Advertisement

Disability After TIAs & Minor Stroke

Canadian investigators suggest that as many as 15% of patients who suffer transient ischemic attack (TIA) and minor strokes become disabled. Ongoing symptoms, diabetes, female gender, and CT/CT angiography-positive metric were predictive of disability after TIA and minor stroke. Just 12% of those who did not have a recurrent event were disabled, compared with 53% of those who did. Abstract: Stroke, September 13, 2012...

PCI, CABG, & Risks of Post-Procedural Stroke

Coronary revascularization with CABG appears to be associated with increased stroke risk at 30 days and at about 1 year when compared with PCI, according to an international investigation. After CABG, the 30-day rate of stroke was 1.20%, compared with 0.34% after PCI. Stroke rates at 12.1 months were 1.83% for those receiving CABG, compared with 0.99% for PCI recipients. The extent of coronary artery disease did not appear to affect stroke risk. Abstract: Journal of the American College of Cardiology, August...

Glycemic Control After Surgery in Kids

Tight glycemic control appears to be achievable following cardiac surgery in children ages 0 to 36 months, with low rates of hypoglycemia, according to a randomized, control trial. The researchers noted, however, that tight glycemic control does not significantly change infection rates, mortality, length of stay, or measures of organ failure when compared with standard care. Abstract: New England Journal of Medicine, September 7, 2012...

Positive Patient Perceptions of ED Communication

Investigators in Connecticut have found that patient perceptions of communication with ED medical teams appear to be positive. Results indicate that patients perceived ED teams to be respectful and willing to listen. “Excellent” scores were given most for the items on the survey, including: “Let me talk without interruptions” (76.1%). “Talked in terms I could understand” (75.2%). “Treated me with respect” (74.3%). Abstract: Journal of Emergency Medicine, September 17, 2012...

Should Procedure Volume Be Considered a Measure of Quality?

Hospital procedure volume does not appear to be a significant predictor of mortality for the performance of panceatectomy, abdominal aortic aneurysm repair, esophagectomy, or CABG. An analysis of discharge data from more than 260,000 patients found mortality risk to instead be primarily attributable to patient-level characteristics. Abstract: Annals of Surgery, October 2012....

The Impact of Decision Aids in Hip & Knee Surgery

Investigators from Washington suggest using patient decision aids appears to reduce rates of elective surgery and lowers cost for some health conditions for which treatment decisions are highly sensitive to patient and physician preferences. Decisions aids were associated with 26% fewer hip replacements and 38% fewer knee replacements. They lowered costs between 12% and 20% over 6 months. Abstract: Health Affairs, September...

Guidelines for Managing Agitated Patients in the ED

Proper management of agitated patients presenting to the ED is essential to keeping staff safe and ensuring appropriate care. In many cases, agitation cases can be managed with non-pharmacologic methods, but medications are becoming increasingly important in acute agitation in EDs. In the February 2012 Western Journal of Emergency Medicine, my colleagues and I at the American Association for Emergency Psychiatry published consensus recommendations on best practices for using medication to manage agitated patients in emergency settings. Rationale & Goals When Calming Patients Non-pharmacologic approaches—verbal de-escalation, quieting the room, and dimming the lighting—should be attempted before medications are administered. When initial verbal methods fail to calm patients, medication may be necessary. Clinicians should make a provisional diagnosis on the likely cause of the agitation because this can help guide medication choices. In many cases, agitation increases over time during ED treatment. By intervening early, to preempt the potential escalation of agitation to severe and dangerous levels, it may be possible to include patients in the medication decision process and use lower doses. The goal of using medication in agitated patients is to calm them without inducing sleep. Excessive sedation may interfere with assessment and treatment of underlying conditions. To the extent possible, medications should be used that specifically target the cause of agitation based on the provisional diagnosis. “The goal of using medication in agitated patients is to calm them without inducing sleep.” No class of medication is considered “best” in all cases of agitation, but three drug classes have been studied and used most frequently, including first- and second-generation antipsychotics and benzodiazepines. Although these drugs may manage acute...

ERs Go Mobile with Reservations

More than 100 hospital emergency departments are borrowing an idea from the restaurant industry: online reservations. Additional concierge services such as mobile apps for wait times make ER experiences more agreeable. ERs are going mobile at least partly to increase patient satisfaction scores, which are tied to hospital reimbursement for Medicare patients under the Affordable Care Act. Higher scores = hospital bonuses. The reservation service requires that patients describe their ailment. Patients who indicate they have serious symptoms such as chest pains are directed to go to the hospital or call 911. Critics argue that if someone is able to make an appointment, it’s not an emergency and may encourage inappropriate use of already crowded emergency rooms. They also claim that the service may discriminate against lower-income patients who don’t have access to smartphones or computers. However, the check-in service has undergone legal review and doesn’t appear to violate the Emergency Medical Treatment and Active Labor Act. A hospital’s triage and throughput process remains the same, and care is provided based on the most urgent medical need. Physician’s Weekly wants to know… Do you think scheduled appointments qualify as an...

Women & Peripheral Arterial Disease: A Call to Action

About 8 million people in the United States have peripheral artery disease (PAD), a condition that, if left untreated, increases heart attack and stroke risks, severely limits walking ability, and causes tissue death requiring limb amputation. The prevalence of PAD is nearly equal between men and women (Figure). Only about 10% of individuals with PAD experience classic, recognized exertional claudication, and many people experience no symptoms at all. As a result, few individuals with PAD receive prompt diagnosis or treatment. “The mortality rate and healthcare costs associated with PAD are comparable to those of heart disease and stroke,” says Alan T. Hirsch, MD. “Women, in particular, suffer an immense burden from PAD, but current data suggest that most women remain unaware of their risk. PAD continues to go largely unrecognized and untreated in women.” An Important Scientific Statement on PAD In the March 20, 2012 issue of Circulation, the American Heart Association (AHA), in collaboration with the Vascular Disease Foundation and the P.A.D. Coalition, released a scientific statement on women and PAD. It recommends that healthcare providers proactively increase awareness of and test women at risk for PAD. It also calls for more women-focused research into the disease. “There is a great need to identify women with PAD and those who are at risk for it, especially African-American women, so that we can help lower cardiovascular ischemic event rates,” says Dr. Hirsch, who was the chair of AHA writing group that developed the call-to-action statement. “This may also reduce the loss of independent functional capacity and ischemic amputation rates.” He notes that women in the United States already attend...

FDA Approves Cometriq to Treat Rare Type of Thyroid Cancer

The U.S. Food and Drug Administration today approved Cometriq (cabozantinib) to treat medullary thyroid cancer that has spread to other parts of the body (metastasized). Medullary thyroid cancer develops in cells in the thyroid gland that make a hormone called calcitonin, which helps maintain a healthy level of calcium in the blood. This type of cancer may occur spontaneously or in families with certain genetic mutations that result in one or more cancers of the endocrine system, including the thyroid gland. The National Cancer Institute estimates that 56,460 Americans will be diagnosed with thyroid cancer and 1,780 will die from the disease in 2012. About 4 percent of thyroid cancers are medullary thyroid cancer, making it one of the rarer types of thyroid cancers. “Cometriq is the second drug approved to treat medullary thyroid cancer in the past two years and reflects FDA’s commitment to the development and approval of drugs for treating rare diseases,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “Prior to today’s approval and the approval of Caprelsa in April 2011, patients with this rare and difficult to treat disease had limited therapeutic treatment options.” The FDA completed review of Cometriq’s application in six months under the agency’s priority review program. This program provides for an expedited six-month review for drugs that may offer major advances in treatment or that provide a treatment when no adequate therapy exists. Cometriq also received orphan-product designation by the FDA because it is intended to treat a rare disease or condition. Cometriq is a kinase...

Why I Wear a White Coat

A recent article in a major newspaper asked why physicians still wear white coats. The theme echoed many recent stories about bacterial contamination of clothing and other inanimate objects. It also brought to mind a controversial rule instituted by the UK’s National Health Service in 2008 that medical and nursing staff could not wear ties or white coats and had to have arms “bare below the elbow.” Despite published papers reporting the existence of bacteria on white coats and ties, the UK policy was not based on any evidence linking coats, ties or long sleeves to transmission of infection to patients. The subject has been debated for years. Yes, the white coat may be contaminated with bacteria. But whatever one wears may also be contaminated. What is the difference between wearing a white coat for few days and wearing a suit jacket or a pair of pants for a few days? I wear a white coat for the following reasons: It has a lot of pockets; It protects my clothes from blood, vomit, pus and poop; It is easy to clean; It is laundered by my hospital. I change it at regular intervals, usually amounting to fewer than 5 days. Thankfully, I don’t get blood, vomit, pus or poop on me every day. When I do, I change coats immediately. I don’t wear the coat when I’m operating or doing a procedure like inserting a central line on the floor. Some days I might only have it on for an hour or two. Some days I’m in an office or doing paperwork and the coat is hanging up. The...

Physician Empathy May Reduce Diabetes Complications

Physician empathy appears to be significantly associated with clinical outcomes in patients with diabetes and should be considered an important part of clinical competence, according to a team of international researchers. Patients of physicians with high empathy scores had significantly lower rates of acute metabolic complications than patients of physicians with moderate and low scores on empathy. Physician age and gender were not associated with acute metabolic complications. Abstract: Academic Medicine, September...

Type 1 Diabetes, Celiac Disease, & Retinopathy

Among people with type 1 diabetes, having celiac disease for more than 10 years appears to be a risk factor for developing diabetic retinopathy. Based on their findings, the Swedish research team suggested that long-standing celiac disease in patients with type 1 diabetes warrants intense monitoring for diabetic retinopathy. Abstract: National Institutes of Health, September 10, 2012...

Urinary Tract Infections Common in Type 2 Diabetics

Patients with type 2 diabetes appear to be at higher risk of developing urinary tract infections (UTIs) than patients without diabetes. An international study found that the incidence of UTIs was 46.9 per 1,000 person-years among those with type 2 diabetes, compared with 29.9 per 1,000 person-years for people without diabetes. Abstract: Journal of Diabetes and Its Complications, August 13, 2012...

Blood Pressure Screening Poor in Pediatrics

Efforts may be needed to better encourage providers to routinely screen patients aged 3 to 18 for hypertension, according to American investigators. Hypertension screening was performed in 35% of ambulatory pediatric visits, compared with 67% of preventive visits and 84% of preventive visits in which overweight/obesity was diagnosed. Source: Pediatrics, September 17, 2012...

Reviewing the Efficacy of Omega-3s in CVD Event Risk

A meta-analysis of 20 studies suggests that omega-3 polyunsaturated fatty acids do not appear to be linked to lower risk of all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke. No statistically significant associations were observed between omega-3 supplement use and any of these major cardiovascular endpoints. Abstract: JAMA, September 12,...

Renal Denervation for Resistant Hypertension

Catheter-based renal denervation (RDN) appears to be a cost-effective strategy for resistant hypertension that may lower cardiovascular morbidity and mortality. In a study, recipients of RDN had an average survival of 18.4 years, compared with 17.1 years for those receiving standard care. RDN was associated with lifetime savings of $3,071 per quality-adjusted life-year. Abstract: Journal of the American College of Cardiology, September...

Goal Setting for Older Adults With Diabetes

To successfully manage type 2 diabetes in older adults, clinicians must recognize and understand the unique challenges these individuals face. While the benefits of tight glycemic control in older adults are similar to those of younger patients, physicians need to understand that barriers may interfere with older adults’ ability to perform self-care before setting goals of care. When establishing overall health goals, there must be a balance between the perceived benefits of tight glycemic control and the risks of treatment, such as hypoglycemia. Diabetes management plans should be formulated for older adults after careful consideration of their health and social backgrounds. Recognize Comorbidities Older adults with diabetes are at higher risk for many medical conditions that are not typically associated with diabetes, including cognitive impairment, depression, and functional decline. Identifying these conditions before forming management plans is essential. Early identification of subtle cognitive dysfunction, especially executive dysfunction, can enable practitioners to simplify treatment plans to avoid complications. Executive functions are important for diabetes self-care. Depression in older adults with diabetes has been linked to poor glycemic control, decreased adherence to treatment strategies, increased functional disability, and higher mortality in clinical studies. To screen for depression, the Geriatric Depression Scale can be of help. Older people with diabetes are also at increased risk of falls due to lower limb dysfunction, cardiovascular disease, polypharmacy, and impaired balance. Since improved glycemic control can help prevent progression of diabetes-related microvascular and macrovascular complications, it may also decrease the fall risks. On the other hand, it’s important to prevent hypoglycemia as it may manifest as dizziness or weakness and increase fall risks. These patients...

Transitioning From Pediatric to Adult Diabetes Care

This Physician’s Weekly feature covering the transitioning from pediatric to adult diabetes care was completed in cooperation with the experts at the American Diabetes Association. During childhood and adolescence, diabetes care gradually shifts from being supervised by parents and other adults or guardians to self-care management. “Preparation for this transition by patients, their families, and healthcare providers is essential,” says Lori Laffel, MD, MPH. Studies have shown that there are often significant gaps in diabetes care for patients as they transition to adulthood for many reasons. These include competing social, emotional, educational, and occupational needs as well as differences in the systems of care for pediatric and adult patients. “With the increasing occurrence of type 1 and type 2 diabetes in childhood and adolescence, more young people with diabetes will require a framework of care and education that prepares older teens and emerging adults for successful self-management and a seamless transfer to adult diabetes care providers,” Dr. Laffel says. Important New Guidance on Transitioning Diabetes Care In the November 2011 issue of Diabetes Care, the American Diabetes Association published a position statement on managing diabetes for emerging adults transitioning from pediatric to adult healthcare systems. The position statement was co-authored by Dr. Laffel and Anne Peters, MD, CDE, on behalf of the Transitions Working Group. The work group included representation from experts in several other medical associations and societies, including the CDC, the Endocrine Society, the American Association of Clinical Endocrinologists, and other well-respected organizations. Pediatric and adult endocrinologists, primary care providers, diabetes nurse educators, dietitians, exercise experts, mental health professionals, and others were part of the collaboration. “In...
Page 1 of 512345
[ HIDE/SHOW ]