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Does Anyone Really Read Anything Online?

Not long ago, I tweeted a link to a very long story. Within 60 seconds, it received three retweets. Since the article would have taken at least 10 minutes to read, it is highly likely that those who retweeted it did not read it. This phenomenon is not limited to Twitter. A couple of recent articles revealed some interesting data about what people really do online. From Time magazine in early March: “A stunning 55% [of those who clicked into an article] spent fewer than 15 seconds actively on a page. [emphasis theirs] The stats get a little better if you filter purely for article pages, but even then one in every three visitors spend [sic] less than 15 seconds reading articles they land on.” Analysis of 10,000 articles shared on social media “found that there is no relationship whatsoever between the amount a piece of content is shared and the amount of attention an average reader will give that content.” A Slate article noted that about 5% to 10% of those who open an article leave it immediately, and 38% of people who click on it “bounce” [leave it] before the end of the first paragraph. At a few hundred words into the article, about half of the remaining readers have left, and very few of the rest make it through to the end. The amount of scrolling can also be tracked. “There’s a very weak relationship between scroll depth and sharing. Both at Slate and across the Web, articles that get a lot of tweets don’t necessarily get read very deeply. Articles that get read deeply aren’t...
CT-Based Lung Cancer Screening in HIV

CT-Based Lung Cancer Screening in HIV

Studies have found that patients with HIV have a two- to five-fold greater risk of lung cancer when compared with patients from the general population. Other research has suggested that CT-based lung cancer screening can help decrease lung cancer mortality in heavy smokers. Pairing these findings together has led to speculation that patients with HIV, particularly those who smoke, may be a key target for CT-based lung cancer screening. However, approximately 20% of chest CT scans show abnormalities suggestive of lung cancer. This could lead to invasive tests with downstream complications. “Because patients with HIV are more likely than the general population to have a history of lung infections or other pulmonary diseases,” explains Keith Sigel, MD, MPH, “they may have more abnormalities on their CT scans. This can increase their risk of false-positive findings on CT-based lung cancer screening.” New Findings For a study published in AIDS, Dr. Sigel and colleagues analyzed data on patients with and without HIV who were at risk of lung disease. The study aimed to determine whether or not HIV had an effect on the development of lung disease by comparing the frequency of incidental findings—particularly pulmonary nodules—observed on chest CT scans. “We looked at the number of patients who had positive screens in each group and followed those patients to determine the end result of those findings on the CT scans,” says Dr. Sigel. Dr. Sigel and colleagues found that, overall, HIV-infected patients did not have significantly more positive scans (29%) than HIV-uninfected patients (24%). However, HIV-infected patients with CD4 counts lower than 200 had significantly higher odds of positive CT scans...
A Resource to Help Care for Obesity

A Resource to Help Care for Obesity

Few providers have the resources or time to implement guidelines for managing overweight and obese patients, according to Louis J. Aronne, MD, FACP. To overcome this obstacle, Dr. Aronne and other experts in obesity and weight-management care developed BMIQ (www.bmiq.com), a website that allows healthcare providers to add a comprehensive, office-based program to their medical practice. The BMIQ program registers patients during office visits and guides physicians on delivering obesity treatment modules. Patients are then given expanded session materials online and are guided to apply for sessions and plan meals as part of their daily routine. Patients can track their weight, food, and activity goals online. They are also encouraged to schedule their next office visit in order to participate in their next module. Enhancing Implementation “BMIQ can serve as a tool for patients and clinicians to enhance the implementation of evidence-based obesity management,” Dr. Aronne says. “For comprehensive obesity management to be effective, clinicians need a program that is easy to implement, flexible to use, and supports patients outside of the office setting.” The BMIQ Professionals Program accomplishes this mission for a low monthly subscription. Subscribers receive their own branded website along with other program components, such as complete program materials for clinicians and pa­tients, including session guides, patient lessons, and references. They also receive a complete 20-session program that can be delivered individually in the office setting, over the phone, or in a group setting. In addition, subscribers receive video tutorials on getting started and delivering each session as well as comprehensive reports for each patient who completes their online assessment. BMIQ provides integrated patient tracking, which...
New Guidelines for Hepatitis C Testing

New Guidelines for Hepatitis C Testing

In 2003, the CDC published recommendations on the laboratory testing and reporting of hepatitis C virus (HCV) infection. The guidance focused on testing for the HCV antibody, a marker of HCV exposure. Since 2003, several efficacious antiviral drugs have been approved by the FDA for the treatment of hepatitis C. “These newer drugs are increasingly being prescribed by physicians,” says Chong-Gee Teo, MD, PhD. “They offer patients the likelihood of a cure from hepatitis C.” Rapid testing for the HCV antibody with similar sensitivity and specificity to bench testing has also become widely available in the last decade. In addition, there has been increasing evidence that many patients who are reactive to an HCV antibody test are not then tested for current HCV infection. As a result of these developments, the CDC updated its guidance on HCV testing and published it in the Morbidity and Mortality Weekly Report. Targeted Testing “The current CDC guideline is geared toward identifying current infection with hepatitis C,” says Dr. Teo, who co-authored the document. “Rather than targeting the HCV antibody as a marker of infection, the target of testing is now the actual HCV genome itself, or HCV RNA. This is a marker of the virus in the blood and, therefore, current infection.” The concern with focusing testing only on the HCV antibody is that this approach cannot distinguish between patients whose past HCV infection has resolved and those who are currently infected. A reactive result to an HCV antibody test can also be a false-positive. Accurate testing of current infection through HCV RNA testing helps identify patients who require preventive services, counseling,...
Taking a Proactive Approach to Diabetic Neuropathy

Taking a Proactive Approach to Diabetic Neuropathy

According to recent estimates, diabetic neuropathy accounts for about $50 billion in both direct and indirect costs associated with diabetes in the United States. “Diabetic neuropathy is one of the most common microvascular complications of diabetes,” says Cecilia C. Low Wang, MD, FACP. “It’s associated with major morbidity and can significantly reduce quality of life for patients.” Diabetic neuropathy occurs in about 60% of patients with diabetes at some point during their lifetime and is more common in those living with diabetes for a number of years. The condition is characterized by impairment of peripheral nerve axons, particularly in the limbs. Diabetic neuropathy often results from chronic hyperglycemia, regardless of the type of diabetes. There are several different types of neuropathy that patients with diabetes may experience, but the most common forms are distal symmetric or sensorimotor diabetic peripheral neuropathy (DPN) and autonomic neuropathy. With DPN, patients typically describe their symptoms as tingling, pain, numbness, or weakness that starts out in the feet and progresses to the hands at a much later stage. With autonomic neuropathy, orthostatic hypotension, blood pressure dysregulation, urinary retention, erectile dysfunction, and gastroparesis are among the clinical consequences of autonomic dysfunction. There can also be significant hypoglycemia unawareness. Diagnostic Considerations “Early recognition and appropriate management of neuropathy in patients with diabetes are important,” says Dr. Low Wang. She notes that a number of treatment options are available for symptoms of DPN but adds that these therapies do not treat the underlying mechanisms of the disease. The American Diabetes Association notes that up to 50% of DPN cases may be asymptomatic. These patients are at risk...
Managing Older Patients With HIV

Managing Older Patients With HIV

In 2015, more than half of people with HIV in the U.S. will be aged 50 or older, according to Wayne McCormick, MD, MPH. “By 2025, the median age is projected to be 60 years old.” The aging HIV population has been due in large part to the success of antiretroviral therapy (ART). “Unfortunately, ART has many side effects that need to be taken into account when managing patients with HIV,” says Dr. McCormick. “Even with successful ART, patients with HIV still have an inflammatory infection. As they live longer, questions are raised about how to manage the comorbidities that are associated with HIV as well as those associated with aging.” A Helpful Initiative To address the unique issues of aging patients with HIV, members of the American Academy of HIV Medicine, the AIDS Community Research Initiative of America, and American Geriatrics Society created and launched www.hiv-age.org. The website was designed by these trusted organizations to allow for ongoing discussion about clinical care and research around HIV and aging. It is also intended to provide ways to share new and emerging infor­mation in this area. The HIV-Age website can help clinicians who seek best practices to care for older patients with HIV as well as interested patients, advocates, and researchers. “We wanted this information to be ‘live’ on the web so that it can be a living document that is changeable based on the ongoing conversations and emerging knowledge,” explains Dr. McCormick. “When research is published in hard copy, it can sometimes become fixed in time. Having a dedicated website allows us to quickly and easily update and correct...

The ABIM Disallows Opposing Voices Regarding MOC

There is much controversy surrounding MOC (Maintenance of Certification) requirements. The American Board of Internal Medicine (ABIM) along with the American Board of Medical Specialties (ABMS) continue their stance imposing these duties upon doctors. Yet, 97% of physicians surveyed on Sermo (the largest online doctors-only community with over 300,000 members) oppose MOC as it currently stands. While life-long learning is very important in our profession, most of us feel MOC is not the way to achieve it. For one thing, we are already required to earn a certain number of CME hours in order to maintain our state medical licenses. So, there is a redundancy of work here. MOC is time-consuming, and many of us feel that the guidelines set in place have no relevancy to medicine in the real world. For learning to be effective, it needs to match the knowledge that is necessary in treating our patients in the exam room. Esoteric medical facts rarely come into play in clinical practice. Yet, that is much of what we are being tested on in our recertification exams. In fact, this past year I took my recertification exam and was expected to answer questions using outdated PAP test guidelines. “…we are not going away. We are seeking fairness and to abolish corruption in this process forced upon us.”   It is not just the time and lack of real world medical knowledge that we oppose but the cost. Doctors are forced to pay 10’s of thousands of dollars out-of-pocket for something we do not believe provides us any value. And we have no choice but to comply because our...
Comparing Approaches to ACL Tears

Comparing Approaches to ACL Tears

Value-based medicine has gained more attention in recent years, leading many providers and healthcare systems to focus on the cost effectiveness of services they offer. This focus is important in orthopedic surgery, where procedures like anterior cruciate ligament (ACL) reconstruction have high costs but can also potentially improve quality of life and functional ability. However, little is known about the cost-effectiveness of ACL reconstruction when compared with structured rehabilitation only. Making the Comparison For a study published in the Journal of Bone and Joint Surgery, Mininder S. Kocher, MD, MPH, and colleagues used a Markov decision model to perform a cost-utility analysis of ACL reconstruction. The authors compared this with structured rehabilitation in the short to intermediate term (6 years) and for the longer term (lifetime). “We analyzed direct benefits, such as health-related quality of life, and indirect benefits, such as increased productivity, decreased risk of additional injuries, and decreased risk of arthritis, which all have additional costs associated with them,” explains Dr. Kocher. Effectiveness was measured in quality-adjusted life years (QALYs). ACL reconstruction was about $4,500 less expensive, on average, and more effective in the short and intermediate term than rehabilitation only. Reconstruction was also less expensive for the long term, with average lifetime costs to society of $38,121 for reconstruction and $88,538 for rehabilitation. Also, ACL reconstruction provided an incremental QALY gain of 0.72 when compared with rehabilitation only. “A lower rate of subsequent instability with ACL reconstruction was the main factor driving the effectiveness gains seen with reconstruction,” Dr. Kocher explains. Subsequent instability of the knee results in poorer quality of life and knee function and...
Resistance Exercise for Knee OA

Resistance Exercise for Knee OA

Research indicates that knee pain occurring with movement due to osteoarthritis (OA) strongly predicts the need for functional assistance and is the second leading cause of disability in the United States. Muscle strengthening through resistance exercise is one of the treatment options for OA-induced pain. According to Kevin R. Vincent, MD, PhD, most patients with knee OA experience pain and therefore do not want to be active. “This causes the muscles around the joint to become weaker, making the joint less stable and ultimately causing patients to become less functional,” he says. “Self-efficacy often decreases when patients feel like they’re not as functional as they once were or as they lose confidence in their own capabilities.” Beyond the functional benefits of resistance exercise, there are other benefits of muscle strengthening to consider, such as psychosocial well-being, cognitive function, and self-esteem. “These factors can all improve with dumbbell sets and resistance exercise,” Dr. Vincent says. “There may also be decreases in anxiety, depression, and negative stress-related emotions.” Stronger muscles can also lower the blood pressure response to exertion and improve glycemic levels. Overall, patients who participate in resistance exercise programs tend to enjoy better outcomes with many of the other treatments used for knee OA. Getting Started Several factors must be taken into account before starting patients on resistance exercise programs. “The level of disease severity and the overall health of the patient should be considered,” says Dr. Vincent. “Physicians should understand the willingness and ability of patients to participate in these programs and then tailor them based on whether they’ll be exercising at home or in a fitness center.”...

Medicare Spends a Lot Unnecessarily

You may find this story hard to believe, but it’s true. A 75-year-old non-smoking man with no serious medical problems and a relatively low-risk family history [father, a life-long smoker, died of a stroke at age 76] has been undergoing routine physical examinations by his primary care physician in Florida every 6 months for several years. The visits include a full battery of laboratory studies, nearly all of which have been completely normal on every occasion. The patient told me that he has been on a statin for about 20 years. At the time it was started, his total cholesterol level was 201 mg/dL. After his last visit, the doctor told him to take his pill every other day because his most recent total cholesterol was 109 mg/dL. Can hypocholesterolemia cause health problems? No one knows for sure, but it has been associated with increased mortality in some studies. I’ve blogged before about the overuse of medical care, particularly Pap smears, in Florida. Why does Medicare pay for all these unnecessary tests and drugs? I can understand that they have no way of knowing that a statin was started and is being continued for no good reason. But what about the cost of the office visits and routine blood work every 6 months? It’s probably not much money per person, but of all the states, Florida has the greatest proportion of people who are at least 65 years old (17.3% in 2012). The population of Florida in 2012 was 19.32 million so it has 3.28 million people over the age of 65. I hesitate to do the math, but...
The Cardiology Workforce Supply

The Cardiology Workforce Supply

Previous workforce estimates implied that inadequate numbers of cardiologists were being trained to meet the needs of an expanding and older population of Americans. “There has been deep concern that a projected shortage in the cardiologist workforce could impact the care of patients with heart disease,” explains Patrick T. O’Gara, MD, FACC. “More recently, however, these forecasts have been called into question. Healthcare systems have shifted from volume-based care to value-based care. Both invasive and non-invasive procedural volumes have declined, as have the associated reimbursements. These trends have placed additional stress on providers and limited the hiring of newly graduating fellows, especially in geographically desirable locations.” A Multifaceted Problem Several factors are influencing the supply of cardiologists, including the aging and increasing population, the cost and duration of training, scientific advances, and the effects of the Affordable Care Act. There are also gender and racial/ethnic gaps in the cardiology workforce and geographic variations throughout the United States. Many cardiologists are practicing in major metropolitan areas, but there are fewer practicing in smaller towns and rural areas. “Many hospitals are rethinking how many cardiologists they need on staff, especially as they see their procedural volumes fall,” says Dr. O’Gara. “There is no longer the lack of invasively trained cardiologists as previously feared. It’s becoming more difficult for newly trained cardiologists to find attractive jobs. In addition, cardiologists are not retiring as rapidly as predicted.” Collaboration Needed to Find Solutions These problems affect all of cardiovascular medicine and are not easy to fix, according to Dr. O’Gara. “As a community, we need to ask where we’re going with the current training...
ICD Use in the Under-Represented

ICD Use in the Under-Represented

Implantable cardioverter-defibrillators (ICDs) have emerged as an important treatment option for select patients with heart failure, those with reduced left ventricular function, and individuals at risk for cardiac arrest or sudden cardiac death. “For years, these devices have served as an effective means of stopping life-threatening abnormal heart rhythms,” explains Venu Menon, MD. Recommendations on ICD use in clinical practice have been provided in guidelines sponsored by the American College of Cardiology (ACC), the American Heart Association (AHA), Heart Rhythm Society (HRS), and the European Society of Cardiology. However, recent guideline updates are lacking because most clinical trials tend to focus on the effectiveness of ICDs that provide cardiac resynchronization therapy (CRT) rather than outcomes of non-CRT defibrillators. “Although many patients have benefited from ICD implants, there are still groups who fall outside the standard guidelines for treatment,” says Dr. Menon. Smaller patient populations or unique circumstances are not typically provided with indications for treatment. As a result, guideline indications for ICD therapy are limited specifically to patients who would have been eligible for enrollment in clinical trials. “Clinicians are often asked to make decisions about ICD therapy for patients who were not included or who were poorly represented in prior clinical trials,” Dr. Menon says. “For these individuals, there are no specific indications for ICD therapy.” Addressing an Important Need In 2014, the ACC, HRS, and AHA released an expert consensus statement, published in the Journal of the American College of Cardiology, on ICD use in patients not included or not well represented in clinical trials. “The statement provides direction on ICD therapy that specifically targets patients who...
Including Gender in EM Research

Including Gender in EM Research

Emerging data have demonstrated the value of gender-specific approaches in evaluating and managing health conditions, but it is unknown if emergency medicine (EM) has embraced the concept of ensuring that women are included in clinical research and that health outcomes are analyzed by gender. “Medical literature is filled with examples illustrating the differential effects of diseases and treatments on men and women, ranging from life-threatening conditions to public health issues,” says Basmah Safdar, MD, FACEP. “Gender medicine is not restricted to issues of women’s health and isn’t limited to reproductive organs, or the so called ‘bikini medicine.’ Emergency physicians are uniquely positioned to investigate and translate data into life-saving outcomes for both men and women.” A Closer Look In a study published in Academic Emergency Medicine, Dr. Safdar and colleagues assessed whether the effect of gender on health outcomes was examined in published EM studies. The majority of EM studies reviewed (79%) reported gender as part of the demographic composition of its participants. From 2006 to 2009, there was a 5% increase in the number of articles that analyzed the effect of gender on health outcomes. However, only 11% of the 750 original studies reviewed in the analysis included gender as a control variable, and 18% included gender as an independent variable. “Overall, just 2% of studies included gender in the primary hypothesis,” adds Dr. Safdar. Another 21% of EM studies did not even list the gender of participants. Use of gender in the analysis did not differ between NIH-funded studies versus non–NIH-funded studies. More Effort Needed “EM needs to make a more concerted effort to ensure that studies...
Protocols Mean No One Has to Think

Protocols Mean No One Has to Think

Let me say up front that I do not object to protocols in principle. I have been responsible for the development of several protocols, both for trauma and for critical care. At their best, protocols serve as guidelines and memory aides prompting us to do the right thing to help and protect our patients. They can be powerful reminders and guides for those who don’t often deal with a particular problem, or conversely, may keep those of us for whom certain critical interventions are routine from becoming complacent. I do object to protocols that take the place of critical thinking, especially when that is coupled with an electronic medical record that forces the physician to follow a checklist. Recently, this was brought home during an episode at my primary hospital. My patient was a 59-year-old man who had under gone a laparoscopic assisted right colectomy. He was a two pack a day smoker and had some modest high blood pressure. He did well with surgery and the initial postop period. On day 3 however, he became hypoxic (low oxygen saturation in the blood), had some tachycardia (rapid heart rate) and had a little confusion. This was enough to trigger a “sepsis alert.” Severe sepsis is an inflammatory response to severe infection. It is an exaggerated expression of the fever and normal inflammation that accompany an infection. It can cause a cascade of low blood pressure, fever, poor tissue perfusion and acidosis leading to organ failure and death. The sepsis initiative is designed to improve outcomes by identifying patients with early sepsis and providing physicians with a standard set of...
Neck Manipulation & Stroke Risk

Neck Manipulation & Stroke Risk

Cervical dissections (CD) of the arteries—small tears in the layers of the arterial walls in the neck—are an important cause of stroke in young and middle-aged patients. CD can result in ischemic stroke if blood clots form after a trivial or major trauma in the neck and later cause blockages to the blood vessels in the brain. “CD accounts for just 2% of all ischemic strokes but 8% to 25% of strokes in patients younger than age 45,” says José Biller, MD, FAAN, FACP, FAHA. “The annual incidence, however, is likely underestimated because asymptomatic CD often goes undiagnosed.” Currently, the underlying pathology for spontaneous CD is unknown, but several factors have been linked to CD (Table 1). Dissections can be either spontaneous or traumatic, and their severity can vary. Research has shown that mechanical forces often play a role in a considerable number of CDs. “Most dissections involve some form of trauma, stretching, or mechanical stress,” says Ralph L. Sacco, MD, MS, FAHA, FAAN. These dissections can also occur with cervical manipulative therapy (CMT), various sporting activities, whiplash injuries, sudden neck movements, and violent vomiting or coughing, even if these events are deemed inconsequential by patients. Although CMT techniques vary, maneuvers often extend and rotate the neck, and some involve a forceful thrust. New Recommendations In 2014, the American Heart Association (AHA) released a scientific statement on CD and its association with CMT. “The statement reviews the current state of evidence on diagnosing and managing CDs and their statistical association with CMT,” says Dr. Sacco, who co-chaired the AHA writing committee that developed the scientific statement. “The association between...
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