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Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study. Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations. Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will, in most cases, be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid or butalbital-containing...
The Effects of DBS on the Motor Symptoms of Parkinson’s Disease

The Effects of DBS on the Motor Symptoms of Parkinson’s Disease

Andrew was diagnosed with Early Onset Parkinson’s Disease in 2009 when he was 35 years old. He lives with his wife and two children in Auckland, New Zealand. In November 2012 and February 2013 he underwent a surgical procedure, Deep Brain Stimulation surgery, to help control his motor symptoms. This has been hugely beneficial to his quality of life. He is the author of a blog youngandshaky.com, which he created to raise awareness of the effects of Parkinson’s Disease. This is his experience of how DBS has helped him and in the usual manner, results may vary. Source: Andrew Johnson. For more on the effects of DBS, check out this intriguing TED talk: Deep brain stimulation is becoming very precise. This technique allows surgeons to place electrodes in almost any area of the brain, and turn them up or down — like a radio dial or thermostat — to correct dysfunction. A dramatic look at emerging techniques, in which a woman with Parkinson’s instantly stops shaking and brain areas eroded by Alzheimer’s are brought back to life. (Filmed at TEDxCaltech.)TEDTalks is a daily video podcast of the best talks and performances from the TED Conference, where the world’s leading thinkers and doers give the talk of their lives in 18 minutes (or less). Look for talks on Technology, Entertainment and Design — plus science, business, global issues, the arts and much more. Source:...
Stratifying Risk in SCD: Planning for the Future

Stratifying Risk in SCD: Planning for the Future

Heart disease remains the leading cause of death in the United States and is responsible for more than 600,000 mortalities each year, according to data from the National Center for Health Statistics. About half of these mortalities are classified as sudden cardiac death (SCD). Of these deaths, about half occur as a victim’s first recognized cardiac event. Research suggests that only a small number of those suffering out-of-hospital cardiac arrests will ultimately survive these events. “SCD is a high priority public health problem that requires multipronged treatment and prevention approaches,” explains Jeffrey J. Goldberger, MD, a professor at Northwestern University’s Center for Cardiovascular Innovation. Recent reports indicate that the incidence of ventricular fibrillation as a cause of out-of-hospital cardiac arrest has been declining but continues to be a leading cause of SCD. Implantable cardioverter-defibrillators (ICDs) are effective but costly and have had a meaningful but, so far, limited impact on SCD. As a result, there are opportunities for new approaches to address SCD (Figure). Approximately $2.4 billion is spent each year on ICDs, but the medical community still has yet to identify the optimal method for determining which patients need these devices most. “Conducting research initiatives to improve our ability to predict risk would enable providers to target ICD use to the most appropriate recipients,” says Dr. Goldberger. “Under current prediction protocols, ICDs are not systematically reaching many patients who can benefit from receiving these devices. By assembling the right resources, there is hope that we can establish risk stratification standards that use medical resources wisely while saving the most lives.” Stratifying Sudden Cardiac Death Risk Developing effective strategies...
Decriminalizing Marijuana: Assessing Unintentional Pediatric Exposure

Decriminalizing Marijuana: Assessing Unintentional Pediatric Exposure

Throughout the United States, the legalization of marijuana is being debated by the public and in government forums. Although still criminalized at the federal level, decriminalization at the state level has received national attention because several states have enacted marijuana legislation for medical and recreational purposes. As of 2013, 18 states and the District of Columbia have passed legislation allowing for the use of medical marijuana, which includes many edible products, and sales are projected to more than double by 2015. More recently, Washington and Colorado have decriminalized small amounts of recreational marijuana. In 2004, the American Academy of Pediatrics released a policy statement that expressed concern about potential abuse of marijuana among adolescents in the context of decriminalization. There has been some evidence of medical marijuana being diverted to adolescents and recent reports of marijuana exposure to younger children. Studies suggest that there has been a slight increase in symptomatic, unintentional marijuana exposures since 2009. “Most of these exposures were from medical marijuana, which was often packaged as food products,” explains George S. Wang, MD, FAAP. “As such, it’s important to examine the effect that decriminalizing marijuana has had on children.” Assessing Trends in Marijuana Exposure In a study from Annals of Emergency Medicine, Dr. Wang and colleagues compared trends in unintentional marijuana exposures to children up to the age of 9 as measured by call volumes that were reported to U.S. poison centers. The authors hypothesized that decriminalized and transitional states would experience greater increases in call volume and have more symptomatic exposures and healthcare admissions than non-legal states. “States that decriminalized marijuana had significant increases in...
We’re Looking for Bloggers!

We’re Looking for Bloggers!

If you have your finger on the pulse of one of the many intriguing arteries of medical news and research—or would simply enjoy writing about your experience on the job, contact us! We’re looking for people who are part of the Physician’s Weekly core audience—physicians, nurses, therapists, medical students, etc—to share their insight and connect with our readers! If you have any interest in writing for Physician’s Weekly, please contact us: editorial@physweekly.com We look forward to hearing from...
Is There A Mental Healthcare Crisis In The U.S.?

Is There A Mental Healthcare Crisis In The U.S.?

We are all shocked when we see news stories of multiple people being killed by someone who seems to have gone off the deep end. While these events are extremely rare, it is a true tragedy to have them happen at all. It is often found that the guilty parties were suffering from some mental illness. These are the extremes of mental illness. However, milder forms of mental illness, such as anxiety and depression are very prevalent in the U.S. The unfortunate reality is that for many of these patients, they just cannot get mental healthcare even if they want access to it. How big is the problem? According to a survey of physicians on Sermo, the number one social network exclusively for physicians, approximately 84% of the doctors polled believe there is a mental healthcare crisis in this country. Often times, the primary care physician is left to care for these patients whom they may not feel comfortable taking care of, just because they cannot get an appointment for the patient with a psychiatrist. I often times have a patient who I believe needs to see a psychiatrist but is unable to get an appointment for up to 6 months. If a patient is having a mental healthcare urgency, they usually end up in the ER for lack of access to outpatient healthcare. But, psychiatrists are not to blame. This is rather due to a broken system that is in need of major reforms. Why is there a mental healthcare access crisis in the U.S.? 1. In the 1960’s, psychiatric hospitals closed their doors, making inpatient services very...

Should We Expand Surgical Residency Training Programs?

A Physician’s Weekly post I wrote last December was on the subject of surgeons possible losing proficiency for doing open cases because of the ever-increasing popularity of laparoscopic and other minimally invasive techniques. This results in declining numbers of open operations for residents during their training. Although some suggested that knowing how to do open cases would be unnecessary in the future, to me that is wishful thinking. One commenter said, “We are seeing the result of this in one of our hospitals with a new surgeon. He frequently aborts cases when he cannot complete them laparoscopically because he does not know how to do the open procedure. Worse, instead of seeking the help of someone who does, he transfers the patient to a medical center.” A resident said, “Observing the big name academic center that I train at, it seems that the massive cadre of fellows has led to an extremely low and less interesting case load for the rest of the general surgery trainees. Overload of floor management onto the trainees seems to exacerbate the problem. Why not substitute some of the current residency training with more focused experience with mentors—maybe even community mentors outside of academic centers—who perform the cases they’re lacking?” The presence of fellows is a huge problem that academic centers that both the Residency Review Committee and the American Board of Surgery have glossed over for years. Fellows are usually not present in large numbers at community hospital programs; therefore, the residents get to do more surgery. Two years ago, I wrote about the fact that community hospital residents do more cases and...
Expert, Real-Time Advice on HCV

Expert, Real-Time Advice on HCV

According to recent reports, an estimated 3 to 4 million Americans are chronically infected with the hepatitis C virus (HCV), and about half of these people are unaware of their status. These patients can progress to advanced liver disease and/or hepatocellular cancer. With early treatment, however, these outcomes can be prevented, and therapies for HCV are rapidly emerging and improving. With more treatment options becoming available, clinicians can potentially cure more patients than what has been previously possible. Several new direct-acting oral agents for HCV have been recently approved for use in the United States. The initial direct-acting agents were approved in 2011, and more oral agents are expecting approval within the next few years. “These treatments have the potential to cure most patients with HCV, but the rapid pace of drug development has left healthcare providers unsure about optimal treatments,” says David L. Thomas, MD, MPH. “We need credible resources with unbiased guidance on how best to treat patients with HCV.” A Helpful New Resource In 2014, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), in collaboration with the International Antiviral Society-USA (IAS-USA), launched HCVguidelines.org, a website that provides up-to-date guidance for the treatment of HCV. The collaboration is the result of ongoing work from the AASLD, IDSA, and IAS-USA. A panel of 26 liver disease and infectious diseases specialists and a patient advocate developed evidenced-based, consensus recommendations for screening, treating, and managing HCV. HCVguidelines.org has been made available to any healthcare provider who treats the disease and for others who need updated information on best practices. “The...
Tackling Heart Failure Readmissions

Tackling Heart Failure Readmissions

According to recent estimates, heart failure (HF) currently affects about 6 million adults in the United States, and the prevalence is projected to increase 25% by 2030. When HF patients are hospitalized, it represents a turning point in the natural history of their disease. “About 25% of HF patients who are discharged from the hospital are readmitted within 30 days,” says Clyde W. Yancy, MD, MSc, FACC. HF patients often need to be readmitted because the underlying cause of HF worsens. Hospitalizations are responsible for the majority of the nearly $40 billion that is spent annually for HF care in the U.S. As a result, these hospitalizations have become a focal point for quality improvement efforts and initiatives aimed at reducing costs. In an effort to improve outcomes, CMS has mandated that hospitals report their 30-day readmission rates for HF and acute myocardial infarction (AMI). The problem with this approach, according to Dr. Yancy, is that public reporting of outcomes is not effective as a hospital performance indicator. “Readmission rates, particularly for HF, are not a good marker of quality of care,” he says. “The emphasis on 30-day readmissions is misguided because the primary driver of these events is often patient population and the community that is served by hospitals.” Clinical investigations have also suggested that public reporting does not provide effective incentives for improvement and has had only minor effects on outcomes. Widespread Concern The changing paradigm to deny payment for HF readmissions within 30 days of discharge has led to widespread concern across hospitals. “Implementing HF programs and readmission reduction strategies are undertakings that require significant analysis,...
Anesthesiologist Guilty on 2 Counts of Manslaughter

Anesthesiologist Guilty on 2 Counts of Manslaughter

A Manhattan jury found Stan Xuhui Li, MD, guilty of manslaughter for overprescribing painkillers to two patients, Joseph Haeg, 37, and Nicholas Rappold, 21, who later suffered fatal overdoses. The 60-year-old anesthesiologist from New Jersey, was found guilty of two counts of second-degree manslaughter, six counts of recklessly endangering the lives of six other patients, and 180 counts of selling prescriptions for controlled substances (view all charges here). Dr. Li ran a pain-management clinic out of a basement office in Queens 1 day each weekend, seeing up to 100 patients a day. Posting a price list on his wall for drugs, Dr. Li accepted payment primarily in cash and pocketed nearly $500,000 over 2.5 years. He prescribed opioids such as oxycodone and anti-anxiety drugs such as alprazolam to high-risk patients—ignoring evidence of drug abuse and addiction, drug diversion, prior overdoses, and degenerating health. Manslaughter In both manslaughter counts, Dr. Li was charged with failing to perform adequate examinations to verify Haeg and Rappold’s reports of chronic pain and ignored repeated warning signs of addiction. According to prosecutors, Haeg received 15 prescriptions for controlled substances from Dr. Li, including oxycodone, within 3 months leading up to his death. In the final month, Haeg received more than 500 pills in two visits, the last visit only 3 days before he died of acute oxycodone intoxication. Rappold also died 3 days after his last appointment with Dr. Li. He was found with a bottle of Xanax with only 35 pills remaining of 90 from a prescription prescribed only 3 days before. Cause of death was acute intoxication by the combined effects of Xanax...
Refusal of Curative Care in the ED

Refusal of Curative Care in the ED

Resuscitating and stabilizing acutely ill or injured patients is a top priority for ED personnel, but traditional aggressive approaches to care may sometimes not suit the needs of those with advanced chronic illnesses who present to the ED with critical or terminal events. When seriously ill ED patients decline care targeted to cure disease, it may be challenging to rapidly shift treatment plans, especially if physicians feel unprepared and untrained for such scenarios. Framing the Conversation “When managing seriously ill patients who refuse curative care, it’s important to consider patient decision-making capacity,” says Sangeeta Lamba, MD. Pertinent information and options, including the risks of refusing care, should be provided. Ideally, patients will be able to communicate that they understand this information and verbalize their rationale for refusal based on personal goals. “It’s also important to involve the patient’s family, surrogates, or healthcare proxy,” adds Dr. Lamba. With clinical deterioration, patients may lose their ability to communicate. Others can then assist with decision making, especially if they know what patients value. “ED clinicians should first discuss overall patient goals and values before addressing specific procedures or issues,” Dr. Lamba says. “This information can help physicians frame future conversations and treatment plans to achieve patients’ objectives. It’s vital to understand the ‘why’ behind patient refusal and to use appropriate language and tone when having such conversations.” The ED team should also present viable alternatives if optimal treatment is not desired by patients or their family. Handling Transitions Once goals are clarified, patients may need to be shifted from curative care to a comfort-care approach. This transition must occur seamlessly and be...
Reducing  Poor Surgical  Oncology Practices

Reducing Poor Surgical Oncology Practices

As part of the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign, the American College of Surgeons (ACS) and the Commission on Cancer (CoC) have developed lists of five measures focusing on tests or procedures that are commonly ordered but not always necessary in surgery and surgical oncology. Although the ACS and CoC developed their own sets of measures, each organization strongly supports the other, according to Stephen B. Edge, MD, FACS, an executive committee member of the CoC. “These measures address the care of different patients,” he says. “The CoC addresses cancer patients in many parts of their care, whereas the ACS addresses all surgical patients.” The Commission on Cancer Measures After vetting a long list of potential measures, the CoC arrived at the measures listed in Table 1. Strong evidence supports using needle biopsy to determine if an abnormal finding may be indicative of breast cancer. Needle biopsy for a worrisome finding on breast imaging or examination improves treatment outcomes when compared with a diagnostic surgical lumpectomy, says Dr. Edge. In 2006, the Institute of Medicine recommended that all patients completing cancer treatment be given a summary of the therapies they received as well as a survivorship care plan. “This recommendation, however, is not being followed for most cancer patients,” Dr. Edge says. “The reasons are multi-faceted and include the time and effort it takes to create these plans and the difficulty in defining exactly how they should be constructed.” He adds that a survivorship plan explaining what tests patients should expect—and informing them that having more tests performed will not help—may reduce anxiety, uncertainty, and...
Little Piggie

Little Piggie

“How long has it been since you went wee wee wee all the way...
Optimizing Patient Education in Knee Osteoarthritis Care

Optimizing Patient Education in Knee Osteoarthritis Care

The goals of knee osteoarthritis (OA) treatment are to improve health-related quality of life and limit the progression of joint damage. “The optimal management of knee OA requires that patients be given a combination of non-pharmacologic and pharmacologic treatments,” says Pekka Mooar, MD. “Educating patients about the nature of their condition and strategies to manage it is important when caring for these individuals.” Informing patients about the pros and cons of the various types of therapies to alleviate pain and improve function takes time, but Dr. Mooar says it is an important part of the process. “Recent guidelines from groups like the American Academy of Orthopaedic Surgeons have provided recommen­dations for the non-pharmacologic and pharmacologic management of knee OA,” he says. “These guidelines make recommendations that are based on only well-designed studies with placebo controls. They do not support many of our traditional or surgical treatment options. For clinicians, this can make patient education even more challenging. Patients must be treated on a case-by-case basis, depending on their specific characteristics.” Lifestyle Interventions One of the most important aspects of managing patients with knee OA, according to Dr. Mooar, is to provide education about the objectives of treatments and the importance of lifestyle changes. “Patients should recognize that they can take action to reduce their chances of requiring knee surgery or arthroplasty,” he says. “Lifestyle changes are among the most effective non-operative treatments, but these options are best used when patients with knee OA are identified early.” Guidelines recommend that patients with knee OA be encouraged to undertake regular aerobic, muscle strengthening, and range of motion exercises,” says Dr. Mooar....

AIDS 2014: HIV Diagnosis Rates Declining

The Particulars: Accurate HIV diagnosis data have been lacking in the United States. This has made it challenging to examine long-term national trends in HIV diagnoses. Data Breakdown: For a study, researchers examined national data on HIV infections that were diagnosed during 2002 to 2011 among patients aged 13 and older. During this timeframe, the overall rate of HIV diagnoses decreased 33.2%, dropping from 24.1 to 16.1 per 100,000 population. Rates dropped 27.1% for men and 49.2% for women during the study period. The rate of diagnoses decreased for all age groups, with the exception of those aged 13 to 24, among whom the rate increased 38.4% during the study period. Take Home Pearls: The rate of HIV diagnoses appears to have decreased by more than 30% between 2002 and 2011. Rates appear to have decreased substantially more among women than men and increased among teens and young...

AIDS 2014: PrEP Deemed Safe for Moms & Fetuses

The Particulars: Previous studies have shown that pre-exposure prophylaxis (PrEP) reduces the risk of HIV transmission and seroconversion among patients without HIV whose sexual partners are infected. Whether PrEP has adverse effects on pregnancy and birth outcomes has not been well defined in clinical research. Data Breakdown: HIV-negative women who were in a relationship with an HIV-positive male partner were recruited for a study. Participants received one of two PrEP options or placebo. No statistically significant difference in the occurrence of pregnancy loss was observed between treatment groups. Occurrences of preterm birth, congenital anomalies, and kidney function and growth throughout the first year of life also did not differ significantly between groups. Take Home Pearl: Women who are not infected with HIV and take PrEP to prevent transmission of the infection from infected male partners do not appear to experience significant fetal harm or additional risk to normal...

AIDS 2014: Benefits Seen With At-Home HIV Treatment

The Particulars: Self-testing for HIV has the potential to overcome the privacy and convenience barriers of facility- and community-based testing. However, little is known about linkage to care after self-testing in areas with a high HIV prevalence. Data Breakdown: Investigators conducting a study offered home HIV testing to participants who performed self-testing for HIV. Some who tested positive for HIV on the home assay could start treatment at home whereas others were assigned to a regional HIV clinic to initiate therapy. At 6 months, 2.2% of home-test patients started therapy, compared with a 0.7% rate among the clinic-test group. No significant difference was observed between groups in patients who were lost to follow-up. Take Home Pearls: Giving patients with HIV the option of starting therapy at home appears to significantly increase the proportion of those who actually begin treatment. More research is needed to determine the optimal approach to initiating...

AIDS 2014: HIV Testing Low Among Teens

The Particulars: Young people account for a disproportionate share of new HIV infections, according to previous research. However, data are lacking on trends in sexual risk behaviors among United States high school students. Data Breakdown: An analysis was conducted of the CDC’s National Youth Risk Behavior Survey, a nationally representative group of U.S. high school students that is conducted annually, between 1991 and 2013. Since 2005, the proportion of sexually experienced participants who had ever been tested for HIV remained stable at just 22%. Female and African-American students were more likely than male, Caucasian, and Hispanic students to be tested for HIV. However, risks for HIV remained higher for African-American students than for Caucasian or Hispanic students. Take Home Pearls: Only one in five sexually experienced U.S. students appear to have ever been tested for HIV. Testing and risk for HIV appears to differ by race and...

AIDS 2014: Can Video Games Increase Patient HIV Knowledge?

The Particulars: Serious games—video games developed for purposes other than entertainment, such as health or social good—is an emerging field. The effects of serious games in educating teens on HIV and AIDS have yet to be determined. Data Breakdown: For a study, teens aged 11 to 14 were randomized to play conventional video games or an iPad-based serious game that identifies behaviors that promote HIV transmission and teaches ways to decrease risks. Those who participated in the serious game did so for 1 hour twice a week for 6 weeks. A 22-item assessment adapted from the AIDS Risk Knowledge Test was used to determine improvements in HIV knowledge from baseline to 3 months. Teens who played the serious game increased their HIV knowledge by 3 to 4 points, compared with nearly no improvement among controls. Participants were more likely to report talking with friends about the serious game, enjoying playing it, and making similar choices in real life. Take Home Pearls: Teens who play an HIV-awareness-promoting, role-playing style video game appear to increase their knowledge of HIV over 3 months. Additional research is required to determine the minimum times needed to play in order to achieve an effect on HIV...
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