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Intensive Lifestyle Interventions: Assessing the Impact

Intensive Lifestyle Interventions: Assessing the Impact

The number of adults who are overweight or obese and have type 2 diabetes is increasing rapidly throughout the United States. An estimated 35% of Americans are obese, and the number of U.S. diabetes cases has steadily risen to nearly 30 million. Alone, both obesity and diabetes can significantly increase healthcare costs, but these costs rise further when obesity and diabetes coexist. “It’s clear that strategies are needed to prevent obesity and diabetes, but it’s also important to improve how these conditions are managed when they develop,” says M. Sue Kirkman, MD. In recent years, clinical trials have been launched to test intensive lifestyle interventions (ILIs) aimed at promoting long-term weight loss and increasing physical activity. These interventions are recommended for overweight and obese individuals with type 2 diabetes. “ILI provides patients with education, support, and follow-up so that they can incorporate changes into their daily lives and overcome potential hurdles to healthy eating and exercise,” explains Dr. Kirkman. However, while it has been assumed that ILI can reduce healthcare costs, few studies have examined the long-term effects of these interventions on costs among obese patients with diabetes. Examining Long-Term Effects The Action for Health in Diabetes (Look AHEAD) study is a randomized clinical trial that has sufficient size and duration to test whether ILI influences long-term healthcare use and costs. A recent study in Diabetes Care was conducted in more than 5,000 overweight or obese adults with type 2 diabetes who participated in the Look AHEAD study. Patients were randomly assigned to an ILI that promoted weight loss or to a comparison group of diabetes support and education...
The Sensitive Subject of HIV Treatment Side Effects

The Sensitive Subject of HIV Treatment Side Effects

Antiretroviral therapy (ART) is essential to keeping HIV from replicating and further infecting CD4 lymphocytes. When taken as prescribed, these medications have significantly increased life expectancy over the past 25 years. HIV has shifted from being an infection with dire consequences to one that is considered a manageable, chronic condition when treated with ART. Dealing With Side Effects While the benefits of modern combination ART (cART) treatments have been well documented, so too have their potential to cause side effects. Some side effects are easily managed, but others—such as insomnia, gastrointestinal abnormalities, fatigue and rashes—can be much more severe for patients. Some may only be present during the first month or two of starting cART treatment while the body adapts to the medication. When side effects become too burdensome, adherence to cART regimens can diminish, leading to serious consequences and putting patients at risk for developing resistance to the components of cART. Poor adherence can also lead to ongoing replication of HIV and subsequent loss of CD4 lymphocytes. Patients may fail to notify their doctors when side effects become so severe that they stop taking their medications. To prevent this non-disclosure, it’s important to establish a clear line of communication as patients begin treatment. Patients should be instructed to be vigilant about any changes in their regular bodily functions and counseled to contact their physician immediately to determine if their treatment is causing any of these changes. Tackling That Sensitive Subject Whether they feel embarrassed or simply that it’s inappropriate, patients may avoid talking openly about side effects like diarrhea. With this in mind, there is an underscored importance...
Examining Why HIV Patients Discontinue ART

Examining Why HIV Patients Discontinue ART

Discontinuation of antiretroviral therapy (ART) among patients with HIV has been found to lead to virologic failure, drug resistance, and onward HIV transmission. “It’s imperative that we understand how many patients in the United States discontinue treatment, why they stop, and which patients are more likely to do this,” says Alison J. Hughes, MPH. “This information can allow us to more effectively target interventions to increase treatment persistence and optimize outcomes of people living with HIV.” New Data For a study published in the Journal of Acquired Immune Deficiency Syndromes, Hughes and colleagues conducted interviews with, and reviewed medical records for, a nationally representative sample of HIV-infected adults receiving HIV care from 2009 to 2010. The research team examined patient characteristics of ART discontinuation—defined as not currently taking ART—based on whether discontinuation was provider- or non–provider-initiated. “The good news was that 93% of patients in HIV care had initiated ART,” says Hughes. “However, of those who initiated ART, nearly 6% discontinued treatment, representing about 22,000 adults in the U.S.” Nearly half of patients reported that their healthcare provider had recommended treatment discontinuation. “We speculate that the high rate of provider-initiated discontinuation reflects treatment guidelines that were in place at the time, which recommended ART only for patients with a CD4 count less than 350 cells/mm3,” adds Hughes. The researchers also found that certain patients were more likely to stop treatment than others (Table). “Younger age, female gender, not having continuous health insurance, incarceration, injection drug use, and a high CD4 cell count were all associated with treatment discontinuation,” explains Hughes. “Unmet need for supportive services, no care in the...

Judgments

About five in the afternoon on a weekday trauma shift we got a call from Native Air, a helicopter medical transport service, about a 17-year-old they were bringing us with multiple fractures sustained in an ATV crash. The accident happened way up in the northern part of the state near St. Johns, a ranching community that borders the Navajo reservation. His vital signs were stable, and they had medicated him for pain and would arrive in 10 minutes. The trauma team assembled in the bay closest to the elevator from the helipad. About 9 minutes later the elevator doors opened and the helicopter crew wheeled our patient in on their flight gurney. I took one look at the patient and cursed under my breath. He had a triangular face with a broad forehead and narrow jaw and chin. His chest was wide and deep, barrel-shaped is the term. His limbs were painfully thin with knobby joints and marked curvature of the long bones, those that weren’t already splinted. His eyes were striking—deep blue, and the sclera, the white of the eyes, were the color of a new robin’s egg. All the markers of Osteogenesis Imperfecta. What the hell was he doing on an ATV? Osteogenesis Imperfecta, also known as ‘brittle bone disease,’ is a genetic disorder, a gene mutation that causes defective collagen synthesis. It may vary in severity, but the classic expression causes weak bones that can break under the patient’s own weight. A sneeze can break ribs. A simple stumble can result in a broken hip or ankle. Patients usually end up confined to wheelchairs by their...

Physicians Underutilize Effective Screening Methods to Detect Alcohol Misuse by Patients

Excessive alcohol use adversely affects an estimated 38 million (30%) adults in the United States, but surprisingly, only 1 out 6 say they talk to their doctor, nurse, or healthcare professional about drinking (1). More than 30 years of research has shown the impact that alcohol screening and brief counseling have—they can reduce the quantity of alcohol consumed on one occasion by 25% (2). Besides any alcohol consumption by individuals under the age of 21 or by pregnant women, unsafe drinking is defined as drinking five drinks per event for men or four drinks for per event for women (3). Similar to how blood pressure or breast cancer screening save lives, alcohol screenings also can reduce the number of adults who are negatively impacted by risky drinking habits. The Centers for Disease Control and Prevention (CDC) reported earlier this year that drinking too much claims about 88,000 lives each year and costs the economy $224 billion in 2006 (4,5). The health and social repercussions of high-risk alcohol consumption are valid public concerns, particularly to the medical community who are in a position to discourage this unhealthy behavior. Together we as physicians can proactively work towards lessening problem drinking by utilizing effective and validated questionnaires in our daily medical practices. We then can identify signs of developing substance use disorders (SUD) before the patient develops overt alcoholism or drug dependence. Two Straightforward Alcohol Screening Tools to Help Physicians Discover a Fuller Spectrum of Problem Drinking As we strive to care for the maximum number of patients in our allotted schedules, it may seem like a daunting task to add another...

My Paper Was Published. Did Anyone Read It?

An orthopedist asked me if I could explain why a couple of papers of his did not generate any feedback. He wasn’t even certain that anyone had read them. He enclosed PDFs for me. Not being an orthopedist, I cannot comment on their validity. But I think I can explain why the papers have not created much interest. Are you familiar with the term “impact factor”? If not here is a link explaining what it is: A journal’s impact factor is an indication of how widely cited its articles are. One can also assume that it is a good indication of how popular the journal is and by inference, how many people read its papers. The impact factor has been criticized, but it is one of the few measures of a journal’s influence. The two papers in question were published in Orthopaedics & Traumatology: Surgery & Research. A list of the top 40 orthopedic journals ranked by impact factor in 2013 showed that it ranked 39th with an impact factor of 1.168. [link] That means the average number of citations for any paper published in OTSR was about 1, and 38 orthopedic journals were more widely cited than OTSR. Some search engines (eg, Google Scholar) give the number of times that a paper has been cited and by whom. But a recent article claims that that 90% of published papers are never cited, and 50% are never read by anyone but the authors and the journals’ peer reviewers. That assertion can’t be verified, but it is probably close to the truth. I was unable to obtain any figures regarding...
Protocol-Based Care for Septic Shock

Protocol-Based Care for Septic Shock

Until recently, the hospital mortality of patients with severe sepsis and septic shock was 50%. In 2001, a single-center ED study found that mortality in patients with severe sepsis or septic shock was significantly lower among those treated according to a 6-hour protocol of early goal-directed therapy (EGDT) than for those receiving standard therapy. That study involved a specific protocol in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets. “Many wondered if all the EGDT steps were needed and if changes in critical illness care have since altered the impact of the catheter-guided sepsis care,” says Donald M. Yealy, MD. To address this question, Dr. Yealy and colleagues designed a multicenter trial comparing alternative resuscitation strategies in patients with septic shock. Published in the New England Journal of Medicine, the study tested whether protocol-based resuscitation was superior to usual care. They also tested whether a protocol with central hemodynamic monitoring to guide treatments was superior to a simpler protocol that used bedside exams to trigger care. “We wanted to see if we could achieve better outcomes by simply recognizing septic shock early and treating it aggressively with fluids and vasopressors absent a catheter-based algorithm,” says Dr. Yealy. Key Findings Conducted in 31 U.S. EDs and in 1,351 enrollees, Dr. Yealy and colleagues randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: 1. Protocol-based EGDT given by a dedicated two-person team. 2. Protocol-based standard therapy by the same team that did not require the placement of a central venous catheter, administration ofninotropes, or blood transfusions. 3....
Identifying Patients With Problematic Drug Use in the ED

Identifying Patients With Problematic Drug Use in the ED

According to the Drug Abuse Warning Network, 2.5 million of the 5.1 million drug-related ED visits nationwide in 2011 were directly related to the use of illicit substances, non-medical use of pharmaceuticals, or a combin-ation of the two. In 2008, researchers found that the total annual cost of illicit drug use was about $151.4 billion. Medical care costs alone account for $5.4 billion of that total annual cost, not including costs for substance use treatment. “Studies have shown that drug users are more likely to use the ED for their medical care and are more likely to require hospitalization than those who don’t use drugs,” says Wendy L. Macias-Konstantopoulos, MD, MPH. The American College of Emergency Physicians and other organizations have recommended using screening, brief intervention, and referral to treatment (SBIRT) in the ED for problematic alcohol use. Many studies have demonstrated the effectiveness of SBIRT for alcohol use, but its effectiveness in addressing problematic drug use may also be promising, especially if implemented in ED settings. The challenge with addressing drug use disorders in the ED is that these problems are often difficult to detect, says Dr. Macias-Konstantopoulos. “Patients tend to deny or underreport illicit drug use,” she says. “If we can improve our ability to identify patients with drug use problems, we have an opportunity to mitigate the subsequent health effects.” New Data In a study published in Annals of Emergency Medicine, Dr. Macias-Konstantopoulos and colleagues sought to identify characteristics that were associated with problematic drug use in ED patients who reported drug use during the past month. Using previously validated tests, investigators prescreened more than 15,000...
Expert Recommendations for Below-the-Knee PAD

Expert Recommendations for Below-the-Knee PAD

Infrapopliteal (IP) arterial disease, also known as “below-the-knee” or tibial disease, is a condition commonly seen in the elderly or patients with long-standing diabetes or chronic kidney disease. One of the most concerning manifestations of peripheral arterial disease (PAD) in these high-risk patients is the development of critical limb ischemia (CLI), a painful and chronic condition that can lead to amputation. As the population ages and number of patients with diabetes rises, the rate of CLI is expected to increase. The incidence of obesity and diabetes is increasing, which in turn has increased the number of patients with PAD in the arteries of the limbs. Oftentimes, the IP arterial bed is calcified and has diffuse, multilevel disease. “There is a paucity of scientific evidence for the generalizability of percutaneous revascularization in these patients,” explains Bruce H. Gray, DO, FSCAI. “This is due to the complexity of the patient population, their comorbidities, and the severity of vascular disease.” In general, guidelines have recommended that non-ambulatory patients with a short life expectancy and extensive necrosis or gangrene undergo primary amputation. Surgical bypass can be considered for ambulatory patients who are acceptable candidates for surgery, which includes those who are expected to survive more than 2 years with a patent IP artery that provides direct flow to the foot and those with an adequate autologous venous conduit. Use of endovascular approaches should be considered first-line therapy for patients: ♦ With significant medical comorbidities that limit life expectancy. ♦ At increased risk for surgery. ♦ Without an adequate distal target for bypass. ♦ With poor venous conduit. Coming to a Consensus In 2014,...
Refining Neurosurgery Practices

Refining Neurosurgery Practices

The American Association of Neurological Surgeons and the Congress of Neurological Surgeons recently joined the American Board of Internal Medicine’s Choosing Wisely campaign with their own list of five practices to avoid in neurosurgery. “The purpose,” says Daniel K. Resnick, MD, “is to alert patients and physicians to common practices that may not be necessary or efficacious.” The Recommendations 1) Do not administer steroids after severe traumatic brain injuries. According to Dr. Resnick, high-quality studies from the last 20 years demonstrate that although steroids decrease intracranial pressure, they are also associated with several side effects. “The net effect of steroids in patients with severe head injuries is a negative one,” he says. 2) Do not obtain imaging (plain radiographs, MRI, CT, or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags. “Decades of experience and hundreds of papers indicate that the chance of finding an issue on imaging that would need to be addressed in patients with acute low back pain but without certain red flags is miniscule,” says Dr. Resnick. “Such imaging leads to unnecessary spending and is a hassle for patients. It often discloses information that is irrelevant and causes angst for patients. It could also lead to needless referrals to surgeons and may promote fear/avoidance behaviors in patients.” 3) Do not routinely obtain CT scans in children with mild head injuries. CT scans expose children to radiation, which has been shown in these patients to increase risks for the later development of cancer, explains Dr. Resnick. “CT should be reserved for children with severe injuries or neurological...
Assessing the Surgical Care of Breast Cancer

Assessing the Surgical Care of Breast Cancer

Clinical trials have shown that survival rates appear to be similar for patients with early-stage breast cancer who are treated with breast-conserving surgery and radiation or with mastectomy. “However, recent studies have indicated that the use of mastectomy is increasing, particularly bilateral mastectomy, among women in the United States with breast cancer,” says Allison W. Kurian, MD, MSc. Typically, bilateral mastectomy is considered both a treatment for the affected breast and a prevention measure for the contralateral breast. Bilateral mastectomy is increasingly being used to treat unilateral breast cancer despite the absence of evidence showing that it offers a survival benefit to the average woman with breast cancer. Bilateral mastectomy has been shown to be an effective secondary prevention strategy for high-risk women with BRCA1/2 mutations, but the procedure may also have detrimental effects. These include higher risks for complications, increased costs, and a negative impact on body image and sexual function. “We need a better understanding of the use of bilateral mastectomy and outcomes associated with its use to improve cancer care,” Dr. Kurian says. A Comprehensive Analysis In a study published in JAMA, Dr. Kurian, Scarlett Gomez, PhD, and colleagues compared the use of bilateral mastectomy, breast-conserving therapy (lumpectomy) with radiation, and unilateral mastectomy and the mortality associated with these procedures. The goals were to determine if there were particular types of patients who were likely to receive a bilateral mastectomy and find out if there were relative differences in mortality among the three procedures. “We could address these questions because we used data from the California Cancer Registry, which covers almost all women diagnosed with breast...
Living for Yourself, Prioritizing Your Needs

Living for Yourself, Prioritizing Your Needs

Research indicates that physicians tend to put the needs of their patients before their own. “We’re never taught that we’re allowed to put any of our own needs first, or even that it’s sometimes healthy to do so,” says Robb Hicks, MD. “Unfortunately, this perception often continues when physicians are developing and maintaining a practice because it requires being as available to patients as possible.” Understanding Priorities Dr. Hicks says that physicians must ensure that their own needs are being met in order to be the best providers for their patients. “That means that physicians must prioritize their time and energy,” he says. “This requires us to put some of our own needs before those of our patients.” Providers who are unable to find a work–life balance are likely to burn out and make mistakes. “While we shouldn’t put all our needs first, we must make daily efforts to maintain our own physical, mental, spiritual, and emotional health,” Dr. Hicks says. “The key is to figure out what things are truly needs, and which are simply desires.” Once there is an understanding of priorities in their life, physicians must notice when their thoughts or behaviors are not consistent with their priorities. “It’s important for physicians to recognize when they sacrifice time with their spouse or their children, or when they give up their routine activities because of work obligations,” says Dr. Hicks. “This is when their priorities have become confused or are out of sync.” Making Positive Changes Recognizing that changes are needed and making these changes are two different things, according to Dr. Hicks. “The inability to create...
The Top 10 Heart Un-Healthy Industries

The Top 10 Heart Un-Healthy Industries

The below table depicts the prevalence of a history of coronary heart disease or stroke among employed adults aged 55 or older, by industry, from 2008 to...
Top Documenters

Top Documenters

The Joint Commission on Accreditation of Hospitals and Healthcare Organizations (JCAHO) has recently named the hospital where I do much of my elective surgery a Top Performer. This means that it met ‘performance standards’ (JCAHO terminology) in key areas of patient care such as pneumonia, heart attacks, heart failure, and surgical care. It sounds great and is being publicized by the hospital marketing people. Does this mean that the hospital actually delivers high quality care? Maybe. Certainly in some areas I am pleased with the care my patients get. But these performance measures correlate poorly with outcomes, as has been shown in several papers critical of the guidelines that make up the measures. The guidelines are supposed to represent evidence-based best practice for specific conditions and to enhance patient safety. I can’t speak for the Internal Medicine based guidelines such as pneumonia care or heart failure, but at least in the surgical arena, the guidelines used by JCAHO have been demonstrated pretty conclusively to be at best clinically irrelevant. They have not shown any demonstrable improvement in surgical site infection or measurably enhanced surgical care. The few studies where enhanced safety or improved outcomes have been shown started with baselines that were below average relative to national standards. It isn’t hard to improve when you are already performing below the national average, and boosting your stats to average doesn’t prove that the guidelines will improve those centers that were already top performers. “The emphasis is on compliance with the protocol, not on the critical assessment of what the patient actually needs.”   Meanwhile, thousands of person-hours are spent documenting...
Will Corporate Greed Destroy Our Healthcare System?

Will Corporate Greed Destroy Our Healthcare System?

In 2013, the CEO of Aetna earned $33.7 million dollars. The average health insurance CEO salary was over $10 million in that same time period. While many will say that is capitalism at work, I really wonder, as I fight to get another MRI covered for a patient, how many MRI’s were denied to generate that kind of salary? And 2014 saw great increases in member enrollment in insurance plans under the ACA. Profits for these plans jumped up 10’s of millions of dollars. My patients are suffering. They cannot afford the premiums they are now forced to pay, often against their will. They cannot afford the high deductibles most of these plans now carry. I have seen patients decide between two needed medications and which of their family members was the sickest to take to the doctor. They could not afford both. Every day, I am seeing more and more diagnostic tests and procedures being denied by insurance companies. I spend hours a week fighting these denials. Most insurance companies have now limited their formularies to exclusively generics. And even so, the expensive generics, such as life-saving asthma inhalers, are being denied. My patients are struggling to afford their healthcare. Many are suffering from bad medical consequences because they cannot afford to get the medical care that they need. I have sent more than one asthmatic patient to the ER who had a severe exacerbation of their disease because their inhaler was too expensive and no longer covered by their insurance plan. “We need to consider cost but not at the expense of the patient.”   While patients...

What Is the Best Way to Die?

A couple of recent articles about dying by well-known physician-authors attracted a lot of media attention. In October 2014, 57-year-old Ezekiel J. Emanuel, writing in The Atlantic, gave a number of reasons why he hoped he would die at the age of 75. He said by then he “will have lived a complete life.” His kids will all be on their own and have had their own children. He doesn’t want to be “feeble, ineffectual, even pathetic.” An anecdote about his own 77-year-old father’s heart attack and bypass surgery described how the man swims, reads newspapers, lives independently with his wife, and is happy. I think many of us would take that scenario if offered to us when we reach that age. But Emanuel was concerned because his father is “sluggish” and not living “a vibrant life.” Emanuel isn’t just worried about becoming sluggish; he’s worried about thinking more slowly and losing his creativity. He goes on and on in this vein. He said he will not commit suicide, but he will stop trying to prolong his life with screening tests [although many would argue that omitting screening tests might actually prolong one’s life] and would not have a cardiac stress test, a pacemaker, or an implantable defibrillator. He said he would even refuse a flu shot and would not accept treatment should he develop cancer. This segues nicely into the second article, “Dying of cancer is the best death” by Richard Smith, a former editor of the BMJ. His premise is that the choice of most people—sudden-death—is fine for the decedent but difficult for the survivors. There may...
Handling Risk

Handling Risk

“For sheer unadulterated ego, no one is a match for fighter pilots. Except maybe surgeons. Surgeons are in a class by themselves.” Tom Wolfe, The Right Stuff The popular perception of surgeons is similar to the popular perception of fighter pilots. Arrogant self-confidence, disdain for thoughtful planning and reflection, quick to take action—‘shoot first, ask questions later,’ reckless courage in the face of danger, all are considered typical of the personality type. Like all stereotypes, there is an element of truth behind the perception. Both surgeons and fighter pilots do jobs that are inherently unnatural. There is nothing ‘natural’ about flying a machine at speeds faster than the sound made by its own engines. There is nothing ‘natural’ about cutting into another human being’s body and rearranging its anatomy. Performing at a high level in these arenas requires a special kind of confidence in one’s own ability and judgment, a confidence that is often mistaken for arrogance. The willingness to take action in the face of uncertainty, to make irrevocable decisions based on incomplete information, is often mistaken for recklessness. Acceptance of personal responsibility for the consequences of those actions may be mistaken for a disdain for cooperative effort. “The ability to tolerate risk and to mitigate it to the extent possible is the mark of a good surgeon.”   I know several former fighter pilots. They’d all make good surgeons. And contrary to the popular perception, they are some of the most conservative and risk averse people I know. I don’t mean politically conservative, although most surgeons and pilots tend to identify with that end of the political...
Lost & Found

Lost & Found

“It’s a doctor’s bag, and inside is this container full of marijuana for medicinal use...
Enhancing Quality in the Pediatric Cath Lab

Enhancing Quality in the Pediatric Cath Lab

According to published estimates, about one in 110 babies in the United States is born with congenital heart disease. On the surface, the incidence of the disease is relatively low, but the consequences can be profound. New, rapidly evolving interventional treatments are extending lives and enhancing the quality of life for children living with congenital heart disease. These advancements are driving a need for quality tools that are specific to pediatric interventional cardiology. In 2014, the Society for Cardiovascular Angiography and Interventions (SCAI) unveiled a new resource that is designed to help pediatric cardiac catheterization laboratories continuously improve care. The resource—called the Pediatric SCAI Quality Improvement Toolkit, or Pediatric SCAI-QIT—provides clinicians with a comprehensive toolkit that complements the adult SCAI-QIT for catheterization laboratories. Introduced by SCAI in 2011, the adult SCAI-QIT features regular updates on continuous quality improvement, accreditation, peer reviews, measurement, public reporting, and patient and physician education. Fulfilling a Need “Pediatric quality improvement requires specific tools and resources that are tailored to the unique medical needs of children,” says Henri Justino, MD, FSCAI, who is also chair of the Pediatric SCAI-QIT. “The toolkit was created by the cardiology community to help cardiologists optimize care for children with congenital heart disease.” The Pediatric SCAI-QIT includes four modules: 1. Catheterization Conferences: Addresses communication that should occur in catheterization laboratories. 2. Procedural Checklists: Reviews action items before, during, and after catheterization procedures. 3. Radiation Safety: Describes the rationale and strategies for reducing radiation exposure to patients and staff. 4. Procedural Quality: Discusses the rationale and overriding goals of quality improvement. “The modules are flexible so that each institution can adopt...
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