James C. Byrd

Efficacy of prophylactic sclerotherapy for prevention of a first variceal hemorrhage

The efficacy of prophylactic sclerotherapy is unclear because published studies of prophylactic sclerotherapy have reached conflicting conclusions. Meta-analysis was used to determine the efficacy of prophylactic sclerotherapy of esophageal varices. The meta-analysis included all English-language articles reporting results of randomized controlled trials of prophylactic sclerotherapy in adults. Prophylactic sclerotherapy reduced the 13-month mortality rate by 11% (95% confidence interval, 4%-19%), which represents a 41% relative reduction in mortality rate. Across studies, the mortality rate reductions were positively correlated with the bleeding rate reductions and negatively correlated with complication rates. The pooled mortality reduction remained significant when sensitivity analyses included the interim results from the abstracts and foreign-language articles. Nonetheless, prophylactic sclerotherapy should not be widely applied at present because complication rates are high and less costly treatments are available. Furthermore, all published studies offered more intensive follow-up to treated patients, which may have confounded the results and consistently inflated the benefits of sclerotherapy.

Outpatient consultation: interaction between the general internist and the specialist.

To define the process of outpatient consultation, the authors conducted a prospective study of 716 consecutive outpatient consultations in a university-based primary care internal medicine practice. The overall consultation rate was 11.9 per 100 patient visits, with 78% of the referrals to other physicians and 22% to non-physician specialists. Consultation rates and patterns of referral varied little between physicians with different levels of experience. Eighteen per cent of the consultations resulted in a no-show by the patient to the consultant. Referring physicians received communications from the consultants 80.5% of the time when appointments were kept. By multivariate regression two variables were shown to be most important in determining the internist’s overall satisfaction: 1) how well the consultant aided the internist in his ongoing management of the patient’s problem, and 2) how well specific questions were addressed by the specialist. Other statistically significant variables were the clarity and promptness of the consultant’s reply, the educational value of the consultation, and specific management recommendations made by the consultant. To improve the consultation process no-shows must be minimized, communication from the consultant maximized, and the interaction between the internist and the consultant bolstered.

Physician extenders for cost-effective management of hypercholesterolemia

OBJECTIVE: Treatment of elevated cholesterol levels reduces morbidity and mortality from coronary heart disease in high-risk patients, but can be costly. The purpose of this study was to determine whether physician extenders emphasizing diet modification and, when necessary, effective and inexpensive drug algorithms can provide more cost-effective therapy than conventional care.DESIGN: Randomized controlled trial.SETTING: A Department of Veterans Affairs Medical Center.PATIENTS: Two hundred forty-seven veterans with type IIa hypercholesterolemia.INTERVENTIONS: Patients assigned to either a cholesterol treatment program (CTP) or usual health care provided by general internists (UHC). CTP included intensive dietary therapy administered by a registered dietitian utilizing individual and group counseling and drug therapy initiated by physician extenders for those failing to achieve goal low-density lipo-protein (LDL) levels with diet alone. A drug selection algorithm for CTP subjects utilized niacin as initial therapy followed by bile acid sequestrants and lovastatin. Subjects were followed prospectively for 2 years.MEASUREMENTS: Primary outcome measurements were effectiveness of therapy defined as reductions in LDL cholesterol (LDL-C), and whether goal LDL-C levels were achieved; costs of therapy; and cost-effectiveness defined as the cost per unit reduction in the LDL-C.MAIN RESULTS: Total program costs were higher for CTP patients than for UHC patients (

Environmental tobacco smoke : medical and legal issues

659±

The impact of educational loan burden on housestaff career decisions

43 vs

Informed consent for patient transfers to a veterans affairs medical center

477±

Frontal Astrocytoma: A Cause of Exertional Syncope?

42 per patient, p<.001). However, at 24 months the patients in CTP were more likely to achieve LDL goal levels (65% vs 44%,p<.005), and also achieved greater reductions in LDL-C 27%±2% vs 14%±2% at 24 months,p<.001). Program costs per unit (mmol/L) reduction in the LDL-C, a measure of cost-effectiveness, was significantly lower for CTP (

The 35-mm slide—Is blue better?

758±

Ascorbic acid requirements for smokers: analysis of a population survey.

58 vs

Laryngeal carcinoma presenting as platypnea

1,058±