Shortcuts-This Week in the Journals

July 2, 2007

ShortcutCommentary By: Josh Olstein, M.D. Chief Resident Internal Medicine

This week, the NEJM released the results of a survey about needlestick injuries among surgical residents. The frequency of needlestick injuries were quite high, residents averaged 3.8 injuries across all years of training. By their fifth year of training 99% of residents had experienced at least one needlestick injury. Perhaps the most shocking statistics however were the frequency of unreported needlestick injuries, including those related to high-risk patients. When surveyed about their latest exposure, 51% of residents failed to report the experience, including 15 of the 91 (16%) exposures. While historically, surgical residents have six times as many needlesticks as their medical counterparts, it is important that we heed this data in light of the welcome addition of our less experienced interns and the high prevalence of transmissible diseases among the patients we care for.

A study published in the BMJ questions the utility of self-monitoring of blood glucose levels among “reasonably” well controlled type-2 diabetics not treated with insulin. 453 patients with a mean hemoglobin a1C of 7.5% were randomized into three groups; usual care without self-monitoring of blood glucose, blood glucose self-monitoring with the advice to discuss the results with their doctors in addition to usual care, and blood glucose self-monitoring with intensive training to apply the results and enact lifestyle changes. The primary endpoint was hemoglobin a1C levels at 12 months. There was no change in hemoglobin a1C among those randomized to usual care and a decrease of only 0.17% among those assigned to self-monitoring with intensive training (p=0.12). Results were calculated using an intention to treat analysis and it should be noted that only about half of those randomized to intensive training were still using their glucometers at the conclusion of the study.

The Annals of Internal Medicine reported a study showing hope for Crohn disease sufferers who have failed or were intolerant of treatment with infliximab, a chimeric TNF antagonist. 325 patients with moderate to severe Crohns (Crohn’s Disease Activity Index (CDAI) 220-450 points) were randomized to receive adalimumab, a fully humanized TNF antagonist, or placebo at times zero and two weeks from time of study entry. Patients were allowed to continue on other treatments concurrently. The primary endpoint was induction of remission (CDAI <150 points) at 4 weeks. 21% of patients in the adalimumab group versus 7% of patients in the placebo achieved clinical remission (p<0.001). This data is congruent with observations from the rheumatoid arthritis literature that all anti-TNF molecules are not created equal. I look forward to seeing longer follow-up in order to determine the efficacy of adalimumab in maintenance of remission among these patients.

Lastly, the Annals of Internal Medicine delves into the world of alternative medicine with a meta-analysis of acupuncture for osteoarthritis of the knee. Studies longer than 6 weeks comparing needle acupuncture with a sham, usual care, or a waiting list control group (waiting for acupuncture) were included. The search strategies were sufficient however evidence of small study and publication biases were evident in the analysis. Intervention effect was assessed as the standardized mean difference in pain assessment scores used in the included studies. A random effects model was used and compared with patients in the waiting list control groups, patients receiving acupuncture reported clinically relevant short-term improvements in pain, -0.96 (95% CI, -1.21 to -0.7). Compared with patients who received sham procedures, difference among those who received acupuncture were considered clinically irrelevant, however significant heterogeneity existed among the trials with a sham control group. The authors suggested placebo and expectation effects may have influenced the results and recommended awaiting the results of upcoming large sham-controlled randomized trial before any changes in management could be advised.

Picture: Vorderkaserklamm near Lofer in Austria Courtesy of Wikimedia Commons

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