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Precursors of Sudden Cardiac Death Elusive in Athletes

Precursors of Sudden Cardiac Death Elusive in Athletes

According to the findings of a study led by researchers from Stanford University, cardiologists appear to make mistakes frequently when interpreting the results of young athletes’ pre-participation screening ECGs. Pediatric cardiologists who participated in the study had an accuracy rate of just 69%. The study, according to the authors, suggests that diseases underlying sudden cardiac death are difficult to interpret in athletes. The accuracy rate did not differ significantly in respondents, despite variations in length of time practicing pediatric cardiology, the number of ECGs read per month, or practice type. In the investigation, 53 pediatric cardiologists were asked to interpret a series of 18 ECGs of athletes with either normal hearts or conditions that would lead to sudden cardiac death. Per cardiologist, the average number of correct interpretations was 12.4. Sensitivity for detecting a cardiac abnormality was 68%, and specificity was 70%. False-positive results were 30%, and false-negative results were 32%. An accurate restriction of athletic participation was given in 81% of cases, compared with 74% of cases in which healthy patients were accurately allowed to participate in sports. The most common cases in which correct guidance was provided were for long-QT syndrome and myocarditis. Correct guidance was provided least often in cases of hypertrophic cardiomyopathy and Wolff-Parkinson-White syndrome. This finding was particularly “disappointing” to the researchers, who noted that the most frequent cause of sudden cardiac death in the United States is hypertrophic cardiomyopathy. Read Athlete Screening ECG Study Abstract Physicians Weekly wants to know… What consequences could arise from the false sense of security offered to patients and families when choices are made by cardiologist to not...

Approaches to Treating Tourette’s Syndrome

Tourette’s syndrome is a childhood-onset condition that is diagnosed when motor and vocal tics have been present for at least 1 year. The syndrome is now viewed as a neuropsychiatry spectrum disorder in which tics are commonly associated with obsessive-compulsive symptoms that do not always meet the full diagnostic criteria for obsessive-compulsive disorder (OCD). Tourette’s has also been associated with disturbances of attention that do not always meet the full criteria for ADHD. The combination of tics, OCD, and ADHD—often called the Tourette’s syndrome triad—can be challenging to diagnose and treat. In the December 9, 2010 New England Journal of Medicine, I had a review published that discussed strategies and guidelines on diagnosing and treating Tourette’s syndrome in clinical practice settings. Tic suppression often occurs in physicians’ offices, so the most opportune time to look for tics is when patients are entering or leaving the examination room. Coexisting psychiatric conditions can be evaluated with clinical rating scales too. Management Strategies Virtually any movement or sound that the body is capable of making can be a manifestation of a tic. The most notorious tics of Tourette’s syndrome include obscene or insulting utterances (coprolalia), but these occur in less than half of all cases. When tics are mild and not disabling, education about Tourette’s and supportive counseling to strengthen self-confidence and self-esteem usually suffice. When tics are disabling, they cause social embarrassment or self-injury for which tic-suppressing therapy is indicated. Treatment options include habit-reversal treatment, a form of cognitive behavioral therapy, or pharmacotherapy. “The most opportune time to look for tics is when patients are entering or leaving the examination room.”...
Overweight Teens Often Missed by Preventive Care

Overweight Teens Often Missed by Preventive Care

Despite the well-documented rise in pediatric obesity, University of California, San Francisco researchers report in Pediatrics that overweight teenagers do not appear to be receiving the preventive care they need. Following a survey from 2003 to 2007 of 9,220 adolescents aged 12 to 17 who were asked if they received screening for nutrition, physical activity, and emotional distress, the researchers found that obese teens received more screening than normal-weight peers, but overweight teens did not. Obese participants in the survey were 40% more likely than normal-weight peers to report undergoing screening of their physical activity and were 60% more likely to be screened for nutrition. Those who were overweight but not obese did not receive more screening than normal-weight teens for physical activity or nutrition in any of the survey years. Screening rates for physical activity were 75.5% for obese participants, 68.8% for overweight participants, and 68.6% for normal-weight participants; corresponding rates for nutrition were 77.6%, 69.7%, and 66.2%, respectively. Over the 4 years of the study, screening appeared to decline overall. In fact, odds for screening dropped by half for both physical activity and nutrition and by 30% for emotional distress, even after adjusting for factors related to screening. Physician’s Weekly wants to know… Do you believe short office visit times, low reimbursement, and/or a lack of local resources for referring patients for pediatric weight management play a role in the level of screenings? How could screening rates for overweight children can be...
Diagnosis & Treatment Often Delayed in Hypertension Patients

Diagnosis & Treatment Often Delayed in Hypertension Patients

Results of a national study indicate that 20% of all patients with pulmonary arterial hypertension (PAH) suffer with the disease for more than 2 years before obtaining an accurate diagnosis and proper treatment. “For a lot of patients, that means the treatment is more difficult and the damage is irreversible,” said lead author Lynnette Brown, MD, PhD, a pulmonologist and researcher from Intermountain Medical Center. “Finding out which patients are getting a delayed diagnosis is the first step in identifying them earlier, when treatment is easier and hopefully more effective.” Among the nearly 3,000 adults with PAH who participated in the study, those with symptom onset before age 36 displayed the highest likelihood of delayed recognition (PAH diagnosis, start of PAH-specific therapy, or diagnosis by right-sided heart catheterization). History of obstructive airway disease and sleep apnea were also independently associated with a delayed recognition of PAH. Dr. Brown and colleagues also found that a 6-minute walk distance of less than 250 meters, right atrial pressure less than 10 mmHg, and pulmonary vascular resistance of less than 10 Wood units were associated with delayed recognition, whereas sex, race/ethnicity, and geographic region were not. “We have a lot more medications available to fight pulmonary arterial hypertension, but we can’t use them all if we don’t get to patients early enough in the course of the disease,” said co-author, Gregory Elliott, MD, chairman of the department of medicine at Intermountain Medical Center. “If we can treat these patients sooner, we may find that we can improve survival.” Drs. Elliot and Brown hope the study results provide guidance in diagnosing PAH. “If a...
Hospitals Report Pervasive Drug Shortages

Hospitals Report Pervasive Drug Shortages

More than 99% of hospitals polled in June 2011 by the American Hospital Association (AHA) reported that they had experienced a drug shortage within the previous 6 months, and nearly 45% indicated they had experienced at least 21 shortages during that time. In the survey of 820 respondents, 80% said they had experienced shortages in surgery/anesthesia, emergency care, cardiovascular, gastrointestinal/nutrition, pain, or infectious disease medications. More than 66% of hospitals reported cancer drug shortages. What’s more, almost 50% reported a shortage of at least one agent daily. Because of these shortages, 80% of hospitals reported delaying patient treatment, and 70% reported treating patients with inferior drugs, although such instances occurred “rarely,” according to the respondents. “The number of drugs in short supply is increasing at an alarming rate, and hospitals are working diligently to reduce the impact to the patients they care for,” said AHA President and CEO Rich Umbdenstock. “Clinicians need more notice about drug shortages so they have time to act to ensure that patient care is not disrupted.” A lack of advance notice about drug shortages may explain why 85% of respondents reported having purchased excess inventory of some drugs. Rationing or restrictions on certain drugs are other ways hospitals try cope with shortages, with most respondents reporting that they have taken those measures — causing drug costs to rise. According to a separate survey released by the American Society of Health System Pharmacists, managing these shortages results in estimated U.S. labor costs of $216 million. More than 90% of directors of pharmacy who responded to the survey said drug shortages were associated with increased burden...

Cardioversion in the RE-LY Trial

About 2.3 million Americans are currently living with atrial fibrillation (AF), and the prevalence is expected to increase to 5.6 million by 2050. AF increases the risk of stroke nearly five-fold and is associated with up to 15% of all strokes in the United States. It imposes a substantial economic burden to the healthcare system, specifically because of stroke management and hospitalizations costs. Recently, the FDA approved dabigatran (Pradaxa, Boehringer Ingelheim Pharmaceuticals, Inc.), an oral anticoagulant indicated to reduce the risk of stroke for patients with AF. The approval was based on findings from the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) trial, which showed that 110 mg dabigatran was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin, as well as lower rates of major hemorrhage. Dabigatran 150 mg was associated with lower rates of stroke and systemic embolism than warfarin, with similar rates of major hemorrhage. An Important Sub-Analysis Currently, guidelines recommend using anticoagulation for at least 3 weeks prior and 4 weeks after cardioversion to reduce the risk of associated thromboembolisms, but this recommendation is based on limited data. In the January 18, 2011 issue of Circulation, my colleagues and I had a study published from a post-hoc analysis of the RE-LY trial among patients with non-valvular atrial fibrillation (NVAF) undergoing cardioversion, a treatment designed to convert abnormal heartbeat back to normal sinus rhythm. According to recent estimates, NVAF represents approximately 95% of all AF cases in the United States. Cardioversion is one treatment option for patients with AF and requires anticoagulation both prior to and following treatment in...

ASCO Annual Meeting 2011

The American Society of Clinical Oncology’s 2011 annual meeting was held June 3-7 in Chicago. The features below highlight some of the news emerging from the meeting. » SNPs Linked to Neuropathy in Breast Cancer » PSA Predicts Long-Term Prostate Cancer Risk  » Validity of Concurrent HPV Testing & Cervical Cytology » The Effects of Ovarian Cancer Screening on Mortality » Smoking, Alcohol, & Physical Activity: The Effect on Cancer Risk  SNPs Linked to Neuropathy in Breast Cancer The Particulars: Neuropathy is one of the most common toxicities experienced by patients on taxane therapy. The resulting pain can be severe, function-limiting, and sometimes irreversible. Advanced age, diabetes, and type, dose, and schedule of taxane have been established as predictors for increased risk, but no biomarkers have been identified to help predict patients who are at greatest risk. Data Breakdown: A genome-wide association study was performed on 2,204 patients under-going paclitaxel therapy with early stage breast cancer with the purpose of identifying single nucleotide polymorphisms (SNPs) that could be associated with a first grade 2 to 4 neuropathy. In the investigation, 613 patients experienced grade 2 to grade 4 neuropathy. Age (12.9% increase per 10 years) and African-American race were identified as significant clinical predictors. Residing in two genes (RWDD3 and TECTA), six SNPs with minor allele frequency greater than 5% were associated with time to neuropathy. The likelihood of neuropathy at 15 months was associated with a missense SNP in RWDD3 (27% for patients with homozygous wild-type, 40% for hetero­zygous, and 60% for homozygous variant) and a TECTA SNP (29% for homozygous wild-type, 32% for heterozygous, and 57% for homozygous variant)....
5 Strategies for Changing Anesthesia Providers

5 Strategies for Changing Anesthesia Providers

For hospitals grappling with the question of whether it’s time to find a new anesthesia provider, a white paper published July 12 by Somnia Anesthesia highlights the “best practices” for those looking to make the switch. The paper also reviews signs that indicate a change may be due and explores how to identify and bring a new anesthesia provider onboard. “Healthcare reform is prompting many hospital administrators to focus on reducing costs, improving quality, and increasing efficiency in the operating room,” said Somnia executive VP and CMO Robert C. Goldstein, MD. “The result is that many facilities are taking a closer look at their anesthesia provider and are contemplating making a change.” Titled “Best Practices for Anesthesia Onboarding and Change Management,” the white paper provides five strategies for making a successful transition to a new provider: 1. Involve stakeholders including a wide range of clinical and non-clinical staff. 2. Identify desired outcomes. 3. Assess clinical, administrative and financial risks. 4. Establish clinical quality and business-related benchmarks. 5. Communicate the change effectively. When looking to improve upon an anesthesia program, hospital administrators should seek out providers who “embrace transparency, provide complete clinical and operational support, and have a clear understanding of the clinical and regulatory environment pertaining to anesthesia,” according to the authors. Download Somnia Anesthesia white paper Physician’s Weekly wants to know… Have you been involved in a change from one anesthesia provider to another? What was the process like? Are white papers like this helpful? Do you tend to view them as skewed information to help highlight the services provided by the creator? Are you currently seeking a...
Why Are Parkinson’s Patients Still Getting Antipsychotics?

Why Are Parkinson’s Patients Still Getting Antipsychotics?

In 2005, the FDA ordered that pharmaceutical companies include “black box” warnings on antipsychotic drug packages regarding the risks posed by the drug class to patients with Parkinson’s disease (PD), particularly because they could worsen symptoms. However, 6 years later, it appears that trends are unchanged. More than half of the nation’s patients with PD and psychosis are still being prescribed antipsychotic drugs, according to results from a study published in the July 2011 Archives of Neurology. For the study, researchers from Pennsylvania, Ohio, and Michigan analyzed Veterans Affairs data from 2002 to 2008 to assess prescription rates of antipsychotics among 1,804 patients with PD but no dementia, 793 patients with PD and dementia, and 6,907 patients with dementia and psychosis but no PD. Roughly 50% of patients with PD and psychosis in 2008 received an antipsychotic prescription, with use of the drugs higher among those with PD and dementia than among those without dementia. Although the overall rate of antipsychotic prescriptions for PD remained unchanged between 2002 and 2008—despite the FDA warning in 2005—a decrease was seen in the use of some antipsychotics. The study authors noted, however, that there was an increase in use of other antipsychotics that were seemingly better tolerated by patients with PD. They stressed that better tolerance from patients does not mean that the drugs are necessarily safer or more effective. “Approximately one-third of our Parkinson’s disease sample had comorbid dementia, and many more likely had mild cognitive impairment,” the research team wrote in their published study. “This has significant clinical implications in Parkinson’s disease given the increased morbidity and mortality associated with...

Enhancing Patient Safety in Surgery

The “Universal Protocol” was designed to increase patient safety in the operating room (OR) by ensuring that the correct patient receives the correct procedure at the correct surgical site. The protocol involves a pre-procedural verification process, surgical site marking, and a preoperative “time-out” immediately prior to starting the procedure. In 2004, the Joint Commission mandated that the Universal Protocol be formally implemented for all accredited institutions. Despite its widespread application, this standardized protocol appears to have failed the prevention of wrong-site and wrong-patient procedures—or “never-events”—as per findings from recent studies. Pitfalls and limitations that may fail the Universal Protocol are hidden in each of the protocol components. The protocol can be cumbersome or distracting for healthcare providers, making it a robotic ritual that diminishes the focus of the OR team. Other major pitfalls include inadequate or inaccurate site marking, the hidden danger that the time-out may absolve the lead surgeon from taking full responsibility, and the continued expansion of the time-out to include secondary safety issues. Additionally, the performance of multiple simultaneous procedures on the same patient and a lack of implementation of the Universal Protocol by non-procedural specialties are potential root causes of wrong-site surgery. A Deep-Rooted Problem Studies estimate that 20% to 30% of all wrong-site and wrong-patient procedures originate before patients are admitted to the hospital. Potential scenarios include inaccurate clinic note dictations relating to a wrong side, the mislabelling of radiographs or other diagnostic tests, or a mix-up of patients with similar or identical names. Recent, unpublished data have revealed that non-surgical specialties (eg, internal and family medicine) are often involved in the etiology of...
Rejection of Medicare & Private Coverage "Overstated"

Rejection of Medicare & Private Coverage "Overstated"

Several recent news articles from the media have discussed a drop in the number of physicians who accept patients with Medicare. However, recent trends in acceptance of various insurance types have not been examined, according to an analysis published in the June 27, 2011 Archives of Internal Medicine. Using data from a national survey, three doctors examined trends in physician acceptance of several insurance types, as well as self-pay patients. Their hope was that understanding “these trends can help informpolicymakers of potential access problems, particularly giventhe shortages in primary care, an aging population, growingprevalence of chronic disease, and insurance expansion underthe Patient Protection and Affordable Care Act.” Looking at data from 2005 to 2008, researchers found only a 2.6% reduction in the number of physicians who accepted patients with Medicare. The decline in acceptance was seen mostly among physicians in private practice. By contrast, physician acceptance of patients with private, non-capitated insurance had a more pronounced decline, dipping from 93.3% in 2005 to 87.8% in 2008. Acceptance of self-paying patients did not change significantly over the study period. Acceptance among both the above groups was still higher than that for patients with Medicaid and private, capitated capped insurance; a decline was seen over the study period among both latter groups. Based on their finding that more than 90% of physicians still accept Medicare patients despite marginal increases in reimbursement, the research team suggested that “anecdotal reports may be overstating access problems.” They noted that the decline in acceptance of private, non-capitated insurance was unexpected and suggested that it may be related to reimbursement and administrative burden. Lower reimbursement may...
New Affordable Healthcare Act Rule Targets Red Tape

New Affordable Healthcare Act Rule Targets Red Tape

The Department of Health and Human Services (HHS) has released for comment the first in a series of proposed new operating rules aimed at standardizing and improving electronic healthcare transactions. The rules will reportedly cut red tape in the healthcare system and eliminate inefficiencies in manual processes, saving an estimated $12 billion over the next 10 years. Under the first proposal, insurers would be required to provide uniform claims and coverage information using uniform formats. Healthcare providers would then be required to use a standard information request to obtain patient-specific information. HHS hopes this process will simplify administrative functions, facilitate the identification as to whether or not patients are eligible for coverage, and learn the status of previously submitted claims. Health plans, healthcare clearinghouses, and certain healthcare providers would be required to be compliant by January 1, 2003 under implementation of part of Section 1104 of the Affordable Care Act. The rule was sparked, in part, by a May 2010 study in Health Affairs that suggested physicians spend almost 12% of every dollar received from patients to cover costs of excessive administrative complexity. The study authors argued that simplifying these complexities could save 4 hours of professional time per physician and 5 hours of support staff time per week. “Doctors and health insurance companies waste thousands of hours and billions of dollars filling out forms and processing paperwork,” said HHS Secretary Kathleen Sebelius. “The Affordable Care Act is helping doctors operate more efficiently and spend their time treating patients, not filling out papers.” Comments on the new rule will be accepted until 5:00 pm EST on September 6, 2011....

Efforts Needed to Meet Anesthesiologist Demand

Anesthesiology is an important medical specialty provided by highly skilled anesthesiologists. Anesthesia care also is provided by certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs). There are approximately 35,000 anesthesiologists, an equal number of CRNAs, and 1,300 AAs actively practicing in the United States. In most states, CRNAs must work under a physician’s supervision. However, 16 states now have opted out of this requirement. Anesthesiologists typically are anesthesia care team leaders and either personally provide anesthesia or oversee CRNAs and AAs. Anesthesiologists have the medical training to manage the overall health of patients when they are at their most vulnerable. There has been growing concern over whether the U.S. is facing a shortage of anesthesia providers. The ramifications of such a shortage are significant. “A shortage of anesthesiologists could limit access to high-quality care, especially in light of the growing demand for surgical and interventional procedures for our aging society,” says Mark A. Warner, MD. Markets for highly specialized medical services are difficult to balance, but understanding current and future demand and supply for anesthesia services may help policymakers, regulators, and professional groups in addressing the problem before it gets out of control. Many factors can play a role in national or local shortages, especially poor workforce planning. This may include limits on the number of training positions, regulations of permission to practice, and limits on earning capacity, especially for anesthesiologists who wish to work in rural areas but have payment limited by Medicare rules that do not apply to CRNAs. New Survey Data A recent study from the RAND Corporation was conducted to assess whether there is...

Improving Care for Falls & Urinary Incontinence

Primary care physicians (PCPs) are often the ones who manage these patient groups, but the care provided in these settings may not always be adequate. A variety of interventions have been utilized to improve care for falls and urinary incontinence (UI) in older patients. While some of these interventions have demonstrated improvements in patient care and outcomes, they’ve often been difficult to implement in current practice environments. They also aren’t always disseminated into small- and medium-sized primary care practices, where many older patients receive their care. In these locations, redesigning internal workflow and healthcare provision processes may be more effective in improving care for these patients. Analyzing Practice Redesign In the October 25, 2010 Archives of Internal Medicine, my colleagues and I had a study published in which we performed a controlled trial in five non-randomly selected primary care intervention and control practices from diverse communities. In collaboration with the American College of Physicians, we augmented the Assessing Care of Vulnerable Elders (ACOVE) intervention to conduct the “ACOVE Practice Redesign for Improved Medical Care for Elders” (ACOVEprime) project to improve falls and UI care. Patients aged 75 and older who screened positive for falls or fear of falling and UI were included in the study. We compared quality of care for falls and UI at intervention sites and compared them with care at control sites. “Practice redesign appeared to improve the care that community-based PCPs provided for older patients with falls and UI.” In our analysis, practice redesign appeared to improve the care that community-based PCPs provided for older patients with falls and UI. Of the 6,051 patients screened in...
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