Advertisement
Cardiology Update 2011

Cardiology Update 2011

Read an exclusive collection of articles on recent topics in cardiology, including the link between CKD and atrial fibrillation, promoting self-care in heart failure patients, reducing the risk of CVD, and continuing statin therapy following hospitalization for...
Patients Wary of Care from Surgical Residents

Patients Wary of Care from Surgical Residents

Most patients approve of teaching facilities and training residents. However, a new study has found that consent rates plummet when patients are given detailed information about the role a resident will play in their surgical procedures. Patient perceptions and willingness to participate in resident education were reviewed by researchers in a study published in a recent issue of Archives of Surgery. Overall, of the 300 patients who completed a questionnaire about their support of resident training, most expressed overall support: 91% felt that their care would be equal to or better than at a private hospital. 68% believed they derived benefit from participation. 85% consented to having an intern participate in their surgical procedure. 94% consented to having a resident participate in their surgical procedure. However, consent rates plunged from 94% to 18% as the level of resident participation increased: 58% consented when a junior resident would be assisting a staff surgeon. 32% gave consent when a staff surgeon would be assisting the resident. 26% consented when a staff surgeon would be observing the resident. 18% gave consent when the resident would be performing the procedure without the staff surgeon present. Although patients are not routinely informed of a resident’s role in surgical procedures, those questioned said that the information could influence their decision on whether to consent. The researchers concluded that policymakers need to consider the variation in patients’ willingness to be treated by physicians in training — but that providing detailed informed consent could adversely affect resident participation and training. Physician’s Weekly wants to know… Should patients be provided with detailed informed consent if it adversely affects...
The Impact of Body Language on Health Exams

The Impact of Body Language on Health Exams

What messages are you unwittingly conveying to your patients through nonverbal cues, and what cues are they sending to you that you may be missing? A recent study in this month’s issue of Journal of Evaluation in Clinical Practice found that both doctors’ and patients’ subtle and unspoken cues – including body language, eye contact, physical appearance, and tone of voice – play a role during health maintenance examinations. Researchers looked at video elicitation interview transcripts involving 18 community-based primary care doctors and 36 patients. Patients often rated the encounter based upon nonverbal cues that convey  whether the physician appears hurried or at ease. They were primarily concerned about the following cues: Did the doctor make them feel comfortable? Did the doctor seem like he/she was in a hurry? Did he/she put them at ease? Was the doctor a good listener? Did he/she make eye contact? Doctors, on the other hand, looked at the nonverbal behavior of patients to help diagnose illness, such as depression. Reviewing patient-doctor interactions may provide a more complete understanding of the kinds of signals upon which doctors and patients rely and, in turn, improve patient care. Physician’s Weekly wants to know… What nonverbal cues of your own do you focus on? How strongly do a patient’s nonverbal cues affect your medical...
Surgeons Question New Transplant Guidelines

Surgeons Question New Transplant Guidelines

Surgeons are concerned that organ availability will decrease because new organ transplant guidelines call for stricter testing of organ donors. Issued by the CDC, the guidelines call for more updated and modern screening tests on organs being considered for transplant,  recommending that organ donors be checked for HIV and hepatitis B and C using the most sensitive screening method, known as nucleic acid testing. Between 2007 and 2010, the CDC found more than 200 cases of suspected HIV, hepatitis B and hepatitis C transmission through transplants; some of the cases resulted in the deaths of the organ recipients. More disturbingly, the CDC also discovered that as of 2008, only about half of the 58 organ procurement organizations in this country voluntarily tested for HIV and hepatitis C on all or some of the potential donors. Nucleic-acid testing can detect an infection acquired 7 days before testing. Standard blood tests measures antibodies to an infection that may take months to appear. Only about half of procurement labs in the country voluntary use the newer test, but it can double screening costs. While surgeons fully support guidelines that may help to decrease disease transmission, they feel that this concern should be balanced with the risks of dying without an organ transplant. However, organs that test positive for infections other than HIV can still be transplanted; stricter screening would just make physicians more aware of potential complications of infections when they do occur. Physician’s Weekly wants to know… Are surgeons overreacting or will stricter screening delay the process and drive up medical...

Considering Artificial Disc Replacement

Neck and low back pain accounts for between $50 billion and $75 billion in direct and indirect costs each year in the United States, and more than 1 million surgeries are performed to address these issues annually. Back pain is particularly problematic, as it’s the fifth leading cause of hospital admission and third most common reason for surgery. Among the working population, 90% will have an incident of low back or neck pain during their career. Although the vast majority of these cases will heal within 3 to 6 weeks with conservative physical therapy and medications, a small percentage of patients will often turn to surgery as a last resort. The gold standard over the past 30 years for degenerative discs or damage to spinal discs has been to fuse that level of the spine with bone using plates and screws. Fusion surgeries, however, can cause stiffness and may take 6 to 12 months to solidify. These surgeries may also increase stress on adjacent spinal levels, leading to degeneration. These discs adjacent to a fusion may become diseased at higher rates than discs not adjacent to a fusion. Preserving Motion with Artificial Disc Replacement About a decade ago, several level 1 FDA trials began exploring motion-preservation treatments, primarily artificial disc replacement. This procedure cleans out a bad disc and replaces it with an artificial device that allows normal range of motion. The half dozen completed trials comparing treatments have shown that the outcomes of artificial disc replacement appear to be superior, or at least equivalent, to fusion surgery. “The outcomes of artificial disc replacement appear to be superior, or...

Tonsillectomy Guidelines for Children

Approximately 530,000 tonsillectomies are performed each year in the United States, making these surgeries the second most routinely performed operation on children. The two most com­mon indications for tonsillectomy are recurrent throat infections and sleep-disordered breathing (SDB). The overall incidence rate of tonsillectomy appears to have significantly increased in the past 35 years, with SDB as the primary indication for surgery. Children with SDB have a significantly higher rate of antibiotic use, 40% more hospital visits, and a 215% higher rate of healthcare usage. A growing body of evidence indicates that tonsillectomy is an effective treatment for resolving SDB and improving quality of life (QOL). In an issue of Otolaryngology–Head and Neck Surgery, the American Academy of Otolaryngology–Head and Neck Surgery published a multidis­ciplinary clinical practice guideline on tonsillectomy in children. “It’s important that clinicians have evidence-based guidelines for these procedures so that they will be empowered to help patients make the best treatment decisions,” says Reginald F. Baugh, MD, who chaired the guideline committee. “The goals of the guidelines are to make surgery safer and to improve QOL for children who undergo tonsillectomy.” The guideline is intended for all clinicians who care for children between the ages of 1 and 18 being considered for tonsillectomy. It helps identify children who are the best candidates for tonsillectomy. It also provides information on peri­operative care, management options for special patient populations, and counseling strategies. Guideline Recommendations for Tonsillectomy The clinical practice guidelines for tonsillectomy in children outlined 10 specific recommendation state­ments to assist clinicians who manage these patients (Table 1). The statements describe specific aspects to consider with regard to surgical indications...
Pri-Med PQRIwizard: Qualify for Your Incentive Payment!

Pri-Med PQRIwizard: Qualify for Your Incentive Payment!

PQRIwizard allows physicians to quickly and easily participate in the Physician Quality Reporting System (PQRS) with an easy-to-use online tool that provides step-by-step guidance through the reporting system. PQRS 2011 is a voluntary pay-for-reporting initiative created by the CMS in 2007. The program allows eligible providers to apply for a 1% incentive payment from Medicare in return for reporting data on quality measures for covered professional services provided to Medicare Part B fee-for-service beneficiaries and paid under the Medicare Physician Fee Schedule. PQRIwizard is an online program similar to tax preparation software. In a few easy steps, the program rapidly collects, validates, reports, and submits physician’s data to CMS. Pri-Med has partnered with CECity, which provides the CMS qualified, online patient registry tool. According to a 2009 CMS report, the agency paid on, average, more than $1,950 per provider and $18,525 per practice. PQRIwizard offers the following measure groups: Diabetes Mellitus Preventive Care Back Pain Coronary Artery Bypass Graft (CABG) Coronary Artery Disease (CAD) Heart Failure Ischemic Vascular Disease (IVD) Rheumatoid Arthritis Chronic Kidney Disease (CKD) Community-Acquired Pneumonia (CAP) Perioperative Care Hepatitis C HIV/AIDS Asthma – New for 2011 Click here for more information or to register for PQRIwizard....
MRSA Contaminates Hospital Privacy Curtains

MRSA Contaminates Hospital Privacy Curtains

Though you dutifully wash your hands, your hand-hygiene efforts may be in vain if you touch privacy curtains before interacting with patients. In fact, within a week of being washed, 92% of the curtains are contaminated with potentially pathogenic bacteria, according to a report by University of Iowa Hospital. The critical role that the physical hospital environment plays in the transmission of hospital pathogens is becoming increasingly apparent. The Iowa study, presented at the ICAAC conference in Chicago this month, detected the rapid contamination of hospital curtains. Of the 13 privacy curtains freshly washed and hung for the study, 12 (92%) were contaminated within a week. Bacteria found included antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus species (VRE). In addition: MRSA was isolated from 21% of curtains. VRE was isolated from 42% of curtains. Overall, 119 of 180 (66%) cultures were positive for either S. aureus (26%), Enterococcus spp. (44%), or gram-negatives (22%). Physician’s Weekly wants to know… What interventions do you think can be put in place to reduce curtain contamination? Are there any other objects in the physical environment that should be...

An Innovative Model for Dementia Care

The Alzheimer’s Association estimates that about 5.3 million Americans have Alzheimer’s disease. Within this group, roughly eight of 10 people have dementia but live outside of nursing homes. Many of these patients have significant behavioral or psychological symptoms that require medical and psychological care. About 10 million Americans are family caregivers for sufferers of dementia, but these people aren’t typically the focus of efforts to improve care for patients. The HABC Care Model for Dementia In the May 10, 2006 JAMA, my colleagues and I developed and assessed a new collaborative model of care for dementia in which patients received 1 year of care management by an interdisciplinary team that was led by an advanced practice nurse working with family caregivers and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing non-pharmacological management. In this analysis, collaborative care resulted in significant improvements in quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. “Improved dementia care benefits patients, their family caregivers, and the entire healthcare system.” In the January 2011 issue of Aging & Mental Health, we successfully translated the memory care model we developed in the 2006 JAMA study into actual practice. We used the framework of the complex adaptive system and reflective adaptive process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). We essentially extended the definition of “patient” to include family members who enable cognitively impaired individuals to live in the community. Within 12 months of the initial HABC...

First-Ever Guidelines Issued for IC/BPS

According to recent data, interstitial cystitis/ bladder pain syndrome (IC/BPS) is more common than previously thought. The most up-to-date data suggest that 2.7% to 6.5% of adult women (about 3 to 8 million) in the United States have compatible symptoms. Of all patients with the condition, approximately 20% are male. IC/BPS has been linked to pain and discomfort that affects physical and psychosocial function, as well as quality of life. Compounding the problem is that IC/BPS is challenging to diagnose and treat, and no cure has been identified. In 2011, the American Urological Association (AUA) created the Guideline on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. The document comes 12 years after the AUA first set out to develop IC/BPS guidelines. “After pulling together 300 or 400 articles in 1998, we decided we didn’t have enough information about the condition,” says Philip M. Hanno, MD, MPH, who chaired the group that created the AUA guideline. “In the last decade, researchers have found that IC/BPS is much more prevalent, and the time was right to provide clinicians with a framework to help treat these individuals.” Diagnosing IC/BPS IC/BPS symptoms are much like those of a urinary tract infection, but they are seen in people with negative urine cultures who do not experience improvement with antibiotic treatment and harbor no other gynecologic or confusable disease that would explain the symptoms. “Patients complain of pain that they perceive to be related to the bladder that is associated with at least one other symptom, which is most often urinary frequency or urgency,” explains Dr. Hanno. “IC/BPS pain is sometimes described by patients as...
Joint Commission Rates Small Hospitals Higher

Joint Commission Rates Small Hospitals Higher

According to a new report released by the Joint Commission, the nation’s most highly regarded hospitals – Johns Hopkins, Mayo Clinic, MGH, Cleveland Clinic – are not included among the top performing hospitals that used evidence-based processes closely linked to positive patient outcomes. Small and rural hospitals led the pack in being the most diligent in following best-practice protocols, such as giving aspirin to a person who is having a heart attack on arrival at the hospital, or the use of corticosteroids in children admitted with asthma, said the report, which was issued this week. For the first time, Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety recognizes hospitals and critical access hospitals that have achieved excellence in accountability measure performance through the Top Performers on Key Quality Measures Program. Three measure sets (heart attack care, heart failure care, and pneumonia care) were followed from 2002-2010, and 6 more measure sets have been followed (surgical care, children’s asthma care, inpatient psychiatric services, venous thromboembolism care, stroke care, and perinatal care test measures).  These sets include both accountability and non-accountability measures. In 2002, hospitals achieved 81.8% composite performance to perform care processes related to accountability measures. In 2010, hospitals achieved 96.6% composite performance, a 9-year improvement of almost 15 percentage points, the report found. More than 9 in 10 hospitals had scores of at least 90%, which is more than 4 times the figure of 9 years ago. The top performing hospitals all scored 95% or better. Starting in January, Joint Commission–accredited hospitals will be required to meet an 85% composite compliance target rate for performance...
Medical School Debt Includes a Pile of Worries

Medical School Debt Includes a Pile of Worries

Some residents appear to pay a high price to become a doctor—and that’s in addition to the cost of education. Suboptimal quality of life and symptoms of burnout are associated with educational debt among residents, according to a study published recently in JAMA. A survey of more than 16,000 internal medicine residents found: 14.8% rated their quality of life “as bad as it can be” or “somewhat bad” 51.5% reported overall burnout 45.8% indicated they were emotionally exhausted 28.9% reported depersonalization The scores increased with amount of debt the residents carried. Moreover, the combination of low quality of life, emotional stress, and educational debt was also associated with lower Internal Medicine In-Training Examination Scores, or IM-ITEs. Residents juggling more than $200,000 in loans scored 5 points lower than physicians who were debt-free. Physician’s Weekly wants to know… Do you feel that money and personal debt can affect a physician professionally? What strategies or systems can be put in place by hospital administrators to relieve this...

Welcome Guidelines for Managing MRSA in Adults & Children

MRSA has been well documented as a significant cause of both healthcare–associated and community–associated infections. It is the predominant cause of skin infections among patients presenting to the emergency room and can also cause more serious, invasive infections, which account for about 18,000 deaths each year in the United States. “MRSA has an enormous clinical and economic impact,” explains Henry F. Chambers, MD. “Many clinicians often have difficulties when managing these infections. When these patients are not properly managed, the results can be severe. Poor management can also promote antibiotic resistance, which is fast becoming a growing concern among clinicians.” A Framework for Clinicians to Address MRSA In the February 1, 2011 issue of Clinical Infectious Diseases, an expert panel of the Infectious Diseases Society of America (IDSA) released its first evidence-based, consensus guidelines on the treatment of MRSA infections. The primary objective of the guidelines was to provide recommendations on the management of some of the most common clinical syndromes encountered by adult and pediatric clinicians who care for patients with these infections. The IDSA expert panel addressed issues relating to the use of vancomycin therapy in the treatment of MRSA infections, including dosing and monitoring, current limitations of susceptibility testing, and the use of alternate therapies for those patients with vancomycin treatment failure and infection due to strains with reduced susceptibility to the drug. “MRSA has an enormous clinical and economic impact. Many clinicians often have difficulties when managing these infections.” “The guidelines provide a framework to help clinicians determine the most appropriate means to evaluate and treat patients with uncomplicated and invasive infections caused by MRSA,” explains...
Will a Drink a Day Keep Dementia Away?

Will a Drink a Day Keep Dementia Away?

Light to moderate drinking—be it of beer, wine, or spirits—seems to reduce the risk for dementia and cognitive decline, according to a study recently released in Neuropsychiatric Disease and Treatment. A meta-analysis of more than 140 studies dating from 1977 that examined the effects of alcohol on the brain showed that moderate drinking reduced the risk for dementia such as Alzheimer’s disease by 23%. Moderate drinking is defined as no more than 2 drinks a day for a man and 1 drink a day for a woman. However, heavy drinking—more than 3 to 5 drinks per day—was associated with an insignificantly higher cognitive risk for dementia and cognitive impairment. Co-authors of the study, Edward J Neafsey, PhD and Michael A. Collins, PhD, believe that alcohol may act as a mild stressor for brain cells and “preconditions” them—making them better able to ward off stress. Cells exposed to increased levels of stress, they release protective compounds, preparing them for something stressful that may kill or damage the cells. If doctors are able to understand this protective cell mechanism, it may lead to future treatment to prevent cognitive impairment and dementias. Physician’s Weekly wants to know… What do you think of these study results—bottoms...

Wanted: Pain Training in Psychiatry

Chronic pain is a public health problem of pandemic proportions that affects more than 70 million Americans. It’s among the most common concerns for healthcare professionals, and the annual costs associated with chronic pain have been estimated at approximately $100 billion due to medical expenses, as well as loss of earnings and productivity. Studies estimate that about 50% of community-dwelling elderly people and as many as 80% of nursing home residents experience chronic pain. One of the most daunting challenges for psychiatric professionals is to distinguish physical and emotional symptoms that patients experience in the context of pain. Despite the fact that the physical and psychological aspects of pain are closely linked, surprisingly few pain-related themes are included in psychiatric residency training. According to current demographic trends, there appears to be a shortage of pain experts, further complicating care for patients. There will be a greater need for training in pain management, especially as the overall proportion of geriatric patients continues to increase. Older individuals, in particular, are at higher risk for developing pain-related conditions.  Analyzing Current Trends of Pain Management Education In a review article published in the January 2011 Archives of Internal Medicine, my colleagues and I assessed why it’s important to teach pain management to psychiatrists. A central theme of our article was that pain education should be an integral part of the core curriculum of psychiatric residency programs. A wide range of psychiatric conditions are associated with heightened pain prevalence, including major depressive disorder, borderline personality disorder, addictions, and PTSD. Since pain is exceedingly prevalent in psychiatric patients, psychiatrists will be faced with increasing numbers of...

The Impact of Complications on Colorectal Cancer Care

Colorectal cancer (CRC) is diagnosed in almost 150,000 patients in the United States each year and is the second leading cause of cancer-related death, accounting for more than 50,000 mortalities annually. The use of adjuvant chemotherapy has been a key quality measure for stage III CRC care because it is associated with a significant survival benefit. Chemotherapy for these patients has been shown to improve survival by as much as 16% after 5 years. However, national data indicate that guideline-recommended care is not provided to many patients. Studies have shown that the rates of adjuvant chemotherapy use for stage III CRC range from only 39% to 71%. Few studies have shed light on the reasons for the underuse of adjuvant chemotherapy in stage III CRC. Some sociodemographic variables (eg, older age, minority ethnicity, and lower socioeconomic status) have been linked to the omission of chemotherapy. However, it’s likely that other clinical predictors— including comorbid diseases, patients opting out of chemotherapy, and the high prevalence of perioperative complications in colorectal surgery—play a role in the receipt of chemotherapy. There may also be physician reluctance to give chemotherapy to patients who are frail or too sick from their surgical recovery. Complications in Colorectal Cancer Surgery In the December 2010 issue of Diseases of the Colon & Rectum, my colleagues and I published a study that examined the extent to which surgical complications are associated with the omission of recommended chemotherapy for CRC patients. We looked at data from 17,108 patients who had surgery for stage III CRC using patients from the Surveillance, Epidemiology, and End Results-Medicare database. Our results showed that at least...

Surgeon Sleep Deprivation: The Case for Informed Consent

Sleep deprivation has been shown to adversely affect clinical performance and impair psychomotor function. It can be challenging for medical systems to ensure that physicians are not fatigued from sleep deprivation because continuity of care and around-the-clock coverage of clinical services are often competing needs. The Accreditation Council for Graduate Medical Education has revised its regulations on resident work hours to restrict trainees in their first postgraduate year to a maximum of 16 hours of continuous work, followed by a minimum of 8 hours off duty. “Unfortunately,” says Michael Nurok, MD, PhD, “there are no such regulations for fully trained physicians.” There are many reasons why fatigue from sleep deficiency occurs, including long work shifts, long work weeks, sleep disorders, or personal circumstances (Table 1). “Researchers have documented the adverse effects of sleep deprivation and sleep disorders on individual performance,” says Dr. Nurok. “In surgery, the risk of complications (eg, massive hemorrhage, organ injury, or wound failure) is thought to increase in patients who undergo elective daytime surgery when these procedures are performed by attending surgeons who have less than a 6-hour window for sleep between procedures during previous on-call nights. Performing elective surgery under these circumstances cannot be rationalized in the context of patient safety.” Elective Surgery & Rescheduling Unlike other practice areas, elective surgery is potentially amenable to rescheduling. However, many competing interests influence the possibility for rescheduling, even when all parties stand to gain by avoiding errors and complications (Table 2). “When no policy exists to facilitate rescheduling or to prohibit sleep-deprived physicians from working, the burden of deciding to proceed with operations or reschedule them...
Smartphones: Clinical Communication Pal or Pest?

Smartphones: Clinical Communication Pal or Pest?

A recent analysis in the Journal of Medical Internet Research found that the use of smartphones for clinical communication increased efficiency among physicians, nurses, and allied health professionals compared with the use of pagers. However, the disadvantages may outweigh the benefits. The challenge is to find an effective means of communication that doesn’t lead to frequent interruptions. A recent analysis in the Journal of Medical Internet Research found that the use of smartphones for clinical communication increased efficiency among physicians, nurses, and allied health professionals compared with the use of pagers. However, the disadvantages may outweigh the benefits. The challenge is to find an effective means of communication that doesn’t lead to frequent interruptions. It’s no secret that effective communication among healthcare professionals is critical to reduce inefficiencies and errors that could jeopardize quality healthcare to patients. Hospitals as a rule strive to improve communication by establishing protocols, strategies, recommendations, and other methods to reduce communication gaps, which can—for some patients—be fatal. In this JMIR study, each senior resident on the general internal medicine units was given a “team smartphone” as the primary means for nurses and allied health professionals to communicate with the teams. Nurses contacted residents by sending emails to the team phone and calling the phone directly for urgent patient issues. In a 24-hour period, these were the findings: Nurses sent an average of 22.3 emails to physicians Physicians received an average of 21.9 emails and 6.4 calls Physicians sent 6.9 emails and sent 8.3 calls While Smartphones were perceived to better facilitate mobility and multitasking over pagers, negative outcomes included frequent interruptions and disagreements between what doctors...
Bacteria Contaminates 60% of Hospital Uniforms

Bacteria Contaminates 60% of Hospital Uniforms

More than 60% of uniforms worn by hospital nurses and doctors tested positive for potentially dangerous bacteria according to a study published this month in the American Journal of Infection Control. Swab samples were collected by pressing standard blood agar plates on the abdominal area, cuffs, and pockets of uniforms. Twenty-one cultures from nurse uniforms and six cultures from doctor uniforms contained multi-drug resistant pathogens; eight of those grew MRSA. Of the physicians and nurses in the study, 58% claimed to change their uniform every day, and 77% defined the level of hygiene of their attire as fair to excellent. While there may not necessarily be a direct risk of disease transmission from uniforms, it’s  disturbing that antibiotic-resistant strains may be right under hospitalized patients’ noses. However, the cornerstone of infection prevention remains the use of hand hygiene. AJIC study details Physician’s Weekly wants to know… How would you rate the hygiene of the medical staff at your facility? How closely do you feel nurses and physicians follow hygiene...
[ HIDE/SHOW ]