CME: Decision Making Matters in Appendicitis

CME: Decision Making Matters in Appendicitis

Studies show that acute appendicitis accounts for more than 11% of pediatric ED admissions, and more than 70,000 children in the United States are hospitalized for it each year. Appendectomy is curative but invasive procedure that requires general anesthesia. For children, this includes perioperative risks and postoperative pain as well as disability. Research suggests that children can miss up to 2 weeks of activities after undergoing appendectomy, and their caregivers may experience similar disruptions to their normal schedules. An Alternative Approach In clinical trials, the rate of perioperative complications in patients undergoing an appendectomy for uncomplicated appendicitis ranges between 5% and 10%. Serious complications, such as reoperations or readmissions, occur in 1% to 7% of these patients. In Europe, several recent randomized clinical trials have shown that taking a non-operative management approach to appendicitis appears to be medically safe and effective in adults, with a success rate ranging between 63% and 85%. Non-operative management approaches to treat appendicitis typically involve intravenous antibiotics until symptom improvement and then a short course of oral antibiotics. “When making a treatment decision involving either a surgery or a less invasive approach, patients and families may have strong and varying treatment preferences,” explains Peter C. Minneci, MD, MHSc. “Each patient may have different risks and outcomes that are most important to them. Some may value avoiding pain and disability while others may value avoiding general anesthesia. In addition, the success of non-operative management of appendicitis may depend on the patient’s and family’s willingness to accept an ongoing risk for recurrent appendicitis. The pros and cons of these treatment options should be described to patients...
CME: A Strategy for Decreasing Influenza’s Impact

CME: A Strategy for Decreasing Influenza’s Impact

Research indicates that about 60% of influenza-related hospitalizations occur in adults aged 65 and older during most influenza seasons in the United States. Many of these patients are frail and at increased risk for functional decline. However, few studies have assessed the need for extended care admissions due to functional decline from influenza-associated hospitalizations among community-dwelling older adults. Additionally, whereas studies have shown that prompt treatment with influenza antiviral agents can reduce the duration of illness and prevent influenza-related complications, data are limited on the benefit of antiviral treatment in this patient population.   Examining the Issue For a study published in Clinical Infectious Diseases, Nancy M. Bennett, MD, MS, and colleagues analyzed predictors of extended care and the potential mitigating effect of antiviral treatment among community-dwelling patients aged 65 and older. Participants were hospitalized with laboratory-confirmed influenza during the 2010-2011, 2011-2012, and 2012-2013 influenza seasons. Extended care was defined as placement in a skilled nursing facility on hospital discharge. Treatment was categorized as early (4 days or less) or late (more than 4 days) in reference to the date of illness onset. “We also assessed a series of variables to determine which predicted loss of functional status and extended care placement,” says Dr. Bennett. The researchers found that among more than 6,500 participants, 18% were discharged from the hospital to extended care facilities. “These patients went from living independently to requiring significant care,” Dr. Bennett adds. A univariate analysis found the following to be predictors of discharge to extended care: Increasing age (10% among those aged 65 to 74, 16% for those aged 75 to 84, and 30%...
CME: Making the Case for Increasing DSME/S Use

CME: Making the Case for Increasing DSME/S Use

According to recommendations from the American Diabetes Association, all individuals with diabetes should receive diabetes self-management education and support (DSME/S) when they are diagnosed with the disease and as needed thereafter. Recently, the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics released a joint position statement on DSME/S. Published in Diabetes Care and available at http://care.diabetesjournals.org, the document aims to enhance patients’ experiences with diabetes care and education, improve overall health, and reduce diabetes-associated healthcare costs. “Currently, there is no consistency with regard to when and how patients with diabetes are referred to DSME/S by their healthcare providers,” says Maggie Powers, PhD, RD, CDE, who was lead author of the joint position statement. “Healthcare providers may also not fully recognize the benefits of DSME/S or how it should be utilized. The joint position statement addresses both of these considerations.” Research shows that DSME/S can improve A1C levels and have a positive effect on other clinical, psychosocial, and behavioral aspects of diabetes, says Jo Ellen Condon, RD, CDE. “Ultimately, DSME/S helps inform, empower, and engage patients to manage the disease on their own and with their healthcare providers,” she says. “Studies show that DSME/S can help lower A1C levels with just one patient visit to these services. Diabetes is a disease that requires patients to be proficient in many self-management skills, and DSME/S is critical to laying the foundation for long-term management. It helps patients become effective self-managers and assists them with important daily decisions about food, exercise, and medications.”   A Helpful Blueprint The joint position statement arms healthcare teams with...
CME: A Program to Rapidly Test for Hepatitis C

CME: A Program to Rapidly Test for Hepatitis C

An ED screening and diagnostic testing program found a high prevalence of hepatitis C. Results suggest that continued efforts are needed to develop and evaluate policies for ED-based hepatitis C screening.   Hepatitis C virus affects about 3 million Americans and is a leading cause of end-stage liver disease, hepatocellular carcinoma, and liver transplants. National recommendations endorse using risk-based hepatitis C screening, which includes screening patients with a history of injection drug use as well as one-time screenings of “baby boomers,” or patients born between 1945 and 1965. Current data suggest that the baby boomer generation accounts for 75% of people infected with hepatitis C, but 1.25 to 1.75 million of them are unaware that they are infected. “Hepatitis C screening has long been considered impractical for EDs, but advances in rapid testing technology, the development of new therapies, and improvements in reimbursement for selective screening has created new opportunities to implement these screenings in the ED setting,” says Douglas A.E. White, MD. Despite these advances, clinical experience with hepatitis C virus screening in EDs is limited.   Testing a New Program Recently, Dr. White and colleagues at Alameda Health System implemented an ED-based screening program for both HIV and hepatitis C into the triage process according to recommendations from the CDC and United States Preventive Services Task Force. As an adjunct to screening, physicians could order HIV and hepatitis C testing when clinically indicated. For a study published in Annals of Emergency Medicine, the research team reported results of the hepatitis C portion of this screening program. The primary objective was to determine the prevalence of hepatitis C...
CME: Dietary Supplements & ED Visits

CME: Dietary Supplements & ED Visits

Herbal products, complementary nutritionals, and micronutrients are all considered to be dietary supplements. The Dietary Supplement Health and Education Act is a 1994 law that defined supplements as food rather than drugs. A consequence of this act is that manufacturers of these supplements are not required to prove that their products have benefits or demonstrate their safety. “Although these products cannot be marketed to treat or prevent disease, they are often taken to address symptoms or illnesses or to maintain or improve overall health,” says Andrew I. Geller, MD. The estimated number of supplement products has increased significantly over the past 2 decades. Recent reports show that about half of all adults in the United States have reported using at least one dietary supplement in the past month. Post-marketing reporting of adverse events from manufacturers of these supplements is required only for serious adverse events, and voluntary reporting may underestimate the adverse events associated with these products. There has been increasing public attention regarding post-marketing removal of some supplement products, which in turn has led to calls for changes in oversight.   Taking a Closer Look “Few clinical studies have examined the safety of dietary supplements that are still available on the market, and data are lacking to quantify the frequency of adverse events associated with dietary supplements in the U.S.,” says Dr. Geller. To address this issue, he and his colleagues had a study published in the New England Journal of Medicine that aimed to estimate the number of ED visits for adverse events relating to dietary supplements. They also sought to identify the associated characteristics of patients,...
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