John P. Geyman

Conservative Versus Surgical Treatment of Mallet Finger: A Pooled Quantitative Literature Evaluation

Background: Although common, mallet finger represents a spectrum of injuries for which there are many questions about the best form of treatment. A long-standing controversy continues as to strategies and techniques of treatment. This quantitative literature analysis is the first that makes use of an evidence-based evaluation process to pool across studies the outcomes of conservative versus surgical treatment of closed mallet finger injuries of both acute and chronic or recurrent types. Methods: Published articles in English were sought using multiple methods, including the MEDLINE and EMBASE databases, reference review, and correspondence with selected experts. Both observational and randomized trials were included. Results were summarized in terms of 95 percent confidence intervals, and sensitivity analysis was performed for two other amounts of residual extensor lag. Results: Of the 41 reports retrieved, 26 met inclusion criteria, including 21 for initial acute treatment (1146 pooled digits) and 5 for chronic or recurrent treatment (148 pooled digits). Successful outcomes were found in about 77 percent of mallet fingers treated conservatively by splintage, including 480 patients who were observed for a 2-year period. Patient satisfaction with conservative treatment was found to be about 83 percent in 6 studies recording overall patient satisfaction (315 pooled patients). Successful outcomes of surgical treatment for acute mallet finger averaged about 85 percent in 3 studies (60 pooled digits) and about 73 percent in 5 studies of chronic or recurrent mallet finger. Conclusions: Conservative treatment of at least 80 percent of mallet finger injuries is safe, effective, well accepted by patients, and cost efficient compared with surgical treatment. Multiple types of surgical procedures are available when surgery is indicated for a limited number of open or otherwise complex mallet finger injuries as well as for chronic or recurrent mallet finger.

Evidence-Based Medicine in Primary Care: An Overview

Editors Note: This article is the first in a series of articles that during the next 2 years will sequentially address various evidence-based approaches to the diagnosis and management of common clinical problems in primary care. Future articles will deal with clinical efficacy and effictiveness, clinical practice guidelines, quality-oflife and outcomes analysis, patient preferences, meta-analysis, cost-effectiveness analysis, decision

Out-of-hospital cardiac arrest in a rural area : A 16-year experience with lessons learned and national comparisons

STUDY OBJECTIVE To evaluate the effectiveness of the emergency medical services (EMS) system in a rural island community in resuscitating victims of out-of-hospital cardiac arrest over the past 16 years. METHODS We conducted a retrospective analysis of all EMS responses to cardiac arrests on San Juan Island, a rural island community of 5,000 people in the Pacific Northwest. Data were collected between January 1977 and July 1994 on the basis of the Utstein criteria. From these data, we calculated survival rates and compared them with published data from other rural and nonrural areas in the United States. RESULTS During this study, 22% of all the patients who sustained a cardiac arrest of cardiac origin on the island survived to hospital discharge. The survival rate for witnessed cases of ventricular fibrillation and ventricular tachycardia was 43%. CONCLUSION The combined paramedic/emergency medical technician system used on San Juan Island has yielded survival rates comparable to those of urban areas. This system may serve as a model for other rural communities, especially those with well-defined geographic areas and established 911 central dispatching.

Patient Preferences for Management of First-Trimester Incomplete Spontaneous Abortion

Background: Approximately 15% of clinically recognized pregnancies end in miscarriage. The probabilities for successful outcome between expectant treatment and dilatation and curettage for management of many first-trimester incomplete spontaneous abortions are comparable. The goal of this study was to assess patient preferences for expectant treatment compared with dilatation and curettage, and the effect of physician recommendation on these preferences. Methods: During individual telephone interviews, patients were read a case scenario and two treatment options. They were educated about the estimated risks, outcomes, and costs associated with each option. The patients then verbally completed a questionnaire assessing their likelihood of choosing each option, their reasons for their choice, and the effect of physician recommendation. Results: Seventy-five women between the ages of 18 and 45 years, recruited from a university-affiliated family medicine clinic, were interviewed. Of these women, 27 had experienced spontaneous abortion (cases), and 48 had not (controls). Seventy-two percent of all participants (confidence interval 0.62-0.82) were likely or highly likely to choose expectant treatment, 23% of women rated the likelihood of choosing this option unlikely or highly unlikely, and 5% were uncertain. No significant difference existed between the case and control populations regarding choice of treatment (P = .566). One half of the women stated they would change their choice given a physician’s recommendation (55% control, 40% case, P < .03) Conclusions: Participants indicated a strong preference for expectant treatment, but gave physician recommendation a significant role in the final decision. Physicians need to offer both options to patients and consider individual patient preferences when making recommendations regarding management of first-trimester incomplete spontaneous abortion.

The generalist disciplines in American medicine one hundred years following the Flexner Report: a case study of unintended consequences and some proposals for post-Flexnerian reform.

Abraham Flexners analysis of U.S. medical education at the turn of the 20th century transformed the processes of student selection and instruction, the roles and responsibilities of faculty members, and the provision of resources to support medical education. Flexners report also led to the nearly universal adoption of the academic medical center as the focal point of medical school teaching, research, and clinical activities. In this article, the authors describe the effects of the dissemination of this model and how the subsequent introduction of public funding for research and patient care transformed academic health centers and altered the composition of the physician workforce, resulting in the proliferation of specialties. They also describe how these workforce changes, along with the evolution of health care financing during the late 20th century, have led to a system that affords the most scientifically advanced and potentially efficacious care in the world, yet so profoundly fails to ensure affordability and equitable access and quality, that the system is no longer sustainable. The authors propose that both health care system reform and medical education reform are needed now to restore economic viability and moral integrity, and that a key element of this process will be to rebalance the generalist and specialist composition of the physician workforce. They conclude by suggesting that post-Flexnerian reform of medical education should include broadening the scope of criteria used to select medical students and reshaping the curriculum to address the evolving needs of patient care during the 21st century.

Anaphylactic Reaction After Ingestion Of Bee Pollen

Bee pollen allergy, although relatively rare, can present a life-threatening medical emergency. Conventional treatment of anaphylaxis is indicated, and further allergic workup is not necessary. There is little awareness of this hazard among the general population. Warnings to include product labeling of potential adverse reactions in sensitive individuals are urgently needed to protect the public from this hazard.

Detection and Treatment of Depressive Syndromes in a Rural Island Clinic

Background: Major depression is a serious and often persistent problem for 5 to 10 percent of patients in primary care. The detection and treatment of depression can be a particular challenge in rural settings. This study describes patterns of care for depression at a rural primary care clinic on an island off the coast of Washington State. Methods: For a period of 2 months, 226 primary care patients were evaluated for depression using a two-stage screening method. Structured chart abstraction was conducted for patients meeting criteria for major depression or dysthymia. Results: Ten percent of the study sample met Diagnostic and Statistical Manual of Medical Disorders, fourth edition, criteria for major depression, 4 percent met criteria for dysthymia, and 8 percent met criteria for major depression and dysthymia. Of the patients who had a diagnosis of major depression or dysthymia by the PRIME-MD, approximately 50 percent had their condition detected by their primary care provider, and approximately 50 percent received guideline level antidepressant treatment. Less than 40 percent of patients whose depression was treated with antidepressants made more than two visits during the 8 weeks after the initial prescription. Conclusions: These findings are consistent with those from other primary care settings and suggest that there are many opportunities for improving the quality of care for depressed patients in rural primary care settings.

Primary care at a crossroads: progress, problems, and future projections.

The tension between generalist and specialist roles in medical education and practice has been marked by recurrent perceived crises for many years in the United States. Primary care was at a crossroads during the 1960s. There was much turmoil within the health care system, and many in the population were unable to gain access to and afford health care. As a result of this turbulence, a major effort was mounted at state and federal levels to increase the proportion and number of primary care physicians. New initiatives included efforts to increase the total number of physicians, passage of Medicare and Medicaid legislation, new emphasis on education programs in primary care, recognition of family practice as a specialty, and emergence of the National Health Service Corps. Today, 25 years later, the health care system as a whole is unraveling and in crisis as a result of soaring costs, the difficulty of providing access to all citizens, and health care outcomes that have fallen short of those achieved in many other industrialized countries. It is ironic how many of the failings of todays health care system mirror those of the 1960s, and how parallel the approaches to address these problems are to those taken a generation ago. Primary care finds itself again at a crossroads as intense pressures mount for fundamental reform of a health care system that has an inadequate primary care base. It is timely to take stock of the progress achieved by the initiatives to expand primary care during the last 25 years. Accordingly, this report addresses the following four objectives: (1) to

Success Strategies For Departments Of Family Medicine

Strong departments of family medicine in academic medical centers help assure the future scope and quality of family practice patient care, the ongoing evolution of family medicine as a scholarly discipline, and a continued flow of qualified medical school graduates into family practice residency programs and eventually into practice. This report presents key strategies of six successful departments of family medicine and describes the methods and skills considered important by the leaders of these departments. Common themes that emerge are (1) recruit and mentor the best faculty, (2) build a reputation for clinical excellence of faculty and residents, (3) become part of schoolwide curriculum activities, (4) establish a scholarly presence, and (5) develop networks of support.

Cost-sharing under consumer-driven health care will not reform U.S. health care.

Various kinds of consumer-driven reforms have been attempted over the last 20 years in an effort to rein in soaring costs of health care in the United States. Most are based on a theory of moral hazard, which holds that patients will over-utilize health care services unless they pay enough for them. Although this theory is a basic premise of conventional health insurance, it has been discredited by actual experience over the years. While ineffective in containing costs, increased cost-sharing as a key element of consumer-driven health care (CDHC) leads to restricted access to care, underuse of necessary care, and lower quality and worse outcomes of care. This paper summarizes the three major problems of U.S. health care urgently requiring reform and shows how cost-sharing fails to meet that goal.