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Managing Rotator Cuff Tears

Managing Rotator Cuff Tears

For many older surgical procedures that are associated with good provider and patient experiences—including rotator cuff tear repair—the strength of the literature supporting their use is weak because it was often deemed unethical to compare treatments that work with placebo. With their high prevalence and potentially large cost burden, rotator cuff repairs are an ideal topic for a clinical practice guideline. However, when the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors recently sought to develop a guideline, they found that the strength of the literature was poor. Therefore, appropriate use criteria (AUC) were developed based on available evidence from the literature and sound clinical judgment of expert clinicians. Examining Best Evidence In developing the AUC, an AAOS writing panel first identified 432 clinical scenarios that clinicians would likely face among patients with rotator cuff tears. “These were based on factors such as symptom severity and the patient’s overall health,” explains James O. Sanders, MD, AUC Section Leader. “They were also based on whether alcoholism or drug abuse was present, if workman’s compensation could affect the outcome, the size of the tear and whether it was old or new, and the patient’s response to prior treatment.” Potential treatments to consider for each scenario included non-surgical modalities, partial repair and/or debridement, repair, reconstruction, and arthroplasty. After the 2,160 total voting items in the AAOS document were modified, a voting panel reviewed the strength of evidence for each scenario and discussed how they would approach it in practice before voting on the appropriateness of the treatments for these scenarios. Panel members assigned each of the voting items a level of...
Proton Therapy for Prostate Cancer: Assessing Long-Term Results

Proton Therapy for Prostate Cancer: Assessing Long-Term Results

The American Cancer Society estimates that there will be 233,000 new cases and more than 29,000 deaths from prostate cancer in 2014. Although the disease can be serious, most men will not die from it. More than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today. The disease can be managed with a variety of treatments, including watchful waiting, chemotherapy, surgery, brachytherapy, and external beam radiation therapy (EBRT) that is delivered with x-rays or protons. “Treatment selection for prostate cancer is dependent on the extent of the disease, the patient’s overall medical condition, and patient preferences,” says Nancy P. Mendenhall, MD. “Ideally, the goal is to find a treatment that will be highly effective and avoid toxicities.” The Role of Protons Radiation therapy is used in two-thirds of cancer patients and is most often delivered with EBRT, a radiation therapy that is produced from a source external to the body. The most common source of radiation in EBRT is x-rays (photons). Most x-ray-based EBRT procedures use sophisticated techniques, such as intensity modulated radiation therapy (IMRT), but there is growing interest in protons as a radiation source. “With proton therapy, a lower radiation dose is deposited in normal non-targeted tissues than with x-rays,” explains Dr. Mendenhall. “This has the potential to reduce toxicity, improve quality of life, and decrease risks for second malignancies. Reducing radiation doses to normal tissues may also permit shorter, less expensive treatment schedules, making proton therapy more convenient for patients.” Recent studies have shown that men with prostate cancer who are treated with proton...
Substance Use Disorders Among Emergency Physicians

Substance Use Disorders Among Emergency Physicians

The prevalence of substance use disorders among physicians ranges between 10% and 14%, a rate that is similar to that of the general population. “Research has shown that several specialties have a higher-than-expected rate of these disorders, most notably anesthesiology, emergency medicine, and psychiatry,” says John S. Rose, MD. Despite the reported higher rates of substance use disorders and participation in Physician Health Programs (PHPs) among these specialties, few studies have focused specifically on the prognosis and recovery of emergency physicians (EPs) in PHPs. Important New Data There are little data on whether EPs who receive treatment by PHPs have similar outcomes with these programs as other physicians. To address this research gap, Dr. Rose and colleagues conducted a study using data from 16 state PHPs that followed participants with substance use disorders for 5 or more years. Published in the Western Journal of Emergency Medicine, the study compared outcomes of EPs with other practitioners who were enrolled in state PHPs. “Research has been limited regarding whether EPs perform as well as other physicians after treatment from PHPs,” Dr. Rose says. “We wanted to determine if there were any characteristics for EPs that were significantly different from those of other physicians.” For the study, investigators reviewed data on 904 physicians with a diagnosis of substance use disorders between 1995 and 2001. They compared 56 EPs with 724 other physicians and assessed rates of relapse, successful completion of monitoring, and return to clinical practice within 5 years. Overall, EPs had a higher-than-expected rate of substance use disorders. “EPs were almost three times as likely to be enrolled in a PHP...
A Closer Look at MI Among Younger Women

A Closer Look at MI Among Younger Women

Over time, the frequency of myocardial infarction (MI) in the United States has been declining overall as improvements have been made with regard to medical therapy for coronary artery disease. Although there has been a decline in the rate of ST-elevation MI (STEMI) in those aged 55 and older, the rate has remained steady in patients younger than 55 and among younger women. “Studies have shown that it’s harder to recognize the signs of MI in women,” says Luke Kim, MD, FACC, FSCAI. “Previous analyses indicate that women tend to receive less aggressive treatment than men.” Analyzing Disparities In a study presented at the Society for Cardiovascular Angiography and Interventions 2014 Scientific Sessions, Dr. Kim and colleagues analyzed data on about 13,000 women and more than 42,000 men aged 55 and younger who were hospitalized with an acute MI from 2007 to 2011 using the Nationwide Inpatient Sample database. The authors looked at temporal trends in MI as well as adverse in-hospital outcomes to compare findings by gender. The researchers observed a slight decline in the number of MIs among younger women between 2007 and 2009 but little change after that. Women had more preexisting health problems than men, including diabetes, hypertension, kidney disease, peripheral vascular disease, congestive heart failure, and obesity. Women were also more likely than men to have non-STEMIs. The study by Dr. Kim and colleagues also revealed that there were disparities in the treatment of MI. “Women who suffered an MI were far less likely than men to be treated with PCI or CABG surgery,” explains Dr. Kim. “They were also more likely to face...
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