Advertisement
Advances in Managing Multiple Sclerosis

Advances in Managing Multiple Sclerosis

According to recent estimates, about 400,000 people in the United States live with multiple sclerosis (MS). There are other conditions that are now known to be distinct from the disease but may be misdiagnosed as MS. Typically, MS can be associated with fatigue, impaired vision, problems with balance and walking, numbness or pain, tremor, and other sensory and physical changes. “With MS, the symptoms are unpredictable and vary from person to person,” explains Mark S. Freedman, MD. “Some patients may experience abnormal fatigue and episodes of numbness and tingling, whereas others lose balance and muscle coordination. All patients with MS will have unique characteristics and symptoms, making treatment challenging.” Disease-Modifying Therapy Some drugs treat symptoms of MS whereas others modify the disease by altering the course of its progression, Dr. Freedman says. “With disease-modifying therapy, the goal is to reduce MS attacks, decrease the number of lesions seen on MRI, and slow or prevent disease progression.” Several therapies have been approved by the FDA to treat MS, some that are taken orally and others that are injected. The National Multiple Sclerosis Society recommends that patients diagnosed with relapsing MS and those whose disease is currently active consider beginning treatment with disease-modifying therapy as early as possible, as these medications lose efficacy as the disease advances. “It can be challenging for patients to take disease-modifying medications over a long period of time,” Dr. Freedman says, “but it’s important that they understand the role of these therapies in their overall MS treatment plan.” Patients must also be made aware of the obstacles that can interfere with adherence to treatment plans. The...
Wanted: Older Adults in Cancer Trials

Wanted: Older Adults in Cancer Trials

Studies have shown that older adults account for most of the cancer diagnoses and deaths that occur in the United States and make up the majority of cancer survivors. More than 50% of cancers in the U.S. occur in people aged 65 and older, a demographic that is expected to grow exponentially in the coming years. However, the evidence base for treating this patient group is lacking. In addition, few policy initiatives have targeted the lack of evidence on older adults with cancer. “Older adults are largely underrepresented in clinical trials, and it’s rare when these trials are designed specifically for older adults,” says Arti Hurria, MD. “This patient population tends to have different experiences and outcomes with cancer treatment than younger counterparts. We’re also expecting a doubling of the U.S. population that is 65 and older, and we project a 67% increase in cancer incidence among this age group. These data emphasize the importance of involving older adults in clinical trials so that we can optimize treatment for these patients.” In response to this issue, the American Society of Clinical Oncology (ASCO) recently released landmark recommendations to improve the evidence base for treating older adults with cancer. The call-to-action statement was developed by ASCO’s Cancer Research Committee and published in the Journal of Clinical Oncology. It made five overarching recommendations to improve the evidence base for treating older adults with cancer (Table). Improving Trial Designs The first recommendation from ASCO is to use clinical trials to improve the evidence base for treating older adults. There is growing recognition that eligibility criteria in clinical trials could be relaxed without...
Examining Information Sharing Preferences

Examining Information Sharing Preferences

Research has shown that older patients often share control over decision-making and personal health information with family members or friends in order to manage medical care issues. However, it can be challenging for clinicians to balance helping patients and their caregivers work collaboratively to manage health information and decision-making while simultaneously respecting the preferences, privacy, and priorities of patients. To help patients manage their healthcare, patient portals have been developed that connect patients with their healthcare records and oftentimes directly with their clinicians through secure messaging. While portals can be helpful, they may not account for all privacy preferences and offer little guidance on when patients would like to bring their families or caregivers into the fold. Examining Attitudes & Needs In previous research, studies have shown that older patients often want control over the privacy of their health information in electronic medical records, but little is known about how this control relates to family dynamics and the use of patient portals. As reported in  JAMA Internal Medicine, Bradley H. Crotty, MD, MPH, and colleagues sought to identify how elderly patients (older than 75) and their family caregivers approached sharing of health information. “This is an issue that many physicians will encounter, but there has not been much research on the topic,” says Dr. Crotty. For the study, investigators recruited participants from the Information Sharing Across Generations (InfoSAGE) Living Laboratory. InfoSAGE is an ongoing study of the information needs of elderly patients and families within a network of senior housing in the Massachusetts area. Participants joined one of 10 discussion groups to explore the issues. Group discussions were then...
The CDI Burden in Surgery

The CDI Burden in Surgery

Despite increased national attention, the incidence of Clostridium difficile infection (CDI) and its associated financial and human costs continue to grow. In fact, the problem has become so critical that CMS would no longer reimburse hospitals for claims associated with this potentially preventable infection if it is acquired during the hospital stay. There are also concerns that new strains of the infection may cause resistance to traditional antibiotic regimens. Recent data have also shown that the burden of CDI is increasing among surgical patients. This is concerning given that surgical care accounts for about 40% to 50% of all hospital stays and healthcare dollars. “Surgery patients frequently receive prophylactic antibiotics and have longer inpatient hospital exposure,” explains Zaid M. Abdelsattar, MD, MSc. Previous reports on how CDI affects surgical patients has been limited by the use of administrative data and failure to capture cases diagnosed after discharge, and reports from single-center studies. A Large-Scale Analysis In a study published in Infection Control & Hospital Epidemiology, Dr. Abdelsattar and colleagues conducted a large-scale analysis of patients with postoperative CDI after 40 different surgeries at 52 academic and community hospitals for a period of about 1 year. The purpose of the analysis—which included more than 35,000 patients in total—was to identify CDI risk factors and determine the impact of the infection on resource utilization. According to the results, only about 0.5% of the study group developed CDI after surgery, but postoperative CDI rates varied significantly between surgical procedures. Three surgical groups had higher adjusted odds ratios (aOR) of postoperative CDI: Lower-extremity amputations: aOR,3.5. Gastric or esophageal operations: aOR, 2.1. Bowel resection...
Opioid Abuse Screening in the ED

Opioid Abuse Screening in the ED

Using screening tools for various substance use problems in the ED can be powerful but can also be time consuming and costly and may require additional staff resources. Some studies suggest that computerized screening may be a solution to this dilemma because they require less staff time and allow scores to be calculated with fewer errors. As tablet computers have become lighter and less expensive and have a longer battery life, screening ED patients with these devices may improve delivery of care. Over the past decade, opioid prescription abuse in the United States has increased exponentially, with deaths from overdose rising to epidemic proportions. In a study published in the Western Journal of Emergency Medicine, Scott G. Weiner, MD, MPH, and colleagues evaluated the feasibility of using an electronic tablet version of a screener for opioid prescription abuse potential in the ED. The authors used the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), a proprietary screening measure that was previously developed and validated in pain clinic patients. Promising Results For the study, 93 adults being considered for ED discharge with a prescription for an opioid were approached and 82 consented to participate. “All patients completed the screening without assistance and no additional staff resources were required,” says Dr. Weiner. “The median time to completion was just 148 seconds, and 95% completed the screening in less than 5 minutes. In addition, 93% of patients rated the ease of completion as very easy. Our results demonstrate that it is feasible to electronically administer a screening tool for opioid abuse potential to ED patients in a time-efficient manner.” Important...
Smoking Cessation After PCI

Smoking Cessation After PCI

It has been well-documented in clinical studies that smoking cessation after patients undergo PCI can improve outcomes. Some research has identified certain predictors of smoking cessation after PCI, including previous cigarette consumption and the number of coexisting coronary artery disease risk factors. Few studies, however, have assessed current trends in smoking cessation after PCI and looked at the potential impact of smoke-free policies that are being enacted throughout many parts of the United States. “Historically, patients who undergo PCI are a group that has more difficulty quitting smoking than others,” says Randal J. Thomas, MD, MS. The Effect of Smoke-Free Policies In a study published in the February 15, 2015 issue of the American Journal of Cardiology, Dr. Thomas and colleagues assessed trends and predictors of smoking cessation after PCI in Olmsted County, Minnesota. The investigators conducted the research at a time when local and statewide smoke-free public policies were enacted in Olmsted County. The study followed 2,306 patients who underwent their first PCI from 1999 to 2009 for 12 months. The researchers conducted structured telephone surveys at 6 and 12 months after PCI to assess smoking status and quit rates during the 10-year period. The authors paid particular attention to quite rates around two dates when three smoke-free ordinances were implemented to reduce secondhand tobacco exposure in Olmsted County. The first date was January 1, 2002, when an ordinance was passed requiring restaurants to be smoke-free. The second was October 1, 2007, when ordinances required both workplaces and the entire state of Minnesota to be smoke-free. The data were then analyzed according to three time periods: 1991 to 2001, 2002...
A Novel Approach for TMJ Dislocation 

A Novel Approach for TMJ Dislocation 

Anterior temporomandibular joint (TMJ) dislocations are among the most common non-traumatic dislocations of the jaw. Although non-traumatic TMJ dislocations are infrequent in the ED, it is important to find useful methods for managing these patients in order to improve patient outcomes in a safer and more effective manner. The traditional approaches to managing TMJ have numerous disadvantages, including the risk of bite injuries, which in turn increases the risk of transmitting diseases like hepatitis and HIV. Traditional approaches also require procedural sedation because the application of additional force to manually manipulate the mandible can be difficult and painful. In addition to these disadvantages, repeated attempts may be necessary before successfully reducing the dislocated TMJ. Another complication with traditional approaches is that they may inadvertently fracture the mandibular or condyle. Other techniques for reducing TMJ have also been tested, but these strategies still require procedural sedation and manual reduction. “Traditional approaches to TMJ can be time consuming, difficult, and sometimes ineffective,” explains Julie A. Gorchynski, MD, MSC, FACEP, FAAEM. “They can also be risky to patients and emergency physicians because it involves intraoral manual manipulation of the mandible as well as procedural sedation.” A New Technique In a prospective study published in the Journal of Emergency Medicine, Dr. Gorchynski and colleagues evaluated a simple and novel syringe technique for reducing acutely non-traumatic TMJ dislocations using a hands-free approach. The technique requires that a syringe be placed between the posterior molars as they slide over the syringe to glide the anteriorly displaced condyle back into its normal position. Over the 3-year study period, researchers collected information on demographics, mechanisms, duration of...
Examining Patient Desires for ED Function

Examining Patient Desires for ED Function

Average ED wait times in the United States vary considerably, but some locations have particularly long wait times. This time spent in the waiting room often frustrates patients and their families as other ED visitors receive care while those who are waiting are given few, if any, updates. Some research has explored educating patients while they wait to be seen by ED personnel, and this appears to be a potentially valuable tool. “Some studies suggest that providing education in the ED waiting room is of interest to patients,” says Jeffrey Druck, MD. In a study published in the Western Journal of Emergency Medicine, Dr. Druck, Paul Leccese, and colleagues aimed to determine baseline knowledge of ED and hospital processes among ED patients. “One of our goals was to establish types of information that waiting room patients wanted, including expected wait times, causes of delays, and the triage process,” explains Leccese. “We also wanted to see how they would like this information to be delivered.” In addition, the study asked participants what they expected regarding wait times for labs, imaging studies, and admission. The authors also assessed links between racial groups and their desire for information as well as whether or not patients wanted educational health materials. New Data For the study, a 32-question survey was administered to patients and showed that 55% of the 544 respondents indicated that they had a primary care physician (PCP). Of these patients, about 53% reported calling a PCP before they came to the ED. About 72% of participants wanted to know about delays, but just 25% wanted to know others’ wait times. “While...
Liver Cancer: Decreasing Morbidity & Mortality

Liver Cancer: Decreasing Morbidity & Mortality

Research has shown that the 5-year survival rate among patients with cancers of the liver undergoing resection is high. Many candidates, however, will not undergo these procedures because of the high morbidity and mortality risk associated with them. “Over the past 20 years, liver cancer surgery has become safer and more effective,” explains T. Peter Kingham, MD, FACS. “One of the reasons for this has been advances in surgical treatment.” Specifically, there has been greater use of hepatic parenchymal preservation, a surgical approach in which less liver is resected. These procedures can benefit patients with single tumors or multiple tumors confined to one side of the liver. Analyzing Changes in Outcomes In a study published in the Journal of the American College of Surgeons, Dr. Kingham and colleagues at Memorial Sloan Kettering (MSK) Cancer Center analyzed the correlation between hepatic resection, mortality, and complication rates using data compiled over 19 years. They analyzed hospital records of all patients who underwent both major and minor hepatectomy for a malignant liver cancer diagnosis at MSK. Patients were divided into three equal groups according to time period: early (1993-1999), middle (2000-2006), and late (2007-2012). Surgical morbidity and mortality rates were then compared between the time periods. According to the results, the 90-day mortality rate decreased over the three time periods from 5% to less than 2% for all patients involved in the analysis. Overall, the complication rate dropped from 53% to 20%. “The number of major hepatectomies decreased from two-thirds of cases to about one-third,” Dr. Kingham adds. The transfusion rate and liver dysfunction also decreased significantly over the study period. Interestingly,...
Key Determinants for Diabetes Drug Adherence

Key Determinants for Diabetes Drug Adherence

Multiple medications are often prescribed to help adults with type 2 diabetes manage hyperglycemia, diabetes-associated conditions like hypertension and dyslipidemia, and other comorbidities. “Prior studies have shown that non-adherence to diabetes medications is associated with many adverse outcomes,” says M. Sue Kirkman, MD. Research indicates that better adherence to diabetes medications improves control of intermediate risk factors. It also reduces the likelihood of being hospitalized, can lower healthcare costs, and may decease mortality. Taking a Closer Look Studies aiming to estimate rates of adherence to diabetes medications vary widely depending on the types of patients involved in the analysis and how investigators define adherence. Most analyses tend to look at either individual-level or system-level factors independently, but few have used large generalizable cohorts. To address this research gap, Dr. Kirkman and colleagues had a study published in Diabetes Care that used a large national database to look at adherence to oral diabetes medications in more than 200,000 adults with type 2 diabetes in the United States. For the investigation, the study team used the medication possession ratio, which Dr. Kirkman notes is a fairly standard way to assess adherence. “We pre-specified a number of variables related to patient, provider, and prescription factors, and then looked at their association with adherence,” she says. “A multivariate model was then developed to look at the independent effects of each variable since many of them correlate with one another.” Important Findings Overall, about 70% of patients involved in the study were adherent to their medications. “We identified several factors that were associated with non-adherence, including younger age, being new to diabetes therapy, being...
Recommendations for Sleep Duration

Recommendations for Sleep Duration

Each year, millions of Americans seek guidance regarding recommended sleep durations. Recently, the National Sleep Foundation convened a multidisciplinary panel of experts to develop new age-specific recommendations for appropriate sleep durations. The panel consisted of experts in sleep, anatomy, physiology, pediatrics, neurology, gerontology, and gynecology. The recommendations resulted from multiple rounds of consensus voting after a comprehensive review of published scientific studies on sleep and health. They were published in the journal Sleep Health and are available for free on the National Sleep Foundation’s website at www.sleephealthjournal.org. “These recommendations used a rigorous, systematic approach in which we reviewed scientific literature relating sleep duration to health, performance, and safety from around the world,” says Max Hirshkowitz, PhD, DABSM, who was lead author of the document. “They are scientifically-grounded and designed to improve the sleep health of the millions of people who rely on experts for this information.” Summarizing Key Highlights The National Sleep Foundation revised the recommended sleep ranges for all various children and teenage groups as well as for younger, middle-aged, and older adults (Table). A new range—“may be appropriate”—was added to acknowledge the variability in appropriate sleep durations that occurs within certain age groups of patients. The recommendations define times into three categories: 1) recommended, 2) may be appropriate for some individuals, and 3) not recommended. “The recommendations will hopefully help people make sleep schedules that are within a healthy range,” Dr. Hirshkowitz says. “They can also serve as a useful starting point for clinicians to have informed discussions with patients.” He adds that the National Sleep Foundation remains committed to regularly reviewing and providing the recommendations so...
Page 1 of 2612345...Last »
[ HIDE/SHOW ]