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New Clinical Guidelines for Treating Exacerbations in Cystic Fibrosis

Cystic fibrosis (CF) is an inherited chronic disease that affects the lungs and digestive system of about 30,000 children and adults in the United States, according to the CF Foundation. Although the disease affects many organs, 85% of deaths in CF results from lung disease. CF is associated with progressive decline of lung function. Episodes of acute worsening of respiratory symptoms—or pulmonary exacerbations—frequently occur, and there are various clinical features associated with exacerbations (Table 1). “Pulmonary exacerbations have an adverse impact on patients’ quality of life and overall cost of care,” says Patrick A. Flume, MD. “They’re also the most common reason for hospitalization of CF patients. Identifying optimal treatment methods for pulmonary exacerbations in CF could lead to significant improvements in quality and length of life for patients living with the disease.” In the November 1, 2009 American Journal of Respiratory and Critical Care Medicine and available for free online at www.thoracic.org, guidelines for the treatment of pulmonary exacerbations in CF were published. Dr. Flume and members of the CF Foundation’s Pulmonary Therapies Committee collaborated to evaluate published results of controlled trials of common treatment methods for exacerbations in an effort to identify best treatment practices. “The intent of this research was to evaluate the evidence supporting therapies and approaches for the management of health decline,” says Dr. Flume. “Our systematic review allowed the committee to make specific treatment recommendations [Table 2] as well as determine areas that require further study. The guidelines are designed for general use in most patients with CF, but they should be adapted to meet specific needs as determined by the patient, their...
Are Parents to Blame for Their Child’s Obesity?

Are Parents to Blame for Their Child’s Obesity?

According to the CDC, childhood obesity has more than tripled in the past 30 years … but who or what is to blame? Over the past several years, the childhood obesity/child protection issue has emerged, attracting both media and professional attention. As a complex and controversial issue, fingers are being pointed in many directions — including at parents. In a recently published paper from the July issue of British Medical Journal, experts argue that the aetiology of obesity is so complex and parental neglect cannot be the root cause of their child’s obesity. However, consistent failure by parents to make efforts to change lifestyle and engage with professionals or weight management initiatives would constitute neglect. This is of particular concern if an obese child is at imminent risk of disorders like obstructive sleep apnea, hypertension, type 2 diabetes, or mobility restrictions. The child health experts wrote, “In all areas of child health, we have a duty to be open to the possibility of child neglect or abuse in any form. Guidelines for professionals are urgently needed, as is further research on the outcomes of child protection actions in obesity and links between early adversity and later obesity.” Physicians can play a key role in fighting childhood obesity. Check out this week’s “In My Opinion” article, Dealing with Childhood Obesity, which explores the strategies physicians can use to positively impact overweight...

Dealing With Childhood Obesity

One-third of the nation’s children are carrying too much weight, and researchers are beginning to uncover that medical professionals are leery of proactively discussing weight issues with their patients. A recent study revealed that, even though 39% believed that treatment of obesity by physicians has the potential to be effective. “Displaying posters on eating habits in patient exam rooms can have a positive impact on patients.”  Given the sensitivity with young patients in particular, medical professionals often respond vaguely with nonspecific health instructions such as, “lose some weight” and/or “get some exercise.” Unfortunately, these vague commands result in gaps in care. Many parents of obese children often walk out of the doctor’s office just as confused as when they came in. As with any other chronic health problem, the challenge of low literacy may also impact how patients understand the information they are presented. Studies indicate that one of three American adults have limited health literacy skills. Although providers can’t cure all physical illnesses their patients face, childhood obesity and the potential of lifelong diabetes are conditions that physicians must try to proactively prevent and treat. Be Visual Community clinics that routinely deal with family obesity issues have found that displaying posters on eating habits in patient exam rooms can have a positive impact on patients. Being visual is an important strategy that can be easily implemented to address this problem. “Seeing is believing” when it comes to height and weight charts. Hanging a colorful height and weight poster of boys and girls ages 2 to 12 in physician offices can be a helpful asset in teaching parents about...
Guidelines for Intracranial Neurointerventional Procedures

Guidelines for Intracranial Neurointerventional Procedures

Rapid advancements in endovascular interventions have facilitated the use of intracranial endovascular interventions to treat cerebrovascular diseases using minimally invasive intravascular techniques. Developments in computer-aided imaging and high-resolution digital subtraction angiography with reconstruction techniques, as well as easier access to the cerebral vasculature through improved microcatheter design, have lured the interest of physicians across multiple specialties. Consequently, the increasing popularity of these interventions has led to some controversy regarding who should perform these procedures and the methods of training. Other controversies surround how the efficacy and safety of endovascular procedures compare with standard open procedures. Considering these issues, guidelines have been released by the American Heart Association (AHA) and American Stroke Association (ASA). Published in the April 6, 2009 issue of Circulation, the guidelines examine current information and data about the safety and efficacy of procedures that are used for intracranial endovascular interventional treatment of cerebrovascular diseases (Table 1). They also provide recommendations based on the best available evidence to date. A Multidisciplinary Approach AFL may be caused by abnormalities or diseases of the heart as well as diseases elsewhere in the body that affect the heart. These include diseases of the heart valves, especially the mitral valve, and chamber enlargement/hypertrophy. Diseases of the heart that have been linked to AFL include ischemia, atherosclerosis, myocardial infarction, hypertension, and cardiomyopathy. Other diseases/conditions associated with AFL include hyperthyroidism, pulmonary embolism, COPD and emphysema, alcoholism, and stimulant abuse. Some patients with AFL will experience few or no symptoms. For this reason, AFL is often identified incidentally with an electrocardiogram. Other ways to diagnose AFL include cardiac rhythm assessment with outpatient Holter monitoring,...
Experimental Paint Kills MRSA Bacteria

Experimental Paint Kills MRSA Bacteria

Researchers at Rensselaer Polytechnic Institute have created nanoscale coating for surgical equipment, hospital walls, and other surfaces that safely and effectively kills methicillin resistant Staphylococcus aureus (MRSA) — the bacteria responsible for antibiotic resistant infections and a huge thorn in the side of the healthcare community. This breakthrough is based on naturally occurring bacteria-killing enzymes that can be added to paint or other materials. When MRSA comes into contact with this special coating, it dies, preventing further spread of the bacteria. The new antimicrobial coating differs from others in that it is toxic only to MRSA, does not rely on antibiotics, leach into the environment, or become clogged over time. It can be washed repeatedly without losing effectiveness and has a dry storage shelf life of up to 6 months. In an article published in the July issue of ACS NANO, 100% of MRSA in a solution were killed within 20 minutes of contact with a surface painted with latex paint laced with the antimicrobial coating. The authors say it’s a selective agent that can be used in a wide range of environments, including paints, coating, medical instruments, door knobs, and surgical...

Managing Thoracic Aortic Disease

Thoracic aortic diseases result in more than 40,000 deaths per year in the United States, but this estimate is likely low because many of these deaths will result from an undiagnosed aortic rupture or dissection and will be labeled as a heart attack. Most thoracic aortic diseases are asymptomatic until they present with catastrophic aortic dissection, aortic rupture, stroke, or other complications associated with a high likelihood of mortality or major morbidity. Acute aortic dissection may present with atypical symptoms and findings, making a diagnosis even more difficult. Awareness of the importance of thoracic aortic diseases and their varied presentations has been lacking. In the April 2, 2010 issues of Circulation and the Journal of American College of Cardiology, my colleagues and I developed guidelines to provide physicians with recommendations for the early diagnosis and management of thoracic aortic disease. The guidelines represent a consensus of 10 co-sponsoring specialty organizations with an additional endorsing imaging organization; it also utilized input of two additional specialty organizations. Scientific and clinical advances in medicine drove the development of the guidelines, significantly impacting the diagnosis and management of aortic dissection, aortic aneurysms, and other forms of thoracic aortic disease. For example, imaging techniques have improved the ability to make diagnoses. A diagnosis of thoracic aortic disease requires dedicated imaging (CT or MRI, and in some cases, echocardiography); standard chest radiography is not sufficient. Improved surgical and endovascular methods of treating thoracic aortic diseases and methods of preserving other organs during and after surgical or endovascular interventions have also improved the management of thoracic aortic disease. Managing At-Risk Patients Patients at risk for thoracic...

Atrial Flutter: Current Concepts & Management Strategies

Typical atrial flutter (AFL), a condition which affects an estimated 200,000 new patients annually, has been defined as a pattern of regular tachycardia originating in the right atrium with an atrial rate of 240 beats/minute or higher. The current prevalence of AFL is high and is projected to increase considerably by 2050. Although not as common as atrial fibrillation, AFL can be a chronic condition. If left untreated, AFL can lead to debilitating symptoms, including shortness of breath, palpitations, dizziness, fainting, chest tightness, fatigue, and weakness. It can significantly impair quality of life and is associated with impaired cardiac output, atrial thrombus formation, and stroke. With proper treatment, however, AFL is rarely life threatening and symptoms can usually be managed effectively. “Atrial flutter is a common condition which should be treated appropriately to alleviate symptoms and prevent clot formation,” says Angelo Biviano, MD, MPH. Dr. Biviano adds that AFL in some patients can be associated with atrial fibrillation, and proper diagnosis and treatment is imperative. Research suggests that elimination of AFL may delay but not prevent fibrillation. Therefore, proper diagnosis and treatment of AFL is imperative. “The good news is that several treatment strategies exist for AFL,” says Dr. Biviano. “Consideration of patients’ medical history as well as their preferences will help guide treatment strategies for patients.” Identifying Causes AFL may be caused by abnormalities or diseases of the heart as well as diseases elsewhere in the body that affect the heart. These include diseases of the heart valves, especially the mitral valve, and chamber enlargement/hypertrophy. Diseases of the heart that have been linked to AFL include ischemia, atherosclerosis,...
Should Fast-Food Chains Serve Statins?

Should Fast-Food Chains Serve Statins?

Would you like a statin with your fries? British researchers have suggested that fast-food restaurants should hand out complimentary cholesterol lowering medication (in addition to their free condiments) in an effort to offset the increased risk of having a heart attack after eating fatty foods. This out-of-the-box thinking was published yesterday in the American Journal of Cardiology. In an analysis of over 40,000 patients, investigators compared the increase in relative risk for cardiovascular disease associated with the total fat and trans fat content of fast foods against the relative risk decrease provided by daily statin consumption. Findings showed that the reduction in cardiovascular risk offered by a low-dose statin is sufficient to compensate for the increased risk in cardiovascular risk from eating a hamburger with cheese and a small milkshake. The authors concluded that “statin therapy can neutralize the cardiovascular risk caused by harmful diet choices.”  However, the authors did emphasize that such a strategy was “no substitute for systematic lifestyle improvements, including healthy diet, regular exercise, weightloss, and smoking cessation.” The authors drew parallels between eating junk food and other “risky pursuits” such as motorcycling, smoking, and driving. Can minimizing the risk of unhealthy food by using a statin be compared to wearing a helmet when riding a...
Risk of Dying from Coronary Heart Disease Drops 50%

Risk of Dying from Coronary Heart Disease Drops 50%

When it comes to the risk of coronary heart disease (CHD), Americans seem to be heading in the right direction.  An article to be published in the September issue of the American Journal of Preventive Medicine has found that Americans have cut their risk of dying from CHD in half over the past 2 decades by smoking less, monitoring their cholesterol intake, and reducing their high blood pressure. The greatest difference in death rates was a result of primary prevention — reducing risk factors among healthy individuals, a prop to physicians and their preventive efforts. Those who had not had a heart attack accounted for 79% of the drop. The study is an encouraging reminder that efforts to reduce risk factors for CHD are becoming more...
"Microneedle" Flu Vaccine May Replace Conventional Injections

"Microneedle" Flu Vaccine May Replace Conventional Injections

A new dissolving microneedle patch may help improve vaccination efforts against influenza compared with traditional needles. This method of vaccination may also allow people without medical training to easily and safely administer the vaccine. The new vaccination patch is made up of hundreds of microscopic needles that dissolve into the skin. This may potentially simplify immunization programs by eliminating the use of hypodermic needles—and their “sharps” disposal and re-use concerns. “We have shown that a dissolving microneedle patch can vaccinate against influenza at least as well, and probably better than, a traditional hypodermic needle,” says Mark Prausnitz, a professor in the Georgia Tech School of Chemical and Biomolecular Engineering. If mass-produced, the microneedle patches may lower the overall cost of immunization programs by reducing personnel costs and waste disposal requirements. While a promising alternative to traditional flu shots, further clinical studies are required to assure safety and effectiveness of this new vaccination delivery...

Preventing Delayed CINV to Improve Patient Outcomes

Chemotherapy-induced nausea and vomiting (CINV) remains a major adverse effect of cancer chemotherapy, despite the availability of several antiemetic drug classes. Although not life-threatening, CINV has a major impact on a patient’s quality of life (QOL) and ranks high on the list of factors most feared by patients receiving chemotherapy. Additionally, symptoms from CINV can be severely debilitating and often result in patients refusing further courses of chemotherapy, which can minimize the likelihood of achieving optimal outcomes. “Failure to control acute nausea and vomiting on the first day of chemotherapy will increase the risk of nausea and vomiting on subsequent days and in subsequent cycles of chemotherapy,” says John W. Mucenski, PharmD. “The downstream economic effects of not adequately controlling CINV with the first course of chemotherapy cannot be underestimated. These include calls to the office, additional visits for intravenous (IV) hydration and antiemetics, and the potential for hospitalization.” CINV is not always confined to the acute period. “Most patients at risk for CINV will be treated with IV antiemetics therapy initially, but will be discharged with oral medications, which are not always as effective as IV agents,” explains Dr. Mucenski. “In many cases, patients will develop delayed-onset CINV, in which nausea and vomiting occur more than 24 hours after chemotherapy administration and last for 5 to 7 days or even longer [Figure 1].” Providers tend to underestimate the number of patients who suffer from delayed-onset CINV, which evidence suggests affects as many as 50% to 70% of patients and occurs more often than acute-onset CINV. This may occur in part since patients often do not report side effects...

Overcoming the Oncology Workforce Shortage

In March 2007, results of a study commissioned by the American Society of Clinical Oncology (ASCO) Board of Directors on supply and demand for oncology services through 2020 were released. The study indicated that that the United States is likely to face a nearly 50% increase in demand for oncology services by 2020, largely because of the expected increases in both cancer survivorship and cancer incidence caused by the aging population. The anticipated increase in the supply of oncologists during that timeframe will not meet the growing demand. Results from the 2007 ASCO study were likely conservative with regard to predictions. As the general population gets older, it’s likely to seek more healthcare services than those who are currently 65 or older. Furthermore, improvements in cancer treatments are enabling patients to live longer. In turn, these individuals may eventually be faced with other cancer diagnoses and/or chronic illnesses later in life. Oncology workforce shortages can affect the entire medical community. Unless actions are taken, it’s likely that we’ll face a crisis in our ability to provide quality cancer care for patients. New Initiatives In the November 2008 Journal of Oncology Practice,ASCO’s Workforce Advisory Group issued a strategic plan to address projections indicating that demand for oncology services will surpass the supply of practicing oncologists in the years to come. While no single action will fulfill the supply and demand gap completely, efforts are being made to develop multifaceted approaches that address oncology workforce shortages so that future demands can be met. “Unless actions are taken, it’s likely that we’ll face a crisis in our ability to provide quality cancer...

New Initiatives to Improve Patient Care

Nurses have the opportunity to make valuable contributions to the growing community of cancer patients who are actively in treatment and those who have survived it. It’s estimated that soon cancer will be the leading cause of death in the world. However, the majority of patients live at least 5 years beyond diagnosis. As a result, nurses from multiple specialties will care for an increasing number of cancer survivors—currently estimated at about 12 million in the United States alone. In response to the growing needs of the oncology patient population, the Oncology Nursing Society (ONS) has launched initiatives to help educate and prepare nurses for the evolving needs of patients and families. The ONS Survivorship Initiative Long after their active cancer treatment ends, patients may continue to develop symptoms or have some symptoms persist. They often return to a non-specialty setting for care and have unique needs that may not always be fulfilled. In an effort to address this problem, the ONS launched a new survivorship initiative to identify gaps in information regarding medical care for cancer survivors and to provide educational resources on survivorship issues. Survivorship issues differ across the age continuum; needs vary for pediatric, young adult, middle-aged, and elderly survivors of the disease. One goal of the ONS initiative is to raise awareness that survivorship care is every nurse’s responsibility—basic registered nurses or advanced practice nurses can make influential contributions as they care for this growing population. The initiative will focus on several areas, including: • Identifying areas for improvement in nursing. • Providing education to ONS members. • Influencing nursing school curriculum. • Providing resources...

Identifying High-Risk Patients for EVAR

Advanced cross-sectional imaging and enhanced screening efforts have enabled physicians to identify abdominal aortic aneurysms (AAAs) with greater frequency. Several studies have compared the outcomes of open repair with endovascular aneurysm repair (EVAR) for the treatment of AAAs. Although much of the data have indicated that EVAR is associated with significant benefits, there have been concerns as to whether the procedure is a sufficiently low-risk surgery for all patients. Of particular concern is a subset of high-risk patients with prohibitively high mortality. “Every surgery requires a risk-benefit analysis before deciding whether or not to proceed,” explains K. Craig Kent, MD. “Aneurysms are incredibly lethal and have been associated with an 85% chance of death when ruptures occur. Few people make it to the hospital in time, and 50% of those who do have an aneurysm rupture die during emergency surgery. The goal in treating aneurismal disease is to prevent the aneurysm from rupturing. However, the challenge is deciding what aneurysms should be repaired based on individual patient characteristics.” Assessing EVAR in High-Risk Patients EVAR for AAA has been shown to offer significant advantages. As a minimally invasive procedure, EVAR does not always require general anesthesia or ICU admission postoperatively. The procedure also eliminates the need for laparotomy and associated complications, decreases blood loss compared with open repair, and avoids the major perioperative intravenous fluid shifts that are observed with open repair. Moreover, it significantly reduces perioperative morbidity and mortality, compared with traditional open surgery. “Many patients who are at high risk for open repair can be safely treated with endovascular repair.” — K. Craig Kent, MD   According to...

A Smoking Cessation Strategy for Thoracic Surgeons

Tobacco use is the leading cause of preventable morbidity and mortality in the United States, and almost 90% of all lung cancers are caused by smoking tobacco. The dangers of smoking are well documented; the harms extend beyond lung cancer surgery and impact the efficacy and tolerability of other treatments such as chemotherapy. While studies have shown that physicians in various healthcare settings can be trained to successfully deliver effective smoking cessation interventions, thoracic surgeons receive little training in this area of care. There are only a few prospective reports of tobacco cessation efforts involving thoracic surgeons in the current literature. However, thoracic surgeons do have a distinct advantage over other healthcare providers because they have an opportunity to take advantage of the “teachable moment” and capitalize on cessation efforts when meeting with patients preoperatively and during recovery. Assessing a Brief Intervention In the March 2010 Annals of Thoracic Surgery, my colleagues and I published a prospective study to evaluate a brief tobacco cessation intervention offered by surgeons in an outpatient thoracic surgery clinic. The primary outcome was abstinence at 3 months. Adult smokers were enrolled in a single-arm pilot trial in which they received a 10-minute intervention that included three components. The first component involved a brief motivational interviewing session in which patients were asked about what they enjoyed and didn’t enjoy about smoking, what (if any) strategies they’ve used in the past to quit smoking, and how they’d like to quit smoking. Patients were also informed of the importance of quitting their habit. The second component was offering tobacco cessation medication for which a one-page handout that...

American Diabetes Association 2010 Scientific Sessions

The American Diabetes Association held its 2010 Annual Scientific Sessions from June 25 to 29 in Orlando. The features below highlight some of the news emerging from the meeting. » Investigational Drug Effective as Metformin Add-On » Minor Kidney Damage in Type 1 Diabetes Increases Mortality » The Impact of Exercise Alone on Diabetes Risk » Omega-3 Fatty Acids, Women, & Type 1 Diabetes » Diabetes A Common Cause of Vascular Death Investigational Drug Effective as Metformin Add-On [back to top] The Particulars: Dapagliflozin is an investigational selective sodium-glucose cotransporter-2 inhibitor. Dapagliflozin is thought to reduce renal glucose reabsorption so that excess blood glucose is instead excreted into the urine. The mechanism of action is independent of insulin. A phase III trial was conducted in metformin patients who had not achieved adequate glucose control. Data Breakdown: All patients were randomized to placebo or one of three doses of dapagliflozin (2.5 mg, 5.0 mg, or 10.0 mg), and patients also continued taking metformin. Mean glycosylated hemoglobin decreased significantly for patients on any of the three doses of dapagliflozin when compared with those on placebo. At 24 weeks, more patients in the dapagliflozin groups achieved a therapeutic response, which was defined as A1C levels of less than 7% (33% to 40.6% in dapagliflozin groups vs 25.9% in controls). Decreases in fasting plasma glucose concentration and weight loss were also significantly greater in the dapagliflozin groups when compared with placebo. Take Home Pearls: Adding dapagliflozin to metformin may improve glycemic control in patients with diabetes who are not responsive to metformin monotherapy. The addition of dapagliflozin to metformin may provide a new...

New Guidelines for Advanced NSCLC

In the most recent update, investigators conducted a literature search for all relevant randomized trials published since 2002, looking specifically for treatment strategies that improved overall survival. Drugs that were found to only improve progression-free survival were evaluated in light of their toxicity and quality-of-life benefits. Several new drugs have entered the market, so it was important to take a fresh look at our first- and second-line therapies. One of the most important additions to first-line treatment for stage IV NSCLC has been the arrival of bevacizumab, which can be used in conjunction with carboplatin-paclitaxel. There have also been new arrivals on the second-line therapy, including pemetrexed and erlotinib. In addition to existing therapies, these new drugs have been evaluated and ranked according to a number of treatment scenarios and the likely benefits that they can confer to patients. According to the evidence, these newer drugs appear to have made an impact on treatment decisions. Clinicians should recognize that it’s important to tailor treatments based on individual characteristics of patients. For example, physical age should no longer be factored into treatment decisions. Instead, patients’ physiological age and performance status are more appropriate benchmarks for deciding on treatments. Additionally, race and genetic makeup appear to impact treatment strategies.  Genes Matter A new aspect of the 2009 ASCO guideline update is the evaluation of genetic biomarkers, which may affect how patients will respond to a particular agent. While there are several biomarkers with evidence supporting an impact on disease progression, none are currently as well-characterized as mutations in the epidermal growth factor receptor (EGFR). When patients have known EGFR mutations, treatment...
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