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19 May 2009 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit Past highlights are accessible as well.

1. Older Women with Vertebral Fractures and Hyperkyphosis Have Increased Mortality Risk

Studies have long linked vertebral fractures to an increased risk for death in older persons. Some studies have suggested that kyphosis (hump back) may also be associated with poor health and death. However, those studies did not assess whether increased kyphosis or the presence of undetected vertebral fractures were the underlying reason for earlier death. Researchers conducted a prospective cohort study of 610 white women between the ages of 67 and 93. The authors measured the degree of kyphosis, bone mineral density, and vertebral fractures. The researchers then assessed the women’s mortality rates over an average follow-up of 13.5 years. They found that women with vertebral fractures and hyperkyphosis had greater risk for mortality than women with only one of these conditions. Among women without vertebral fracture, kyphosis and death were not associated. Nevertheless, the authors conclude that excess curvature of the spine is a clinically important finding that should be assessed and addressed.

2. Quality Measures More Important than Procedure Volume in Predicting Coronary Bypass Outcomes

When choosing a surgeon or surgery center, quality of care is the most important factor. With regard to coronary artery bypass surgery, patients and payers often associate high procedure volume with better outcomes. However, the relationship between volume and quality of care is not well understood. Researchers collected data on 81,289 patients cared for by 1,451 surgeons at 164 hospitals to determine how surgery volume and differences in quality of care influence mortality and readmission rates. The researchers found that hospital and surgeon procedure volume had few consistent associations with outcomes. However, overall adherence to quality measures was strongly associated with differences in mortality rates, regardless of procedure volume. According to researchers, this finding is important because improving quality of care at hospitals is potentially more feasible and desirable than increasing case volume. They suggest that efforts to increase quality of care so patients can “shop for the best” is a wise approach that hospitals should undertake wherever coronary artery bypass surgery is done.

3. Splinting Reduces Pain and Disability in Base-of-Thumb Osteoarthritis

Osteoarthritis is the most common cause of joint pain in middle-age and older persons. While osteoarthritis typically occurs in large joints, it can also affect the hands. Base-of-thumb osteoarthritis (BTOA) is common and it causes considerable pain and disability. Recommendations for management of BTOA include drugs and steroid injections, which can have troublesome side effects. Researchers studied 112 patients with BTOA to determine whether wearing a hand splint could improve pain and hand function. Fifty-seven patients were randomly assigned to wear a custom-made nighttime splint, and 55 patients were randomly assigned to usual care. Nighttime splinting had no effect after one month, but it significantly reduced patients’ pain and disability after 12 months. The study authors conclude that splinting could be an inexpensive and effective alternative to drug treatment for patients with BTOA.

4. USPSTF Recommends Syphilis Screening for Pregnant Women

Syphilis is a sexually transmitted disease that can cause serious problems for pregnant women and their offspring. Because the disease is passed along to the fetus, syphilis can cause stillbirth or death soon after birth, bone deformities, and nervous system problems. Syphilis does not always cause symptoms, so a woman may be unaware that she is infected. Therefore, the USPSTF recommends that all pregnant women be screened for syphilis at their first prenatal visit. If the blood and follow up tests are positive, the woman should be treated with antibiotics. Antibiotic treatment protects the woman and her baby from the affects of syphilis. Researchers conclude that the benefits of screening for syphilis outweigh the harms. Potential harms include unnecessary worry and unnecessary antibiotic treatment.

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