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Should All Surgeons Undergo Video Assessment?

A superb study by the Michigan Bariatric Surgery Collaborative showed that the more skilled surgeons were, the better were their outcomes. Surgeons submitted a video of their choice depicting their performance of a laparoscopic gastric bypass. Since it was self-selected, it was presumably their best work. At least 10 of their peers, blinded as to the name of the surgeon, rated skills on the video, which had been edited to include only the key portions of the case. Surgeons in the lowest quartile of ratings for surgical skill had significantly more postoperative complications, readmissions, reoperations, and deaths. A New York Times article about the paper featured a couple of short video clips—one from a not-so-skilled surgeon and one from a very skilled surgeon. The differences are obvious and dramatic. According to the discussion section of the paper, the Michigan bariatric surgeons are now watching each other operate and will soon be receiving anonymous feedback about their technique from their peers. It is not clear whether this will improve the skills of the lower-rated surgeons or have any effect on outcomes. Many people rightfully praised the research. Some suggested that all surgeons should be scrutinized in this same fashion. I agree that the study was well done and shows that better surgeons have better outcomes. But there are some problems with generalizing this to all surgeons. The American Board of Surgery recently noted that there are about 30,000 board-certified general surgeons in the United States. This raises a number of logistical issues. Let’s say we focus on the most common major surgical procedure: laparoscopic cholecystectomy. Ten surgeon raters would have to...
Updated Guidelines for Assessing Cardiovascular Risk

Updated Guidelines for Assessing Cardiovascular Risk

Cardiovascular disease (CVD) caused by atherosclerosis continues to be the leading cause of death and is a major cause of disability as well as a significant source of healthcare costs in the United States. In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released an updated clinical practice guideline to help clinicians better identify adults who may be at high risk for developing atherosclerotic CVD. The update, published jointly in the Journal of the American College of Cardiology and Circulation, also provides recommendations for identifying patients who could benefit from lifestyle changes or drug therapy to help prevent CVD. “These guidelines were last updated about 10 years ago,” says David C. Goff, Jr., MD, PhD, who co-chaired the ACC/AHA risk assessment guideline writing group. “Since that time, we have collected a large amount of research that has further enhanced our understanding of how best to care for these patients and improve our approaches to determining who should get specific types of preventive treatments.” Risk Assessment A key goal of the ACC/AHA guideline is to ensure that preventive treatments—especially lifestyle changes and drug treatment—are used in those who are most likely to benefit from them. To do this, the guideline includes high-quality risk assessment methods that use risk factors that are known to lead to atherosclerosis (Table 1). Factors such as age, cholesterol levels, blood pressure, smoking, and diabetes can be easily collected by clinicians and then integrated into a risk score to guide care and prompt discussions with patients.   “The vast majority of heart attacks and strokes could be prevented if patients knew...
Neurosurgeons Successfully Implant 3D-Printed Skull

Neurosurgeons Successfully Implant 3D-Printed Skull

When a Dutch woman with a rare condition needed a new skull, surgeons 3D-printed one for her and put it on her brain like a cap. An entire human cranium can now be added to the growing list of 3D-printed body parts that includes a fingertip, a hand, prosthetic eyes, arms, a jaw, and even a new foot for a duck. The plastic skull was made by an Australian firm and placed on the brain of a Dutch woman at Utrecht University’s University Medical Center in the Netherlands. The operation, which lasted 23 hours, took place about three months ago, and Dutch News just reported that the patient has returned to work — plastic noggin and all. “The patient has her sight back entirely, is symptom-free, is back to work, and it is almost impossible to see that she’s ever had surgery,” lead neurologist Ben Verweij said in a statement. Prior to the procedure, the woman’s skull was more than three times thicker than a normal skull due to a rare condition. The increased thickness caused the woman’s skull to press on her brain, leading to severe headaches and vision loss. Although the report doesn’t name the condition, Camurati-Engelmann disease is among the ailments that can cause skull bones to thicken. “Implants used to be made by hand in the operating theater using a sort of cement which was far from ideal,” Verweij said of the procedure, according to Dutch News. “Using 3D printing we can make one to the exact size. This not only has great cosmetic advantages, but patients’ brain function often recovers better than using the...
NSAIDs: Striving for Judicious Use

NSAIDs: Striving for Judicious Use

Every winter when cold and flu season hits, millions of people take non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen to ease the aches and pains associated with being sick. In addition, about 23 million Americans use over-the-counter NSAIDs every day. There were also close to 98 million prescriptions for NSAIDs filled last year, making them one of the most commonly prescribed medication classes in the United States. Addressing AEs Like all medications, NSAIDs can cause adverse events (AEs), particularly when they are used inappropriately. Both selective and nonselective NSAIDs can cause significant and even life-threatening events, including gastrointestinal, renal, and cardiovascular AEs. It’s important to counsel patients about appropriate use of NSAIDs. The FDA recommends using NSAIDs at the lowest effective dose for the shortest period of time required to provide therapeutic effect. The incidence of NSAID-related AEs increases significantly with concurrent use of multiple NSAID products and higher doses and longer duration of use. Many patients knowingly use prescription and OTC NSAIDs at the same time, increasing their risk of AEs. However, many more likely do so unknowingly because they’re unfamiliar with the term NSAID and don’t know which products are NSAIDs. Many patients are also unaware that some cold and pain medications contain NSAIDs that are combined with antihistamines, decongestants, or other analgesics, which can lead to using multiple NSAID products at the same time. A lack of patient awareness about NSAIDs—combined with the availability of OTC NSAID products—complicates their appropriate use. Ensuring Proper Use There are several steps physicians can take to ensure appropriate NSAID use. A thorough medication review at each patient visit, including...
Examining Physician Rx Drug Abuse

Examining Physician Rx Drug Abuse

Substance use is one of the most frequent causes of impairment among physicians, and some reports estimate that 10% to 15% of doctors will have a substance use disorder in their lifetime. “Substance-related impairment among physicians is a serious problem, with significant consequences for patient safety and public health,” says Lisa J. Merlo, PhD, MPE. “The rate of physician substance use is similar to that of the general population, but physicians are more likely to misuse prescription drugs. Understanding the reasons for prescription drug misuse may help us more successfully identify, treat, and monitor addicted physicians.” A key challenge to treating substance use disorders is that most physicians do not refer themselves for treatment, making it difficult to collect data on this issue. One strategy is to partner with physician health programs (PHPs) to recruit study participants. PHPs were established to ensure that distressed or impaired physicians are treated and monitored for the long term so that they can safely return to practice. “Studies have shown that nearly 80% of physicians who participate in PHPs remain substance free—with no relapse—at 5 years follow-up,” Dr. Merlo says. “Unfortunately, many doctors with substance use disorders have these problems for years before they seek help or are referred to a PHP.” Exploring the Issue Despite the impact of substance use among physicians, few analyses have looked at prescription drug misuse in this population. Studies have suggested that access to prescription medications may increase the risk of substance abuse among physicians. However, Dr. Merlo says that more information is needed to understand the reasons for prescription drug misuse among physicians and to develop...

Hospital Medicine 2014: Treating Asymptomatic Bacteriuria in the ED

The Particulars: Studies have suggested that asymptomatic bacteriuria (AB) should not be treated in most patients, but the definition of the term “asymptomatic” is often unclear when applied to acutely ill patients in the ED. These individuals may have any number of presenting symptoms that are attributable to urinary tract infections (UTIs), which can result in treatment with antibiotics. Data Breakdown: For a study, investigators examined the range of presenting signs and symptoms that triggered the initiation of antibiotics in patients being admitted from the ED with a UTI diagnosis. Among those with urinalyses testing positive for pyuria, nitrites, or leukocyte esterase, 82% received antibiotics in the ED for their UTI or other infection without or without UTI. Of those treated for UTIs, 42% had no urinary symptoms or systemic signs of infection, and none had an indication to treat asymptomatic bacteriuria. Take Home Pearl: Nearly half of patients diagnosed with UTIs and treated with antibiotics in the ED appear to have asymptomatic bacteriuria without a clear indication or need for antibiotic...

Hospital Medicine 2014: Improving Syncope Evaluation in the ED

The Particulars: Data indicate that evaluation and risk stratification of syncope often does not follow evidence-based guidance. This is occurring despite syncope being a challenging and costly condition. An evaluation algorithm that uses a patient’s history, physical examinations, and simple tests (eg, orthostatic vital signs, electrocardiograms, and hemoglobin) may help clinicians adhere to practice guidelines for evaluating and managing syncope. Data Breakdown: Researchers in California reviewed the charts of patients evaluated for syncope in the ED and analyzed them for adherence to evidence-based guidance. The team found that history data were important for risk stratification but were not obtained or documented for many patients. For example, orthostatic vital signs were only performed in 25% of patients. A substantial number of admissions and tests were performed outside the algorithmic guidance. Trained reviewers who used the algorithm had improvements in diagnostic accuracy. Take Home Pearls: The evaluation and management of syncope in the ED appears to vary from best-practice protocols. Using an evaluation algorithm that utilizes a patient’s history, physical examinations, and simple tests appears to increase diagnostic...

Hospital Medicine 2014: Barriers to ED Admission Handoffs

The Particulars: Research has shown that ED admission handoffs have unique structural and contextual challenges that require optimal communication between ED and hospital providers. These challenges can sometimes include changes in providers, departments, and physical locations when a patient’s clinical trajectory is uncertain. Few studies have assessed barriers to effective communication during ED admission handoffs. Data Breakdown: A survey found that ED physicians reported communicating clinical information less frequently than admitting physicians. Nearly all ED physicians felt they had to defend their decisions, and many noted that face-to-face communication was rare. Clinical duties distracted physicians frequently during handoffs, whereas environmental factors more commonly distracted ED providers. The least frequently communicated content areas were treatments initiated in the ED (71.9%), trends in the patient’s clinical condition (57.3%), and pending studies (34.8%) Take Home Pearls: Although most clinical information appears to be communicated regularly during ED admission handoffs, ED and admitting providers appear to have different perceptions on communication. Efforts to improve handoffs should be multifaceted and include inter-disciplinary team...
ACC.14

ACC.14

New research is being presented at ACC 14, the American College of Cardiology’s 63rd  Annual Scientific Session & Expo, from March 29-31 in Washington, DC. Meeting Highlights Celiac Disease Increases CAD Risk Diet Soda & Cardiac Events Onsite Cardiac Surgery Impacts PCI Outcomes Validating Atherosclerotic CVD Pooled Cohort Risk Equations Test Could Quickly Rule Out MI Comparing Bariatric Surgery & Medical Therapy for Diabetes ICD Vs. CRT-D Renal Denervation for Uncontrolled Hypertension Balloon- Vs Self-Expandable TAVR Aspirin Use in Non-Cardiac Surgery     News From the Meeting Evaluation of Low-Dose Clonidine and Aspirin in Patients at Risk For ASCVD TAVR With a Self-Expanding Prosthesis Shows Lower Mortality Than Surgery Gout Drug Tames the Heart One-Third of Children Tested in Texas Have Borderline or High Cholesterol One-Year Results Show Real-World TAVR Procedures Consistent With Clinical Trials Studies Suggest Coronary Calcium Scores Can Assess Long-Term Risk for Heart Disease McNamara Lecture to Detail the Power of Congenital Heart Diseases Incremental Progress Using Data to Drive Health Care Studies Highlight Innovative Strategies for Reducing Hospital Readmissions Perspectives: Debates in Hypertension LAPLACE-2 and GAUSS-2 Explore Different Aspects of PCSK9 Use Aleglitazar to Reduce CV Events in Patients With ACS and Diabetes Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy DESCARTES, MENDEL-2, RUTHERFORD-2 Trials Look at Impacts of Evolocumab  Validation of Pooled Cohorts 10-Year Atherosclerotic CVD Risk Equations Is ‘Spring Ahead’ a Heart Risk? New ACC/AHA/HRS Guideline Addresses Management of Patients With AFib Vascular Disease, Marital Status Linked? HEAT PPCI Burns Angiomax Metformin No Help in MI Recovery Gout Drug Tames the Heart Still No Clear CHOICE for TAVI Statins Tied to Boost...

Surprising Results of Three Studies

I like studies that question accepted practices. I also like to question studies that question accepted practices. [See this post about discrediting discredited practices.] Here are three studies with surprising and thought-provoking results. A few years ago, the idea of rapid response teams surfaced. These teams were supposed to be called when patients on regular floors became unstable. It was thought that such teams would be able to intervene more rapidly than simply paging the patient’s physician. Nearly every hospital established rapid response teams, and early studies tended to confirm that they were efficacious. So, all was well. But a recent paper from Critical Care Medicine shows that rapid response teams increase costs and intensive care unit admissions without showing any improvement in risk-adjusted patient outcomes. Naysayers will complain that it wasn’t a randomized, prospective, double-blind study. But it was a large before-and-after cohort study from a respected institution–the Mayo Clinic–and it is probably impossible to do a randomized trial now. The authors concluded that hospitals should at least evaluate their own experiences with rapid response teams. Another study, this time in JAMA, questions the validity of using rates of venous thromboembolic events as markers of hospital quality. It seems the more diligently one looks for VTEs, the more one finds them. Hospitals that did more imaging studies looking for VTEs had significantly higher rates of VTE. It’s called “surveillance bias.” The hospitals with high rates of VTE also had significantly higher rates of adherence to prophylaxis guidelines. So, if a patient was looking for a hospital with high-quality care in the area of venous thromboembolic events, the rate...
Hospital Medicine 2014

Hospital Medicine 2014

New research is being presented at Hospital Medicine 2014, the Society of Hospital Medicine’s annual meeting, from March 24-27, in Las Vegas. Meeting Highlights Barriers to ED Admission Handoffs Improving Syncope Evaluation in the ED Treating Asymptomatic Bacteriuria in the ED   More From the Meeting Registration Meeting Brochure Featured Speakers Main Meeting Schedule Pre-Courses Annual Meeting Committee Annual Meeting Faculty Special Interest Forums Hotel Information Spouse/Family Activities Exhibits Awards Testimonials FAQs    ...
Managing Inpatient Blood Glucose

Managing Inpatient Blood Glucose

Research indicates that hyperglycemia is a common finding among both medical and surgical patients, regardless of whether or not they have diabetes. When compared with patients who have normal glycemic levels, those with uncontrolled hyperglycemia have higher mortality and morbidity. These patients tend to have: • Delays in healing. • Poor immune responses. • Higher risks for cardiovascular events, inflammatory issues, and thrombosis. The extra care associated with these issues can increase healthcare costs unnecessarily. Need for Changes Many hospitals in the United States have protocols intended to implement intensive insulin therapy routinely in critically sick patients. However, based on new evidence, Amir Qaseem, MD, PhD, MHA, FACP, warns that physicians should not use intensive insulin therapy to strictly control blood glucose in hospitalized patients with or without diabetes. According to Dr. Qaseem, a potentially major harm in using intensive insulin therapy is that it can increase the risk of hypoglycemia. “This can lead to the same poor outcomes and adverse effects that we try to avoid with efforts to prevent or treat hyperglycemia,” he says. “Physicians should avoid aggressive glucose management and instead target levels of 140 mg/dL to 200 mg/dL when using insulin therapy.” Finding Balance To help clinicians find a balance between hyper­glycemia and hypoglycemia, Dr. Qaseem and colleagues at the American College of Physicians (ACP) reviewed recently published studies and developed recommendations on inpatient glycemic control. The document was published in the American Journal of Medical Quality. The first recommendation made by the ACP committee was that clinicians should avoid intensive insulin therapy to strictly control blood glucose or to normalize blood glucose in surgical...
Examining National Trends in Unscheduled Hospitalizations

Examining National Trends in Unscheduled Hospitalizations

Published data demonstrate that hospitalizations represent a significant portion of the annual expenditures for the United States healthcare system. A recent analysis by the RAND Corporation showed that emergency physicians are playing a greater role in healthcare beyond the services they provide in the ED. “Gaining a better understanding of recent changes in the sources of unscheduled ED admissions may provide opportunities to improve the quality and cost of inpatient care,” says Keith E. Kocher, MD, MPH. Analyzing the Effects In the journal Medical Care, Dr. Kocher and colleagues published an observational study examining the sources of unscheduled hospitalization over a 10-year period using data from the Nationwide Inpatient Sample. They also assessed implications for inpatient mortality and length of stay. Unscheduled hospitalizations were categorized as those related to transfers, direct admissions from outpatient providers, and the ED. Study results showed that about 82% of unscheduled admissions to the hospital came through the ED in 2009, representing a sharp increase from the 65% rate that was observed in 2000. Unscheduled hospitalizations arising from direct admissions and the ED changed substantially, while those due to transfers remained relatively stable. Direct admissions from clinics or doctors’ offices declined from about 31% to 14% of unscheduled admissions. Lower Mortality, Shorter Stays “In 2009, hospitalizations through the ED were associated with lower mortality overall when compared with direct admissions,” says Dr. Kocher. “These hospitalizations were also associated with a shorter hospital length of stay. These findings occurred despite a higher severity illness among patients and a greater chronic disease burden in 2009. It’s remarkable that patients admitted to the hospital from the ED...
Enhancing Patient Outcomes After Cardiac Surgery

Enhancing Patient Outcomes After Cardiac Surgery

According to recent estimates, roughly 350,000 to 500,000 patients undergo cardiac surgery each year. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Studies demonstrate that mortality and morbidity for CABG surgery have decreased during the past decade. At the same time, however, the highly skilled and dedicated personnel in cardiac operating rooms (ORs) are human and will make errors. Studies show that about 12% of cardiac surgery patients will experience an adverse event, and about one-third of deaths associated with CABG operations may be preventable. Efforts have been made to refine techniques, use advanced technologies, and enhance the coordination of care to improve cardiac surgery outcomes. Studies assessing the impact of these interventions on patient safety have suggested that little progress has been made in reducing or preventing errors. “It appears that preventable errors are often not related to failures in technical skills, training, or knowledge,” says Joyce A. Wahr, MD. “Instead, they typically represent cognitive, systematic, or teamwork failures. Communication, cooperation, coordination, and leadership among physicians are critical non-technical components that deserve greater emphasis.” A Scientific Statement In 2013, the American Heart Association (AHA) commissioned a scientific statement to summarize the evidence regarding risks to patient safety and clarify interventions that can help reduce perioperative risks and human error in cardiac surgery. The statement involved clinicians from key cardiac surgery specialties, including surgeons, anesthesiologists, nurses, and others. The comprehensive review focuses primarily on the human, environmental, and cultural factors that affect teamwork. In particular, it addresses how cardiac surgery teams can enhance communication within the OR and with other...
Voodoo

Voodoo

“I don’t care what the internet says. I’m sure there’s another explanation for your recurring pain besides voodoo.”  ...
Smartphones & Cancer Care

Smartphones & Cancer Care

More clinicians are beginning to recognize the untapped potential of smartphones to assist them when providing cancer care. While there are many benefits of using smartphones, clinicians may be surprised by how these devices can sometimes alter patient-physician relationships. A Help for Providers The benefits of smartphones are profound for patients because these devices can provide greater access to physicians. In cancer care, clinicians can similarly benefit from smartphone use in many ways. “For example, certain hospital systems have developed methods for clinicians to remotely access medical records via smartphones and tablets. These systems may be particularly helpful when covering for colleagues or fielding calls from home,” says Justin F. Gainor, MD. “Patients can also take and send pictures to their providers to determine if they need to be seen should a visible abnormality develop.” Smartphones can also serve as quick reference tools. With smartphone applications, physicians have quick and easy access to medical calculators, drug references, the National Comprehensive Cancer Network guidelines, and countless other helpful tools. Exercise Caution “Although smartphones have great potential for assisting cancer care, they can also interrupt conversations or limit the amount of time patients have with their physicians,” notes Dr. Gainor. Rarely, certain smartphone features, such as the ability to audio record a visit, can also alter the tone and dynamic of a patient encounter. When caring for cancer patients who use smartphones as a resource, clinicians should educate them on the challenges that come with this type of use, according to Dr. Gainor. “It’s often difficult to know the source of information provided in applications or mobile websites,” he says. “Many...

AAOS 2014: Can Allergies Explain Postoperative Joint Replacement Pain?

The Particulars: Previous research has found that joint replacements can sometimes end in implant failure that is due to factors other than infection or apparent biomechanical issues. It is possible that pain persisting after an apparently successful joint replacement may be due to an allergic reaction to components of the implant, but few studies have explored this possibility. Data Breakdown: In a small study, researchers assessed patients who experienced persistent pain after undergoing hip, knee, or shoulder replacement surgery and were scheduled for a revision implant. Overall, 58% of patients who were tested for allergies had a positive test relating to their joint replacement. Those with preoperative allergic reactions mostly had reactions to metals, whereas as those who tested for allergies postoperatively mostly reacted to bone cement. Of 15 patients with a revision implant that was chosen based on allergy testing, 14 reported that their condition improved moderately or “a lot.” This compared favorably to the three patients out of 20 whose revision implant was not chosen based on allergy testing. The authors pointed out, however, that their study had a significant loss to follow-up, no placebo-control arm, and a small number of subjects overall. Take Home Pearls: Choosing revision joint replacement implants based on allergy testing appears to decrease patient complaints of persistent postoperative pain. Additional, larger outcome studies are needed to confirm these...

AAOS 2014: Gastric Bypass Improves Knee Pain & Function

The Particulars: Elevated BMI has been linked to symptomatic knee osteoarthritis (OA) in previous studies. Data are lacking on the impact of weight loss following gastric bypass surgery (GBS) on knee pain and function. Data Breakdown: For a study, knee symptoms were compared among patients who underwent GBS with those who underwent total knee replacement for symptomatic OA. Data were collected preoperatively and at 6 and 12 months after surgery. The percentage improvement in average knee pain scores was similar between the two groups at 6 and 12 months follow-up. However, the GBS group had a significantly greater percentage improvement in physical function at 6 months (66.3% vs 46.7%) and a similar (though marginally non-significant) difference at 12 months (68.4% vs 51.5%). Take Home Pearls: When compared with total knee replacement, GBS appears to offer comparable knee pain reduction and improved mobility in obese patients. Bariatric consultation should be considered for obese patients with knee symptoms but without advanced OA or other conditions that are amenable to orthopedic...
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