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Sanjay Gupta’s “WEED” Documentary

Sanjay Gupta’s “WEED” Documentary

CNN’s Dr. Sanjay Gupta’s documentary on weed. How Dr. Sanjay Gupta changed his view on medical marijuana. (CNN) — Over the last year, I have been working on a new documentary called “Weed.” The title “Weed” may sound cavalier, but the content is not. I traveled around the world to interview medical leaders, experts, growers and patients. I spoke candidly to them, asking tough questions. What I found was stunning. Long before I began this project, I had steadily reviewed the scientific literature on medical marijuana from the United States and thought it was fairly unimpressive. Reading these papers five years ago, it was hard to make a case for medicinal marijuana. I even wrote about this in a TIME magazine article, back in 2009, titled “Why I would Vote No on Pot.” Well, I am here to apologize. I apologize because I didn’t look hard enough, until now. I didn’t look far enough. I didn’t review papers from smaller labs in other countries doing some remarkable research, and I was too dismissive of the loud chorus of legitimate patients whose symptoms improved on cannabis. Instead, I lumped them with the high-visibility malingerers, just looking to get high. I mistakenly believed the Drug Enforcement Agency listed marijuana as a schedule 1 substance because of sound scientific proof. Surely, they must have quality reasoning as to why marijuana is in the category of the most dangerous drugs that have “no accepted medicinal use and a high potential for abuse.” They didn’t have the science to support that claim, and I now know that when it comes to marijuana neither of...
Updated Guidelines for HIV Care

Updated Guidelines for HIV Care

According to the CDC, nearly 1.2 million Ameri-cans are living with HIV and about 50,000 people in the United States are infected with the virus each year. Studies have estimated that as many as 80% of patients with HIV have their virus under control and live long, full lives. “With HIV continuing to become a manageable but complex chronic disease, HIV specialists and primary care physicians (PCPs) now need to provide the full spectrum of healthcare to these patients,” says Michael A. Horberg, MD, MAS, FACP, FIDSA. “PCPs and other healthcare providers need a better grasp of the impact that HIV care has on routine healthcare.” A Helpful Update In 2009, an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America (IDSA) released evidence-based guidelines for the management of people infected with HIV. Recently, these guidelines were updated to replace the 2009 recommendations and published in Clinical Infectious Diseases. Since 2009, new antiretroviral drugs and classes have become available, and the prognosis of people with HIV infection continues to improve. The guideline update also incorporates new information based on publications from 2009 to 2013. “The updated IDSA guidelines are intended for use by healthcare providers who care for HIV-infected patients,” says Dr. Horberg, who was on the expert panel that developed the update. “These new recommendations reflect the fact that people with HIV are now living much more normal life spans. As such, there is a greater need to focus on preventive care, including screening for high cholesterol, diabetes, osteoporosis, depression, and substance abuse, among other health conditions.” Although there are better survival rates,...
Making the Case for More Specialist Training

Making the Case for More Specialist Training

Experts have reported that population growth among the elderly and the increasing prevalence of chronic diseases in these older Americans will have profound implications for the United States healthcare system in the coming decades. An estimated 89 million Americans will be 65 and older by 2050, a figure that is more than double the current population for this age group. In addition, more than 90% of elderly Americans report having one or more chronic diseases. “This trend is likely to continue,” says Timothy M. Dall, MS. “It will be challenging for the medical community to overcome the combination of increased longevity and high rates of chronic diseases like hypertension, diabetes, and obesity.” Primary care physicians (PCPs) play an important role in providing preventive services and caring for the elderly population, but recent data suggest that the need for specialist care is also likely to increase as medical knowledge and treatment options continue to advance. “Specialists play essential roles in diagnosing, treating, and monitoring patients with various health problems,” says Dall. “Understanding the needs and demand for both primary care and specialist services can help inform decisions about the number and mix of healthcare providers that the U.S. will need to train so that care is accessible, of high quality, and affordable.” Forecasting the Future In a study published in Health Affairs, Dall and colleagues forecasted future demand for healthcare services and providers. This forecast was based on projected changes in demographic characteristics and other predictors of healthcare use as well as the estimated impact of expanded medical coverage under the Affordable Care Act. According to the analysis, growth and...
CROI 2014

CROI 2014

New research is being presented at CROI 2014, the annual Conference on Retroviruses and Opportunistic Infections, from March 3 to 6, in Boston. Conference Highlights Relocating After an HIV Diagnosis Mitigating Neuronal Injury in HIV Combination Therapy May Eradicate HCV Success With ED Opt-Out HIV Testing The Cancer Burden in HIV   News From the Meeting Trial Bodes Well for Long-Acting HIV Drugs Raltegravir Combo Gives New Anti-HIV Alternative HIV Drug Linked to Low Bone Density in Babies Researchers Report Treatment Clears HIV in Second Baby Interventions to Reduce HIV Missing Some Drug Users Long-Acting HIV Drug Eyed as Prevention HIV Tx Tied to Low Infection From Sex New Advances for HIV Prevention on the Horizon HCV Drug Combo Has Near-Perfect Response Rate All-Oral HCV Regimen Works in 9 Out of 10 HIV No Bar to HCV Therapy With New Agents TB, HCV in Spotlight Along With HIV   More From the Meeting General Information About CROI Electronic Materials Registration & Housing Important Dates Schedule of Events Agenda Abstracts CME Information Venue Information Frequently Asked Questions  ...

The Ongoing Decline of Resident Education

A paper from Johns Hopkins looked at traditional, every fourth night calls compared to reduced-hours interns working staggered shifts of an every fifth night call or “night float.” “Night float” means working a shift that begins in the evening and ends in the morning, typically 8:00 PM to 8:00 AM. The study found that although interns working on the “night float” or every fifth night shifts got significantly more sleep than the control group of interns working longer shifts every fourth night, “both the every fifth night and night float models increased hand-offs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with night float that it was terminated early.” [Emphasis added] A JAMA Surgery paper received far less attention but had a similar theme. It surveyed 213 surgical interns from 11 university hospitals in July 2011 and May 2012 (the first academic year that the new 16-hour limit was in force). Although 82% of the interns reported a neutral or good quality of life, more than one-quarter had symptoms of emotional exhaustion and depersonalization, and 32% said their work-life balance was poor. Two-thirds said they thought about their satisfaction with being a surgeon daily or weekly, and 14% said they considered dropping out of surgery training at least weekly. More than half of the residents said that the work-hour changes had decreased their time spent in the operating room. At the end of their intern year, 44% said they did not believe that the work-hour limits led to reduced...
Reducing Risks of Foot Complications in Diabetes

Reducing Risks of Foot Complications in Diabetes

Foot complications such as amputation and foot ulceration are common consequences of diabetic neuropathy and peripheral arterial disease (PAD). These complications have been identified as major causes of morbidity and disability in people with diabetes. “Early recognition and management of risk factors for foot complications is critical,” says Paul J. Kim, DPM, MS. “Efforts to identify and treat these complications early in the disease course can prevent or delay adverse outcomes.” The American Diabetes Association notes that the risk of foot ulcers or amputations is increased in people who have various risk factors. “Neuropathy, peripheral vascular disease, and foot deformities are the most important risk factors for foot complications,” says Dr. Kim. “Poor blood glucose control is the trigger for the cascade for these complications.” Helpful Exams A range of tests might be useful when identifying patients at risk for foot ulceration, but this has created some confusion among practitioners as to which screening tests should be adopted in clinical practice. To clear this confusion, the American Diabetes Association has issued several recommendations on what should be included in comprehensive foot exams for adults with diabetes in its annual Standards of Medical Care in Diabetes (Table 1). All adults with diabetes are recommended to undergo a comprehensive foot examination to identify high-risk conditions at least once a year. During these exams, clinicians should ask patients about their history of previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, tobacco use, and foot care practices. A general inspection of skin integrity and musculoskeletal deformities should also be performed. Neurologic exams are designed to identify loss of protective...
Managing Painful Diabetic Neuropathy

Managing Painful Diabetic Neuropathy

Diabetic peripheral neuropathy (DPN) is one of the most common complications associated with diabetes. Recent esti­mates show that DPN affects approximately 50% of people with diabetes in the United States. Painful diabetic neuropathy (PDN) has been defined as the clinical scenario in which neuropathic pain arises as a direct consequence of DPN. About 25% of people with diabetes will get PDN. Current Options Several prescription medications are available for DPN and may provide a degree of pain relief, but these agents can potentially cause side effects. Another option for PDN is transcutaneous electrical nerve stimulation (TENS). With TENS, low-voltage electrical currents are delivered directly to the area of pain or at pressure points. Clinical studies assessing the efficacy of TENS have shown encouraging results for pain relief. Unfortunately, traditional TENS systems consist of general purpose devices with cables and electrodes that are often not compatible with an active lifestyle. A Simple, Convenient Therapy The Sensus Pain Management System (developed by NeuroMetrix, Inc.) was cleared by the FDA for use by patients suffering from chronic pain, including PDN. The system is a lightweight, self-contained TENS device that is configured to patients’ unique physiology. In contrast to general purpose TENS, Sensus is simple and convenient. It’s worn discretely under clothing below the knee and without wires or complex controls. Patients initiate a 60-minute therapy session with the push of a button. Pain relief typically begins within 15 minutes and often lasts for 30 minutes following the session. In addition, Sensus is the only TENS device cleared by the FDA for use during sleep. The device provides a continuous mode delivering a...
Cannonball

Cannonball

“Yep, a classic case of being shot with a cartoon...
H. Pylori Testing & Uninvestigated Dyspepsia

H. Pylori Testing & Uninvestigated Dyspepsia

Gastritis, dyspepsia, and peptic ulcer disease are common causes of abdominal pain that may be caused by Helicobacter pylori infection. When people with peptic ulcers have H. pylori infections, antibiotic treatment can help speed the initial healing of some ulcers and may prevent ulcers from returning. Testing for H. pylori infection is uncommon in EDs in the United States despite abdominal pain being one of the most common complaints in ED visits. Test & Treat In general, a “test and treat” strategy is recommended for patients with uninvestigated dyspepsia who do not have “red flags” for cancer. Successful identification of infection in the ED and initiation of antibiotic treatment may reduce future risk of gastritis, gastric lymphoma, and gastric cancer. This approach may also be cost-effective by reducing future healthcare costs and symptom severity. Why Test? In my opinion, there are a few reasons why testing and treating for H. pylori infection should not be performed in ED patients who have uninvestigated dyspepsia and do not have red flags for more serious disease. First, testing can occur at the bedside with almost real-time results. Second, a positive test leads to an immediate change in how patients are managed. Third, treatment of H. pylori infection may have beneficial downstream effects on healthcare utilization. These include decreases in: • Long-term proton pump inhibitor use. • Inappropriate use of endoscopy. • Future doctor visits. In our ED at George Washington University, the prevalence of H. pylori infection is roughly 25% in symptomatic patients. Using a test and treat approach, we have anecdotally observed a high degree of physician and patient satisfaction. How...
Understanding Cannabinoid Designer Drugs

Understanding Cannabinoid Designer Drugs

Over the last few years, research has shown that abuse of synthetic drugs is becoming more common throughout the country. In response to this, the United States Drug Enforcement Agency has listed an increasing number of synthetic cannabinoids (SC) as Schedule 1 substances, and Congress has passed the Synthetic Drug Abuse Prevention Act. “SC products have received substantial media attention for being sold as legal highs,” explains Patrick M. Lank, MD. Common SCs include “Spice” and “K2,” and these drugs are often packaged as incense. Tough Spot for EDs Complications from SC use have led to an increase in hospital visits, particularly for EDs. “The initial growth of SC use in the U.S. was sparked by reports that they had effects similar to marijuana,” says Dr. Lank. “An added advantage was that they were thought to be undetectable on routine urine drug screens and were widely available by legal public consumer means. We have learned over time that the clinical effects of SCs are quite different from those caused by smoking marijuana.” There is growing concern for the potential of long-term immunologic, neurologic, and psychiatric complications with SC use, specifically in adolescents. Dr. Lank says emergency physicians (EPs) are in a particularly difficult position as the use of new synthetic drugs increases in popularity. “EPs often must treat patients who abuse SCs despite having relatively little knowledge of these substances,” he says. “Considering the increasing popularity of SCs, it’s important to assess EP knowledge of these designer drugs and explore ways to optimize care for patients presenting to EDs after exposure to these drugs.” New Data & Insights In...
Going Straight to PCI for Patients With STEMI

Going Straight to PCI for Patients With STEMI

Research indicates that mortality and morbidity can be reduced in patients with STEMI when they have faster times to reperfusion. Guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) recommend that PCI devices be activated within 90 minutes of first medical contact in this patient group. Although the adoption of various strategies has led to significant improvements in national reperfusion metrics, research suggests that the ACC/AHA guideline-recommended goals have yet to be systematically achieved. Other studies indicate that delays with triage and ED evaluation may contribute to the inability to achieve timely reperfusion. Adopting a New Approach As an interventional cardiologist in Canada, Akshay Bagai, MD, MHS, worked in a hospital cath lab where patients with pre-hospital electrocardiograms (ECGs) showing that they had STEMI were routinely brought directly to the lab by emergency medical services (EMS). “We found that we were saving time by bypassing the ED,” he explains. When Dr. Bagai learned that this practice was not endorsed in the United States, he and his colleagues sought to study the approach further. In an analysis published in Circulation: Cardiovascular Interventions, Dr. Bagai and colleagues reviewed data from the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project, a program among North Carolina hospitals that collaborated to develop a coordinated, regional system to care for STEMI patients. From 21 of these hospitals, they studied 1,687 patients with pre-hospital STEMI who had been transported via EMS for primary PCI and were either evaluated in the ED or taken directly to the cath lab. Key Findings The median time from first medical contact to reperfusion...
How Nurse Burnout Affects Hospital-Acquired Infections

How Nurse Burnout Affects Hospital-Acquired Infections

Previous research has linked invasive devices and clinical practice to hospital-acquired infections (HAIs). There is now evidence suggesting that elements of nursing care are also linked to the prevalence of HAIs. Few studies have rigorously examined the possible underlying mechanisms of the relationship between nurse staffing and HAIs. In the American Journal of Infection Control, my colleagues and I had a study published that assessed job-related burnout among registered nurses to determine its accountability for the relationship between nurse staffing and infections acquired during hospital stays. Burnout Affects Infection Rate Our findings show that job-related burnout among nurses appears to be a plausible explanation for some HAIs. Nurses had an average total of 17 years experience, caring for an average of about six patients. Almost 37% reported high levels of burnout. At the hospitals involved in the study, 16 of 1,000 patients acquired some type of infection, particularly urinary tract infections (UTIs), surgical site infections (SSIs), and gastrointestinal infections, as well as pneumonia. For modeling and further analysis, we limited the types of infection to UTIs and SSIs. As patient loads escalated, the number of UTIs and SSIs increased significantly. In additional modeling, nurse burnout was highly associated with these infections, a finding that hasn’t been reported in previous research. A 10% increase in a hospital’s composition of high-burnout nurses was linked to an increase of nearly one UTI and two SSIs per 1,000 patients. Perhaps the most important finding from our model was that reducing nurse burnout by 30% could prevent more than 4,000 UTIs and more than 2,200 SSIs each year and save up to $69 million...

Controversy Over BMJ Paper Hints at Print Medical Journal Demise

By now, you must be aware of the Canadian mammography study that appeared in the BMJ last week. It found that “Annual [screening] mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available.” And there was an associated risk of overdiagnosis. It was a randomized prospective trial involving almost 90,000 women over a 25-year period. The full text is here. Just about everyone, supporter or critic, has weighed in with an opinion about the paper. Here’s a different take. Earlier this month, I gave a talk at the Academic Surgical Congress in San Diego. The subject was “Social Media and Innovation in Surgery.” In it, I speculated about the probable demise of the traditional printed medical journal. I cited some experts who have deplored the current method of peer review of papers. I suggested that because of its immediacy, online peer review would emerge as the standard. While you might not think of the BMJ as social media, it does have an online rapid response system allowing letters to the editor to be published immediately, eliminating the usual delay of several months. If you look at the rapid responses, you will note that there are two major criticisms of the mammography study. One is that the mammography machines used were possibly not of the highest quality. Others have said that any study that lasts as long as the Canadian study will be subject to criticism about technology or techniques. If that disqualifies this study, then there is no point in...
Stop Leaving Women’s Health to Chance

Stop Leaving Women’s Health to Chance

Every cell in the human body has a sex, which means that men and women are different right down to the cellular level. Yet too often, research and medicine ignore this insight — and the often startlingly different ways in which the two sexes respond to disease or treatment. As pioneering doctor Paula Johnson describes in this thought-provoking talk, lumping everyone in together means we essentially leave women’s health to chance. It’s time to rethink. Source:...

ISC 2014: Improving Stroke Treatment Times & Outcomes

The Particulars: Prior research suggests that less than 30% of acute ischemic stroke patients meet the door-to-needle time (DTN) goal of 60 minutes or less, as recommended in guidelines. The national initiative Target: Stroke was launched in 2010 to increase the number of patients who meet this goal. Data Breakdown: The Target: Stroke initiative included the identification and dissemination of 10 best practice strategies associated with fast DTN times as well as clinical decision support tools. The program also facilitated hospital participation, implementation of effective strategies, and sharing of best practices. Annual DTN times in acute ischemic stroke patients before the program (2003-2009) were compared with DTN times after program initiation (2010-2013). The average DTN time decreased from 77 minutes prior to the program to 67 minutes after it was initiated. The rate of patients with DTN times of 60 minutes or less increased from 29.6% to 54.2%. Take Home Pearl: Hospitals that implement the Target: Stroke initiative appear to substantially improve DTN times in acute ischemic stroke...

ISC 2014: Few Stroke Patients Receive Recommended Treatment

The Particulars: Guidelines recommend that tPA be administered intravenously within 3 to 4 hours of the onset of stroke symptoms to reduce disability. They also recommend that endovascular therapy be utilized when appropriate to reopen clogged arteries. Little is known about the percentage of patients who receive these recommended treatments. Data Breakdown: Investigators reviewed 370,000 Medicare stroke claims from 2011. The study team found that 81% of patients had access (within an hour’s drive) to a hospital capable of administering tPA whereas 61% had access to a primary stroke center and 56% had access to a hospital capable of performing endovascular therapy. However, only 4% of patients received tPA within 3 to 4 hours of symptom onset, and less than 1% underwent endovascular therapy. Take Home Pearl: Many patients appear to live within an hour’s drive of a hospital equipped to treat acute stroke, but very few receive guideline-recommended treatments for...

ISC 2014: Treating Stroke With Uric Acid

The Particulars: Some studies have suggested that uric acid may be neuro-protective in brain ischemia. Research has yet to determine if this endogenous antioxidant molecule can improve functional outcomes in patients with ischemic stroke. Data Breakdown: For a study, acute ischemic stroke patients were treated with alteplase within 4.5 hours of symptoms onset. Patients were randomized to placebo or uric acid. Among those who received uric acid, nearly 40% were relatively free of disability at 90 days, compared with 33% of patients who received placebo. Uric acid was especially beneficial for women, patients with high blood sugar levels, and those with moderate stroke. Take Home Pearls: When combined with standard clot-busting medication, uric acid appears to reduce stroke-related disability. This treatment may be particularly effective in women and those with moderate stroke or high blood sugar...
Decision-Making Preferences After AMI

Decision-Making Preferences After AMI

In recent years, experts have called for greater partici­pation by patients in medical decision-making processes, but research suggests that shared decision making is not yet routinely incorporated into medical care. “In some cases, there may be a perception among patients that they need to defer decision making to their physicians,” says Harlan M. Krumholz, MD, SM. “This is certainly the sense by many cardiologists about patients hospitalized with an acute myocardial infarction (AMI).” Surveying the Scene To further investigate decision-making preferences among patients, Dr. Krumholz and colleagues conducted a study using combined data from two similar AMI registries. Published in JAMA Internal Medicine, the study group asked patients to indicate who they felt should make decisions on treatment options in AMI after they are given information about the risks and benefits of the possible treatments.   More than two-thirds of patients reported that they preferred to actively participate in decision making about their care, but about one-quarter stated that they wanted to make the decision alone. Most patients indicated that physicians and patients should have equal participation. About 15% suggested that patients should dominate the decision. “The key take-home message is that decision-making preferences vary among patients after an AMI, but many prefer an active style,” says Dr. Krumholz. Difficult to Predict Seven variables were associated with a greater likelihood of patients preferring active decision making, including female sex, Caucasian race, higher education, smoking, heart failure, lower Global Registry of Acute Coronary Events risk score, and not undergoing PCI during the hospitalization. Those who preferred an active role tended to be younger, but the majority of all age groups...
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