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Sphincter Blues

“One of life’s underappreciated pleasures is the filling and emptying of one’s hollow viscus.” —attributed to Samuel Johnson, but maybe not. Admit it, we all love filling our tummies, that much is obvious. But isn’t a good bowel movement also a pleasurable sensation? Yes, it’s inconvenient, and we’re taught from childhood that it’s somehow nasty and not to be talked about. If you’re honest with yourself, though, you’ll admit that the time you get to spend sitting by yourself in the bathroom getting rid of what your digestive system is casting off can be a pleasant experience. Our fecal continence, being able to hold everything in until the time is right, is a complex system integrating both voluntary and involuntary muscles, sensory nerves, and some of the densest collections of touch receptors in the entire body. There are more pressure and temperature receptors in the anal skin than in the fingertips. An old joke tells of a Hand Surgeon and a Colon Surgeon debating the relative importance of their areas of specialization. The Hand Surgeon waxes poetic about how hands can do everything from hard labor to playing a sonata to gently comforting a crying baby. The Colon Surgeon then has the Hand guy cup his hands. The Colon guy then fills them with his dinner—roast beef chunks, mashed potatoes and gravy. Then he tells him, “Now open your fingers and just let gas through.” That’s what our anal sphincters do every day. Sometimes, surgeons like me are forced to pervert this natural process by the creation of a colostomy or ileostomy, pulling the intestine through the abdominal wall...

Reducing Attrition Rates: Finding True Grit

In case you haven’t noticed, a hot new topic in education is “grit.” In order to reduce the long-standing 20% attrition rate of surgical residents, some say we should select applicants who have more conscientiousness or grit. A few months ago, a paper reported that surgery residents who dropped out of programs had decreased levels of grit as measured by a short-form survey. But due to unexpectedly low attrition rates in the programs participating in the research, the study was underpowered to show a significant difference in outcomes of high- vs low-grit individuals. It’s hard to argue with the premise that choosing applicants with high reserves of grit might lead to better retention and performance of residents. I blogged about this 3 years ago in a post called “Harvard says train residents and medical students like Navy SEALs.” Unfortunately, identifying who has grit will be much more difficult than simply testing those applying for surgical residency training. Below is the 8-item grit survey, which is scored on a 1 to 5 Likert scale. 1. New ideas and projects sometimes distract me from previous ones 2. Setbacks don’t discourage me 3. I have been obsessed with a certain idea or project for a short time but later lost interest 4. I am a hard worker 5. I often set a goal but later choose to pursue a different one 6. I have difficulty maintaining my focus on projects that take more than a few months to complete 7. I finish whatever I begin 8. I am diligent The survey is rather easy to “game.” You can take it online and...
When Surgery Requires a Physician Assistant

When Surgery Requires a Physician Assistant

In collaboration with 15 specialty surgical organizations, the American College of Surgeons (ACS) has published and released its seventh edition of Physicians as Assistants at Surgery. The report is meant to provide guidance to CMS and third-party payors on how often an operation might require the use of a physician as an assistant. According to the ACS, a physician as an assistant during an operation should be a trained individual who can participate in and actively assist surgeons in completing surgeries safely. However, when surgeons are not available to serve as assistants, a qualified surgical resident or other qualified healthcare professional—such as a nurse or physician’s assistant with experience in assisting a procedure—can be used. The Update To update the report, each participating organization reviewed the 2012 and 2013 American Medical Association (AMA) Current Procedural Terminology (CPT) codes that were applicable to their specialty and classified by the CPT as “surgery.” The result was the addition of 107 new codes to the report, as well as the revision of 74 previously included codes. “CMS asks the specialty societies to make comments as to whether the surgical procedures for which the codes are assigned are appropriate for a physician assistant,” says Mark Savarise, MD, FACS, who served as ACS’s alternate advisor to the AMA CPT editorial panel. “In 2013, new codes came out for the use of skin substitutes, for instance, so those codes had to be reviewed.” Dr. Savarise notes that a slight discrepancy exists between the ACS and CMS. “The ACS and surgical specialty societies keep lists for procedures that require physician assistants and classifies them as ‘almost...
Arrival Times & STEMI Outcomes

Arrival Times & STEMI Outcomes

For patients that are presenting with ST elevation myocardial infarction (STEMI), national guidelines recommend that the door-to-balloon time be less than 90 minutes. “The problem is that when patients present to the hospital with a STEMI in the middle of the night, there may be delays in care,” explains Jorge F. Saucedo, MD. Studies have suggested that STEMI patients who present during off-hours—weeknights, weekends, and holidays—have slower reperfusion times. “A greater emphasis has been placed on providing quality care 24/7 for STEMI,” says Dr. Saucedo. It remains unclear, however, if patients who present during off-hours receive similar quality care to those who present during on-hours. A Closer Look In a study published in Circulation: Cardiovascular Quality and Outcomes, Dr. Saucedo, Tarun W. Dasari, MD, and colleagues compared the care provided and survival outcomes for more than 27,000 STEMI patients arriving during off-hours with nearly 16,000 such patients who arrived during regular business hours at 447 hospitals in the United States. The analysis revealed that STEMI patients arriving during weeknights, weekends, and holidays had a 13% higher mortality risk when compared with those arriving during on-hours. “Overall, the in-hospital all-cause mortality was similar at slightly more than 4% for both groups, but the risk-adjusted all-cause mortality was higher for those who presented during off-hours,” Dr. Saucedo says. Importantly, time of day was not associated with delays in aspirin administration, electrocardiogram tests, or intravenous clot-busting medications. However, the average door-to-balloon time was 56 minutes for those receiving care during on-hours, compared with 72 minutes for off-hour STEMI patients. “About 88% of on-hour patients achieved door-to-balloon times of less than 90 minutes,...
Screening for Delirium in EDs: Seeking Validation

Screening for Delirium in EDs: Seeking Validation

About 10% of older adults who seek care in EDs throughout the United States experience delirium. The condition can foretell other health issues and causes distress to patients and caregivers. Delirium also puts patients at increased risk for poor outcomes. Studies indicate that the condition adds between $38 billion and $152 billion annually to healthcare expenditures in the U.S. Patients who are discharged home from the ED with unidentified delirium have 6-month mortality rates that are nearly three-fold higher than those of counterparts whose delirium is detected in the ED. However, studies show that emergency providers identify delirium in only 16% to 35% of cases. The Heart of the Issue Unrecognized delirium in older adults presents a major health challenge and increases the burden placed on the healthcare system. Several screening instruments have been developed to identify delirium in various settings, but the ED is a unique environment because of intense time demands and high patient volume. Caring for adults with delirium in the ED setting is challenging and requires a separately evaluated screening instrument for the condition. For a study published in Annals of Emergency Medicine, Michael A. LaMantia, MD, MPH, and colleagues conducted a systematic review of existing studies on delirium in EDs to determine why the condition is so frequently undiagnosed in older adults. “We sought to determine whether any standardized instruments had been well studied for identifying delirium in the ED,” says Dr. LaMantia. Information was collected on a range of studies performed using seven delirium screening tools in the ED environment. These included the: 1. Confusion Assessment Method (CAM). 2. CAM-ICU. 3. CAM-ED. 4....
An Update on Secondary Stroke Prevention

An Update on Secondary Stroke Prevention

In 2014, the American Heart Association/American Stroke Association (AHA/ASA) updated guidelines for secondary prevention in patients with ischemic stroke or transient ischemic attack (TIA). “These guidelines are updated every few years so that clinicians can stay up to date on the most current research on strategies to maintain a low risk of recurrent events,” explains Walter N. Kernan, MD, who chaired the AHA/ASA writing group that updated the recommendations. The document, which was published online in Stroke: Journal of the American Heart Association, was last updated in 2011. After an initial ischemic stroke or TIA, 3% to 4% of affected patients will have a new ischemic stroke each year. “This figure is historically low because careful attention has been paid to using science-based interventions for secondary prevention,” says Dr. Kernan. “However, the scientific developments in the area of secondary prevention for stroke and TIA are accumulating rapidly. As a result, guideline updates are needed at least every few years.” New Features The updated guidelines include new sections on nutrition and sleep apnea (Table 1) and revisions of several other sections, including those dealing with hypertension, dyslipidemia, diabetes, carotid stenosis, and atrial fibrillation (AF). Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances. These include aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. The AHA/ASA document also has made it easier for clinicians to recognize new changes to the guidelines by including a table that details the major additions and revisions. Using the Guidelines “For clinicians who use...
CVD & Stroke: Examining Hospitalization & Mortality Trends

CVD & Stroke: Examining Hospitalization & Mortality Trends

Over the last decade, physicians and professional organizations have focused their efforts on improving the quality of care for cardiovascular disease (CVD) and stroke to ensure that proven interventions are appropriately administered. Groups such as the American College of Cardiology (ACC), American Heart Association (AHA), Society for Cardiovascular Angiography and Interventions (SCAI), and American Stroke Association (ASA) have supported efforts to measure performance and monitor care for CVD and stroke through registries and national quality improvement campaigns. In addition, CMS has initiated efforts to improve care and publicly report 30-day mortality and readmission rates for myocardial infarction (MI) and heart failure (HF). Several reports suggest that hospitalization rates and outcomes for CVD and stroke have improved recently, but many of these analyses have focused on specific communities, populations, or conditions and did not assess the conditions together or look at demographic or geographic differences. “We need to consistently look at temporal trends in CVD and stroke outcomes over the long term to see where our efforts are working and to identify areas for improvement,” says Chandan M. Devireddy, MD. New Long-Term Data In a study published in Circulation, researchers analyzed a national cohort of all Medicare fee-for-service beneficiaries from 1999 to 2011 to evaluate trends in various CVD and stroke outcomes. The analysis explored rates of hospitalization, mortality, and readmission as well as payments, length of stay, and discharge disposition for unstable angina, MI, HF, and ischemic stroke. The study also assessed rates of hospitalization for all other conditions as a comparison and examined variations in demographic and geographic subgroups over time.   “The strength of this research is...
Preventing Complications of Diabetes

Preventing Complications of Diabetes

More than 29 million Americans have diabetes, and the disease ranks as the seventh leading cause of death in the United States. About 86 million adults in the U.S. have prediabetes, but structured lifestyle-change programs have been shown to help prevent or delay type 2 diabetes by 60%. Although encouraging, the task of preventing complications in patients diagnosed with type 2 diabetes can be challenging because these individuals often do not qualify for enrollment into diabetes prevention programs. With type 2 diabetes, several types of complications can occur over time, including coronary heart disease, cerebrovascular disease, retinopathy, nephropathy, and neuropathy, among others. Many of these complications produce no symptoms during the early stages of diabetes, but most can be prevented or minimized with a combination of regular medical care and blood sugar monitoring. “Even after patients are diagnosed with type 2 diabetes, clinicians should make efforts to ensure that other prevention strategies are initiated and used throughout follow-up,” says John B. Buse, MD, PhD. Guide Patients to Interventions It is critically important that physicians recommend lifestyle interventions to patients who are diagnosed with type 2 diabetes, according to Dr. Buse. The American Diabetes Association has released toolkits for clinicians that are intended for use with their patients, including segments on optimizing care of the disease (Table 1) and preventing cardiovascular complications (Table 2), among several others. Dr. Buse says these resources and others can be especially helpful when having discussions with patients about what they will need to do to prevent diabetes-related complications. Clinical guidelines recommend screening patients for prediabetes early in order to prevent progression to type 2...
Measles in America

Measles in America

From January 1 to August 2014, there were nearly 600 confirmed measles cases reported to CDC’s National Center for Immunization and Respiratory...
Guidelines for PrEP to Prevent HIV Infections

Guidelines for PrEP to Prevent HIV Infections

Since the early days of the HIV epidemic in the United States, clinicians have made continued efforts to educate people on behaviors that could significantly reduce their risk of acquiring HIV infection. However, over the last 10 to 15 years, the rate of new infections in the U.S. has remained steady at about 50,000 per year. Recently, pre-exposure prophylaxis (PrEP)—daily doses of two specific antiretroviral medications to uninfected patients at high-risk of HIV infection—has been shown to be safe and effective to prevent HIV acquisition. “Despite our best efforts, we haven’t seen declines in annual HIV infection rates,” says Dawn K. Smith, MD, MS, MPH. The CDC recently released guidelines on PrEP to provide clinicians the information they need to use this prevention strategy and help drive down the rate of new HIV infections. Important Recommendations Published in the Morbidity and Mortality Weekly Report, the CDC guidelines report that taking PrEP regularly provides substantial protection against HIV acquisition in multiple populations. The guidelines offer recommendations on indications for prescribing PrEP medication. PrEP is recommended for HIV-uninfected patients who: ♦  Are in an ongoing sexual relationship with an HIV-infected partner. ♦  Are gay or bisexual men who have had sex without condoms or have been diagnosed with a sexually transmitted infection within the past 6 months, and are not in a mutually monogamous relationship with a partner who recently tested HIV-negative. ♦  Are heterosexual and do not always use condoms when having sex with partners known to be at risk for HIV (eg, injection drug users or bisexual men of unknown HIV status), and are not in a mutually monogamous...
Knee & Hip Arthroplasties: Analyzing the Obesity Effect

Knee & Hip Arthroplasties: Analyzing the Obesity Effect

Published reports have shown that the number of total knee arthroplasty (TKA) procedures performed in the United States more than tripled from 1993 to 2009, while the number of total hip arthroplasty (THA) surgeries doubled during the same timeframe (Figure 1). “In the setting of healthcare reform and cost containment initiatives, increasing surgical volumes have gained greater attention,” says Peter B. Derman, MD, MBA. Several explanations have been proposed regarding the increasing prevalence of total joint arthroplasties, and it is likely that a multitude of interacting factors play a role. These include obesity, the aging population, supplier-induced demand, and changing expectations about the quality of an active lifestyle, among other factors. TKA vs THA Observational studies have described various trends in arthroplasty, examining its economic ramifications as well as projecting future utilization. Dr. Derman and colleagues conducted a study, published in the Journal of Bone & Joint Surgery, to further the understanding of why there has been a more rapid growth in TKA when compared with THA. “The increasing incidence of overweight and obesity was of particular interest to us,” says Dr. Derman. “Studies have linked high BMIs with an elevated risk of knee arthritis, but this relationship is less robust with respect to the hip. We postulated that this differential effect might explain why knee replacement volumes are growing faster than hip replacement volumes.” Weight & Age For the analysis, Dr. Derman and colleagues used data obtained from the Nationwide Inpatient Sample on TKA and THA volume, length of hospital stay, and in-hospital mortality. The sample included details on over 8 million admissions at more than 1,000 hospitals...
Detecting Acute HIV in the ED

Detecting Acute HIV in the ED

Detecting HIV in the acute stage is important because patients are highly infectious at that time and may spread the infection unknowingly. “Diagnosing HIV at the acute stage can also lead to earlier treatment, which in turn can improve patient health and decrease risks for further transmission,” says Michael S. Lyons, MD, MPH. However, it can be difficult to detect HIV in the acute stage because symptoms do not stand out. In addition, the least expensive and most commonly used HIV tests often miss acute HIV. Research indicates that screening for HIV in EDs is important but controversial. This is because EDs are already overwhelmed and do not historically participate in prevention interventions. Resistance to adding HIV screening services in the ED is likely to be greatest in geographic areas of low HIV prevalence. “If acute HIV is seen more commonly than expected in EDs—even in areas of lower prevalence—then we should be motivated to do more HIV screening,” says Dr. Lyons. “We should also strive to use the best screening technology that is currently available.” Exploring the Issue For a study published in the American Journal of Public Health, Dr. Lyons and colleagues sought to better understand how many ED patients have undiagnosed HIV in the acute stages of infection. A cross-sectional seroprevalence study was conducted, enrolling 926 randomly selected adults (ages 18 to 64) from an urban ED in an area of low-to-moderate HIV prevalence. According to the results, the overall prevalence of undiagnosed HIV was 0.76%, amounting to seven cases in total. While there were few cases overall, a surprisingly high percentage of these—nearly half—were in...
Where Elderly Disabled Americans Live

Where Elderly Disabled Americans Live

The following depicts the share of the top nine states among the total population aged 65 and older with a disability, based on data from 2008 to 2012....
Depression & Mortality in Older Diabetics

Depression & Mortality in Older Diabetics

Data indicate that patients with diabetes have almost double the risk of being depressed, when compared with those with­out the disease. Studies have assessed the link between depression and mortality among patients with diabetes, but the role of age in this association is still being explored. Studying the Association For a study published in the Journal of the American Geriatrics Society, Carol M. Mangione, MD, MSPH, and colleagues assessed the relationship between depression and long-term mortality among more than 3,000 patients with diabetes. Patients were divided into those aged 65 and older and those younger than 65. “It’s well known in geriatrics that people older than 65 often have less typical presentations of depression, so it can be easily missed,” says Dr. Mangione. “We felt there may be fewer depression cases diagnosed in older patients. In addition, since other investigations have shown that older patients are less likely to get treated for depression, we hypothesized that the impact of having diabetes and depression would be greater among older adults.” The study team’s findings confirmed their suspicions. The risk for early mortality among depressed patients with diabetes was 49% higher than that of counterparts without depression. However, depressed patients aged 65 and older with diabetes had a 78% higher mortality risk than non-depressed diabetics in the same age group. “There was a trend toward higher mortality among younger diabetics with depression when compared with diabetics without depression in the same age group, but it was not statistically significant,” adds Dr. Mangione. Putting Findings Into Practice According to Dr. Mangione, the associations observed in the study should send a message to...
Teens With HIV: A Look at Treatment Trends

Teens With HIV: A Look at Treatment Trends

In recent years, the incidence of HIV infection has decreased for most age groups. Study results have shown that presenting to care earlier in the disease course can limit immune deterioration and HIV transmission. The CDC recommends that all people aged 13 and older be tested for HIV, a recommendation that appears to have made an impact on testing rates. However, recent research indicates that HIV incidence rates are actually increasing among adolescents. Taking a Closer Look “Studies have shown that more adults aged 18 and older are entering care with higher CD4 counts than what has been seen in the past,” says Allison L. Agwu, MD, ScM. “However, data from adult studies don’t necessarily represent trends in adolescents. My colleagues and I wanted to see if these same improvements in CD4 counts are also occurring in adolescents.” For a retrospective cohort study published in JAMA Pediatrics, Dr. Agwu and colleagues assessed data on nearly 1,500 antiretroviral therapy-naïve patients aged 12 to 24 who presented for care between 2002 and 2010 at any of 13 clinics in the HIV Research Network. Throughout the study, the proportion of patients who presented for care with a CD4 count less than 350 cells/mm3 remained between 30% and 45%. “These patients are presenting having already met criteria for treatment,” Dr. Agwu says, “We’ve shown that these patients are actually less likely to be treated.” African Americans, Hispanics, males, heterosexuals, older patients, and those with higher HIV-1 RNA levels were more likely than their counterparts to present for care with CD4 counts less than 350 cells/mm3. According to Dr. Agwu, providing extra support and...
Guidelines for Diagnosing OSA

Guidelines for Diagnosing OSA

Between 10% and 17% of Americans have moderate to severe sleep apnea, according to recent estimates. The prevalence of the condition has been increasing in recent years, due in part to the escalating obesity rate in the United States. However, an estimated 80% of those with sleep apnea remain undiagnosed. Addressing the Issue “Polysomnographs are considered the reference standard for an obstructive sleep apnea (OSA) diagnosis, but it requires specialized facilities,” explains Dr. Qaseem, lead author of the recent guidelines on OSA from the American College of Physicians (ACP). “Polysomnographs are also resource intensive and expensive and require patients to stay overnight for observation. As an alternative to polysomnographs, portable monitors are increasingly being used because they are much cheaper and more convenient for patients.” Portable monitors are broken down into types II through IV, with polysomnographs being designated as type I (Table 1). Two Recommendations The ACP recommends that a sleep study be performed for patients with unexplained daytime sleepiness. “This is a weak recommendation based on low-quality evidence,” Dr. Qaseem says, “but we believe that there is a need to have a targeted approach to diagnosing OSA. This starts with evaluation of the risk factors and common symptoms. Patients with daytime sleepiness have been shown to be the most responsive to OSA treatment, whereas there is a lack of evidence supporting treatment benefits to improve other outcomes, such as hypertension, diabetes, or coronary disease, especially in patients without daytime sleepiness.” To perform a sleep study in these patients, the ACP recommends polysomnographs for diagnostic testing. “If polysomnographs are available, they should be used,” adds Dr. Qaseem. “Portable...
Assessing Asthma Control

Assessing Asthma Control

The Asthma Control Test (ACT) has long been used as a quick survey to assess how well asthma symptoms are controlled among patients aged 12 and older, while the Childhood ACT (CACT) is used for such testing in younger children. More recently, the Asthma APGAR system has emerged as an alternative to ACT/CACT because of an implied ability to assess asthma control and reasons for inadequate control. However, little is known about how the Asthma APGAR system compares with ACT/CACT in the assessment of asthma control. Comparing Tests For a study published in Mayo Clinic Proceedings, Barbara P. Yawn, MD, MSc, MSPH, and colleagues sought to compare the impact of the Asthma APGAR system versus that of ACT/CACT on patient outcomes. Participants required daily asthma therapy and were asked to complete ACT in written form, several other asthma-related questions, and then the Asthma APGAR test. Children aged 5 to 11 completed the CACT, often with help from a parent. “The ACT and APGAR tests are highly comparable,” says Dr. Yawn, whose study results showed an overall agreement of 84.4% between the tests. “However, ACT doesn’t identify factors that may contribute to poorly controlled asthma. In contrast, the APGAR test was able to identify an actionable item for asthma control in more than three-quarters of cases. For pulmonologists, this can help speed up care by informing us about where to look for problems. The Asthma APGAR system was designed to not only help identify poor or inadequate control, but also to highlight the most common reasons why it isn’t under control. Our study demonstrated that the Asthma APGAR system could...
A Question About Today’s Standard of Care

A Question About Today’s Standard of Care

To all of my medical friends and colleagues, especially to PA’s, NP’s, and Nurses, I need some guidance. Is it acceptable for a specialty surgeon, for example and orthopedic surgeon, to leave routine postoperative care to a PA and Hospitalist and never see a patient postop until the office follow up 1 to 3 weeks after discharge? I ask because there are surgeons at one of my primary hospitals who maintain that they do not need to round on patients after routine elective surgery as long as the Hospitalist is dealing with the patient’s medical issues, and the surgeon’s PA sees the patient and keeps the surgeon informed. The question has arisen because regulation language has been proposed at one of my primary hospitals requiring the surgeon to follow the patient for at least 48hrs after surgery. The fact that I am dismayed by the need for such a regulation tells you where I stand, but I am an old dinosaur. Perhaps the modern standard of care has changed, and it is perfectly acceptable for a surgeon to delegate routine postop care to a PA as long as the patient is doing well and there are no complications. What is the current practice? Say a healthy 70-year-old has an elective hip replacement. Is it acceptable for the postop care to be handled by the surgical PA with medical management by the Hospitalist? Does the operating surgeon have any duty to see that patient in the hospital if the PA is able to tell him/her that the patient is doing well with no surgical-related problems? I was trained in an...
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