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Editors' Briefs

This NEW monthly LINKS page comprises interesting, relevant articles uncovered by our editorial staff members. They will offer short commentary to accompany or link-up with a Journal article of their choice. The objective is not only to be entertaining and informative, but also provide readers thought provoking ideas and boldly go where no one has gone before. We hope you enjoy these briefs of wit and wisdom.

john dark Empirical Evaluation of Very Large Treatment Effects of Medical Interventions
The Journal of the American Medical Association
Link to Article

Someone out there had to do this sort of analysis, and it makes me glad to have become a cardiac surgeon. Tiago Pereira and colleagues examined 85002 forest plots in 3082 reviews published in the Cochrane Database of Systematic Reviews. There were a mind-boggling 225000 measures of effect.

The bottom line is that most large effects (odds ratio >5) come from very small trials—median 20 participants—and often are not confirmed in subsequent meta-analyses. When mortality, something most of us believe to be important, the effect was even less likely to be true.

A single outstanding example, which is of interest to our readers, was that the initial large effect of ECMO for neonatal respiratory failure came from a trial with no major flaws and the effect is sustained in meta-analysis.

The bottom line, as emphasised in the accompanying Editorial, is that dramatic results are often too good to be true!

John Dark

dan dilling Disparities in Access to Lung Transplantation for Cystic Fibrosis Patients by Socioeconomic Status
American Journal of Respiratory and Critical Care Medicine
Link to Article

In an article in AJRCCM published ahead of print, a group of authors from the University of Washington in Seattle argue that—in the United States—low socioeconomic status negatively influences access to lung transplantation for cystic fibrosis (CF) patients.

In a cohort of 2167 patients in the CF Foundation registry who underwent a lung transplant evaluation, patients receiving Medicaid (government supported health care coverage, usually accessed by the poor) had a 1.56 fold higher odds ratio of not being accepted for transplant compared to those with private health insurance. After statistical adjustment, the authors determined this association to be independent of race, geography, education level, or disease severity - although residence in a low-income zip code and low education level were also independently associated with not getting listed.

Are we that heartless? Or are we greedy? Do we triage patients based upon insurance status or poverty status? I doubt it. In my opinion there are probably some "unmeasured" factors not included in the CF database that are influencing these trends (ie robustness of the social support system, levels of health care literacy, and attitudes toward complicated therapies). Proxies for such factors that exist in the database and that the authors used in their modeling of this query are simply inadequate. There might also be some systematic bias in our social safety nets with some regions of the USA not being able to provide adequate lifelong medication and other therapy coverage through Medicaid systems (but this is my conjecture). In any event, I hope we are not to blame. Judge for yourself.

Dan Dilling

javier carbone Biomarker Discovery in Transplantation - Proteomic Adventure or Mission Impossible?
Clinical Biochemistry
Link to Article

There is a paucity of sensitive and specific biomarkers for the early prediction of transplant complications such as rejection or infection. Currently, very few of these are ready for routine clinical use. This article summarizes the current status of biomarker achievements in the different areas of solid organ transplantation. Barriers to using biomarkers in clinical decision making are discussed in the article.

Javier Carbone

roger evans Homosociality: An Interesting Concept
The Wall Street Journal
Link to Article

Recruitment can be a challenging exercise. Person-environment fit is a critical issue. Some people are more easily integrated into the proverbial "team" than others. The recruitment goal is to avoid, or at least minimize, the potential for conflict. Yet, by the same token, diversity has well-acknowledged benefits. Creative people are often "different" and, as such, they can be a problem, particularly when they find themselves amongst mundane people with more than a hint of vanilla.

As described by Erin McKean of the Wall Street Journal, when hiring, the temptation is to be conservative. As a result, people have a tendency to hire others who look and act like them. This is called "homosociality," and is defined by McKean as follows:

Homosociality can be innocuous (for example, mentoring relationships based on the "you remind me of my younger self") but can become exclusionary, a process sometimes called "homosocial reproduction," where only the people who resemble the managers are promoted.

In my opinion, the "team" concept promotes homosociality. Therefore, in medicine and surgery, sports analogies should be abandoned. They're destructive, and outright stupid. Besides that, there are very few sports personalities I would choose to emulate. There are simply too many d _ _ k heads this brief can't contain.

Roger Evans

THE LAST WORD: Roger's Briefs

Review: "Best briefs I've ever owned. I now have every color to coordinate with my wardrobe. Red is very special! And, should my pants fall down, people will simply assume I'm a cyclist, but far better than Lance Armstrong!

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