Shortcuts- This Week in the Journals

September 15, 2008

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Commentary by Cara Litvin MD, Executive Editor, Clinical Correlations 

It’s been easy to become distracted from medicine with all the other news going on this week. First Ike ravaged Texas and now Wall Street appears to be crumbling. Nevertheless, medical news continues and ShortCuts lives on…

Several themes emerged within journals this week. The focus of the NEJM was on the knee, with two articles devoted to this vulnerable joint. The first reported the results of a randomized trial comparing arthroscopic surgery to optimized physical and medical therapy in patients with moderate to severe osteoarthritis of the knee. After 2 years of follow up, there was no additional benefit to surgery when using a symptom scoring system as the primary outcome. In the second study, the prevalence of incidental meniscal findings on MRI of the knee was found to be from 19% in younger women to as high as 56% among older men age 70 to 90. 61% of the subjects who had meniscal tears were asymptomatic. Taken together, these two studies make the indications for arthroscopic surgery all the more murky, and more studies are needed to clarify when arthroscopy is truly indicated.

An interesting article in the NY Times highlighted a recently declining rate of ICD implantation in the US. We all know that ICDs have been shown to reduce mortality in patients with a markedly decreased EF (including SCD-HeFT and MADIT), yet, as the article points out, the odds of an ICD actually saving a life are still small, and come in the face of high costs, recently publicized malfunctions and other risks. Ideally, finding other ways to identify who will reap the most benefit from the devices may fuel further use. A Medicare registry of patients who have received ICDs has been created with the hopes of answering this question, but the results are not expected until 2010.

JAMA devoted its entire issue to medical education, a topic near and dear to all of our hearts. The most publicized study in the issue examined the relationship between on-call workload with on-call sleep duration in a cohort of medical interns between 2003 and 2005 (shortly after ACGME duty hour restrictions were implemented). Mean sleep on-call was 2.8 hours in a 30 hour shift. Not surprisingly, more admissions were associated with more sleep loss and a lower likelihood of participation in educational activities. Certainly stirs up flashbacks to my internship…The corresponding editorial proposes continued development of alternative resident work hour regulations and urges consideration of entirely “novel scheduling systems” in order to reduce workload in addition to work hours for residents, with the hopes of also improving patient safety.

Archives of Internal Medicine even tied in to the theme of medical education with a study evaluating the sign-out system in an internal medicine residency program. Sign-out deficiciencies were attributed to several adverse events, including delays in diagnosis and transfers to the ICU. With continued residency work hour regulation, improving sign-out systems obviously becomes a crucial component of work hour reform.

And last but definitely not least, also published in JAMA this week was a meta-analysis to study the effect of internet-based instruction for health professions learners, including medical students. The review included 201 eligible studies of internet based instruction and outcomes, finding that such learning is associated with large positive effects and is comparable to non-internet methods. Great news for this blog and an excuse to keep on visiting us!

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