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Core Curriculum in Primary Care Medicine, Part II, 2nd Edition: Orthopedic/Sports Medicine HEALTHSTREAM, 209 10TH AVENUE SOUTH, SUITE 450, NASHVILLE, TN 37203. PHONE: (800) 521-0574 OR (615) 301-3205.

PRICE: $49 individual/single-user license, $99 institutional/multiple-user license.

HOW SUPPLIED: Single CD-ROM containing Macintosh and PC versions.

DOCUMENTATION: Included on the CD-ROM.

HARDWARE REQUIREMENTS: Macintosh--16 MB RAM, System 7.1, double-speed CD-ROM drive, 640 x 480 display with thousands of colors, standard Macintosh sound. Pentium PC--16 MB RAM, Windows 95, hard disk with 8 MB of free space, double-speed CD-ROM drive, 640 x 480 display with thousands of colors, MPC standard sound board and speakers.

CUSTOMER SUPPORT: Toll-free number, onscreen help, and Internet assistance.

DEMONSTRATION DISK: No.

MONEY BACK GUARANTEE: 100% within the first 30 days.

RATING: Good, for both content and interface.

HealthStream, formerly SilverPlatter, produces a series entitled The Core Curriculum in Primary Care Medicine, Part II, consisting of 9 lectures in adult primary care on CD-ROM. Other topics in this series include infectious diseases, gynecology, dermatology, cardiovascular medicine, foot and ankle, endocrinology, neurology, and hematology/oncology. The company also produced an earlier series of CD-ROMs (Part 1) that covered 9 additional topics.

The orthopedic/sports medicine CD-ROM is an electronic rendition of a continuing medical education (CME) lecture with conference audio and slides. This type of presentation has several advantages over its live counterpart, primarily the option to review information at the pace, place, and time determined by the user. The program's pages load quickly and smoothly from a 24x CD-ROM drive.

This program contains an introduction and 6 lectures. The first lecture is a 50-slide discussion of overuse injuries (OUI). The speaker estimates orthopedic/sports medicine injuries represent 20% of all office visits to a primary care physician, primarily represented by OUI. The majority of the lecture is devoted to the causes and circumstances under which stress injuries occur, such as increases in exercise duration, intensity, or frequency. There was a strong focus on running-related injury with little attention to upper extremity problems or other spores. The focus is on the mechanism of injury and the diagnosis of OUI; treatment receives cursory attention with emphasis on. nonsteroidal anti-inflammatory drugs and rest, ice, compression, and elevation.

The second lecture, made up of 18 slides, reviews the swollen knee and its etiology and evaluation. Unfortunately, the time dedicated to this topic is inadequate and cursory, especially with regard to physical evaluation and treatment. Simple descriptions and static images are insufficient to describe the examination of the knee when the electronic medium easily allows for dynamic demonstration (none of the lectures on the disk contains video footage). Knee joint aspiration and fluid analysis were well described (Figure 1). The role and predictive values of imaging studies (magnetic resonance imaging [MRI], plain films) are adequately covered.

[Figure 1 ILLUSTRATION OMITTED]

The hand and wrist receive comprehensive coverage with an 80-slide presentation. Anatomy is reviewed in detail and used as the foundation on which the pathology is described. The most common office complaints are described in detail: trigger finger, ganglion cyst, mucous cyst, mallet finger, Dupuytren disease, Boutonniere deformity, skier thumb, flexor tendon injury, carpal tunnel syndrome, and de Quervain tendonitis. Treatment plans are clear and concise and include minor surgical procedures, such as surgical drainage of a felon (Figure 2). This lecture alone justifies the purchase of this program.

[Figure 2 ILLUSTRATION OMITTED]

The fourth topic considered is the shoulder, with a scant 36 slides to cover a joint with several cardinal movements and a complicated anatomy. Sternoclavicular articulation is not included although this is an important joint with respect to traumatic injury. The speaker presents diagnostic concepts with respect to age and describes the rotator cuff and acromioclavicular separation grading scales (Figure 3).

[Figure 3 ILLUSTRATION OMITTED]

The lecture on elbow pain is comprehensive (47 slides). Text and static images fully clarify the physical examination and pathology. There are detailed discussions of fractures, dislocations, tendon ruptures, bursitis, and the common OUI. There is a description of neuropathies, in particular ulnar nerve entrapment, and the clinical tests used in their clarification. The differential diagnosis of elbow pain, including cervical radiculopathy and thoracic outlet syndrome, is explored along with treatment guidelines, with specific attention to early mobilization to avoid a frozen joint.

The final lecture of 32 slides discusses the arthritic hip. The signs, symptoms, and evaluation precede a lengthy discussion of treatment. Plain radiographs are emphasized over MRI studies (useful in the evaluation of avascular necrosis) and CAT scan (not deemed useful). Discussions include conservative measures, such as education, weight loss, assisted ambulation, and analgesics and should these fail, surgical options and issues. Deep venous thrombosis prophylaxis, complications (dislocation, infection rate of 1%), and rehabilitation discussions end this segment.

Multimedia features include multicolored highlighters (helpful if using the slides in a presentation), a carousel in which slide order can be altered to create a unique presentation, searchable and printable transcripts with or without the associated slide images, and the ability to capture screens for printing. A section is provided for personalized notes on a specific page (though there is no index for these notes) and a global note pad is available from the Options menu. Users may read sections and individual pages in any order. Previously viewed slides appear in red text in the Go To menu window. However, there is no way to bookmark a selection of text or slide for later review. Audio may be accelerated to twice normal speed, theoretically cutting review time in half. Printing slides associated with transcripts greatly increased printing time and produced images too small to be of value.

Users cannot change screen fonts and font size, but the program's choices make for easy viewing of both the text and slides. There are no hypertext links for related information, but there is a global search feature for finding text containing similar words. References are not provided either within the body of the text or through hypertext links.

A strong feature of the program is its Internet connectivity. There is an option to launch the user's browser from within the application and link to any of HealthStream's pages or another Web site. HealthStream provides a biweekly update to physicians on primary care topics. Evidence for the opinions is based on articles from PubMed (a free bibliographic database), which the user may access. The articles provide links to additional Web sites with similar content, as well as to a feature called MD Digest that offers abstracts on general medical topics from reputable journals. There are patient education pages that provide guidance for specific diseases. The MD Opinion page allows users to ask opinions of specialists (and family physicians) through a searchable database.

After completing the disk users may take a CME examination. If a sufficient percentage of questions is answered correctly, a score sheet can be printed and submitted for credit. If users have trouble with questions during the examination, they can click the Review Topic button to see the relevant segment of the presentation. Unfortunately, the questions cannot be printed.

In summary, for $49 users receive 4 hours of American Academy of Family Physicians/American Medical Association category 1 CME credit (approximately $12 per credit hour) and a permanent portable reference plus the Web content. Those with significant knowledge of the subject will find the information basic and far from comprehensive. However, aside from suggestions to enhance the interface the disk is a good source of general information and merits review by primary care physicians. Because there was less of a sports medicine focus than the title promised, "Common Office Orthopedic Problems" would more accurately reflect the contents. Completion of the program does not prepare a physician to assume a role on the sideline as a team physician.

Peter A. Coldwell, MD
Mercy Health Partners
Family Practice Residency Program,
Toledo, Ohio
E-mail: pcoldwell@pol.net

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