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House Passes 9/11 Healthcare Bill

In a 268 to 160 vote, the House of Representatives approved a $7 billion health bill for first responders and residents of New York City who fell ill due to breathing toxic fumes, dust, and smoke at ground zero after the World Trade Center towers collapsed—over 9 years ago. The bill currently excludes illegal immigrants from qualifying for the health benefits. Over the next 8 years, the bill calls for providing $3.2 billion to monitor and treat injuries caused by exposure to toxic dust and debris. New York City would be responsible for 10% of those health costs. Just over $4 billion will be allocated to reopen the September 11th Victim Compensation Fund, which provides compensation for any job and economic losses. Sponsors of the bill site that there are nearly 60,000 people enrolled in a variety of health monitoring and treatment programs related to the 9/11 attacks. Supports of the bill argued that the nation has a moral obligation to help those who risked their lives when responding to the crisis. Those who opposed the bill argued that it was unnecessary due to programs such as the Victim Compensation Fund, as well as raising concerns about the government’s huge budget deficit. This was the second time this year that the House voted on the 9/11 health bill. In July, the vote fell short of the two-thirds margin required to pass the...
Laparoscopy: Surgeons Suffer Occupational Injuries

Laparoscopy: Surgeons Suffer Occupational Injuries

Compared to open surgical techniques, there is no doubt that laparoscopy provides patients with improved safety, quicker recovery, shorter hospital stays, and cosmetic advantages — but at what cost to the surgeons? New research has found that surgeons who perform laparoscopic surgery appear to experience greater physical stress and mental strain compared to open surgery. And the toll may be much greater than what was previously assumed. A recent study by Adrian E. Park, MD, published in the Journal of the American College of Surgeons, sought to confirm the prevalence of minimally invasive surgery-related operator symptoms and discomforts within a broad population of laparoscopic surgeons. Of more than  300 laparoscopic surgeons who completed a comprehensive survey, nearly 87% reported experiencing physical discomfort or symptoms they attributed to performing minimally invasive surgery — a staggering statistic that extends far beyond previous estimated rates of discomfort, which ranged between 20% and 30%. “Focus is always on the tip of the spear — where it will affect and interact with the patient,” Dr. Park explains to Physician’s Weekly. “More focus should be directed at the other end of the spear, where it’s being manipulated. Our survey results serve not only as a contribution to the scientific literature but a clarion call to all who have a stake in the quality and safety of surgical care.” For more results from the survey, read the full article, Laparoscopy: Patients Benefit, But Do Surgeons...
CRC Surveillance in Patients With IBD

CRC Surveillance in Patients With IBD

Certain patients with inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn’s disease of the colon, have an increased risk of developing colorectal cancer (CRC) when compared with patients without IBD. While IBD is relatively rare in the general population, it remains one of the important high-risk conditions predisposing patients to CRC. The majority of patients with IBD will not develop CRC, but two factors that increase CRC risk have been identified: 1) CRC risk increases after 8 to 10 years of having ulcerative colitis, and 2) the more extensive the colonic involvement, the higher the CRC risk. Patients with disease limited to the rectum do not have an increased risk of CRC, while patients with ulcerative proctosigmoiditis or left sided colitis have an intermediate risk. The greatest risk is for those whose entire colon is diseased. The risks are similar for those with extensive Crohn’s colitis. An individualized and sensible approach to CRC surveillance in patients with IBD is essential. In the February 2010 issue of Gastroenterology, the American Gastroenterological Association (AGA) released a medical position statement and technical review on the diagnosis and management of colorectal neoplasia in IBD. The goal of the statement was to ensure that patients receive the highest level of treatment. The recommendations were designed to help identify high-risk individuals and develop individualized surveillance plans based on each patient’s unique situation. Assessing Risks The AGA position statement provides important information on assessing CRC risk in IBD patients. Disease duration, more extensive disease, severity of inflammation, primary sclerosing cholangitis, and a family history of sporadic CRC have all been associated with an increased risk...

Laparoscopy: Patients Benefit, But Do Surgeons Suffer?

When compared with open surgical techniques, the benefits of minimally invasive surgery have been well documented in medical literature, including increased safety, quicker recovery, shorter hospital stays, and cosmetic advantages. Nonetheless, surgeons who perform a majority of their cases laparoscopically appear to encounter physical stress and mental strain beyond what they experience when performing open surgery. New survey findings suggest that surgeon burden may be greater than previously assumed. “Surgeon injuries appear to be a significant problem that not only affects surgeons but also all stakeholders in the delivery of healthcare, particularly surgical care,” says Adrian E. Park, MD. “Any type of surgery, particularly minimally invasive surgery, takes a physical and mental toll on surgeons. They continuously adapt to ensure the best outcome for patients, often dipping hugely into their own health reserve. We’re not going to serve our patients, the public, or the healthcare system well if we have prematurely shortened careers because of the physical tolls and cognitive ravages of what we do.” Scant literature is available on the extent to which strain during labiaplasty affects surgeons’ bodies when compared with open surgery. In a study in the March 2010 Journal of the American College of Surgeons, Dr. Park and colleagues published a study that sought to confirm the prevalence of minimally invasive surgery-related operator symptoms and discomforts within a broad population of laparoscopic surgeons. Since previous surveys, the adoption rate of minimally invasive procedures has steadily grown, and more surgeons are now performing these surgeries than ever before. According to findings from the study, a fairly astounding number of injuries or symptoms were related to occupation...

Joint Pain Unresolved with Glucosamine and Chondroitin

Over the past 10 years, general practitioners and rheumatologists have commonly prescribed glucosamine and chondroitin supplements to relieve joint pain in patients. Many patients buy the supplements over-the-counter. In 2008, $2 billion worth of glucosamine supplements were sold worldwide — a 60% increase from 2003. However, in a surprising new study published in this week’s issue of BMJ, researchers wrote that the supplements do not appear to relieve symptoms. Glucosamine and chondroitin are typically taken in combination or separately to reduce osteoarthritis pain, particularly in the knees and hips. Researchers from Switzerland carried out a large scale review of studies that examined the efficacy of glucosamine and chondroitin.  Ten published trials consisting of over 3,800 patients with diagnosed osteoarthritis of the knee or hip were assessed. Findings showed no clinically relevant effect of glucosamine and chondroitin on reducing joint point or reducing the narrowing of joint space — used in combination or alone. Simply put: They did not work. Some patients continue to insist that the supplements work. Have you prescribed either or both to patients and observed a significant benefit?...

Laparoscopy: Patients Benefit, But Do Surgeons Suffer?

While patients often reap the benefits of laparoscopic procedures, the surgeons who perform these operations appear to be experiencing occupational injuries. Catch the article in the next Physician’s Weekly eNewsletter. Register to receive the Physician’s Weekly...
Tell Us What Kind of Information You Find Valuable!

Tell Us What Kind of Information You Find Valuable!

Physician’s Weekly editors regularly scour the web for the latest developments in healthcare that may be of interest to medical professionals. But we need your help: What kind of information would you like to see posted here? Are you overwhelmed by recent healthcare legislation and looking for summaries of its implications for your hospital or practice? Do you rely on us for a synopsis of trending healthcare topics? Would you find occasional practice management tips useful? This is your blog; please let us know how we can make it a valuable resource that you will return to again and...

Updated Practice Guidelines for Ovarian Cancer

A major challenge in treating ovarian cancer is that by the time most patients are diagnosed with the disease, it has already progressed to stage III or IV. The difficult-to-examine location of the ovaries deep in the pelvis tends to prevent physicians from detecting ovarian cancer at a more curable stage. Until recently, patients with the disease were often thought to exhibit no symptoms during the earliest stages of the disease. Recent studies have demonstrated that certain symptoms are more common in women with ovarian cancer when compared with women in the general population. Up to 90% of women with the disease will experience symptoms earlier. Symptoms suggestive of ovarian cancer include bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms (urgency or frequency), particularly if the symptoms are new (onset within the past year) and frequent (occurring more than 12 days per month). However, these symptoms are non-specific and are often mistaken for other conditions. Awareness of symptoms may allow physicians to detect ovarian cancer earlier. The National Comprehensive Cancer Network (NCCN) recently released clinical practice guidelines in oncology for ovarian cancer. One of the new revisions is an emphasis on the possibility that early-stage symptoms of ovarian cancer may be present. “Improving screening methods and early detection remain the key for women with ovarian cancer,” says Robert J. Morgan, Jr., MD, FACP who chaired the NCCN panel that developed the guidelines. Managing Allergic Reactions Chemotherapy drugs have the potential to cause infusion reactions, either during an infusion or following completion of an infusion. Reactions to platinum drugs (eg, carboplatin and cisplatin) tend...
Analyzing Poor Medication Adherence After MI

Analyzing Poor Medication Adherence After MI

Approximately, 1.5 million cases of myocardial infarction (MI) occur each year. An estimated 5% to 10% of patients who survive an MI die within the first year after the index event, and half are rehospitalized. Studies have demonstrated that medications such as aspirin, β-blockers, ACE inhibitors, and statins taken after MI are associated with improved short- and long-term outcomes, providing protection against subsequent cardiovascular events. Despite proven benefits, a large proportion of patients who have had an MI appear to discontinue use of their prescribed medications over time. Most medications should be taken indefinitely, but long-term data on factors affecting medication adherence are lacking. New Data on Medication Adherence In a study published in the October 2009 American Journal of Medicine, my colleagues and I published an analysis assessing patients hospitalized with MI from 1997 to 2006 to determine adherence to statins, β-blockers, and ACE inhibitors/angiotensin receptor blockers (ARBs). The study also looked at factors that appeared to be associated with improved adherence. Data demonstrated that adherence to guideline-recommended medications decreased over time, with 3-year medication continuation rates of 44%, 48%, and 43% for statins, β-blockers, and ACE inhibitors/ARBs, respectively. Our findings illustrated that many patients discontinued use of prescribed cardioprotective medications after MI, with less than half continuing medications 3 years after their MI. Results were particularly striking because the study included patients who were well-insured with relatively low out-of-pocket expenses for prescription drugs. Considering the insurance status of the patients assessed, adherence is presumably even worse among the general population. Assessing Adherence Factors A potential cause of poor medication adherence after MI may be a “knowledge translation...
Doctors Rationalize Accepting Industry Gifts

Doctors Rationalize Accepting Industry Gifts

Have you ever accepted a free pen, dinner, or trip from a pharmaceutical company in “reward” for prescribing their drugs? Despite expanding institutional conflict-of-interest policies and state laws preventing the undue influence that gifts from pharma companies can have on physicians, companies continue to do it. Why do some physicians accept these handouts? A study published by researchers at the Carnegie Mellon University in the Journal of the American Medical Association found that physicians rationalize their acceptance of such gifts as a form of reward for the sacrifices they made obtaining their education. Over 300 pediatric and family medicine residents answered a survey about the acceptability of receiving gifts from pharmaceutical companies.  Some of the doctors were first asked about the sacrifices they made in getting their medical education before answering the questions. Another group was asked about the sacrifices and then asked whether such sacrifices could potentially justify accepting gifts — being introduced to the idea of rationalizing the acceptance before completing the survey. The control group was only asked about the acceptability of receiving gifts without being asked about their personal sacrifices. Reminding physicians first of their medical training burdens more than doubled their willingness to accept gifts — from 21.7% to 47.5%, and suggesting the rationalization in addition to reminding them of their medical training burdens increased their willingness to 60.3%. Do you agree with the...
New Superbug Surfaces in Three States

New Superbug Surfaces in Three States

An alarming new adaptable gene that can turn several common germs and types of bacteria into superbugs, resistant to almost all antibiotics, has infected people in the United States — California, Massachusetts, and Illinois. Originating in India, the superbug is thought to evolve due to the overuse and incorrect use of antibiotics — encouraged by over-the-counter sales of antibiotics in South Asia. Each of the patients that was infected had been to India prior to their arrival to the United States and has been effectively isolated and treated. However, there continues to be cause for concern that this superbug will spread in the U.S. When most people hear the word “superbug,” they think of MRSA, a bacterial infection highly resistant to some antibiotics that has been found in hospitals for years, but MRSA can be treated. The new superbug, however, has acquired a gene (NDM-1) that renders it resistant to almost all antibiotics. The bacteria first attack the digestive system and then enter the blood stream, potentially causing multiple organ failure. At this time, the most effective way to control the spread of these new drug-resistant bacteria is to diagnose it and quickly isolate the patient. Physicians should maintain heightened awareness in patients who have recently traveled to India or Pakistan. The CDC advises any hospitals that find such cases to put the patient in medical isolation, check the patient’s close contacts for possible infection, and look for more infections in the hospital. If you have encountered this new superbug in your practice we would welcome comments...
Rapid Desensitization for Chemotherapy Allergies

Rapid Desensitization for Chemotherapy Allergies

Chemotherapy in the 21st century is only now beginning to evolve from its early, traumatic treatments. We are still using the potent toxins that kill every dividing cell and make patients physically sick and bereft of the normal protections that help to prevent infections and subsequent malignancies. However, in the past few years, we have seen the emergence of elegant, less traumatic, and more targeted cancer therapies such as tyrosine kinase inhibitors and monoclonal antibodies. These agents have had a profound effect on extending overall survival while also having fewer adverse treatment effects that have historically been seen with chemotherapy. Allergies May Develop In addition to the terrible burden of cancer, patients can become allergic to their chemotherapy. This happens with some frequency with both older and newer treatments. Older treatments — carboplatin, for example — can cause allergic reactions so often that oncologists will need to perform skin testing routinely to check for the onset of allergies. The newer monoclonal antibodies can also cause serious and life-threatening reactions. These factors can complicate treatment for patients and clinicians alike. For board-certified allergists, much time is spent helping patients tolerate the treatments and therapies that they need but which cause them to have allergic reactions. When managing allergies, the desensitization process involves giving the actual allergen substance. This includes giving antibiotics to desensitize patients who are allergic to antibiotics. In some cases, it may mean giving stinging insect venoms to desensitize patients who are allergic to stings from bees, wasps, hornets, and fire ants. In other cases, clinicians may need to administer inhalant allergens (eg, cat, dog, dust mite, and...

Managing Catheter-Associated Urinary Tract Infections

Catheter-associated bacteriuria, the most common healthcare-associated infection, results from the widespread use of urinary catheterization. Oftentimes, the use of urinary catheters is inappropriate in hospitals and long-term care facilities. “Considerable personnel time and other costs are expended by healthcare institutions throughout the world to reduce the rate of catheter-associated infections, especially those that occur in patients with urinary tract symptoms,” says Thomas M. Hooton, MD. Strategies to reduce the use of catheterization have been shown to be effective in published literature. The data demonstrate that use of such strategies is likely to have a significant impact on the incidence of catheter-associated urinary tract infections (CA-UTI). An expert panel of the Infectious Diseases Society of America (IDSA) released new guidelines that address CA-UTI in adults aged 18 and older. Published in the March 1, 2010 issue of Clinical Infectious Diseases, the guidelines are aimed at assisting physicians in all specialties who perform direct patient care, especially of patients in hospitals or long-term care facilities. “These evidence-based IDSA guidelines provide diagnostic criteria and strategies to reduce the risk of CA-UTIs,” explains Dr. Hooton, who was the lead author of the guidelines. “They also provide strategies that have not been found to reduce the incidence of urinary infections. Management strategies are presented to assist clinicians who treat patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. Implementing the strategies outlined in the guidelines should be a priority for all healthcare facilities.” Reducing the Incidence According to the guidelines, the most effective way to reduce the incidence of CA-UTI is to reduce the use of urinary catheterization (Table 1). This requires restricting...
Improved Communication Benefits Surgical ICUs

Improved Communication Benefits Surgical ICUs

In complex environments like surgical ICUs, integrated team performance and effective communication skills are vital to positive patient outcomes. These skills are critical because breakdowns in communication have reportedly been responsible for nearly 85% of sentinel events that lead to increased length of stay in the hospital, higher morbidity, and more litigious actions. Patients most susceptible to negative outcomes as a result of communication errors are those who are acutely ill in the surgical ICU. Improving communication among healthcare teams enhances the quality of care and has the potential to reduce the likelihood of negative patient outcomes. Identifying Communication Barriers In surgical ICUs, it’s important to ensure that the knowledge and experience of attending surgeons are appropriately utilized by the residents and fellows executing the care. Anytime there is a communication breakdown or a barrier that prevents essential information flow, there is a risk of accentuating negative patient outcomes either directly or indirectly. In the January 2010 Journal of the American College of Surgeons, my colleagues and I initiated a prospective observational trial to evaluate communication between surgical ICU residents and fellows following the occurrence of hypotension, new arrhythmias, desaturation, and tachypnea. Our study found that a third of these critical events were never reported to an upper level physician, and a quarter of these events resulted in negative short-term outcomes.   There are many reasons why these events may not be properly communicated to senior surgeons, including overconfidence, complacency, and/or fear of appearing to be incompetent. Much of this behavior is attributed to the traditional evaluation of medical students where individual performance is rewarded. However, it’s clear that efforts...
Smoking Rates at a Standstill

Smoking Rates at a Standstill

Smoking rates in the United States continue to stay at about 1 in 5 adults, according to health officials on Tuesday. Although smoking rates in this country have fallen dramatically since the 1960s, the decline has plateaued over the past few years. The National Health Interview Survey and Behavioral Risk Factor Surveillance System indicated that about 21% of U.S. adults were smokers in 2010, which is about the same percentage as in 2005. Teen smoking, at nearly 20%, does not appear to be improving either. CDC director Dr. Thomas Frieden says smoking is the number one preventable cause of death in this country, with about 1,000 tobacco-related deaths each day. Even more disturbing, a second report released by the CDC found that up to 98% of children who live with a smoker have measurable tobacco toxins in their body. While tobacco taxes and smoking bans have helped reduce rates in some states, overall, health officials attribute lost momentum on reduced funding for anti-tobacco campaigns and “shrewd” marketing by cigarette...

How Operative Duration Affects Clinical Outcomes

Infectious complications, particularly surgical site infections (SSIs), are well documented to increase costs, morbidity, mortality, and length of stay (LOS). Surgical operative duration has long been suggested as a risk factor for infectious complications (ICs). The causes for this association may be multifactorial. For example, prolonged tissue exposure to the air can desiccate the wound, increasing tissue death and worsening tissue healing. Increased operative duration has also been associated with increased tissue trauma, which raises the metabolic demand on the body to heal these wounds. Lastly, greater operative duration has been shown in previous research to increase the risk of blood loss, periods of hypothermia during surgery, and the need to re-dose antibiotics perioperatively. Determinants of operative duration can include any of the following: 1. The proficiency of the surgeon. 2. The presence of surgical trainees. 3. Communication among operative professionals. 4. Emergency operation. 5. Operating room (OR) staffing. 6. Technology. 7. Process efficiency. New Study Data In a study published in the January 2010 Journal of the American College of Surgery, my colleagues and I sought to gain a better understanding of the link between operative duration and outcomes, particularly ICs and LOS. Considering that all ICs are significant after surgery, our investigation included some of the most important infections that can impact postoperative surgical patient care, including SSIs, sepsis, urinary tract infections, intravascular catheter-related infections, and pneumonia.   “Strategies that reduce operative duration as well as improve IC rates and LOS need to be identified.” After analyzing nearly 300,000 general surgery operations performed at 173 hospitals with the National Surgical Quality Improvement Program (NSQIP) database, we found...
Updating Hepatocellular Carcinoma Trends

Updating Hepatocellular Carcinoma Trends

The incidence of hepatocellular carcinoma (HCC) in the United States has historically been lower than that of other countries, but studies have shown that rates of the disease have increased substantially in recent decades. In addition, primary liver cancer mortality rates have increased faster than mortality rates for any other leading cause of cancer. “It’s important for clinicians to learn about the changing epidemiology of malignancies because this information directly impacts patient care,” says Jennifer C. Obel, MD. Several treatment options are available for patients with early-stage HCC, including resection, transplantation, and liver-directed therapies like chemoembolization (in well-selected patients with localized HCC). However, many patients who are diagnosed with HCC have advanced disease and are only candidates for palliative therapies. “Most HCC is thought to be associated with either chronic hepatitis C virus (HCV) or hepatitis B virus (HBV) infection,” Dr. Obel says. “In the U.S., more than 3 million people are chronically infected with HCV. Chronic infection with HBV is less common overall, but more common among certain ethnic groups.” HCC typically develops in patients with underlying cirrhosis. Commonly reported risk factors for cirrhosis include alcohol-induced liver disease, HCV and HBV infection, obesity, and type 2 diabetes. Assessing Incidence & Survival In the March 2009 issue of the Journal of Clinical Oncology, researchers at the National Cancer Institute examined trends in HCC from 1975 to 2005. The report found that the incidence of HCC tripled in the United States during this time period. Between 2000 and 2005, liver cancer rates increased significantly among African-American, Hispanic, and Caucasian men between the ages of 50 and 59 (Table 1). The...
Pain Management & Patient Safety

Pain Management & Patient Safety

According to current estimates, more than 76 million people in the United States suffer from chronic or acute pain. Opioid analgesics are a widely accepted treatment for severe acute pain, but use of these medications to treat some types of chronic pain remains controversial. “The challenge with chronic pain is that it can occur in the context of numerous diseases and syndromes,” explains Daniel J. Castillo, MD. “The problems associated with opioid use—including underprescribing, overprescribing, tolerance, dependence, and drug abuse—highlight the importance of safe opioid use in hospitals and other healthcare settings.” Research has shown that pain is a leading cause of disability and can have deleterious effects on ability to work, functional status, and other quality-of-life domains. Unalleviated pain can impair the immune response, impede wound healing, affect gastrointestinal and pulmonary functions, suppress appetite, and delay ambulation after surgery. The number of opioid prescriptions for pain management has increased substantially over the last 20 years, in part due to a growing consensus that opioids are appropriate for some patients with pain. At the same time, there has been an increase in prescription opioid misuse and associated mortality, affecting adolescents and adults of all ages.   A Sentinel Event Alert issued by the Joint Commission in 2012 provides a number of actions that can be taken by hospitals to avoid the unintended consequences of opioid use among hospital inpatients (Table 1). It also provides clinicians with strategies for avoiding accidental opioid overuse (Table 2). “Opioids can be helpful for some patients, but it’s important that clinicians recognize and understand that there are risks to consider,” Dr. Castillo says. Joint...
Salmonella Outbreak Persists

Salmonella Outbreak Persists

The current salmonella scare is the largest outbreak of this strain since the CDC  started surveillance of outbreaks in the 1970s. And according to the CDC, for every case of salmonella reported, there may be 30 that are not. While no deaths have been reported due to the recent salmonella outbreak, the number of illnesses (which can be life-threatening, particularly to those with weakened immune systems) is expected to increase. Infection rates often spike between July and October so physicians are likely to continue to see patients surfacing with symptoms over the next couple of months. People who could become extremely ill — especially if they are not on antibiotics — include infants, the elderly, and those with weakened immune systems. The most common symptoms are gastronintestinal such as diarrhea. Other symptoms include nausea, fever, vomiting, and muscle pains, beginning 12 to 72 hours following the consumption of contaminated food. Physicians should continue to encourage their patients to take the proper precautions in reducing the risk of salmonella infection. The CDC recommends buying only refrigerated eggs; keeping eggs refrigerated; discarding cracked or dirty eggs; washing anything that comes into contact with raw eggs; avoiding foods with raw eggs; and cooking food containing eggs to an internal temperature of 160°...
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