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Mild TBI: Identifying Patients at Risk

For emergency nurses, it can be challenging to identify patients with a mild traumatic brain injury (MTBI) and how best to manage these individuals at discharge. A study has found that emergency nurses need to be aware that patients may have an MTBI regardless of their presenting symptoms or injury severity (see also: Caring for Mild Traumatic Brain Injuries). In the study, researchers compared the frequency and severity of MTBI symptoms by discharge diagnosis in 52 ED patients at least 2 weeks after injury who were discharged with concussion or closed head injury, head laceration, motor vehicle crash (MVC), or whiplash or cervical strain diagnoses. Most participants (84.6%) reported having MTBI symptoms, and headache and fatigue were the most common. Female patients had almost twice as many symptoms, on average, as male patients. The majority of patients were more cautious after their injury. Of all MVC patients in the analysis, 83.3% reported moderate severity scores for all four Post-Concussion Symptom Scale categories; these represented the highest overall severity scores. Although MVC participants reported the most severe MTBI symptoms, they had the least head injury education. Conversely, patients diagnosed with a concussion or closed head injury received the most head injury education. Abstract: Journal of Emergency Nursing, September 2012.  ...

Medical Therapy Matters Prior to Interventions in PAD

Research from Michigan suggests that use of statins and aspirin prior to percutaneous revascularization among patients with peripheral arterial disease, or PAD, appears to reduce the number of peripheral vascular events by more than half when measured at 6 months. The authors noted, however, that appropriate medical therapy—which also includes abstinence from smoking—was underutilized in this population. Abstract: Circulation: Cardiovascular Interventions, December 11, 2012...

Diabetes Remission After Gastric Bypass

Many severely obese adults who undergo gastric bypass surgery appear to experience a durable remission of type 2 diabetes, according to a large cohort study. However, more than one-third (35.1%) of patients who had their diabetes go into remission experienced a relapse within 5 years. Source: Obesity Surgery, November 18, 2012...

EHR Adoption Poor in Pediatrics

A survey of more than 1,600 pediatric facilities has found that adoption of fully functional electronic health records (EHRs) among pediatricians appears to lag behind that of other institutions. Barriers to adopting EHRs included financial and productivity concerns, but pediatricians were also worried about finding EHR systems that met their needs. Abstract: Pediatrics, December...

A New Guideline for Breast Cancer Screening

The American Society of Breast Disease has released new guidelines to help physicians inform women on how breast density affects breast cancer screening and cancer risk. Available online at www.asbd.org, the guidelines emphasize the importance of primary care physicians and those in obstetrics and gynecology to collaborate when keeping women informed as they make breast health decisions. Abstract: American Society of Breast Disease...
Trends in AF Among Hospitalized ACS Patients

Trends in AF Among Hospitalized ACS Patients

Among patients hospitalized with an acute coronary syndrome (ACS), overall rates of atrial fibrillation and associated mortality decreased between 2000 and 2007, according to a study from...

Resuming Blood Thinner Use After a GI Bleed

Among patients with a warfarin-associated index gastrointestinal (GI) bleeding event, the decision to not resume warfarin within 90 days appears to be associated with higher risks for thrombosis and mortality. A cohort study demonstrated that resuming warfarin did not significantly increase the risk for recurrent GI bleeding. Abstract: Archives of Internal Medicine, September 2012...

Emergency Medicine Info on the Web

A recent national survey reported that 60% of adults access health information online. Although the internet can be a helpful resource for many consumers, prior studies have suggested that the accessibility and accuracy of web-based health information are not always adequate. When patients can correctly identify risk factors and symptoms of potential medical emergencies, appropriate and timely medical care may be provided. Health information gathered from the internet may impact medical choices and outcomes. Improvements of Medical Info on the Internet In the November 2011 issue of Western Journal of Emergency Medicine, my colleagues and I published results from a study in which we sought to determine whether the completeness and accuracy of emergency medical information available online has improved over time. We evaluated medical content (descriptive information, completeness, and accuracy) on the top 15 healthcare information sites, as determined by internet traffic, for four common ED diagnoses: myocardial infarction, stroke, influenza, and febrile child. Online Exclusive: Table of Most Accurate Medical Websites According to our findings, the completeness and accuracy of online emergency medical information available to the general public has improved since 2002. Only two of 12 of the websites reviewed in 2002 boasted greater than 50% of aggregated medical information. In our study, 11 of 12 websites accomplished this feat. In addition, seven contained greater than 70% of aggregated medical information on the four common ED diagnoses we analyzed. None of the websites reviewed in 2008 contained questionable or dangerous information or recommendations, representing an improvement since 2002. Importantly, our analysis did not find a significant correlation between credentialing and completeness of website or credentialing and...

FDA Approves Osphena for Postmenopausal Women With Pain During Sex

The U.S. Food and Drug Administration today approved Osphena (ospemifene) to treat women experiencing moderate to severe dyspareunia (pain during sexual intercourse), a symptom of vulvar and vaginal atrophy due to menopause. Dyspareunia is a condition associated with declining levels of estrogen hormones during menopause. Less estrogen can make vaginal tissues thinner, drier and more fragile, resulting in pain during sexual intercourse. Osphena, a pill taken with food once daily, acts like estrogen on vaginal tissues to make them thicker and less fragile, resulting in a reduction in the amount of pain women experience with sexual intercourse. “Dyspareunia is among the problems most frequently reported by postmenopausal women,” said Victoria Kusiak, M.D., deputy director of the Office of Drug Evaluation III in the FDA’s Center for Drug Evaluation and Research. “Osphena provides an additional treatment option for women seeking relief.” Osphena’s safety and effectiveness were established in three clinical studies of 1,889 postmenopausal women with symptoms of vulvar and vaginal atrophy. Women were randomly assigned to receive Osphena or a placebo. After 12 weeks of treatment, results from the first two trials showed a statistically significant improvement of dyspareunia in Osphena-treated women compared with women receiving placebo. Results from the third study support Osphena’s long-term safety in treating dyspareunia. Osphena is being approved with a boxed warning alerting women and health care professionals that the drug, which acts like estrogen on vaginal tissues, has shown it can stimulate the lining of the uterus (endometrium) and cause it to thicken. In fertile women, this thickening of the endometrium occurs monthly before menstruation. Postmenopausal women no longer experience menstruation, and a...

When and How to Ask Your Doctor Questions

A patient wrote to me and asked when he should speak up and how to ask his doctor questions. I’m not sure I have all the answers. I hope some of my physician colleagues will comment. There is a fine and very fuzzy line between asking good questions and being a pain in the ass. And that line is drawn in different places by different doctors. It ranges from zero tolerance for questions (See Dr. Sung on the TV show “Monday Mornings,” who, when asked a question about a procedure he recommended, said, “Not do—dead.”) to the most open-minded, usually a primary care doc or psychiatrist. There are issues of time, urgency, the physician’s perception of the patient’s level of understanding, the complexity of the disease or operation, and many more. I had no problem with patients who researched their symptoms online. However, I would hate it when a patient brought a portfolio with 100 pages of downloaded material for me to comment on. There is a lot of garbage on the Internet. And speaking of online information, WebMD published a list of 18 questions that they suggest patients ask their doctors about proposed treatments. I can pretty much guarantee you that if you pull this list out, most doctors will not be too happy. Many of these questions should be part of any reasonable doctor’s explanation of informed consent or treatment before the subject of questions arises. I think you should always ask what your options are. Informed consent discussions should include the risks, benefits, and alternatives for any procedure. The doctor should tell you what the risks and...

FDA Approves Stivarga for Advanced Gastrointestinal Stromal Tumors

The U.S. Food and Drug Administration today expanded the approved use of Stivarga (regorafenib) to treat patients with advanced gastrointestinal stromal tumors (GIST) that cannot be surgically removed and no longer respond to other FDA-approved treatments for this disease. GIST is a tumor in which cancerous cells form in the tissues of the gastrointestinal tract, part of the body’s digestive system. According to the National Cancer Institute, an estimated 3,300 to 6,000 new cases of GIST occur yearly in the United States, most often in older adults. Stivarga, a multi-kinase inhibitor, blocks several enzymes that promote cancer growth. With this new approval, Stivarga is intended to be used in patients whose GIST cancer cannot be removed by surgery or has spread to other parts of the body (metastatic) and is no longer responding to Gleevec (imatinib) and Sutent (sunitinib), two other FDA-approved drugs to treat GIST. “Stivarga is the third drug approved by the FDA to treat gastrointestinal stromal tumors,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “It provides an important new treatment option for patients with GIST in which other approved drugs are no longer effective.” Stivarga was reviewed under the FDA’s priority review program, which provides an expedited six-month review for drugs that may provide safe and effective therapy when no satisfactory alternative therapy exists, or offer significant improvement compared to marketed products. The drug was also granted orphan product designation because it is intended to treat a rare disease. The safety and effectiveness of Stivarga for this use were evaluated in...

Kadcyla Approved for Late-Stage Breast Cancer

The U.S. Food and Drug Administration today approved Kadcyla (ado-trastuzumab emtansine), a new therapy for patients with HER2-positive, late-stage (metastatic) breast cancer. HER2 is a protein involved in normal cell growth. It is found in increased amounts on some types of cancer cells (HER2-positive), including some breast cancers. In these HER2-positive breast cancers, the increased amount of the HER2 protein contributes to cancer cell growth and survival. Kadcyla is intended for patients who were previously treated with trastuzumab, another anti-HER2 therapy, and taxanes, a class of chemotherapy drugs commonly used for the treatment of breast cancer. “Kadcyla is trastuzumab connected to a drug called DM1 that interferes with cancer cell growth,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “Kadcyla delivers the drug to the cancer site to shrink the tumor, slow disease progression and prolong survival. It is the fourth approved drug that targets the HER2 protein.” Referred to as T-DM1 during clinical research, Kadcyla was reviewed under the FDA’s priority review program, which provides for an expedited six-month review of drugs that may provide safe and effective therapy when no satisfactory alternative therapy exists, or offer significant improvement compared to marketed products. Other FDA-approved drugs used to treat HER2-positive breast cancer include trastuzumab (1998), lapatinib (2007) and pertuzumab (2012). The safety and effectiveness of Kadcyla were evaluated in a clinical study of 991 patients randomly assigned to receive Kadcyla or lapatinib plus capecitabine, another chemotherapy drug. Patients received treatment until either the cancer progressed or the side effects became intolerable. The study was...

America’s Best Hospitals in 2013

According to a new report released this week from Healthgrades, of the nation’s 50 top hospitals in terms of patient outcomes, 21 (42%) are in 7 Midwestern states. And of the nation’s top 20 cities with the lowest in-hospital mortality rates, 12 are in the Midwest – and none are on the West Coast or in New England. Healthgrades names its “America’s Best Hospitals” by reviewing the 262 institutions that comprise the Distinguished Hospitals for Clinical Excellence in 2013 (the top 5% of hospitals in the nation). To be eligible for the Healthgrades Distinguished Hospital Award for Clinical Excellence, a hospital had to have been evaluated for its performance in at least 19 of the 27 Healthgrades procedures and conditions, based on Medicare inpatient data, including sepsis, bowel obstruction, hip replacement, back and neck surgery, and carotid surgery. The 100 best hospitals, in Healthgrades’ methodology, represent the top 2% of hospitals in the nation, earning the Clinical Excellence award for at least 4 consecutive years. To earn a spot on the “America’s 50 Best Hospitals” list (representing the top 1% of the nation’s hospitals), an institution must earn the award for at least 7 consecutive years. Based on Healthgrades statistics and analysis, from 2009 to 2011, if all other hospitals performed at the level of America’s 100 Best Hospitals, 165,636 lives could have potentially been saved. View the full report, including the list of America’s 100 Best Hospitals in...

Surgical Approach & SSI Outcomes for Obese Patients

Across general abdominal surgical procedures among obese patients, laparoscopic surgery appears to reduce the risk of surgical site infections (SSIs) by 70% to 80%, when compared with open surgery. A meta-analysis of 44 studies found an odds ratio of 0.19 for SSIs after laparoscopic surgery when compared with open surgeries. Abstract: Annals of Surgery, December...

Volume & Costs of Inpatient Surgery in the Elderly

Volume-based referral policies do not appear to steer patients toward hospitals with high average costs for inpatient surgery in the elderly. A University of Michigan study found that the lowest-volume hospitals had considerably higher case-mix-adjusted episode payments for CABG and abdominal aortic aneurysm surgeries, but not for colectomy, when compared with the highest-volume hospitals. Abstract: Journal of the American College of Surgeons, December...

Immediate Reconstruction After Mastectomy

The rate of immediate reconstruction (IR) use for women with breast cancer who undergo mastectomy appears to have increased significantly between 2000 and 2010, according to a large analysis. Several modifiable factors strongly predicted IR use, including insurance status, hospital size, hospital location, and physician volume. Abstract: Breast Cancer Research and Treatment, November...

Fall Risks High for Those With HIV

Middle-aged patients infected with HIV appear to have a high risk for falls. A study found that multiple comorbidities, medications, and functional impairment were predictive of falls. Of 359 subjects, 250 persons (70%) reported no falls; 109 (30%) had one fall or more; and 66 (18%) were recurrent fallers. Researchers suggested that fall risks be assessed routinely as a part of care for those with HIV. Abstract: Journal of Acquired Immune Deficiency Syndromes, December 1,...

Inadequate Training in Concussion Management

Survey results of pediatric primary care and emergency medicine providers suggest that these physicians may not have adequate training or infrastructure to systematically diagnose and manage concussions despite regularly caring for these patients. The vast majority of respondents (91%) reported caring for at least one concussion in the previous 3 months, but 16% reported being inadequately trained to educate patients and families about the diagnosis. The investigators suggest that specific provider education, decision support tools, and patient information may improve and standardize concussion management. Abstract: Pediatrics, December...

Examining Causes of Dizziness in the ED

A nationwide study suggests that dizziness in the ED, although generally benign, appears to help clinicians indicate whether or not patients have serious neurologic disease. Dizziness was most often caused by peripheral vertigo (32%) or orthostatic hypotension (13%). Serious neurologic diagnoses were independently associated with: Age older than 60. Imbalance as the chief complaint. Any focal examination abnormality. Abstract: Mayo Clinic Proceedings, November...

Pain Management Update

We at Physician’s Weekly are proud to present this monograph on pain management. Created with the assistance of key opinion leaders and experts in the field, these features offer clinical and evidence-based information and news surrounding the management of pain, a condition that continues to be a leading cause of visits to hospitals, doctors, and providers across other healthcare settings. Physician’s Weekly will continue to feature pain management news in the coming...
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