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Early Management of Acute Ischemic Stroke

Early Management of Acute Ischemic Stroke

In 2013, the American Heart Association (AHA) and American Stroke Association (ASA) updated guidelines on the early management of acute ischemic stroke, representing the first update to these recommendations since 2007. Several substantial changes were incorporated into the new guidelines. The new document incorporates an AHA/ASA science advisory from 2009 that recommends the use of tissue plasminogen activator in appropriate patients who present to hospitals within 3.0 to 4.5 hours of symptom onset. It’s also recommended that door-to-needle times be less than 60 minutes for patients who are eligible for thrombolysis. The FDA approvals of the Trevo Retriever (Concentric Medical) system and Solitaire Flow Restoration (Covidien) device were significant new advances that were addressed in the guideline update. These devices are alternatives to coil retrievers and offer clinicians a new mechanical approach for restoring blood flow to occluded arteries. The updated AHA/ASA guidelines recommend that the Trevo Retriever system and Solitaire Flow Restoration device be the preferential choice when mechanical thrombectomy is pursued. Since 2007, several studies have focused on the use of decompressive surgery for malignant cerebral edema. These new data led to the recommendation that this approach be considered for acute ischemic stroke patients with large infarcts because of its potential life-saving capabilities and because it can restore a reasonable quality of life in appropriately selected patients. Implications for Emergency Medicine & Stroke Emergency physicians and nurses should be intimately integrated into the care of stroke patients. The AHA/ASA guideline recognizes that the saying “time is brain” is more critical than ever before. Timely, definitive care must be delivered in the ED. Emergency physicians need to be...
Guidelines for Managing Gout

Guidelines for Managing Gout

The incidence of physician-diagnosed gout has risen over the past 20 years and now affects about 8.3 million adults in the United States. Uric acid excess has been identified as the key contributor to gout. When hyperuricemia develops, crystals containing the salt of uric acid can form and deposit in joints, causing pain and swelling that can be debilitating for patients and adversely affect quality of life. Published research has indicated that gout may be attributed to excess uric acid promoted by several comorbidities, including hypertension, obesity, metabolic syndrome, type 2 diabetes, and extensive treatment with thiazide and loop diuretics for cardiovascular disease. Important New Guidelines on Gout To improve patient care, the American College of Rheumatology (ACR) published evidence-based guidelines for managing gout in Arthritis Care & Research. A U.S. expert task force was convened to develop two guidelines, the first focusing on systematic non-pharmacologic and pharmacologic therapeutic approaches to hyperuricemia, and the second covering therapies and prophylactic anti-inflammatory treatments for acute gouty arthritis. The guidelines provide recommendations based on medical literature spanning from the 1950s to the present. “These guidelines promote greater awareness of the need for urate control and the increasing burden and prevalence of gout,” says Robert A. Terkeltaub, MD, who was senior author on both ACR guidelines. “The intent is to educate physicians on effective ways to prevent gout attacks and provide them with recommendations for using therapies and diet and lifestyle measures for long-term care.” Hyperuricemia According to the guidelines, initial measures for treating gout should include patient education about the role of uric acid in the disease and non-pharmacologic approaches. “Patients should...

Whatever Happened to Robotic Thyroidectomy?

In case you missed it, there was a brief romance between thyroid surgeons and robots. Thyroid surgeons, itching to join the crowds migrating to robot-assisted surgery, came up with the idea to use the robot to perform thyroidectomies. It appears that the push began in Korea, and to add some pizzazz to the mix, a trans-axillary approach to avoid a scar in the neck was incorporated. As is often the case, the initial results were favorable. Then reality set in. The early euphoria gave way to the revelation that American patients were larger and more difficult to operate on than patients in Korea. But randomized trials of selected patients were suggested. A paper from Wayne State in Detroit found complications in 4 (22%) of 18 cases—3 episodes of temporary vocal cord paresis and a post-operative hematoma that required re-operation. Hospital stay was a median of 2 days. More than 90% of conventional thyroidectomy patients are done as same day surgeries. After receiving 13 reports of complications, Intuitive Surgical, the company that manufactures the robot, decided it could no longer support the use of its robot for thyroid surgery. At this point, a surgeon from the MD Anderson Cancer Center took the unprecedented step of publicly renouncing her previous stand on robotic-assisted thyroid surgery (RATS). In an editorial in the December 2012 issue of the journal Surgery, she said, “After performing nearly 40 RATS procedures, we came to the conclusion that the main benefit of RATS—translocation of the surgical incision to the axilla—did not offset the risks and liability of performing an operation that was not supported by the equipment...

2013 VEITHsymposium: Elastic Recoil Common With Angioplasty for CLI

The Particulars: Research indicates that restenosis is a common drawback of balloon angioplasty for treating infrapopliteal arterial obstructions in patients with critical limb ischemia (CLI). Two major mechanisms—elastic recoil and neointimal hyperplasia—that may lead to restenosis after balloon angioplasty are not well understood. Data Breakdown: Swiss investigators conducted a study to assess the extent of early recoil in patients with CLI who underwent tibial arterial balloon angioplasty. Elastic recoil was found in 96.7% of lesions, with a mean luminal compromise of 29.4%. Take Home Pearls: Early recoil appears to occur relatively frequently in patients with CLI who undergo tibial balloon angioplastly and may significantly contribute to restenosis. These findings support the use of dedicated mechanical scaffolding approaches to prevent restenosis in tibial...
Cardiovascular Disease & Diabetes

Cardiovascular Disease & Diabetes

According to the American Diabetes Association, cardiovascular disease (CVD) is the major cause of morbidity and mortality for people living with diabetes. “The common conditions that coexist with type 2 diabetes, such as hypertension and dyslipidemia, are clearly risk factors for CVD,” explains Robert H. Eckel, MD. “Diabetes itself confers additional risk for CVD, including coronary heart disease, stroke, peripheral vascular disease, and heart failure. Obesity, metabolic syndrome, and inflammation are other key components to the link between diabetes and CVD.” “Large benefits are seen when multiple CVD risk factors are addressed globally.” Published analyses have shown that controlling individual CVD risk factors helps to prevent or slow CVD in people with diabetes. “Large benefits are seen when multiple CVD risk factors are addressed globally,” says Dr. Eckel. “Clinical trials have shown that lowering glucose aggressively can further help reduce CVD risk, but an individualized approach is necessary for most patients with diabetes.” Individualizing Care for Diabetes The American Diabetes Association recommends an A1C of less than 7% for most patients, but Dr. Eckel notes that A1C goals may differ from patient to patient, depending on their individual characteristics (Table 1). “There are several aspects to consider when selecting a target A1C level, including age, duration of diabetes, the extent of diabetes complications, psychosocial support, physical activity limitations, and risks of hypoglycemia. All of these factors—and other cardiometabolic components—will play a role in guiding how aggressively diabetes should be treated.” Blood Pressure & Cholesterol In addition to glycemic control, the management of blood pressure and cholesterol is important to helping prevent or slow CVD in patients with diabetes (Table...

2013 VEITHsymposium: Mechanical Thrombectomy in Hemodialysis Access Occlusions

The Particulars: Data are lacking on the safety and efficacy of using the AngioJet mechanical thrombectomy system (Bayer HealthCare) for treating occluded arteries and veins in hemodialysis patients. Data Breakdown: For a prospective, multi-center registry study, researchers recorded patient history, adjunctive treatment, outcomes, and adverse events in hemodialysis patients with occluded arteries who were treated with the AngioJet catheter. Adjunctive therapies included lytic delivery by the AngioJet (13%), stenting (41%), and balloon angioplasty (88%). Full patency was achieved in 89% of cases and remained at 78% when measured at 91 days. Initial hospitalization adverse events were rare. The graft failure rate was 4%. Take Home Pearl: Mechanical thrombectomy, when combined with adjunctive treatments, appears to be a safe and effective strategy for treatment hemodialysis access...

2013 VEITHsymposium: Treating CCSVI in Patients With Multiple Sclerosis

The Particulars: Previous research indicates that multiple sclerosis (MS) is associated with chronic cerebrospinal venous insufficiency (CCSVI). Data indicate that 30,000 patients worldwide have undergone endovascular procedures to treat CCSVI since 2009. However, the safety and efficacy of these procedures has not been established in clinical trials. Data Breakdown: In a prospective, double-blind, randomized controlled trial, researchers investigated the safety and efficacy of percutaneous transluminal venous angioplasty (PTVA) for correcting CCSVI in patients with MS. PTVA was safe and not associated with serious adverse events in the trial. However, no differences were observed in clinical symptoms, brain lesions, or quality of life between patients with MS who underwent the treatment and those who did not. Take Home Pearls: PTVA for correcting CCSVI in patients with MS appears to be safe. However, use of the treatment does not appear to provide sustained...

2013 VEITHsymposium: IVC Filter Use in PEVI

The Particulars: Studies have had varied results on the safety and validity of inferior vena cava (IVC) filter use to prevent iatrogenic pulmonary embolism (PE) that can result from percutaneous endovenous interventions (PEVI) for lower extremity DVT. Data Breakdown: For a study, patients undergoing PEVI for lower extremity DVT were randomized to receive an inferior vena cava filter or did not receive a filter. New PE was detected in 1.4% of patients in the filter group, compared with an 11.3% rate for the no filter group. Filter removal was performed in about one-third of patients at an average of 180 days, with zero complications. Take Home Pearl: Use of IVC filters among patient undergoing PEVI for lower extremity DVT appears to lead to a significant reduction in the development of iatrogenic...

2013 VEITHsymposium: Vascular Graft Enables Early Cannulation

The Particulars: In hemodialysis patients, early cannulation has been shown to reduce the number of days for which central venous catheters are required, thereby potentially reducing mortality and morbidity. Research is lacking on whether the novel Gore Acuseal vascular graft (W.L. Gore & Associates, Inc.) allows for early cannulation. Data Breakdown: The cumulative patency of the Gore Acuseal vascular graft was studied in a prospective, non-randomized, multi-center trial. The graft had a 6-month patency of 84%, compared with a 75% patency rate that was seen in a historical control group. Within 28 days of graft implantation, about 76% of grafts were successfully cannulated three consecutive times, allowing for the central venous catheter to potentially be removed. Take Home Pearl: The Gore Acuseal vascular graft appears to allow for early cannulation in hemodialysis patients without reducing graft...

2013 VEITHsymposium: A Novel Approach to Submassive Pulmonary Embolism

The Particulars: Research indicates that patients with submassive pulmonary embolism (PE)—unlike those with massive PE—are typically managed conservatively despite right ventricular (RV) dysfunction that could result in poor outcomes if unresolved. Ultrasound-accelerate thrombolysis (USAT) may represent a safe, more aggressive treatment approach for patients with both massive and submassive PE. Data Breakdown: A retrospective evaluation was conducted in seven patients with massive PE and another 50 patients with submassive PE who were treated with USAT. The authors found that the right-ventricle-to-left-ventricle diameter (RV/LV) ratio was reduced from 1.5 at baseline to 1.0 at 48 hours follow-up. Data from 30-day follow-up found that the RV/LV ratio in six patients was further reduced to a range of 0.6 to 0.9. For USAT recipients, the average length of stay was 1 day in the ICU and 7 days in the hospital. No in-hospital mortalities were observed in the study. Take Home Pearls: Patients with both massive and submassive PE who undergo USAT appear to achieve rapid resolution of RV dysfunction. This resolution appears to continue to improve with...

2013 VEITHsymposium: Chimney Stents for TEVAR

The Particulars: Thoracic endovascular aortic repair (TEVAR) has emerged as an acceptable treatment for thoracic aortic diseases and typically involves a hybrid approach. Singular approaches—including the use of a parallel graft, or chimney, to revascularize target vessels—are used in emergencies and other select cases. Use of chimney grafts in elective procedures has not been well documented. Data Breakdown: Italian researchers used chimney stents in patients with aortic arch tear, type B aortic dissection, a type 1 endoleak from a previous TEVAR, and penetrating aortic ulcer. Emergency treatment was provided to about one-quarter of patients. Technical success was achieved in 100% of cases, with no endoleaks. Chimney stents were associated with a perioperative mortality rate of 3.8%, and supra-aortic vessel patency was obtained in all patients. Both mortality and chimney graft complication rates were 15.4%. During an average 36.8 months follow-up, 23% of patients developed type 1 endoleaks. Take Home Pearl: The chimney technique for aortic arch pathologies appears to be relatively safe and feasible in patients who are at high risk for surgery or who are ineligible for conventional...
2013 VEITHsymposium

2013 VEITHsymposium

The 2013 VEITHsymposium, the 40th Annual Symposium on Vascular and Endovascular Issues, was held Nov. 19-23 in New York City. Why You Should Attend VEITHsymposium   Meeting Highlights Chimney Stents for TEVAR A Novel Approach to Submassive Pulmonary Embolism Vascular Graft Enables Early Cannulation IVC Filter Use in PEVI Treating CCSVI in Patients With Multiple Sclerosis Mechanical Thrombectomy in Hemodialysis Access Occlusions Elastic Recoil Common With Angioplasty for CLI   More From the Meeting General Information Register Program Faculty CME Certificates 2012 Online Library...
Washington, We Have a Problem

Washington, We Have a Problem

People come to me for answers, and my profession pitches doctors as the ones with answers.  We fix problems. This, of course, is not true—a fact that I have come to see as a core problem in the practice of medicine in America, and a reality that (as everything seems to do) comes largely from the way we pay for medicine.  We are paid to fix problems.  How do we fix problems?  With procedures. The best evidence for this are the things at the heart of healthcare: codes.   There are three types of codes that dominate the financial and clinical lives of anyone in healthcare: ICD codes – Codes for medical problems CPT codes – Codes for medical procedures E/M codes – Codes used by doctors who don’t do procedures so they can get paid for office visits. What this encourages from the medical profession is predictable: lots of problems treated by lots of procedures.  This is good for doctors who do procedures, especially ones that are cutting-edge (like robotic surgery) or ones that seem particularly dramatic and/or heroic (open heart surgery, heart stents).  These are the things the headline consuming public is most hungry for.  Just like it grabs more headlines to catch a terrorist plot just before it has its horrible effect than to prevent it early in the process, it’s a lot sexier to do a procedure to treat heart disease than to simply prevent the disease in the first place.  Which is the better outcome?  Preventing heart disease.  Which is paid more?  Not even close. The Problem with Problems A more subtle (and perhaps...
Oncologist Compensation Report 2013

Oncologist Compensation Report 2013

Nearly 22,000 physicians across 25 specialty areas participated in Medscape’s third physician compensation report.  Data collected among oncologists surveyed found that oncology was the 10th highest ranked specialty, with a mean income of $278,000 (click here to view the average income by specialty). Orthopedics ($405,000), Cardiology ($357,000), Radiology ($349,000), Gastroenterology ($342,000), Urology ($340,000), Anesthesiology ($337,000), Plastic Surgery ($317,000), Dermatology ($306,000), and General Surgery ($279,000) ranked above Oncology. Ten percent of oncologists earn $500,000 per year or more, and 14% earn $100,000 per year or less. From 2011-2012, 46% of oncologists said that their compensation remained the same. Oncologists in the Southwest earn the highest compensation ($347,000), compared to the Northeast, which earns the lowest compensation ($230,000): Source: Medscape Other highlights from Medscape’s report include the following: A significant pay gap continues to exist between full-time male and female physicians. Men earned $293,000 on average, compared to $240,000 for women. 51% of oncologists feel fairly compensated 51% of oncologists would choose medicine as a career if they had to do it all over, while 57% would choose the same specialty. The largest percentage of oncologists (25%) spends 30 to 40 hours per week seeing patients. 25% of oncologists see between 25 and 49 patients per week, and 26% of oncologists see between 50 and 75 patients per week. Due to the nature of the specialty, oncologists spend a considerable amount of time with each patient: 32% spend a mean of 17-20 minutes with each patient, and 27% see patients 21 minutes or longer. 32% of oncologists spend 10-14 hours a week on paperwork and administrative activity (24% spend 5 to 9...

AHA 2013: Trends in PCI Complications

The Particulars: PCI-related technology has advanced significantly in recent years. However, current data on PCI-related complications is lacking. Data Breakdown: For a study, investigators analyzed data from more than 2 million procedures in adults who underwent PCI between 2005 and 2010. The overall complication rate for PCI was 7.4% during the study period, with a 1.2% in-hospital mortality rate. The most common complications were: Complication Rate Vascular issues 2.0% Cardiac issues 1.8% Respiratory failure 1.6% Postoperative stroke 1.1% Infectious issues 0.7% Postoperative DVT 0.4% Renal/metabolic issues 0.2% Take Home Pearls: The rate of PCI-related complications appears to be low. The most common complications after PCI appear to be cardiac and vascular in...

AHA 2013: Comparing Stroke Outcomes After Different Catheterization Techniques

The Particulars: In previous studies, transradial (TR) catheterization has been shown to have a lower risk of bleeding and access site complications when compared with transfemoral (TF) catheterization. TR catheterization has also been shown to improve patient comfort and cost less than TF catheterization. However, experts are concerned that the TR approach may have an increased risk of neurological complications. Data Breakdown: Researchers conducted a meta-analysis of 13 studies containing stroke risk data on more than 11,000 patients who underwent TR or TF catheterization. The analysis found no difference in stroke rates between the two catheterization methods. The findings were also consistent in several sensitivity analyses. Take Home Pearl: The risk of stroke appears to be similar following both TF and TR catheterization...

AHA 2013: CABG Vs PCI in Diabetics

The Particulars: Data from studies comparing CABG to PCI has been inconsistent when assessing these procedures in patients with diabetes and multivessel coronary artery disease (CAD). Little is known about the effect of these procedures in the era of drug-eluting stents. Data Breakdown: Canadian researchers reviewed data from eight trials comparing PCI and CABG in patients with diabetes and stable CAD. Mortality rates were similar at 1 year for both CABG and PCI. However, the mortality rate was lower for CABG patients at 5 years (relative risk, 0.67) when compared with PCI patients. Repeat revascularization rates were lower for CABG at 1 and 5 years than for PCI. However, rates of stroke were higher with CABG than with PCI at both 1 and 5 years. Overall results were similar among trials using bare-metal stents and drug-eluting stents. Take Home Pearls: Among patients with diabetes and CAD, CABG appears to have about a 35% lower mortality rate and 60% lower rate of repeat revascularization when compared with PCI. However, the rate of stroke with CABG appears to be twice as high as the rate with PCI in diabetes with...

AHA 2013: Program Improves QOL in STEMI Patients

The Particulars: Current guidelines recommend that regional systems be implemented to optimize reperfusion for patients with ST segment elevation myocardial infarction (STEMI). This treatment, however, is often delayed or not provided. A comprehensive systems-of-care program may improve quality of life (QOL) in patients with STEMI. Data Breakdown: The American Heart Association recently launched “Mission: Lifeline,” a national STEMI systems-of-care program that defines and promotes ideal elements for regional STEMI care. Among patients registered with the program, several domains improved significantly between 2008 and 2012, including: Primary PCI and pre-hospital ECG use. Time from first medical contact. Time from first door to primary PCI. During the study period, the rate of eligible patients who were not reperfused decreased by half. Mortality also decreased over time. Take Home Pearls: The AHA’s “Mission: Lifeline” STEMI systems-of-care program appears to significantly improve QOL in STEMI patients. The initiative also appears to increase the use of...

AHA 2013: Telemonitoring Reduces Heart Failure-Related Readmissions

The Particulars: Some studies suggest that the 30-day readmission rate for patients with heart failure (HF) is as high as 25%. Excess HF readmissions now come with financial penalties from CMS. A nurse-based home telemonitoring program may be a cost-effective approach to reducing readmission rates among HF patients. Data Breakdown: For a study, HF patients were randomized to usual care or a telemonitoring program that consisted to two home visits by a nurse. The home visits focused on HF education and used home telemonitoring equipment. The equipment transmitted daily vital signs, weight, and pulse oximetry readings for 3 months. The All-cause readmission rate was 12.5% for the telemonitoring group, compared with a 27.5% rate observed in the usual care group. Respective HF 30-day readmission rates were 2.5% for those receiving telemonitoring and 10% for those receiving usual care. The telemonitoring program costs about $51,000, which is less expensive than the estimated $183,500 that comes with CMS penalties for excess HF readmissions in 2013. Take Home Pearls: Home telemonitoring appears to significantly reduce 30-day readmission rates for patients with HF. The program also appears to be cost-effective when compared with usual...
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