a Second Year Resident at NYU Langone Medical Center

Peer Reviewed by Neil Shapiro, MD, Editor-In-Chief, Clinical Correlations

References

1.  McMahon et al. Evaluation of a redesign initiative in an internal-medicine residency. NEJM 2010; 362:1304-1311.  http://content.nejm.org/cgi/content/short/362/14/1304

2.  Browne J, et al. “Resident Duty-HOUR Reform Associated With Increased Morbidity Following Hip Fracture” J Bone Joint Surg Am 2009; 91: 2079-85. http://www.ejbjs.org/cgi/content/abstract/91/9/2079

3.  Deyo et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303: 1259-1265. http://jama.amaassn.org/cgi/content/full/303/13/1259?home

4.  McHutchinson et al. Telaprevir for previously treated chronic HCV infection. NEJM 2010; 362: 1292-1303. http://content.nejm.org/cgi/content/short/362/14/1292

5.  Stein et al. Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism. Annals of Int Med 2010; 152: 434-443. http://www.annals.org/content/152/7/434.full

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