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In This Issue of Archives of Internal Medicine
March 27, 2006

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2006;166(6):601. doi:10.1001/archinte.166.6.601

Associations Between the Age at Diagnosis and Location of Colorectal Cancer and the Use of Alcohol and Tobacco

While colorectal cancer (CRC) prevention guidelines state that screening in the general population should begin at age 50 years, those with a genetic predisposition should have testing performed at an earlier age. However, there are no such recommendations for exogenous CRC risk factors. Therefore, Zisman and colleagues queried a large cancer registry database to analyze the relationship between age at diagnosis of 161 000 patients with CRC and their alcohol and tobacco use histories. When compared with patients who never used tobacco or alcohol, current users of tobacco, alcohol, and both tobacco and alcohol presented with CRC at younger ages (adjusted age differences of 5.2, 5.2, and 7.8 years, respectively, P<.001). If confirmed, these data would suggest that tobacco and alcohol users should potentially have their CRC screening initiated at an earlier age.

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A Trial of Disclosing Physicians' Financial Incentives to Patients

Concern regarding financial conflict of interest for physicians has led to calls for disclosure of compensation systems and their incentives to patients. This article reports the results of a randomized trial of a single mailed disclosure letter sent to patients of 2 large physician groups. Patients reacted to the disclosure positively, and the disclosure interventions were associated with improved knowledge of physicians' compensation models and with self-assessed understanding among patients of the potential impact of financial incentives on care. Patients' trust in their physicians was unharmed, and their loyalty to their physician group strengthened. The results suggest that for physician groups with similar compensation systems, disclosure to patients should be considered an effective method to enhance the patient-physician relationship.

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Current Antibiotic Therapy for Isolated Urinary Tract Infections in Women

Kallen et al analyzed data for isolated outpatient urinary tract infections in women. They found that quinolones had replaced sulfas as the most commonly prescribed antibiotics for this indication (48% vs 33%; P<.05). There were few significant predictors of quinolone use, suggesting that this increase was not limited to a few subgroups of patients or to certain settings. More than one third of the quinolones used were broader-spectrum quinolones. The authors suggest that the increase in the use of quinolones may not represent a rational response to sulfa resistance patterns and that current methods of measuring resistance may tend to promote overuse of this important class of antibiotics.

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Competency in Cardiac Examination Skills in Medical Students, Trainees, Physicians, and Faculty

In this study, Vukanovic-Criley et al used a validated, 50-question, computer-based test to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills, using computer graphic animations and virtual patient examinations. They tested 860 participants at all levels of training as well as practicing physicians. Mean scores improved from first- to third-year medical students (P = .003) but did not improve thereafter. Scores did not differ significantly among third- and fourth-year medical students, internal medicine and family medicine residents, full-time faculty, voluntary clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (P<.001), with the highest scores in all 4 subcategories of competency. Cardiac examination skills do not improve after the third year of medical school and may decline after years in practice.

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Relationship Between Accurate Auscultation of a Clinically Useful Third Heart Sound and Level of Experience

Confidence in the clinical utility of the third heart sound (S3) has diminished, given reports of poor physician performance and significant interobserver variability. With the hypothesis that the auscultation of a clinically useful S3 improves with advancing level of experience, Marcus et al compared the S3 auscultated by interns, residents, cardiology fellows, and cardiology attendings to phonocardiography and several objective markers of left ventricular function. While fellow and attending auscultation of the S3 significantly correlated with phonocardiography, intern and resident auscultation did not. The S3 generally demonstrated low sensitivities and high specificities for abnormal left ventricular function, and the best test characteristics were exhibited by the more experienced groups. While correlations between the S3 and abnormal markers of left ventricular function were superior for phonocardiography, these associations improved with each level of auscultator experience.

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