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In This Issue of Archives of Internal Medicine |

In This Issue of Archives of Internal Medicine FREE

Arch Intern Med. 2012;172(12):904. doi:10.1001/archinternmed.2011.957.
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STATIN THERAPY IN THE PREVENTION OF RECURRENT CARDIOVASCULAR EVENTS

In a sex-based meta-analysis on statins therapy for secondary prevention of cardiovascular events (including 11 randomized controlled trials representing 43 191 patients), Gutierrez et al showed that statins reduced cardiovascular event rates in both women and men, but this benefit failed to reach statistical significance for women in 2 outcomes: all-cause mortality and stroke. The investigators attributed this discrepancy to the small number of women included in the trials and a worse baseline cardiovascular profile in some of these women.

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NATURE AND IMPACT OF GRIEF OVER PATIENT LOSS ON ONCOLOGISTS' PERSONAL AND PROFESSIONAL LIVES

What does oncologists' grief over patient loss look and feel like? What is the impact of this grief on oncologists' personal and professional lives? This qualitative study explores these questions in depth. Oncologists' grief was found to be a unique, affective mourning experience that included a sense of self-doubt, guilt, failure, holding hard knowledge, powerlessness, sadness, loss of sleep, and crying. The impact of patient loss on oncologists included burnout, compartmentalization, and a normalization of death. Emotional impact on oncologists included difficulty keeping emotional boundaries and emotional exhaustion. Impact on patients included treatment decisions, distraction, distancing and withdrawing from dying patients, and being motivated to improve care for patients. Personal impact included grief spillover and gaining perspective on life. Patient loss has a significant impact on oncologists' personal and professional lives. Education and institutional support are necessary to help oncologists cope better with loss and grief and may have a positive impact on patient care.

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EFFECT OF A 3-STEP CRITICAL PATHWAY TO REDUCE DURATION OF INTRAVENOUS ANTIBIOTIC THERAPY AND LENGTH OF STAY IN COMMUNITY-ACQUIRED PNEUMONIA

Carratalà et al carried out a randomized trial to determine whether the use of a 3-step critical pathway, including early mobilization and use of objective criteria for switching to oral antibiotic therapy and for deciding on hospital discharge, would be as safe as, and more effective than, usual care in reducing the duration of intravenous antibiotic therapy and length of stay (LOS) in patients with community-acquired pneumonia. The median LOS was 3.9 days in the 3-step group and 6.0 days in the usual care group (< .001); median duration of intravenous antibiotic therapy was 2.0 and 4.0 days, respectively (< .001). No significant differences were observed in readmissions, case-fatality rate, and patients' satisfaction. The use of a 3-step critical pathway was safe and effective.

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PHYSICIAN PERCEPTION OF THE IMPACT OF PRODUCTIVITY MEASURES ON ACADEMIC PRACTICE

Summer et al surveyed physicians in the department of medicine at a large academic medical center that recently introduced a model for measuring physician work to determine the impact of work targets on attitudes and behaviors toward teaching, research, and clinical care. Nearly half of physicians were more inclined to take on activities that counted toward productivity targets. However, this was associated with changes in the way physicians practiced clinical medicine, which included behavior aiming to maximize provision of services captured by the productivity measure. Physicians also perceived a negative impact on nonclinical activities. Academic medical centers have begun measuring physician work at least in part to incentivize physicians to perform more clinical duties that immediately generate revenue, but such policies have many unintended consequences that have a negative impact on the tripartite mission of academic medical centers.

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INCREASING OCCURRENCE OF ATYPICAL FEMORAL FRACTURES ASSOCIATED WITH BISPHOSPHONATE USE

Meier et al analyzed a population of 477 patients 50 years or older who presented to a single university medical center between and 2010 with a first subtrochanteric or femoral shaft fracture. They identified 39 patients with atypical fractures and 438 patients with classic subtrochanteric or femoral shaft fractures based on systematic admission radiograph review. Of those patients with atypical fractures, 82% had been treated with bisphosphonates vs 6% in the classic fracture group. Longer use was associated with a constant increase in atypical fractures. Interestingly, contralateral fractures occurred in 28% of atypical cases vs 0.9% of classic cases. The incidence rate of atypical fractures was low (32 cases per million person-years) and increased by 10.7% per year on average. On the basis of the rarity of such events and the known benefit of bisphosphonates, the authors conclude that the absolute benefit-risk ratio stays positive.

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Incidence rates of classic subtrochanteric or femoral shaft fractures and atypical fractures among residents of the state 50 years and older.

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Incidence rates of classic subtrochanteric or femoral shaft fractures and atypical fractures among residents of the state 50 years and older.

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