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Minimizing Distress in Children Before Surgery

More than 3 million children in the United States have major surgery every year, and these procedures often require them to undergo general anesthesia. The prospect of surgery is stressful regardless of the patient’s age, but doctors need to be particularly sensitive when patients are children. The entire surgical team should work closely together and with the child’s parents to minimize the stress and trauma that they may face before and after surgery. The preoperative process is particularly critical. Much of the anxiety and trauma children experience after surgery is because of the procedures we put them through prior to their operation, from giving them shots to putting masks on their faces to deliver the anesthetics. It’s estimated that 50% of children who have major surgery suffer some sort of postoperative behavioral changes after their operation, including night terrors and other longer-lasting emotional issues. Make Efforts to Minimize Impact Doctors can take simple steps toward minimizing the emotional distress that children face before and after surgery: 1. Spend time with parents before the surgery. Explain precisely what will happen and when it will happen. Include details on when and how anesthesia will be administered, and how it could affect their child’s behavior after the operation. Many children experience “emergence delirium,” where they are thrashing, crying, and inconsolable, which can be terrifying for parents. To circumvent this, describe details on expectations to alleviate postoperative stress. Also ensure that parents are active participants preoperatively. 2. Minimize trauma from needles and anesthesia masks. If possible, give children oral midazolam about 30 minutes prior to surgery so that they are comfortable and relaxed...

Preventing Occurrence of Microalbuminuria in Type 2 Diabetes

Data presented at Renal Week 2009 demonstrate that an angiotensin receptor blocker—olmesartan—appears to provide vascular protection in patients with type 2 diabetes by controlling blood pressure and delaying the occurrence of microalbuminuria. According to the World Health Organization, about 170 million people in the world had diabetes in 2000, and that figure is expected to double within the next 20 years. The most prevalent form—type 2 diabetes—is usually associated with central (visceral) obesity, hyperinsulinemia, and insulin resistance as well as hypertension and dyslipidemia. This constellation of findings, often termed “the metabolic syndrome” (Figure 1), leads to premature cardiovascular, cerebrovascular, and renal disease. Role of Microalbuminuria Treatment and prevention of the metabolic syndrome, especially hypertension, are paramount to improving outcomes in patients with diabetes. “Unfortunately, treatment often comes too late because the metabolic syndrome has already translated into organ damage when interventions are implemented,” says Hermann G. Haller, MD. “Ideally, clinicians should strive to prevent this organ damage using markers for diagnostics as well as treatment. One of the integral markers is microalbuminuria.” Microalbuminuria occurs when there is excess leakage of albumin from glomerular capillaries into urine. Microalbuminuria is a marker of generalized vascular disease as well as incipient diabetic nephropathy. While microalbuminuria is not indicative of overt cardiovascular disease (CVD) or kidney failure, it is an early marker and indicates the first pathological changes in the organs. ROADMAP Study The ROADMAP (Randomized Olmesartan and Diabetes Microalbuminuria Prevention) study was initiated to determine whether olmesartan, an angiotensin-receptor blocker (ARB), could prevent the development of microalbuminuria in subjects with type 2 diabetes (plus one additional cardiovascular risk factor) who had no...

Applications of Ultrasound in Breast Cancer

For decades, whole breast radiation therapy has been standard treatment for breast cancer patients following lumpectomy. The goal of radiation treatment is to kill any remaining cancerous cells around the lumpectomy cavity while limiting the dose to normal, healthy tissues, such as the heart and lungs. Recently, partial breast irradiation (PBI) has gained momentum in efforts to reduce the overall treatment time and limit the volume of breast and normal tissues being irradiated. This involves targeting only the lumpectomy cavity surrounded by a small margin to account for variability in daily treatments. Imaging Limitations CT imaging has been the standard tool used for radiation treatment planning and has provided clinicians with great anatomic detail. However, CT is limited in its ability to visualize certain soft tissues, such as lumpectomy cavities, and its ability to distinguish them from adjacent normal tissue. Uncertainty in identifying the borders of the lumpectomy cavity can cause either undertreatment of areas at risk or unnecessary overexposure of healthy tissue to radiation in some patients. In addition, another challenge is the fact that a lumpectomy cavity can move and change shape as the tissue heals in the weeks following surgery. Traditionally, physicians have relied on the surgery scar to serve as a marker to localize the lumpectomy cavity. Several studies have found that locating the lumpectomy cavity based solely on this scar may result in a partial miss of the cavity in over 50% of cases. While the radiation oncology community widely recognizes inconsistent set up of patients on the radiation table and changes to the lumpectomy cavity over time, one practical solution to this problem...
Navigating Patients Through Depression

Navigating Patients Through Depression

Although depression is a highly treatable illness, it can become more difficult to treat the longer it goes undiagnosed or undertreated. A new survey of 2,001 adults living with depression found that many of these individuals engage in unhealthy behaviors that may jeopardize recovery. The survey was part of a new depression educational program called Missing Pieces, which was developed by leading mental health experts and supported by Eli Lilly and Company to help people identify the information patients need to better understand depression. Analyzing Key Findings According to the survey, it took an average of about 6 years for respondents to seek diagnosis from a healthcare professional. “An alarming finding was that 57% of patients surveyed waited more than 6 months to get depression treatment,” says Thomas N. Wise, MD, who was on the multidisciplinary expert panel that helped shape the development of the survey as well as educational materials for the Missing Pieces program (Figure 1). “Social stigma, embarrassment, and negative reactions often play a role in delays for seeking treatment. The survey highlights the need for more public information on depression and its symptoms. Patients need to become more aware of the symptoms so that they seek treatment earlier.” Among survey respondents who waited 6 months or longer to be diagnosed, 69% reported delaying their diagnosis because they lacked knowledge about depression or basic facts about available treatments and where to get help. Although 91% of the survey population had been prescribed an antidepressant, only 7% of these individuals felt very knowledgeable about the basic aspects of their treatment. “Patients are missing pieces of vital information...

Highlights From CHEST 2009

New research presented at CHEST 2009, the annual international scientific assembly of the American College of Chest Physicians, from October 31 to November 5 in San Diego addressed key issues in the field of chest diseases. The features below highlight just some of the studies that emerged from the assembly. Statins May Prevent Clotting in CVD Patients The Particulars: Studies have indicated an association between atherosclerosis and venous thrombosis. Researchers investigated the association between statin use and incidence of venous thromboembolism (VTE) in patients with cardiovascular disease (CVD). Data Breakdown: Patients with CVD not taking statins were three times more likely to develop VTE than those receiving the medication (26.3% vs 8.3%). Even after controlling for factors related to VTE, statin use was still associated with a low risk of developing VTE. Patients receiving high-dose statins (>40 mg/day) had a lower occurrence of VTE than those on standard-dose statins. Take Home Pearls: Statins may provide potentially life-saving benefits for patients with CVD by helping reduce the incidence of blood clots. Patients with atherosclerosis receiving statins had a significantly reduced risk of developing VTE, and those on higher doses of statins had the lowest likelihood of developing VTE. Race May Be a Predictor of RLS The Particulars: Restless legs syndrome (RLS) may not be easily recognized by patients and clinicians. Providing education about RLS signs and symptoms may raise awareness and lead to earlier diagnosis and treatment. There are significant ethnic differences in disease prevalence, but the exact causes are unknown. Data Breakdown: Researchers analyzed standardized interview responses from 190 patients seen at a primary clinic. Among African Americans, the...

New Recommendations Managing Depression During Pregnancy

It has been estimated that between 14% and 23% of pregnant women will experience depressive symptoms during their pregnancy. An investigation published in 2003 reported that about 13% of women take an antidepressant at some time during their pregnancy. “Depression in pregnant women frequently goes unrecognized and untreated for a host of reasons, including concerns about the safety of some treatments for pregnant patients and their offspring,” says Kimberly A. Yonkers, MD. “There may be risks associated with both untreated depression and the use of antidepressants that can complicate treatment decisions.” A New Review An evidence-based report from the American Psychiatric Association (APA) and the American College of Obstetricians and Gynecologists (ACOG) has been published to assist clinicians and patients as they weigh the risks and benefits of various treatment options for depression during pregnancy. The APA and ACOG convened a work group consisting of clinical research experts within the fields of obstetrics and gynecology, psychiatry, and pediatrics, which critically evaluated and summarized information about risks associated with depression and the use of antidepressants during pregnancy. The resulting recommendations were published jointly in the September 2009 issue of Obstetrics & Gynecology and the September/October 2009 issue of General Hospital Psychiatry. “Typically, OB-GYNs, nurse practitioners, and nurse midwives are the clinicians who most often see women who are pregnant,” says Dr. Yonkers. “They can be the first clinician to make a diagnosis of depression in some cases. Other times, they may be the first to observe depressive symptoms that are worsening. In the past, reproductive health practitioners have reported feeling ill-prepared to treat these patients because of the lack of...

Preventing Clostridium Difficile Infections

According to published data, Clostridium difficile infection (CDI) now rivals MRSA as the most common organism to cause healthcare-associated infections (HAIs) in the United States. The pro­portion of hospital discharges in which patients received a diagnostic code for CDI more than doubled between 2000 and 2003, and rates continued to increase in 2004 and 2005. “In addition to increased frequency of CDI, current research also shows that these infections are increasing in severity,” says Erik R. Dubberke, MD. CDI has been associated with increased lengths of hospital stay, higher costs, and greater morbidity and mortality. According to study data, CDI has been shown to increase lengths of hospital stay by about 3 days. Costs have also been significant; the total U.S. hospital costs for CDI management have been estimated at about $3.2 billion per year. The infection has been associated with attributable mortality rates of 16.7% at 1 year. New Guidance In 2008, a task force to create a concise compendium of recommendations for the prevention of common HAIs was appointed by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Recommendations were published in the October 2008 supplement to Infection Control and Hospital Epidemiology and are available at www.preventingHAIs.com. The document is designed to help hospitals focus and prioritize their efforts to implement evidence-based practices for the prevention of HAIs, including CDI. According to the compendium recommendations, fluoroquinolones had been infrequently associated with CDI. However, new research has found that these agents are one of the primary predisposing antimicrobials associated with the infection. “Most antibiotics have been associated with CDI,” explains Dr. Dubberke....
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