Advertisement
Is Your iPad Really a “Mobile Germ Warehouse”?

Is Your iPad Really a “Mobile Germ Warehouse”?

As I have written before, there is a veritable cottage industry of papers identifying bacterial contamination of nearly every inanimate object you can think of. One of the latest involves contamination of the surfaces of electronic devices and in particular, iPads. Without giving references, a New York Times article entitled “Cleaning the mobile germ warehouse” says, “Repeated studies show what accumulates [on device surfaces] is germy nastiness worse than what is on the bottom of your shoe.” A least it’s not a toilet seat comparison. The Times cites a recent letter to the editor of the American Journal of Infection Control, which states that the screens of 20 hospital-provided iPads were cultured looking for Staph aureus, Clostridium difficile, and gram-negative organisms. Three grew Staph, but neither of the other organisms was found. They then inoculated screens with MRSA and C. diff. to test various disinfection techniques. The use of wipes containing bleach effectively decontaminated all the screens. [I wonder if Apple approves of using bleach on iPad screens.] The Times piece launched into a long discussion of how screens should be cleaned without any mention of the problem of extrapolating what can be found on a hospital’s iPad screens to what might be found on your iPad screen or whether inoculating screens with bacteria is comparable to what might be found with normal home or non-medical office use. The senior author of the iPad screen study is quoted as saying, “That devices can be a source of disease transmission is not a subject of debate anymore.” His study mentions no references to disease transmission by iPads or smart phones....
Combating Antibiotic Resistance

Combating Antibiotic Resistance

Several factors contri­bute to the urgency of the antibiotic resistance crisis in the United States. “Discovering the next generation of antibiotics is exceedingly challenging,” says Brad Spellberg, MD. Pharmaceutical companies are hesitant to develop antibiotics because they tend to be a poor financial investment. The London School of Economics recently estimated that a new antibiotic would have an average net value of -$50 million at discovery. Further complicating the issue is the overtly hostile regulatory environment, particularly for antibiotics. Fighting Back According to Dr. Spellberg, who co-authored a paper on how to combat antibiotic resistance that was published in Medscape Infectious Diseases, the U.S. needs a national prospective surveillance system to track where antibiotic resistance to specific pathogens is occurring geographically and the frequency of these cases. “The lack of this data is a significant detriment to policy efforts aimed at fighting resistance,” Dr. Spellberg adds. “We also need a publicly available, national data collection system to monitor variation in antibiotic use across healthcare systems and geography.” Antibiotic stewardship has been recommended to combat antibiotic resistance, but Dr. Spellberg says the cornerstone of this strategy lies in stressing the importance to physicians and patients to not overuse these drugs. “Simply telling people to not overuse antibiotics is ineffective,” he says. “We need technologies that support stewardship and economic policies that promote appropriate use of these drugs.” Practical Solutions Rapid diagnostic testing has emerged as a technology to inform providers about what antibiotic to use, if any, for patients. “It’s difficult to determine which patients have bacterial or viral infections,” says Dr. Spellberg. “Rapid diagnostics have the potential to eliminate...
Smoking Cessation in People With HIV/AIDS

Smoking Cessation in People With HIV/AIDS

Published research shows that cigarette smoking rates among people living with HIV/AIDS are substantially higher than those of the general public. “The prevalence of smoking adults in the United States is about 18%, but that figure increases to approximately 50% for people with HIV/AIDS,” says Damon J. Vidrine, DrPH, MS. “Furthermore, people with HIV/AIDS are at higher risk from the adverse health consequences of smoking, including heart disease, cancer, pulmonary disease, and overall mortality.” A recent study found that more than 60% of deaths among people living with HIV/AIDS can be attributed to smoking. “Smoking can also interfere with the efficacy of medications used to keep HIV/AIDS under control,” adds Ellen R. Gritz, PhD. Despite compelling evidence suggesting that people with HIV/AIDS could benefit considerably from smoking cessation treatment, large-scale trials conducted exclusively in these patients are scarce. “Few studies have looked at interventions that have been effective for long-term smoking abstinence in these patients,” says Dr. Gritz. “We need more studies that focus on the unique needs of people with HIV/AIDS in the context of this patient group being economically disadvantaged.” A Unique Smoking Cessation Intervention Dr. Gritz, Dr. Vidrine, and colleagues had a study published in Clinical Infectious Diseases that compared a usual care (UC) approach with an innovative cell phone counseling-based smoking cessation intervention in low-income, multiethnic people with HIV/AIDS who smoked. “We wanted to develop and implement a smoking cessation intervention that addressed the complex medical and social needs encountered by these patients,” says Dr. Vidrine. “This is one of the largest studies to look at a smoking cessation intervention that exclusively targets people living...
Updating Adult Vaccination Recommendations

Updating Adult Vaccination Recommendations

Research has shown that current vaccination rates for adults are low. “There are 14 different infectious agents for which vaccines are recommended for adults, but vaccination rates are low for a number of reasons,” says Carolyn B. Bridges, MD. “There is limited public awareness about the need for vaccines for adults besides influenza. Also, patients rely on recommendations about vaccines from their providers, but many providers don’t routinely assess vaccination status and follow with recommendations for the vaccines their patients need.” Each year, the Advisory Committee on Immuni­zation Practices (ACIP) reviews and updates its recommended immunization schedule for adults aged 19 and older. Each February, the schedule is updated on the CDC website (www.cdc.gov/vaccines). The schedule provides a brief summary of ACIP recommendations using figures and footnotes to describe which patients are recommended to receive each vaccine and a table that describes the primary contraindications and precautions for each vaccine. Strategies for Improvement A number of strategies can help incorporate adult vaccinations into clinical practice, including systems changes so that vaccines are routinely assessed and offered. Other strategies include using reminders for healthcare providers (HCPs), such as prompts in electronic health records, using protocols or standing orders for office staff, and sending reminders to patients about needed vaccines. According to Dr. Bridges, one of the most important elements in improving vaccination rates is making sure patients hear from their provider about which vaccines they need. The CDC has partnered with many organizations to update the Standards for Adult Immunization Practice. The standards are a call to action for providers to: – Assess vaccination needs among patients in every clinical...
Lifestyle Strategies for Heart Risks

Lifestyle Strategies for Heart Risks

In 2013, the American Heart Association and the American College of Cardiology published a first-ever joint clinical practice guideline on lifestyle management to reduce cardiovascular disease (CVD) risks. Published simultaneously in Circulation and the Journal of the American College of Cardiology, the guideline is based on a systematic evidence review from studies published between 1990 and 2012. It summarizes key nutrition and physical activity topics for managing blood pressure (BP) and cholesterol. Healthy Eating & Physical Activity “To lead a lifestyle that can reduce CVD risks, heart-healthy eating habits and physical activity are paramount,” says Robert H. Eckel, MD, who co-chaired the expert writing group that developed the guidelines. To lower cholesterol, the guideline strongly recommends limiting saturated fat and trans fat. To lower BP, an emphasis is placed on restricting sodium to no more than 2,400 mg/day. Further reductions of sodium intake to no more than 1,500 mg/day are linked to an even greater reduction in BP. “Eating a heart-healthy diet is more about the overall diet rather than isolating specific foods that are eaten,” adds Dr. Eckel. A heart-healthy diet should focus on fruits, vegetables, and whole grains and include low-fat dairy products, poultry, fish, and nuts. It should also limit red meat, sweets, and sugar-sweetened beverages. “Following this pattern should help limit the intake of saturated fat, trans fat, and sodium to the recommended levels,” Dr. Eckel says. Adaptations to heart-healthy diet plans should be considered based on each person’s caloric requirements, personal and cultural food preferences, and nutrition therapy for other health conditions, such as diabetes. The guideline also recommends moderate- to vigorous-intensity aerobic exercise,...
Reducing Ambulance Diversions

Reducing Ambulance Diversions

Recent data indicate that about 45% of EDs in the United States report being “on diversion” at some point within a given year to alleviate crowding. “Although ambulance diversion has been used for quite some time, several studies link these diversions to negative consequences,” explains M. Kit Delgado, MD, MS. “These include prolonged transport times, delays in care, higher mortality, and lower hospital revenue.” Efforts have been made to reduce ambulance diversion in the past. These strategies include implementing ED patient-flow improvements. “Optimizing front end operations, such as patient triage, registration, and tracking, is also important,” says Dr. Delgado. “Other improvement efforts include adopting hospital-wide full capacity protocols to expedite the transfer of admitted patients from EDs to inpatient units.” New Insights on Diversion & Crowding Questions remain about the strategies that can best reduce diversion without increasing ED crowding and how best to coordinate these efforts. In the Western Journal of Emergency Medicine, Dr. Delgado and colleagues had a study published that systematically reviewed simulation model investigations. “Our overall goal was to gain insights on how to optimally reduce ambulance diversion,” Dr. Delgado says. The analysis identified 10 studies that used simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems. Results showed that ambulance diversion only minimally improved ED waiting room times. Strategies that were found to reduce diversion considerably include: 1. Adding holding units for inpatient boarders. 2. Adding ED-based fast tracks. 3. Improving lab turnaround times. 4. Smoothing out elective surgery caseloads. “The desired effect of reducing ED waiting room times by diverting ambulances is likely to be very small,” says...
Anaphylaxis Care in the ED

Anaphylaxis Care in the ED

Guidelines and updated emergency medicine (EM) practice parameters have been issued for the management of anaphylaxis in the ED, but research indicates that significant knowledge and practice gaps persist. In July 2011, a round-table meeting called Anaphylaxis in Emergency Medicine was conducted, consisting of a multidisciplinary group of experts who reviewed the current guidelines and how they are applied in different emergency medical settings in the United States. The experts agreed that the root cause for many treatment gaps for anaphylaxis was the lack of a practical definition of anaphylaxis as it relates to EM. “There is concern that EM professionals may not be using current guidelines and practice parameters fully,” explains Richard Nowak, MD, who chaired the Anaphylaxis in Emergency Medicine roundtable panel. “This results from not having a consensus in published guidelines on the definition of anaphylaxis. Another key factor is that there are differences in signs and symptoms of how anaphylaxis presents in EDs, compared with those occurring in allergists’ offices.” A Practical Definition of Anaphylaxis In 2013, Dr. Nowak and colleagues published an article in the Journal of Emergency Medicine that customized anaphylaxis guidelines for EM. Articulating a simple standardized practical definition of anaphylaxis and describing characteristic findings in the clinical criteria for identifying it were an important emphasis (Table 1). The working definition was modified, building upon definitions suggested by other groups, so that it is clinically more relevant to emergency providers. Dr. Nowak and colleagues also developed consensus statements that encouraged practical application of guidelines when managing anaphylaxis (Table 2). “These statements expand the discussion on how to diagnose and manage anaphylaxis in...
Patient Factors in Bariatric Surgery Choices

Patient Factors in Bariatric Surgery Choices

Gastric bypass surgery and laparoscopic adjustable gastric banding are two commonly performed bariatric procedures, but each has different profiles for risk and effectiveness. Few studies have explored the factors that might lead patients to proceed with one procedure over another. In the Journal of the American College of Surgeons, a study was conducted to investigate the reasons why obese patients choose one type of weight loss operation over another. First author Caroline M. Apovian, MD, FACP, FACN, and colleagues studied 536 adults who had either gastric bypass (297 patients) or gastric banding (239 patients). A Deeper Look According to the results, diabetes status played an important role in decision- making for patients who were choosing between gastric bypass and laparoscopic adjustable gastric banding procedures. Those with diabetes were more likely to proceed with gastric bypass surgery. “This could be the result of patients and their physicians understanding that obesity causes type 2 diabetes, and that gastric bypass surgery can be life-saving and restore normal glucose levels,” says Dr. Apovian. Other patients who were more likely to select gastric bypass over the laparoscopic banding procedure included those who wanted greater weight loss and those willing to assume a higher mortality risk to reach their ideal weight. BMI appeared to play a smaller role in the decision-making process for patients choosing between bariatric surgeries. “Psychological and emotional issues appear to influence surgery decisions,” Dr. Apovian says. “It’s important to consider the patient’s individual preferences and what matters most to them.” In addition, the study found that patients reporting more uncontrolled eating were more likely to undergo laparoscopic banding than gastric bypass....
Occupational Injuries Among Orthopedic Surgeons

Occupational Injuries Among Orthopedic Surgeons

Orthopedic surgery requires surgeons to spend many hours per week in body positions that are known to contribute to musculoskeletal injuries. Although efforts have been made to improve ergonomics and reduce strains that occur during surgery, these techniques are often not widely adopted. Adherence to ergonomic guidelines can be difficult, and many surgeons are unaware of current guidelines. “The combination of these factors suggests that surgeons are at high risk for occupational injuries, such as carpal tunnel syndrome, back sprains, and torn ligaments,” says Manish K. Sethi, MD. “The demand for orthopedic services is growing, but we’re in the midst of a shortage of orthopedic surgeons. Injuries to orthopedists could have substantial consequences for the healthcare system.” Examining the Issue In the Journal of Bone & Joint Surgery, Dr. Sethi and colleagues assessed occupational injuries among orthopedic surgeons using an electronic survey that was sent to orthopedists in Tennessee. “There have been very few studies that have explored occupational injuries in physicians, and no studies to our knowledge have specifically involved orthopedics,” says Dr. Sethi. “Our analysis is among the first contributions to the literature on injuries among orthopedists, an area that clearly needs greater awareness.” The survey was designed to capture information about respondents’ subspecialty, practice setting, and length of time in practice as well as basic information about any injuries that were sustained. Information was also collected on how injuries affected surgeons with regard to days of work lost and if any institutional resources were made available during recovery. The study team found that 44% of respondents had sustained one or more injuries at the workplace at...

The UK 48-hour Trainee Work Week Is a Sham

“NHS junior doctors have little time to eat or sleep.” Said the headline of an article from the Herald in Edinburgh, Scotland. It described a NHS (National Health Service) manual—no longer posted on the Internet—advising trainees to “be prepared for dehydration and hunger” and to keep water and a food bar handy because they would rarely have a chance to eat. A man whose daughter, a junior doctor, was killed in an auto accident on her way home from the hospital blamed it on the fact that she had worked a long shift. For the record, she had worked a 12-hour shift overnight. Of junior doctors, he said, “They are under intense pressure, they are working excessive hours, they are getting no respite.” I tweeted the link to the story with a question wondering how it could be that conditions are so bad in the UK. After all, I thought the European Working Time Directive (EWTD) stated that trainees in the European Union could only work 48 hours per week. A flood of tweets in response soon explained the true situation to me. I was amazed, and you will be too. It seems that the so-called 48-hour work week is a sham. Trainees can work only 48 hours per week, but it’s averaged over 6 months—6 months! What hospitals apparently do is work the junior docs like dogs and then give them a week off so that the average per week is only 48 hours. Here are quotes from some of the UK physicians: That’s the key; as long as they give you a week off and the average...
COPD & Cognitive Issues

COPD & Cognitive Issues

As the third leading cause of death in the United States, COPD affects about 13.7 million patients. Recent research has suggested that as many as 77% of patients with COPD and hypoxemia have some form of cognitive impairment. Despite this association, the link between COPD and mild cognitive impairment (MCI) has not been established in well-designed, population-based studies. Investigating the Link In a study published in Mayo Clinic Proceedings, Balwinder Singh, MD, MS, and colleagues analyzed data from 1,927 individuals aged 70 to 89 who participated in the Mayo Clinic Study of Aging to see if there was an association between COPD and MCI. Patients underwent a nurse assessment, neurological evaluation, and neuropsychological testing when they entered the study. A panel diagnosed MCI using standardized criteria and then reviewed medical records to identify people with COPD who developed MCI. According to the analysis, patients with COPD had a higher prevalence of MCI than those without COPD (27% vs 15%). Findings were similar for both men and women involved in the study. “In addition, COPD was associated with almost two-fold higher odds of MCI,” says Dr. Singh. The associations of COPD with overall MCI and amnestic MCI were independent of age, sex, education, apolipoprotein E genotype, BMI, depression, and a history of coronary artery disease, diabetes, hypertension, and stroke. The investigation also revealed that there appears to be a dose-response effect for COPD duration. “We observed a 1.60 odds ratio for MCI in patients who had COPD for 5 years or less, but this ratio jumped to 2.10 in patients who had a COPD duration that exceeded 5 years,” Dr....
The Economic Burden of Cancer Survivors

The Economic Burden of Cancer Survivors

According to recent estimates, about 13.7 million people in the United States with a history of cancer were still living in 2012. “The prevalence of cancer survivors has increased substantially over time,” says Gery P. Guy Jr., PhD, MPH. “Even more cancer survivors are expected as advances are made in treatment and early detection and as life expectancy continues to increase.” As the number of cancer survivors grows, it is important to understand how medical expenditures and lost productivity affect these individuals. This includes exploring the role of employment disability, hours worked, and missed work days. In the past, studies of medical expenditures used cancer registry data, administrative claims, and other sources to describe the economic burden of patients who have survived cancer. However, analyses of expenditures on a national level tend to only include cancer survivors who are receiving cancer-related healthcare. Few studies have assessed multiple components of the economic burden of cancer survivorship, and most of these were conducted in a single state. “To gain a better perspective on this issue,” says Dr. Guy, “we need to quantify medical expenditures and the indirect morbidity cost of lost productivity among adult cancer survivors of all ages on a national level.” To address this need, Dr. Guy and colleagues conducted a study using the 2008 to 2010 Medical Expenditure Panel Survey to compare the economic burden of adult cancer survivors with individuals who did not have a history of cancer. The study, published in the Journal of Clinical Oncology, looked at the lost productivity that is associated with employment disability, missed work days, and lost household productivity. Considerable Costs...

ADA 2014: Is It Depression or Diabetes Distress?

The Particulars: Researchers have yet to clearly define whether the symptoms of depression observed in patients with diabetes are actually depression or a reaction to living with a stressful, complex disease that is often difficult to manage. Data Breakdown: A study group from the University of California, San Francisco developed diabetes-specific distress measures that reflected whether patients had been feeling worried about a variety of problems associated with diabetes, including hypoglycemia. Study participants also completed the Patient Health Questionnaire-8 (PHQ-8) to measure depressive symptoms. Those with high levels of distress and depressive symptoms were assigned to one of three interventions meant to reduce diabetes distress rather than manage depression. Distress and depressive symptoms were lower with all three interventions over a 12-month period and maintained throughout the study. Among those who scored higher than 10 on the PHQ-8 at the beginning of the study, 84% reduced their levels to below 10 after receiving the interventions. Take Home Pearl: Many of the depressive symptoms reported by patients with type 2 diabetes appear to be related to concerns about their diabetes rather than clinical depression. These symptoms appear to be treatable by diabetes care teams without requiring psychologic or psychiatric...

ADA 2014: Long-Term Effects of Diabetes Prevention

The Particulars: A lifestyle program designed to reduce weight and increase activity levels, along with use of metformin, was found to decrease the development of type 2 diabetes in a diverse group of people at high risk for the disease after 3 years follow-up in the Diabetes Prevention Program (DDP) study. The long-term effects of this program, however, have not been thoroughly explored. Data Breakdown: As an extension of the DDP study, investigators compared interventions used in DDP with placebo after an average of 15 years. When compared with patients in the placebo group, those assigned to the lifestyle intervention arm in the DDP study had a 27% lower rate of type 2 diabetes, and those in the metformin arm had a 17% lower rate. Patients who did not develop diabetes had a 28% lower occurrence of microvascular complications that those who did develop the disease. Take Home Pearl: Interventions designed to prevent the development of type 2 diabetes appear to remain effective even beyond 15...

ADA 2014: Can Hepatitis B Vaccination Prevent Diabetes?

The Particulars: In previous studies, investigators have found that hepatitis C can complicate outcomes in patients with diabetes. However, little is known about the relationship between hepatitis B and diabetes. Data Breakdown: Researchers used a national database to review patients with information on both fasting blood glucose and hepatitis B status for a study. Diabetes occurred in 1.13% of patients who received the hepatitis B vaccination, compared with a 5.67% rate for those who had not been vaccinated against hepatitis B. After multivariate adjustment, hepatitis B vaccination still had a large protective effect against diabetes (odd ratio, 0.48). Take Home Pearls: Hepatitis B vaccination appears to prevent some patients from developing diabetes. Additional research is needed to further investigate this...

ADA 2014: Diabetes Missed in Many Asian Americans

The Particulars: In the Veterans Affairs system, researchers have observed that many patients with diabetes on renal dialysis are thin, Asian men who exercise frequently and have access to healthcare. The current recommendation of screening for diabetes in adults aged 45 and older with a BMI of 25 kg/m2 or higher and one known risk factor may not be sufficient for the Asian-American population. Data Breakdown: Diabetes screening tests were performed on participants in a study who self-reported being Chinese, Filipino, Japanese, Korean, or of mixed Asian ancestry. To detect diabetes, the optimal BMI cut points were higher than 24 kg/m2 for all patients, women, those aged 55 and older, and those with isolated post-challenge hyperglycemia. The optimal cut point was higher than 25 kg/m2 when screenings were limited to fasting plasma glucose or A1C measurements, and greater than 26 kg/m2 for men and those aged 35 to 54. Take Home Pearls: Using the recommended BMI cut point of 25 kg/m2 or higher for diabetes screening does not appear to identify a substantial number of Asian Americans with the disease. A BMI cut point of 24 kg/m2 may be more appropriate for diabetes screenings this...

ADA 2014: The Effects of Diet on Diabetes Risk

The Particulars: Previous studies have shown that lifestyle changes can prevent or delay type 2 diabetes in high-risk patients. However, data are lacking on the impact of improving the quality of diet on diabetes risk among healthy adults. Data Breakdown: For a study, researchers examined patients who either improved or worsened the quality of their diet over 4 years and assessed the impact these changes had on diabetes risk during a subsequent 4-year period. Patients whose diet quality scores decreased more than 10% experienced a nearly 20% higher subsequent diabetes risk. Conversely, those whose dietary scores improved 10% had a lower subsequent risk of developing diabetes. Take Home Pearl: Healthy adults who improve the quality of their diets appear to decrease their diabetes risk, but those who worsen their diet quality appear to have a higher diabetes...

1 in 20 Americans Are Misdiagnosed Every Year

Really? A paper published in April found that about 12 million Americans, or 5% of adults in this country, are being misdiagnosed every year. This news exploded all over Twitter. Anxious reports from media outlets such as NBC News, CBS News, the Boston Globe, and others fanned the flames. The paper involves a fair amount of extrapolation and estimation reminiscent of the “440,000 deaths per year caused by medical error” study from last year. Data from the authors’ prior published works involving 81,000 patients and 212,000 visits yielded about 1600 records for analysis. A misdiagnosis was determined by either an unplanned hospitalization (trigger 1) or a primary care physician revisit within 14 days of an index visit (trigger 2). The words “misdiagnosis” and “error” were used interchangeably. A quote from the paper: For trigger 1, 141 errors were found in 674 visits reviewed, yielding an error rate of 20.9%. Extrapolating to all 1086 trigger 1 visits yielded an estimate of 227.2 errors. For trigger 2, 36 errors were found in 669 visits reviewed, yielding an error rate of 5.4%. Extrapolating to all 14,777 trigger 2 visits yielded an estimate of 795.2 errors. Finally, for the control visits, 13 errors were found in 614 visits reviewed, yielding an error rate of 2.1%. Extrapolating to all 193,810 control visits yielded an estimate of 4,103.5 errors. Thus, we estimated that 5126 errors would have occurred across the three groups. We then divided this figure by the number of unique primary care patients in the initial cohort (81,483) and arrived at an estimated error rate of 6.29%. Because approximately 80.5% of US adults...

Is it Possible to Live a Full Life as a Surgeon‏?

Not too long ago, a fourth-year medical student asked me that question. Here’s what I told him. I became a surgeon because it appealed to me more than any other specialty. Like most others of my era, I was young and had gone the traditional route—4 years of college followed immediately by med school. I had experienced few adventures [in fact, none] and had not yet met my wife-to-be. I never even considered what impact my choice would have on my personal life. The subject simply did not come up. I worked hard in medical school but had a great time. I think I had more fun in med school than I did in college. My residency prepared me well for the rigors of a surgical career. I spent the first 4 years of my training taking call about half every other night and half every third night. As a chief resident, I was in call every night. Somehow I found the time to have a relationship and got married at the end of my third year. My wife of 40 years is a saint. I have wonderful children and now grandchildren too. I was fortunate in my career to have had the opportunity to supervise the training of a number of surgeons who are helping people every day. Although I’ll never climb Everest, go an African safari, ski the Swiss Alps or do many other things that might be important to others, I’ve had an interesting and fulfilling life. Wilderness? Not so much. But love and relationships? I got ’em. But it is different for the millennial generation....
Page 1 of 3123
[ HIDE/SHOW ]