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Do OR Checklists Improve Outcomes?

“Implementation of the WHO Surgical Safety Checklist was associated with robust reduction in morbidity and length of in-hospital stay and some reduction in mortality,” says the conclusion of a paper in the May 2015 issue of Annals of Surgery. Now I am not against checklists. When I was a surgical chairman, I implemented and used one in both the operating room and the SICU. They probably do not add costs and may be helpful. However, there are some problems with the paper. The authors looked at 5,295 operations done in two Norwegian hospitals. The intervention was a 20-item checklist consisting of three critical steps–the sign in before anesthesia, the timeout before the operation began, and the sign out before the surgeon left the operating room. Using a stepped wedge cluster design, patients were randomized to control or the checklist. Complications occurred in 19.9% of the control patients and 11.5% in those who got the checklist, a significant difference with p<0.001. A look at Table 2 finds that of 27 complications or groups of complications, 14 occurred in significantly fewer patients in the checklist group. Of the significant 14, a few, such as cardiac or mechanical implant complications, could possibly have been prevented by the implementation of the checklist. For most of the others, the relationship between the use of a checklist and a post-operative complication is tenuous. How could a checklist possibly prevent technical complications like bleeding requiring transfusion, surgical wound dehiscence, and unintended punctures or lacerations? Urinary tract infection, pneumonia, asthma, pleural effusion, dyspnea, and the nebulous categories of “complications after surgical and medical procedures” and “complications to...
Reconnecting With Those Who Inspired You

Reconnecting With Those Who Inspired You

I got an e-mail recently from a Dr. Tim Race, MD, FACS. I didn’t remember knowing a Dr. Race and almost deleted it. I’m all over Social Media these days and have gotten some increased notice because of some columns I’ve written for Physician’s Weekly. I’m happy to respond to friend requests on Facebook, and often respond to comments on my PW posts. But e-mails from people who aren’t on my friend list are uncommon, and I don’t usually open them. As I said, I almost deleted the message until I noticed the subject line. “NMCB-5” it said. That brought it back to me. I’d known a Petty Officer Race when I was the battalion surgeon for Naval Mobile Construction Battalion Five during my operational tour, the year after my internship. I had been a naïve, young (very young) doctor who went from playing at being a Naval Officer to thinking I might one day actually become one. For the first time in my life, people expected me to lead, to take sole responsibility for potentially life or death decisions, and to be the expert that others turned to with questions about my area of responsibility. It was transformative. Tim Race had been the Public Health technician for the battalion, a Third Class Petty Officer, just out of C-school and a bit of a troublemaker. He took his duties seriously enough, but was smart and cocky. He had little patience with the regulations and protocols of enlisted life in the Navy. My first act as a division officer when I reported to the battalion was to convince the Master-at-Arms...
Guidelines for Methadone Safety

Guidelines for Methadone Safety

Methadone is used for the treatment of opioid addiction and for chronic pain, but safety of the drug has recently been called into question. “Methadone is increasingly being prescribed for pain even though it was previously used almost exclusively for the treatment of addiction,” explains Roger Chou, MD. “Recent data indicate that accidental overdoses associated with the use of prescription methadone have increased substantially. Methadone accounts for around 5% of opioid prescribing but about 30% of accidental overdose deaths.” Comprehensive Recommendations on Methadone Safety Recently, the American Pain Society (APS) released its first methadone safety guideline in partnership with the College on Problems of Drug Depen-dency and in collaboration with the Heart Rhythm Society. “Guidelines on methadone safety have been published by other groups, but these have focused on cardiac arrhythmias, which account for a small minority of deaths relating to use of the drug,” says Dr. Chou, who was lead author of the APS methadone safety guideline. “In addition, other guidelines have not used a formal process for grading evidence and recommendations.” The APS expert panel reviewed more than 3,700 scientific abstracts on various topics relating to methadone safety to prepare its guideline, which was published in the Journal of Pain. “All clinicians who prescribe methadone should use the guideline because it gives general recommendations as well as more specific advice,” Dr. Chou says (Table). “This includes information about starting doses and how to increase them. It also provides guidance on when to perform baseline ECGs and repeat them.” Recommendations were rated as strong or weak; a strong recommendation was indicated if potential benefits outweighed harms or burdens...
Bariatric Surgery: Looking at Long-Term Follow-Up

Bariatric Surgery: Looking at Long-Term Follow-Up

Many published studies on bariatric surgery are retrospective, short-term analyses with insufficient follow-up. “Obesity is a chronic illness that is linked to important comorbidities,” says Nancy Puzziferri, MD, MS. “Obesity treatments need to be assessed in long-term studies, particularly for invasive procedures like bariatric surgery.” There is plenty of short-term evidence about the benefits and risks of bariatric surgery for up to 1 year after the procedure, but few data are available about long-term outcomes. Some short-term reports may reach optimistic conclusions regarding the effect of bariatric surgery because follow-up is incomplete. This can lead to over-estimating the beneficial effects of these operations. A Systematic Review of Bariatric Surgery In a systematic review published in JAMA, Dr. Puzziferri and colleagues sought to determine the association of bariatric surgery with outcomes of weight loss, diabetes, hypertension, and hyperlipidemia. The analysis involved studies that lasted at least 2 years in duration and with at least 80% follow-up of patients. Of the more than 7,000 clinical studies reviewed in the analysis, less than 1% met inclusion criteria. Studies of the long-term outcomes of bariatric surgery demonstrated substantial and sustained weight loss for gastric bypass procedures that exceed outcomes from gastric banding. “Despite the increasing popularity of gastric sleeve operations, there were few long-term studies with reliable follow-up for these procedures,” says Dr. Puzziferri. The review in JAMA also found that just 16% of the studies reviewed reported outcomes at more than 2 years after bariatric surgery, and less than 3% reported weight loss outcomes for more than 80% of the original cohort. In addition, few studies measured comorbidity improvement after the completion...
Echocardiography Use in Pediatric Heart Patients

Echocardiography Use in Pediatric Heart Patients

With the rapid advance-ment of cardiovascular imaging technologies, it is important for physicians to understand how best to incorporate these options into clinical care and how to choose between imaging modalities. Recently, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, and other expert societies released the first appropriate use criteria (AUC) for suspected heart disease in pediatric patients. The AUC document specifically addressed the use of initial transthoracic echocardiography in outpatient pediatric cardiology. “The purpose of the new criteria is to improve patient care and outcomes in a cost-effective manner as well as enhance quality within practices,” explains David G. Nykanen, MD, FACC, FRCPC, FSCAI, who was a member of the AUC technical panel that developed the document. “We wanted to give clinicians a roadmap to follow when determining whether or not it was appropriate to use echocardiograms in this complex patient population.” Echocardiography: Judicious Use For the AUC document, experts identified 113 indications for outpatient pediatric echocardiography based on common clinical scenarios and/or clinical practice guidelines. Each indication was then rated for echocardiographic assessment as “appropriate,” “may be appropriate,” or “rarely appropriate.” Dr. Nykanen says the AUC document can familiarize pediatricians and pediatric cardiologists on when echocardiography may help elucidate a diagnosis and when other diagnostic pathways may be more useful. “Echocardiograms are expensive diagnostic tests,” he says. “We need to be judicious with how and why we order these tests.” The writing committee offered assistance for determining the reasonable role of initial transthoracic echocardiography when evaluating pediatric patients in outpatient settings, and tackled various aspects for consideration. “For example,” says Dr. Nykanen, “we...
Women & IHD: Coming to a Consensus

Women & IHD: Coming to a Consensus

In recent decades, physicians have used the male model of testing to identify coronary artery disease (CAD) in women, but studies show that there are gender-specific differences in the pathophysiology of coronary atherosclerosis. “These differences are multifactorial and include obstructive and non-obstructive CAD as well as dysfunction of the coronary microvasculature and endothelium,” explains Jennifer H. Mieres, MD, FACC, FASNC, FAHA. “As such, the term ischemic heart disease (IHD) best describes the varied pathophysiology in women. Women with IHD are at increased risk for coronary events.” Using the male model approach has led to under-diagnosis and under-treatment of IHD for women, which in turn has led to higher case fatality rates and greater morbidity. More recently, efforts have been made to ensure gender equality in the quantity and quality of research by better representing women in clinical trials and registries. These efforts were made to optimize management strategies for women with suspected and known IHD. A New Consensus on Coronary Artery Disease in Women In 2005, the American Heart Association (AHA) published a consensus statement on the use of CAD imaging for evaluating symptomatic women with suspected myocardial ischemia. Since that time, many reports have provided additional high-quality evidence, including data on coronary CT angiography (CCTA) and cardiac MRI (CMR). In 2014, the AHA updated this statement and published it in Circulation. The update provides sex-specific data on the diagnostic and prognostic accuracy for exercise treadmill testing (ETT) with electrocardiography, stress echocardiography, stress myocardial perfusion imaging (MPI) with single-photon emission CT or positron emission tomography, stress CMR, and CCTA. “In the past, clinicians didn’t recognize the importance of non-obstructive...
AAOS 2015

AAOS 2015

New research was presented at AAOS 2015, the annual meeting of the American Academy of Orthopaedic Surgeons, from March 24 to 28 in Las Vegas. The features below highlight some of the studies emerging from the conference. TKA & THA Outcomes by Gender The Particulars: There is limited evidence suggesting that outcomes following total knee arthroplasty (TKA) and total hip arthroplasty (THA) differ by gender. However, little is known about gender-related morbidity and mortality rates following these procedures. Most gender studies involving TKA and THA have focused more on procedural failure rather than morbidity and mortality. Data Breakdown: Researchers reviewed patients who underwent first-time TKA or THA from 2002 to 2009 in a study. Women who underwent THA were significantly older than men, whereas no difference in age was observed by gender among TKA patients. Following surgery, men were: ♦  15% more likely to visit the emergency department within 30 days. ♦  60% more likely to have an acute myocardial infarction (AMI) within 4 months following THA. ♦  70% more likely to have an AMI within 4 months following TKA. ♦  50% more likely to require revision surgery within 2 years of total knee replacement (TKR). ♦  25% more likely to be readmitted within 2 years of TKR. ♦  70% more likely to experience an infection or need revision surgery within 2 years of TKR. Take Home Pearls: Women appear to undergo a first total joint replacement at an older age than men. However, women appear to be less likely than men to experience complications or require revision surgery. The Costs of Perioperative Delirium The Particulars: Few studies have...
Malnutrition Among the Elderly in EDs

Malnutrition Among the Elderly in EDs

According to published research, malnutrition is a common but underdiagnosed condition among older adults and has been linked to physical and cognitive decline, a lower quality of life, and a higher risk of death. Studies suggest that the elderly are particularly vulnerable because of loss of appetite, comorbidities, medications, and environmental factors. These factors can influence the availability and desirability of food and the ability to eat and absorb nutrients. Although there are accurate instruments to screen for malnutrition, implementation of these screening protocols is often inconsistent in different healthcare settings, including EDs. Taking a Deeper Look at Malnutrition In a cross-sectional study published in Annals of Emergency Medicine, Timothy F. Platts-Mills, MD, MSc, and colleagues assessed the feasibility of screening for malnutrition and its prevalence among cognitively intact older adults in the ED. The investigators found that more than half of older adults who visited the ED were either malnourished or at risk for malnutrition. “We found that 16% of elderly patients in the ED were malnourished, which is higher than malnutrition rates seen in the community,” says Dr. Platts-Mills. “We also found that despite clear signs of malnutrition or risk of malnutrition, more than 75% had never previously been diagnosed with malnutrition.” Importantly, cases of malnourishment did not appear to result from a lack of access to healthcare, critical illness, or dementia. Nearly all patients had a primary care physician, lived in a private residence, and had some type of health insurance, and more than one-third had a college education. The prevalence of malnutrition was not appreciably different between men and women or between those living in...
Linking Asthma to OSA Risk

Linking Asthma to OSA Risk

Mounting evidence suggests there is a strong relationship between asthma and obstructive sleep apnea (OSA), whereby each disorder deleteriously influences the other. However, little is known regarding which condition leads to the other. Understanding the initiating processes of the potentially self-reinforcing asthma–OSA cycle could help reduce the burden of both conditions. Asthma & OSA: Chicken or the Egg? For a study published in JAMA, Mihaela Teodorescu, MD, MS, and colleagues examined the asthma–OSA relationship among a cohort of patients without OSA at baseline. Self-reported asthma and asthma duration were recorded beginning in 1988, and laboratory-based sleep studies were conducted every 4 years through 2013. “We followed the incidence of OSA in asthmatics versus non-asthmatics,” says Dr. Teodorescu. The study team found that asthma increased the risk of OSA development at 4 years by about 40%. At the first 4-year follow-up, 27% of patients with asthma experienced incident OSA, compared with a 16% rate among those without asthma. Similar rates of OSA were observed when looking across the full study period. The researchers found the association between OSA and asthma was not significantly affected by: ♦  Baseline and 4-year changes in BMI, neck or waist girth, or waist-to-hip ratio. ♦  Menopausal status. ♦  Asthma controller use. ♦  The availability of follow-up polysomnography. “Our findings suggest that asthma most likely leads to the development of OSA, regardless of the presence of predisposing factors for sleep apnea,” adds Dr. Teodorescu. The researchers added that the longer patients had suffered from asthma, the higher their likelihood was of developing OSA. “This has important implications for younger populations because asthma starts to develop during...
Caring for COPD Caregivers

Caring for COPD Caregivers

As COPD progresses, patients with the disease experience more frequent bouts of shortness of breath and exacerbations. Activities of daily living become increasingly difficult, often leaving family members to take over household chores that had always been performed by their loved one with COPD. These individuals may also have more frequent visits to the emergency department (ED) that result in hospitalization, which in turn can take family caregivers away from their preferred lifestyles and cause tremendous stress. Addressing Caregiver Burden The burden placed on family caregivers is worsening because COPD continues to rise in prevalence and is now the third leading cause of death worldwide, according to the World Health Organization. “Unfortunately, public awareness of COPD is very low,” says Sidney S. Braman, MD, FACP, FCCP. “Any efforts to increase awareness have focused mostly on patients and their suffering, but there has been little focus on family members and the impositions placed on them that come with caring for a person with COPD.” To help highlight COPD as a progressive disease with a large impact on family caregivers, the COPD Foundation, with support from Sunovion Pharmaceuticals Inc., developed the COPD Together campaign. The campaign’s website—www.copdtogether.com—helps family caregivers understand the disease and its progression. It also provides information on avail-able medications and other treatment options, such as pulmonary rehabilitation, as well as preventative options. Lifestyle tips, information on self-care, and a COPD caregiver’s guide are other important features of the campaign. “COPD patients and their caregivers can both use the My Diary tool to track medications, satisfaction levels, and symptom occurrence and progression,” adds Dr. Braman. “This tool can aid...
Guidelines for Managing Fatigue in Cancer Survivors

Guidelines for Managing Fatigue in Cancer Survivors

With recent advances in cancer screening and treatment, the number of cancer survivors in the United States has increased substantially in recent years. The American Cancer Society estimates that there are about 13.7 million cancer survivors in the U.S., and this figure is expected to rise to nearly 18 million by 2022. Over the years, the Cancer Survivorship Committee of the American Society of Clinical Oncology (ASCO) has issued evidence-based clinical practice guidelines, assessment tools, and screening instruments to help identify and manage late effects of cancer and its treatment. Recently, ASCO released a guideline for managing survivors who experience symptoms of fatigue after completing primary cancer treatment. The practice guideline pertains to cancer survivors diagnosed at age 18 or older who have completed treatment with curative intent and are in clinical remission without the need for therapy. It is also applicable to patients who are disease free and have transitioned to maintenance or prophylactic therapy. Examples of these patients include breast cancer survivors receiving hormonal therapy and people with chronic myelogenous leukemia receiving tyrosine kinase inhibitors. ASCO’s guidelines are intended to inform all members of patients’ healthcare team as well as patients, family members, and caregivers of cancer survivors. Fatigue Is a Common Problem “Many cancer survivors will experience some level of fatigue during their course of treatment,” explains Julienne E. Bower, PhD, who was co-chair of the ASCO writing group that developed the guidelines. “About 20% to 30% of cancer survivors deal with persistent fatigue for years after they’ve been treated for cancer. Fatigue is among the most common and distressing long-term effects of cancer treatment and...
ACC 2015

ACC 2015

New research was presented at ACC.15, the annual scientific sessions of the American College of Cardiology, from March 14 to 16 in San Diego. The features below highlight some of the studies that emerged from the conference. CPAP Decreases Acute HF Rehospitalization Rates The Particulars: Prior research has identified sleep-disordered breathing in heart failure (HF) as a significant risk factor for patients with different forms of HF that can impact clinical outcomes. However, data are lacking on whether compliance with continuous positive airway pressure (CPAP) treatment influences readmission rates among patients with acute HF and sleep apnea. Data Breakdown: Patients who had been hospitalized for HF and determined to have sleep apnea within 4 weeks of discharge were examined for a study. Among those who were compliant with their CPAP treatment, average pulmonary artery systolic pressure levels decreased, whereas non-compliant patients experienced an increase in these levels. The average number of rehospitalizations decreased by 0.8 visits from baseline to 6 months follow-up in the compliant group but increased by 1.1 visits in the non-compliant group. Take Home Pearl: Compliance with CPAP therapy appears to reduce 6-month readmission rates among patients with acute decompensated HF who are found to have sleep apnea shortly after being discharged from the hospital. Sedentary Behavior & Coronary Artery Calcification The Particulars: Physical activity has been shown to have multiple cardiovascular benefits in numerous studies, but no definitive relationship has been shown between physical activity and coronary artery calcification (CAC). Little is known about the relationship between sedentary behavior and CAC, independent of physical activity. Data Breakdown: For a study, researchers analyzed data on more...
AAPM 2015

AAPM 2015

New research was presented at AAPM 2015, the annual meeting of the American Academy of Pain Medicine, from March 19 to 22 in National Harbor, MD. The features below highlight some of the studies that emerged from the conference. Perception of Being a Burden & Suicidality The Particulars: Few studies have assessed whether the perception of being a burden is associated with suicidality in acute and chronic pain patients. Data Breakdown: American researchers conducted a study to compare community people without pain, acute pain patients, and chronic pain patients for affirmation of being a burden. Affirmation of the perception of being a burden was used in hierarchical regression models to predict five suicide questions regarding current passive and active suicide ideation, preference for death over disability, current suicide plan, and history of suicide attempts. Patients with chronic pain and those with acute pain were most likely to perceive themselves as being a burden. Affirmation of the perception of being a burden statistically significantly predicted each of the five suicidality questions in both groups of pain patients. Take Home Pearl: Among patients with either acute or chronic pain, the perception of being a burden appears to be associated with all forms of suicidality. Psychosocial & Functional Outcomes in Low Back Pain Patients The Particulars: Patients with chronic low back pain have reported psychosocial and functional impairments as a result of their pain in multiple studies. However, the relationship between these two types of outcomes has not been well defined in this patient population. Data Breakdown: Patients with chronic low back pain who participated in a study completed anxiety, disability, pain,...
Sexual Risk & Men Who Have Sex With Men

Sexual Risk & Men Who Have Sex With Men

In recent years, annual increases have been observed in the number of HIV infections among men who have sex with men (MSM). Understanding trends in sexual risk behaviors among MSM may help shed light on why these increases are occurring and help clinicians develop interventions to address the issue. Analyzing the Data on Sexual Risk Behaviors To gain a better understanding of the trends in sexual risk behaviors among MSM, Gabriela Paz-Bailey, MD, PhD, and colleagues analyzed 2005, 2008, and 2011 data from nearly 30,000 MSM from 20 major cities in the United States. “One-third of HIV-positive MSM who did not know they were infected reported having sex without a condom with someone they perceived to be HIV negative or whose HIV status was unknown,” says Dr. Paz-Bailey. “However, we found that this rate was 60% lower for men who knew they were HIV positive.” The percent of men who did not know their current HIV status increased with longer periods since they were last tested. “Only 4% of those who were tested within the past 3 months were HIV-positive but unaware of their infection, compared with 5% and 7% of those tested in the past 4 to 6 months or 7 to 12 months, respectively,” says Dr. Paz-Bailey. Over the study period, the percent of MSM who reported having sex without a condom at least once in the previous 12 months increased from 48% in 2005 to 57% in 2011. “It could be that with effective treatment now available, HIV is not seen as big a threat as it once was,” says. Dr. Paz-Bailey. “Research indicates that people...
Examining Office Visit Trends for Diabetes

Examining Office Visit Trends for Diabetes

According to recent estimates, diabetes affects nearly 29 million people in the United States, putting these individuals at risk for other chronic conditions, such as cardiovascular disease, stroke, and other conditions. Diabetes ranked as the seventh-leading cause of death in the U.S. in 2009 and 2010, and costs for managing the disease are nearly $245 billion each year. Studies indicate that patients with diabetes have medical expenditures that are about 2.3 times higher than those without the disease. Considering the growing epidemic of diabetes, the U.S. Department of Health and Human Services has set one of its Healthy People 2020 goals to reduce the burden of the disease. In a recent data brief from the CDC’s National Center for Health Statistics, Jill Jacobsen Ashman, PhD, and colleagues set out to examine trends for visits to office-based physicians by patients with diabetes from 2005 through 2010. The data brief also described age differences in the utilization of healthcare by patients with the disease in 2010. All estimates were made using data from the 2005–2010 National Ambulatory Medical Care Survey. Office-Based Visits According to the data brief, the overall number of visits by patients with diabetes increased by 20%, rising from 94.4 million in 2005 to 113.3 million in 2010 (Figure 1). “Visits by patients with diabetes represented about 11% of all office-based physician visits in 2010,” adds Dr. Ashman. From 2005 to 2010, the number of visits by patients with diabetes increased across all age groups except for those younger than 25, with the largest percentage increase (34%) occurring among individuals aged 25 to 44. Researchers also found that the...
CME: Guidelines for Diagnosing OSA

CME: 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...
CME: Updated Guidelines for Assessing Cardiovascular Risk

CME: Updated Guidelines for Assessing Cardiovascular Risk

Cardiovascular disease (CVD) caused by atherosclerosis continues to be the leading cause of death and is a major cause of disability as well as a significant source of healthcare costs in the United States. In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released an updated clinical practice guideline to help clinicians better identify adults who may be at high risk for developing atherosclerotic CVD. The update, published jointly in the Journal of the American College of Cardiology and Circulation, also provides recommendations for identifying patients who could benefit from lifestyle changes or drug therapy to help prevent CVD. “These guidelines were last updated about 10 years ago,” says David C. Goff, Jr., MD, PhD, who co-chaired the ACC/AHA risk assessment guideline writing group. “Since that time, we have collected a large amount of research that has further enhanced our understanding of how best to care for these patients and improve our approaches to determining who should get specific types of preventive treatments.” Risk Assessment A key goal of the ACC/AHA guideline is to ensure that preventive treatments—especially lifestyle changes and drug treatment—are used in those who are most likely to benefit from them. To do this, the guideline includes high-quality risk assessment methods that use risk factors that are known to lead to atherosclerosis (Table 1). Factors such as age, cholesterol levels, blood pressure, smoking, and diabetes can be easily collected by clinicians and then integrated into a risk score to guide care and prompt discussions with patients.   “The vast majority of heart attacks and strokes could be prevented if patients knew...

Top 10 Best & Worst States for Docs to Work

A recent article published in Forbes announces the best and worst states for doctors to work, released by WalletHub. Based on 12 metrics, including earning potential, compensation, hospitals per capita, insured population rate, patient population (such as patients over age 65), and the cost of malpractice insurance, data were gathered from the Census Bureau, Bureau of Labor Statistics, Department of Health and Human Services and other various organizations. Their findings were as follows: Best States to Work 1. South Carolina 2. Minnesota 3. Texas 4. Mississippi 5. Kansas 6. Wisconsin 7. Tennessee 8. Iowa 9. Idaho 10. North Dakota   Worst States to Work 1. Rhode Island 2. New Jersey 3. Oregon 4. New York 5. Maine 6. Maryland 7. Connecticut 8. Alaska 9. Delaware 10. New Hampshire Source: Wallethub Are you surprised by these...

Do I Need an Annual Physical?

Let’s see what the New York Times has to say. Last Friday, this question appeared in its “Ask Well” column. The author, Karen Weintraub, acknowledged that annual physicals “don’t help people avoid death, hospitalizations, worry or future appointments.” She also mentioned that yearly checkups can generate unnecessary procedures, complications, and needless expense. She then quoted two doctors. One, Pieter Cohen, MD, of Harvard, said if you don’t get a complete physical, “you’re only going to the doctor when you’re sick, and that makes absolutely no sense.” Really? To whom? The other doctor, David Himmelstein, MD, a professor of public health at the City University of New York, said, “I think I take better care of people if I know who they are and have some sense of connection to them.” He thinks he does? In the era of evidence-based medicine, justifying an annual physical examination based on two completely unfounded quotes is puzzling. The article concluded with some thoughts about how to improve the annual physical such as “making more time for genuine interaction between doctor and patient.” How well does a doctor get to know a patient he sees once a year? Even if an annual physical took an hour to do, would that be enough time to get to know someone well? Show me the data to support the idea that getting to know patients better and having genuine interactions with them leads to better outcomes. About 45 million Americans get annual physicals every year. At a conservative estimate of $200 per exam, that’s $9 billion not counting the inevitable lab tests and x-rays that are ordered....
Perioperative AF: Assessing Long-Term Stroke Risks

Perioperative AF: Assessing Long-Term Stroke Risks

Studies have shown that atrial fibrillation (AF) and flutter affect more than 33 million people throughout the world, and the presence of chronic AF has been associated with a three-fold greater risk of stroke. When stroke occurs in patients with AF, these individuals are at greater risk of longer hospital stays, worse disability, and higher mortality. New-onset perioperative AF is one of the most common perioperative arrhythmias, but its incidence ranges widely because studies have included different populations in terms of the type of surgery performed and patient characteristics. “Although it’s well known that AF raises the risk of stroke in general, there is increasing interest to fully understand the clinical burden of perioperative AF,” says Hooman Kamel, MD. “It’s possible that even brief perioperative episodes of AF can increase the risk of stroke.” Studies have shown a strong association between perioperative AF and length of stay, hospital costs, and mortality. Furthermore, the condition has been repeatedly associated with a higher short-term risk of perioperative stroke in the setting of cardiac surgery. However, data are scarce with regard to long-term stroke risks from perioperative AF in patients undergoing other types of surgery. Some research has suggested that perioperative AF may result as a transient response to the physiological stress of surgery itself. Overall, the long-term risks of stroke after patients experience perioperative AF are unclear. Taking a Closer Look Dr. Kamel and colleagues conducted a study to determine the long-term risk of ischemic stroke after perioperative AF of patients undergoing a variety of surgeries. Published in JAMA, the analysis used a population-based sample of more than 1.7 million patients...
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