Volume 110, Issue 7

Coronary artery disease is the leading cause of death in the United States. The combination of noninvasive cardiovascular testing and invasive cardiac procedures accounts for a substantial portion of the yearly healthcare expenditure in the United States. Although the diagnosis of ischemically-driven chest pain may appear to be simple and straightforward, it often takes an astute clinician to confirm that clinically significant coronary artery blockage is the cause of a patient's chest pain. Cardiovascular research has provided convincing evidence that aggressive treatment of hypertension and hyperlipidemia—along with a management plan, based on the patient's combined risk factor profile, that includes blood glucose assessment, tobacco cessation, weight loss, healthy eating choices, and consistent aerobic exercise—must be provided to achieve optimal care for our patients. Over the ensuing decade, we will likely continue to see a shift away from routine percutaneous treatment of coronary lesions in favor of an aggressive assessment of a patient's cardiac risk profile followed by a treatment plan centered on active patient involvement including appropriate lifestyle changes and selective medications.

Context: Manual medicine—specifically osteopathic manipulative treatment (OMT)—is commonly used in treating patients aged 18 years or younger. However, no published reports have described characteristics of this patient population or the conditions for which OMT is used with these patients. To better counsel parents, train physicians and other healthcare providers, and prioritize research, an improved understanding of the use of OMT in children is needed. Objective: To characterize pediatric patients and their conditions as seen in a medical school–based osteopathic manipulative medicine clinic. Study Design: Retrospective analysis of administrative data on the use of OMT. Setting: Faculty osteopathic manipulative medicine specialty clinics associated with the University of New England College of Osteopathic Medicine. Patients: Data were analyzed from patients seen in the clinics from January 1, 2007, through December 31, 2007, if they were younger than 19 years at their first visit during that period. Outcomes Measures: Factors included in the data analysis were patient age at first visit, age at time of visit, number of visits during the study period, types of clinical diagnoses, and visits with nonmusculoskeletal diagnoses. Results: A total of 407 patients generated 1500 clinic visits. Data showed a mean of 3.7 visits per patient (25th-75th percentiles = 2-5 visits) during the 1-year study period. The mean age at the first clinic visit was 7 years, 3 months, with the 25th-to-75th percentile being 1 year, 9 months, to 12 years, 3 months. Clinic visits by age group (ie, age at time of visit) as percentages of total visits were as follows: 0 to 11 months, 13.7%; 1 to 4 years, 33.3%; 5 to 12 years, 28.9%, older than 12 years, 24.2%. Diagnoses provided in visits covered a wide variety of common pediatric conditions. For the entire study population, 43.5% of visits included nonmusculoskeletal diagnoses. The percentages of visits with nonmusculoskeletal diagnoses for each age group were as follows: 0 to 11 months, 33.7%; 1 to 4 years, 64.0%; 5 to 12 years, 48.8%; older than 12 years, 17.7%. Conclusion: Pediatric patients seen in the faculty osteopathic manipulative medicine specialty clinic included the entire pediatric age range and a wide range of common pediatric conditions. A substantial number of visits involved treatment for nonmusculoskeletal conditions. Further investigation is needed to determine if the patient sample of the present study is representative of other clinical settings or geographic regions.

Context: Consumption of 8 alcoholic drinks per week or 5 alcoho lic drinks on one occasion by a pregnant woman can affect the developing fetus. However, it can be difficult to determine which patients are at risk. Objective: To evaluate how well the answer to a single question about binge drinking could help identify women at risk of an alcohol-exposed pregnancy (AEP). Methods: Using data from a study of methods to prevent AEPs, the authors compared the efficacy of self-reported answers to a screening question about binge drinking (5 or more standard drinks on one occasion) within the past 90 days with answers to a question about drinking quantity (weekly consumption of 8 or more standard drinks) within the past 90 days. Results: The participants were 354 women of childbearing age who met screening criteria for being at risk of an AEP. The binge question was answered positively by 346 women (97.7%) at risk, while only 209 women (59.0%) reported that they drank 8 or more drinks in a week. Conclusion: A single question about binge drinking can effectively and quickly identify the majority of women at risk of an AEP.

Context: Current limitations on residency duty hours came about after the death of a patient in 1984 in a New York City hospital. This tragedy served as the catalyst for a new public awareness and subsequent change in philosophy regarding resident duty hours, fatigue factors, and risks to patients from the long and tedious shifts of residency. However, it has proven difficult to limit resident physician duty hours. Objective: To analyze the impact of resident duty hour limitation (RDHL) implementation on residents, faculty, and patients. Methods: The authors conducted a survey of faculty and resident attitudes and experiences regarding RDHLs in the graduate medical education department at Arrowhead Regional Medical Center (ARMC) in Colton, California. They also conducted a review of the literature on faculty and resident attitudes and experiences before and after implementation of RDHLs. Results: Of 60 surveys sent to ARMC faculty members in 2009, 12 (20.0%) were returned. Of 140 surveys sent to ARMC residents, 96 (68.6%) were returned. The survey results and literature review indicated that most faculty physicians initially believed that decreasing resident duty hours would limit the time available to residents for educational experiences and participation in treatment procedures, operations, and consultations. In addition, faculty initially believed that fewer training hours would diminish the quality of residents' educational experiences. Residents also expected negative outcomes from RDHLs. However, statistical data on actual outcomes revealed that residency programs are not adversely affected by limiting resident work hours to 80 hours per week. Furthermore, benefits of RDHLs appear to include improved patient care and well-rounded and psychologically balanced residents. Conclusion: A survey and literature review revealed a number of benefits of RDHLs. It is unclear, however, whether additional limitations of resident work hours are necessary or could accommodate the growing amount of information and skills that are required to become a competent physician.