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Guideline Adherence Impacts Mortality in Schizophrenia

Adherence to the 2009 Schizophrenia Patient Outcomes Research Team (PORT) pharmacologic guidelines appears to help reduce mortality among patients with schizophrenia, according to a study from Johns Hopkins University. The authors recommend that clinicians consider adopting outcomes-monitoring systems and innovative service delivery programs to improve adherence to the PORT guidelines. Abstract: Schizophrenia Bulletin, October 30, 2012...

Diabetes Update Vol. 2

We are proud to present this diabetes monograph with feature stories on several important topics relating to the disease. Most of the articles were created with the assistance of key opinion leaders recommended by the American Diabetes Association. These features rely on clinical and evidence-based information and the expertise of our contributing physician authors. Physician’s Weekly will continue to feature diabetes news in the coming months and we hope you find this information...

Trends in AF Among Hospitalized ACS Patients

Among patients hospitalized with an acute coronary syndrome (ACS), overall rates of atrial fibrillation (AF) and mortality from it decreased between 2000 and 2007, according to a study from Massachusetts.  Despite the findings, investigators noted that AF still exerts a significant adverse effect on survival among patients hospitalized with an ACS. Improving the identification and treatment of ACS patients who have AF or are at risk for it may reduce the incidence and resultant complications of the dysrhythmia. Abstract: American Journal of Medicine, November...

Surgical-Site Antisepsis in Cesarean Deliveries

Rates of surgical site infection (SSI) appear to be similar between cesarean deliveries using chlorhexidine-alcohol and those using povidone-iodine. A retrospective cohort review found that the duration of cesarean delivery was the only significant predictor of SSI. Abstract: Obstetrics & Gynecology, November...

Evaluating & Managing Patients With Congenital Heart Disease

Survivors of congenital heart disease (CHD) are at greater risk for neurodevelopmental issues from both biological and environmental risk factors when compared with heart-healthy children. As survival rates in CHD have improved, the focus of clinical research has transitioned from striving for short-term survival to enhancing long-term morbidity. How common is neurodevelopmental impairment? View figure. A New Scientific Statement on CHD In the July 30, 2012 online issue of Circulation, my colleagues and I from the American Heart Association (AHA) released a scientific statement reviewing factors that increase risk for developmental disorders in those with CHD. The statement provides an algorithm for treating these developmental disabilities and stratifies risk; age-based management of CHD patients is also reviewed. The statement also discusses the impact of developmental disorders on quality of life for these individuals. A key recommendation is that children born with CHD should receive early evaluation for related neurodevelopmental disorders. High-risk patients should be referred for further developmental and medical evaluation. Developmental disorders can be identified and managed with continuous surveillance, appropriate screening, early evaluation, periodic reevaluation, and continuous, comprehensive treatment coordinated by a central care provider. Other recommendations include: Establishing a “medical home” to coordinate care between various specialists. Reassessing risk of developmental disorders each time the medical home is visited. Referring high-risk patients with CHD for early interventions before developmental disorders are formally diagnosed. Conducting periodic re-evaluations throughout infancy and childhood at 1 to 2 years, 3 to 5 years, and 11 to 12 years of age for developmental disorders in children with CHD deemed high risk. Considering potential benefits from higher-education or vocational counseling when high-risk...

A New Guideline for Treating Hypertriglyceridemia

Hypertriglyceridemia can substantially increase the likelihood of patients developing heart disease when compared with those who have normal triglyceride levels. While treatment strategies for this condition are well established, its causes differ from patient to patient, as do the risks they pose to each individual. Clinical practice guidelines from the Endocrine Society on hypertriglyceridemia were published in the September 2012 Journal of Clinical Endocrinology and Metabolism (view and print guideline summary here). They recommend that more attention be paid to how personal history, physiology, and lifestyle interact to affect risk. “In recent years, much of the focus surrounding lipids has concentrated on cholesterol,” explains Lars Berglund, MD, PhD, who chaired the Endocrine Society task force that developed the most recent guidelines. “Although there are evidence–based guidelines from respected medical associations that address lipids, data on the complex role of triglycerides in heart disease continue to accumulate. Considering this recent emergence of data on triglycerides, it was important to focus on a guideline that specifically discusses this component of heart disease care.” Individualized Approach with Elevated Triglycerides Dr. Berglund stresses that clinicians should not view elevated fasting triglyceride levels as a standalone factor. “Triglycerides should be looked at in the context of other risk factors for cardiovascular disease (CVD) and metabolic disease,” he says. “Assessment should include the evaluation of secondary causes of hyperlipidemia, including endocrine conditions and medications [Table 1]. Central obesity, hypertension, abnormalities of glucose metabolism, liver dysfunction, and family history of dyslipidemia and CVD should be assessed.” For example, patients with triglyceride levels in the moderate range—200 mg/dl to 999 mg/ dl—may have changes in HDL and...

The Lupus Initiative

The Lupus Initiative is a national education program designed to reduce health disparities experienced by patients with lupus. The Lupus Initiative has developed a free resource toolkit for practitioners of medicine – CME activities, case studies, a curriculum on lupus and health disparities, communication tools and more – to  assist and support in the diagnosis, treatment, and management of patients disproportionately affected by lupus based on race, ethnicity, and gender.  Learn more about the resource toolkit and how to request a free copy. In 2009, the Department of Health and Human Services (HHS) solicited applications and chose the ACR to lead an educational effort aimed at eliminating ethnic, racial, and gender disparities in the diagnosis and treatment of lupus. The ACR created The Lupus Initiative to further that effort. The goal of the Initiative is to develop and disseminate innovative lupus curricula and other teaching resources for physicians and health professionals in training and in practice. The Initiative has developed an infrastructure, researched the viability of resource options, and organized the development and review of a variety of educational materials concerning lupus. Since its inception, the Initiative has been guided by a national consortium of experts in lupus and health disparities from academia, research, patient services, and the federal government. The consortium is chaired by ACR volunteer Sam Lim, MD, MPH, supported by more than 30 ACR members who contribute considerable time, in addition to their expertise, to ensure the success the project. One of the truly unique features of The Lupus Initiative is its broad circle of collaborations and partnerships. The Lupus Initiative is inclusive of physicians and...

Patients With CKD Have Higher Rates of CDI

Patients with chronic kidney disease (CKD) appear to have a higher risk of Clostridium difficile infection (CDI) and hospital-associated morbidity and mortality when compared with patients who do not have CKD. A team of American researchers found that patients with CKD had a CDI rate of 1.49%, compared with a 0.70% rate for those without CKD. Abstract: Mayo Clinic Proceedings, November...

Hospital Length of Stay in Non-STEMI Patients

Duke University research suggests that patients with non-STEMI who spend more than 2 days in the hospital after their event appear to have more comorbidities and in-hospital complications than those with shorter lengths of stay (LOS). Patients with longer LOS were also less likely to receive evidence-based medications or PCI. Abstract: American Journal of Medicine, November...

A Look at Suicide Among Physicians

Mental illness appears to be an important comorbidity for physicians who complete a suicide, according to findings from a data review. After assessing postmortem toxicology data, researchers observed low rates of medication treatment for their mental illnesses. The authors noted that inadequate treatment and having more job stress may be modifiable risk factors to reduce suicidal death among physicians. Abstract: General Hospital Psychiatry, January...

Highlights from the 2013 Adult Immunization Schedule

The Advisory committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention has issued the 2013 adult immunization schedule, posted online this week in the Annals of Internal Medicine. Because current levels of vaccine uptake for adult vaccines are low, the recommendations stress the importance of providers routinely assessing patients’ vaccination histories and providing routinely recommended vaccines. A strong recommendation from physicians offering vaccination has been associated with increased uptake of vaccines. Physicians are also encouraged to implement reminder/recall systems and standing orders. View figure of the Recommended Adult Immunization Schedule, or click here to download. Changes in the 2013 vaccination schedule include the following: PCV13. Updates have been added for the first time on the use of 13-valen pneumococcal conjugate vaccine (PCV13) and the timing of administration of PCV13 relative to the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in adults. PC13 is recommended for immunocompromised adults aged 19 and older. The schedule also clarifies which adults would need 1 or 2 doses of PPSV23 before age 65. Tdap. Recommendations have been expanded to include routine administration of Tdap vaccination to adults age 65 and older as well as pregnant women. Pregnant women should receive the Tdap vaccine during each pregnancy, ideally between 27 and 36 weeks’ gestation to increase the likelihood of optimal protection for the woman, the fetus during pregnancy, and the first few months of the infant’s life. Influenza. The guidelines continue to recommend influenza vaccination for patients 6 months and older. Mild allergy to eggs is no longer a contraindication for the influenza vaccination – but patients with this allergy should receive the...

STS 2013: Identifying Small, High-Risk Lung Tumors

The Particulars: Currently, there is no reliable method for identifying pathologically staged, node-negative non-squamous non-small cell lung cancers (NSCLC) smaller than 2 cm (T1a). As adoption of low-dose CT screening rapidly increases, it is possible that a novel molecular assay may help detect T1a node-negative tumors early. Data Breakdown: Investigators conducted a validation study in 269 NSCLC patients who underwent resection of T1a node-negative tumors, analyzing a novel molecular assay. Overall post-surgical survival rates were 83%, 69%, and 52% in low-, intermediate-, and high-risk groups, respectively. Results were similar when analysis was restricted to tumors 1 cm or smaller. The hazard ratio associated with the prognostic assay high-risk category was 3.78. Take Home Pearls: A novel molecular assay appears to reliably identify patients with T1a node-negative tumors at up to 50% risk of mortality. Such identification may help maximize early detection of NSCLC tumors with low-dose CT...

STS 2013: CABG Bests PCI in Long-Term Outcomes

The Particulars: Optimal treatment approaches vary in the treatment of stable, multivessel coronary artery disease. Evolving technology, variable study designs, and differing interpretations of results are factors to this variation. Data Breakdown: In a large, long-term study, researchers reviewed outcomes at 4 years follow-up for patients aged 65 and older who underwent CABG or PCI. Mortality was 21% lower for CABG patients than PCI recipients. CABG patients had a lower risk for heart attack, but PCI patients had a lower risk for stroke. CABG patients had a 19% lower risk for the composite outcome of stroke, heart attack, and/or mortality. Take Home Pearls: Patients who undergo CABG appear to have lower overall risks for heart attack, stroke, and mortality when measured 4 years after their procedure. PCI, however, correlated with a lower risk for stroke than CABG. Patient education on treatment options prior to revascularization is...

STS 2013: Lung Transplants From Heavy Smokers

The Particulars: The general consensus among experts is that lung transplantation using donor organs from those who smoked heavily may worsen prognosis. However, a shortage of donors has sparked efforts to expand the donor pool, and using heavily smoking donors (HSDs; >20 pack years) may alleviate some of the burden. It is unknown if double lung transplantation (DLT) can be safely performed in adults using lungs from HSDs. Data Breakdown: For a study, DLT recipients with HSDs were compared with patients who did not receive these organs from heavy smokers. Recipients with HSDs were hospitalized for 2.5 days longer than the control group. However, researchers observed similarities in both groups in freedom from bronchiolitis obliterans syndrome, decrement in post-transplant forced expiratory volume in 1 second (FEV1), peak post-transplant FEV1, median survival, and malignancy-related mortality. Take Home Pearl: Using donor lungs from heavy smokers during double lung transplants appears to be safe, but more research is...

STS 2013: Feasibility Test of Volume Criteria for T Staging

Purpose: Size criteria have been used as a gold standard for a long time in cancer staging of all kinds of solid tumors. However, real tumor mass is usually neither spherical nor symmetrical in shape. Therefore, single length (diameter) of tumor does not stand for the tumor volume exactly, because of its asymmetry and irregularity in shape. In this study, we conducted the feasibility test of volume criteria for T staging. Methods: (1) From July 2005 until June 2006, 26 NSCLCa tumor masses were enrolled for the study. Estimated Tumor Volume (ETV-CT) was calculated using a formula from the lengths in three dimensions of the tumor from preoperative CT images, and Real Tumor Volume (RTV) was measured after complete tumor dissection in op room with measuring cylinder. We analyzed data sets between ETV and RTV to show the formula function well. The calculated tumor volume (ETV-CT) was compared to the measured tumor volume (RTV) in 26 tumor mass cases for consistency test by Pearson correlation coeffi cient. (2) From April 1998 to July 2012, 406 masses were enrolled. Among them, T1a, T1b, T2a, T2b, and T3 in N0 and N1, 228 cases were selected. From the reports of their tumor permanent biopsy, we calculated the estimated tumor volumes and analyzed survival data according to the volume ranges for staging: ~10cc, 10~30cc, 30~50cc and 50cc~. Results: Pearson correlation coefficient (r) between measured tumor volume and calculated one in 26 cases is 0.9784. By comparing new volume (V) staging with the standard T staging, V staging shows higher results than T staging in overall survival function (log-rank p=.0012 vs. p=.0068), in...

STS 2013: Suction or Waterseal Drainage After Lung Resection?

Purpose: Pleural suction is used after lung resection in order to promote lung expansion and minimize air leak duration. Published randomized trials failed to prove this advantage but they are limited in number and underpowered in many cases. The aim of the AirINTrial study was to test the hypothesis that pleural suction may reduce the rate of prolonged air leak (PAL) in a large, randomized cohort. Methods: All candidates to lung resection (with the exception of pneumonectomy) were considered eligible for this single-center study. At the end of operation, patients were stratified by the type of resection (anatomical versus non anatomical) and randomized into the pleural suction arm (-15 cmH2O, group A) or into the waterseal arm (group B) in a 1:1 ratio. Suction or waterseal was maintained for three days and then chest drains were either removed or connected to a Heimlich valve. The main end-point was to compare groups in terms of prolonged air leak (defined as the rate of patients having a chest drain still in place by POD 7). Results: Starting in February 2010, 500 patients were randomized over a 32-month period: 250 in group A and 250 in group B. Twenty-one patients in group B (8.4%) required pleural suction due to large pneumothorax and/or diffuse subcutaneous emphysema. On POD 7, the chest drain was still in place in 25 patients in group A and in 34 patients in group B (10% and 14% respectively, p 0.26). Subgroup analysis showed that pleural suction reduced PAL rate in the subgroup of patients who underwent anatomical resection (n=296, 9.6% in group A and 16.8% in group B,...
Newsworthy Research from 2012 ACR/ARHP

Newsworthy Research from 2012 ACR/ARHP

More than 20 rheumatology studies were selected as newsworthy and highlighted during the 2012 ACR/ARHP Annual Meeting.  ACR/ARHP 2012 Headlines Bone medication may save osteoarthritis knees. According to research presented this week at the American College of Rheumatology Annual Meeting in Washington, D.C., a daily dose of strontium ranelate — a medication prescribed for osteoporosis — may delay knee osteoarthritis progression. The study also revealed that taking strontium ranelate may improve knee pain, reduce joint damage and the need for surgery. View press release. Mobile calls from doctor can place rheumatoid arthritis on hold. Mobile phone monitoring in people with rheumatoid arthritis increases the likelihood that people with the disease will follow treatment, according to research presented this week at the American College of Rheumatology Annual Meeting in Washington, D.C. View press release. Extra weight linked to rheumatoid arthritis risk in women. Being overweight is linked to a higher risk of rheumatoid arthritis in women, according to new research findings presented this week at the American College of Rheumatology Annual Meeting in Washington, D.C. View press release. Other research from the meeting includes fibromyalgia and the brain, depression a risk factor for mortality in rheumatoid arthritis in men, antibodies signaling CVD, and much more! View all 2012 Annual Meeting Press Releases Additional Resources ACR in the News:  Click here to visit the ACR newsroom. Rheumatology Images Available for Media Explore over 1,500 images of rheumatic diseases ranging from common conditions such as rheumatoid arthritis to rare conditions including multicentric reticulohistiocytosis. Download and collect scholarly images for professional development, rheumatic research and educational presentations. Click here....

STS 2013: Tri-Modality Therapy for Superior Sulcus NSCLC

Purpose: Trimodality therapy incorporating preoperative chemotherapy (cisplatin-etoposide, CisP/Etop), radiation, and surgery is generally considered the standard of care for Superior Sulcus (SS) cancers. Intergroup SWOG 9416 demonstrated 5-year survival of 44%, with relapse mainly in distant sites. To address this issue, S0220 was designed to substitute single-agent docetaxel (DTX) for CisP/Etop during the consolidation phase after surgery. Methods: Similar to S9416, patients with histologically proven and radiologically defined T3 -T4, N0-N1, M0 SS NSCLC underwent induction therapy for 2 cycles concurrently with radiation therapy (45 Gy). Non-progressing patients were to undergo surgical resection within 7 weeks after completion. Consolidation DTX 75 mg/m2 IV was planned every 3 weeks for 3 doses. Results: From 7/03 to 10/07, 46 patients were registered with 44 eligible. 38 (86%) completed induction, 29 (66%) underwent surgical resection, and 20 (45%) completed the entire treatment regimen; 69% of surgically resected and 90% of those initiating consolidation DTX completed therapy. 28/29 (97%) underwent a complete (R0) resection, 2 (7%) died, both of ARDS. Surgical complications occurred in 55%; 31% had atrial fibrillation. Of the eligible, known site of first recurrence was local in 2, local-systemic in 1, and systemic in 10, 7 of them in the brain only. The 3-y PFS is 56% (95% CI 40% – 70%) and 3-y OS is 61% (44%-74%). These results are not dissimilar from the other SS induction group trials. Conclusions: This trimodality therapy approach provides an excellent R0 and local control, but distant failure continues to be the most common site or relapse and cause of death, particularly brain recurrence. Strategies to improve treatment outcomes must address both improved...

STS 2013: Vein Graft External Support System for CABG

Purpose: Vein graft failure has been attributed to increased pressure in the venous conduit. Previous animal studies have demonstrated that external support for these grafts have resulted in a reduction in neointimal formation and graft thickening. This study aims to show safety and potential improvement to vein graft patency when covered with a flexible external wire device. Methods: This is a 3 center randomized study with the use of the external supporting device to either the circumflex or right coronary artery system. Thirty patients were successfully recruited for the study. All saphenous veins were harvested with an open technique and surgery performed with cardiopulmonary bypass (CPB). Flow measurements were recorded in all vein grafts after discontinuation of CPB. ECG and CK-MB were recorded pre- and postoperatively. Patients were reviewed at 6 weeks, 6 months, and planned coronary angiography at 12 months to assess vein graft patency with OCT and IVUS. Results: All 30 patients underwent an uneventful CABG operation. Th e device was successfully deployed to the randomized vessel. Mean patient age was 64 ± 8 yrs, left ventricular ejection fraction 56 ± 9%, and logistic euroscore 1.83 ± 1.18. Mean cross clamp and bypass times were 00:59 ± 00:18 and 01:42 ± 00:26, respectively; final TTFM fl ow 67 ± 28 ml/min and pulsatility index 2.24 ± 1.11. Mortality was 0%. Four patients had SAEs but these were unrelated to placement of the external mesh. Length of hospital stay was 7 ± 2 days. Patients are planned to undergo coronary angiography from November 2012. Conclusions: This study has demonstrated the feasibility of deploying this device to vein grafts...
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