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The Art of Giving Bad News

The Art of Giving Bad News

As a brand new intern, I had this art form thrust on me. It was during my third month of my intern year of my family practice residency that I first met this patient who would be the first to receive my version of bad news. The patient was in his 20s and suffering from advanced stages of AIDS. This was back in the day when we were just starting to use combination therapy to treat HIV infections. This man was admitted to the hospital with headaches and some other neurologic symptoms (which I do not recall more than a decade and a half later). The MRI came back and the radiologist reported a CNS lymphoma in an inoperable location. And at his advanced stage of AIDS, he was not a surgical candidate anyway. The case was discussed with his attending physician, our chief resident, and myself. The attending dumped the actual task of informing the patient of his diagnosis and dire prognosis. And being the chief resident, he then tasked this job to the scut monkey on the internal medicine rotation: me. He did not offer to go with me to the patient’s bedside or give me any words of advice. Basically, he ordered me to do it, and as any good intern scut monkey would do, I obeyed. I went to the medical library and researched his condition before anything else. There was not much information in the literature. I prayed and then walked up the stairs to push the deed further away than if I had taken the elevator. My hands were shaking and I was...
CME: Cardiometabolic Risk, Type 2 Diabetes, & Heart Disease

CME: Cardiometabolic Risk, Type 2 Diabetes, & Heart Disease

The term cardiometabolic risk refers to having a high 10-year and/or lifetime risk for cardiovascular disease (CVD). Specific causes that can increase cardiometabolic risk include hyperglycemia, hypertension, dyslipidemia, obesity, and insulin resistance. When patients have one or more of these risk factors and are physically inactive or smoke, cardiometabolic risk is further increased. “Patients with type 2 diabetes often have many risk factors associated with cardiometabolic risk,” explains Cecilia C. Low Wang, MD, FACP (Figure). “It’s important to consider cardiometabolic risk as part of a comprehensive approach to patient care.” This allows clinicians to consider multiple disease pathways and risk factors to facilitate earlier intervention. The State of Risk According to current estimates, two of every three Americans are overweight or obese, and about 86 million have prediabetes. Nearly half of all adults in the United States have high cholesterol, and about one-third have high blood pressure (BP). “While it’s important to track A1C among patients with type 2 diabetes, it’s also critical to manage BP and cholesterol because these are two of the most important cardio-metabolic risk factors,” Dr. Low Wang says. Research has shown that good BP control can reduce diabetes-related deaths by 32% and lower the risk of stroke by 44% and micro-vascular complications by 37%. Addressing Risk Factors There are non-modifiable and modifiable cardio-metabolic risk factors to consider when managing patients with type 2 diabetes. Non-modifiable risk factors include age, race and ethnicity, gender, and family history. Modifiable factors include obesity, dyslipidemia, inflammation, hypertension, smoking, physical inactivity, unhealthy diet, and insulin resistance. “Patients should understand that having diabetes means being at higher risk for CVD,”...
CME: The 2015 Immunization Schedule for Adults

CME: The 2015 Immunization Schedule for Adults

Based on three changes in the area of adult immunizations that occurred recently, the CDC’s Advisory Committee on Immunization Practices (ACIP) has approved an updated schedule of recommended adult immunizations for use in the United States. The schedule reflects the recommendation that all adults aged 65 or older receive the 13-valent pneumococcal conjugate vaccine (PCV13), a recent FDA approval to expand the patient age range for receipt of the recombinant influenza vaccine to now include all adults aged 18 and older, and a revision on contraindications and precautions for the live attenuated influenza vaccine. The revision changed the statement “influenza antiviral use within the last 48 hours” from a precaution to a contraindication. It also changed asthma and chronic lung diseases; cardiovascular, renal, and hepatic diseases; and diabetes and other conditions from contraindications to precautions. Pneumococcal Vaccines “The biggest change in the 2015 schedule is the inclusion of the ACIP recommendation for routine administration of PCV13 in series with the 23-valent pneumococcal polysaccharide vaccine for all adults aged 65 and older,” says David K. Kim, MD, lead author of the schedule, which was published in Annals of Internal Medicine. “Previously, PCV13 was recommended only for adults aged 19 to 64 with certain health conditions that put them at increased risk for pneumococcal disease. The significant morbidity and mortality associated with pneumococcal disease—from pneumonia to blood-borne infections and meningitis—disproportionately affects adults, particularly older adults.” Of the 40,000 cases of invasive pneumococcal disease (IPD) that occur annually in the U.S., 13,500 occur among adults aged 65 and older. Also, approximately 20% to 25% of IPD cases and 10% of community-acquired pneumonia...
EMR Alerts: Crying Wolf

EMR Alerts: Crying Wolf

Anyone who has spent time on the Internet has seen those annoying pop-up ads that contaminate commercial websites. Now, thanks to the Electronic Medical Record, physicians can enjoy the same type of interference as they are trying to negotiate patient charts. One of the features of most EMR systems is pop-up alerts that trigger for any number of reasons and interrupt the flow of charting to inform you of some problem or demand some action. Some of these are useful, such as a pop-up warning that the patient is allergic to the antibiotic that you just tried to order. Others are merely annoying, such as the Medicare two midnight certification you have to attest to before you can make your over-65 patient an inpatient admission. But the net effect of all of these pop-ups is alert fatigue. They happen so often, and are so often for trivial reasons, that you tend to ignore them and click the boxes until the alert goes away and you can get on with your work. I recently had six Priority Alerts (oh my!) trigger on one patient in the course of a routine 23-hour postoperative observation period following an uncomplicated hernia repair. The patient was doing fine, and none of the ‘Priority Alerts’ was valid, or in my opinion a priority. Two were completely off base and had I just ‘clicked boxes’ would have resulted in unnecessary imaging and testing with some potential morbidity. “So if most doctors are ignoring the alerts, what good are they?”   How did we get here? I wish I knew. I tried to research some of the...
Antiviral Therapy for Influenza

Antiviral Therapy for Influenza

Influenza has been well established as a potentially dangerous pathogen and common cause for clinic visits in the United States. Antiviral treatment within 2 days of the onset of influenza symptoms has been shown to reduce the probability of associated complications. Few studies, however, have assessed antiviral use for influenza in the outpatient setting. Taking a Closer Look For a study published in Clinical Infectious Diseases, Fiona Havers, MD, MHS, and colleagues analyzed data on antiviral receipt among outpatients aged 6 months and older with acute respiratory illness as well as antibiotic receipt among patients diagnosed with influenza. Participants included patients who presented during the 2012-2013 flu season to one of five sites in the CDC’s ongoing U.S. Influenza Vaccine Effectiveness Study. “We consider children younger than 2 years, adults aged 65 and older, those with a chronic medical condition, pregnant women, patients who were immunocompromised such as those with HIV or AIDS, and people of Native American, Alaska Native, or Pacific Islander race to be at increased risk for influenza complications,” explains Dr. Havers. “All these patients are recommended to promptly receive antiviral treatment if they present with flu-like symptoms.” According to the study results, only 19% of high-risk patients who presented for care within 2 days of flu symptom onset received antiviral treatment, regardless of laboratory testing results and despite guidelines suggesting that they would benefit from such treatment. Among all patients with polymerase chain reaction-confirmed influenza, 15% received an antiviral prescription. Overall, fewer than 8% of participants received an antiviral prescription. “In contrast, we found that 30% of outpatients who had influenza, based on laboratory testing,...
AKH CME: Hemophilia Clinician Education Series

AKH CME: Hemophilia Clinician Education Series

CME Credit: 0.25 hour activities The Clinician Education Series is a collection of free educational presentations supported by an educational grant from Baxalta Incorporated and jointly provided by SolutionSight, Inc and AKH Inc. These presentations provide clinical information and therapy management approaches for hemophilia...
AKH CME: Bridging the Gap: Clinical Trial Design and Implication for Translating Research into Clinical Practice in Epilepsy

AKH CME: Bridging the Gap: Clinical Trial Design and Implication for Translating Research into Clinical Practice in Epilepsy

CME Credit: 0.25 hour activities Epilepsy affects some 2.3 million adults and 467,711 children in the United States. Selecting the best drug for a particular patient and for a specific seizure type can be challenging for clinicians. Evidence based recommendations on the efficacy, tolerability, and safety of several AEDs were developed in 2004. Since this publication, new agents and data have emerged. Concurrently, optimal treatment designs for trials have been brought into question and new study designs developed. The regulatory requirements for the EU and the US vary substantially and their trial outcomes do not directly correlate to clinical application. There is an urgent need for education on the safe and appropriate interpretation and application of trial data to clinical...
Atrial Fibrillation: A Welcome Guideline Update

Atrial Fibrillation: A Welcome Guideline Update

Studies have shown that the incidence and prevalence of atrial fibrillation (AF) increases as people age. Fortunately, awareness of AF and its associated risk of thromboembolism and stroke have increased, and new treatment options, including newer anticoagulants, have emerged. Catheter ablation was once performed at only select academic centers, but has since become a more mainstream therapy as new evidence supports its safety and efficacy. Antiarrhythmic drug therapy is also being used more widely, and the appropriateness and safety of rhythm control strategies have been more clearly defined in recent years. Importantly, clinicians’ ability to prevent AF-related stroke has been improved with the development of enhanced risk prediction tools and new drug therapies that are safer and more effective than previous treatments. With all the available treatment choices for AF and the continued emergence of new evidence, it can be challenging to recognize which treatment options are most appropriate across the various permutations of symptom burden, stroke risk, and comorbidities. Several organizations have previously released guidelines and advisories for managing AF, but recommendations from these documents have been somewhat fragmented and many have remain unchanged since 2006. Helpful Recommendations Recently, the American Heart Association, American College of Cardiology, and the Heart Rhythm Society—in collaboration with the Society of Thoracic Surgeons—released updated evidence-based guidelines for managing AF. Published in Circulation and the Journal of the American College of Cardiology and available for free online, the guidelines are comprehensive in that they surveyed the state of science from published studies and evaluated 22 other AF-related guidelines or statements. “One key component of the guidelines was to revise and simplify the classification...
Cardiac Biomarker Testing in the ED

Cardiac Biomarker Testing in the ED

Cardiac biomarkers have emerged as a powerful tool to rapidly detect an acute coronary syndrome (ACS), but these biomarkers can also be detected in various other illnesses (eg, false-positive result). Throughout the United States, EDs are increasingly using sensitive assays for cardiac biomarkers to diagnose ACS early so that clinicians can initiate potentially life-saving evidence-based therapies in a timely fashion. Non-traumatic chest pain is a symptom that is typically associated with suspected ACS and ranks among the most common reasons for visits to the ED. However, cardiac biomarker testing is not routinely recommended for all patients who present to the ED. “Most patients who are diagnosed with ACS initially present to the ED with chest pain,” explains Anil N. Makam, MD, MAS. He notes that even with highly sensitive assays, decisions to test for cardiac biomarkers should be considered in the context of patients’ clinical presentation. “Using cardiac biomarker testing in patients with an extremely low probability of ACS is likely to result in substantial downstream harms from false-positive test results,” Dr. Makam says. “These include patient anxiety, inappropriate additional testing, and unnecessary treatments.” However, it is challenging to estimate the potential extent of harm from false-positive test results because little is known about the current rates of cardiac biomarker testing in EDs. Assessing Test Use For a study published in JAMA Internal Medicine, Dr. Makam and Oanh K. Nguyen, MD, MAS, sought to determine the overall use of cardiac biomarker testing and stratified testing by disposition status and selected characteristics. The retrospective study involved adult ED visits that were selected from the 2009 and 2010 National Hospital Ambulatory...
Rx Pain Drugs Surveying Practices & Beliefs

Rx Pain Drugs Surveying Practices & Beliefs

According to current estimates, the clinical use of prescription opioids nearly doubled between 2000 and 2010. As more patients have been prescribed these medications, there has been an increase in the incidence of opioid abuse, addiction, injury, and death. “More recently, the medical community has started to pay greater attention to the mounting epidemic of prescription opioids,” says G. Caleb Alexander, MD, FACP. Examining Trends In a research letter published in JAMA Internal Medicine, Dr. Alexander and colleagues sent surveys to 1,000 internists, primary care physicians (PCPs), and general practitioners in the United States and received a 58% response rate. The survey examined beliefs and self-reported practices regarding prescription opioid use. “Nine of every 10 PCPs reported that prescription drug abuse was a moderate or big problem in their community,” Dr. Alexander says. “Nearly half said they were less likely to prescribe opioids to treat pain when compared with a year ago.” PCPs appear to be recognizing the risks associated with prescribing opioids, including addiction and death by overdose. “Our findings suggest that PCPs have become aware of the scope of the prescription opioid crisis and are responding in ways that are important,” says Dr. Alexander. “This includes reducing over-reliance on these medications.” He adds that healthcare providers play a key role in helping to turn this epidemic around. Other Key Findings The study also showed that 85% of respondents stated that opioids are overused in clinical practice. Many reported that they were “very” or “moderately” concerned about serious risks, such as addiction, death, and motor vehicle crashes that may be linked to opioid overuse. Most respondents reported believing...
Elective PCI: Examining How Information Is Presented

Elective PCI: Examining How Information Is Presented

For patients with stable coronary disease, studies have shown that PCI does not reduce the risk for death or myocardial infarction (MI), even when it is added to optimal medical therapy (OMT). “Studies of patients undergoing elective PCI demonstrate that most patients believe that the procedure will reduce their risk for MI or death,” explains Michael B. Rothberg, MD, MPH. “The reasons behind these beliefs are unknown.” Examining Decisions In JAMA Internal Medicine, Dr. Rothberg and colleagues had a study published that explored how the presentation of potential benefits and risks of PCI and OMT influences patients’ beliefs and decision making. Specifically, the analysis looked at the effect of information presentation on beliefs about PCI and willingness to choose it. In an online survey, more than 1,200 adults aged 50 and older were asked to imagine having experienced chest pain and being referred to a cardiologist. They were then randomized to one of three scenarios. In the first, patients received no information about the effects of PCI on MI. In the second, participants were told specifically that PCI will not reduce the risk for MI. In the third, patients were told why PCI does not reduce the risk for MI. Then they answered questions about the procedure and whether they would choose it. Presenting factual information affected participants’ beliefs and decisions regarding PCI (Figure). “Over 70% of participants who received no information about whether PCI would prevent MI believed that the procedure would do so,” says Dr. Rothberg. “Simply stating that PCI would not prevent an MI reduced this percentage to 39%, and explaining why PCI would not prevent...
Opioid Use & Reverse Shoulder Arthroplasty

Opioid Use & Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty (RSA), a procedure designed for treating diseased rotator cuff tears with arthritis, can be used to improve function and provide pain relief. Opioids are being used more commonly as a non-surgical approach for these patients, but little is known about outcomes for RSA in individuals with a history of preoperative opioid use. “Some studies have looked at preoperative opioid use in hip, knee, and spine surgery, but none have been reported in patients undergoing a shoulder surgery like RSA,” explains Brent J. Morris, MD. Exploring the Issue In a study published in the Journal of Shoulder and Elbow Surgery, Dr. Morris and colleagues compared preoperative and postoperative outcomes from 32 RSAs in patients with a history of preoperative opioid use with 36 RSAs performed in patients who did not use these drugs before surgery. There were no differences between patient cohorts with regard to demographics or comorbidities. According to the findings, preoperative opioid use was associated with significantly lower preoperative shoulder function. Lower shoulder function was also observed at the final follow-up assessment at 2 years after RSA for those who took preoperative opioids. Both groups experienced significant improvements on tests for shoulder function and range of motion measurements from the preoperative to the final follow-up assessment. “The non-opioid group, however, had significantly better outcomes,” says Dr. Morris. The study also noted that the magnitude of improvement between the preoperative opioid group and the non-opioid group was nearly identical. Examining the Implications “Our results indicate that improvements can be expected in patients with a history of preoperative opioid use, but these patients shouldn’t expect to reach...
Dealing With the Aging Surgeon

Dealing With the Aging Surgeon

According to published research and anecdotal evidence, the aging surgeon remains a problem throughout hospitals and medical centers across the United States. Some studies have shown that patient mortality rates are higher for surgical procedures performed by older surgeons. However, other analyses have suggested that surgeon age is a relatively weak predictor of operative mortality in aggregate and should be taken into context when evaluating performance among individual surgeons. “Dealing with the aging surgeon is a common problem that is encountered by nearly every chief of surgery, vice president of medical affairs, and hospital president at some point during their tenure,” explains Mark R. Katlic, MD, MMM, FACS. “Many surgeons lack self-awareness in their perceived cognitive abilities as they age. This is an especially important issue considering that the number of U.S. surgeons aged 70 and older still practicing approaches may approach 20,000.” A Complex Issue In the Annals of Surgery, Dr. Katlic and colleagues published an article that explored issues surrounding the aging surgeon. According to Dr. Katlic, it is important to remember that human faculties diminish with age but with great variability. “As is true with everyone, surgeons are probe to deterioration in cognitive and physical faculties that comes with increasing age,” he says. “However, functional age doesn’t equal chronologic age. It’s more important to evaluate functional age rather than to implement policies that mandate a specific retirement age for surgeons because each individual is unique.” Several arguments have been made to support the case against mandatory retirement for surgeons based on age, including the Age Discrimination in Employment Act of 1967, which outlawed forced retirement based...
Hypertension Trends in the U.S.

Hypertension Trends in the U.S.

Healthy People 2020 is a national initiative that was launched in 2010 and outlines 10-year goals and objectives for health promotion and disease prevention. Reducing the burden of cardiovascular disease is part of the initiative, and Healthy People 2020 established the following goals for adults in the United States regarding blood pressure (BP) control. ♦  Decrease the prevalence of hypertension to 26.9%. ♦  Increase the percentage of hypertensive patients on BP medication to 69.5%. ♦  Increase hypertension control to 61.2% (this requires controlling hypertension in 88.1% of those on BP treatment). A Status Update A study published in Circulation assessed the current status and progress toward the Healthy People 2020 goals. For the analysis, Brent M. Egan, MD, and colleagues used the National Health and Nutrition Examination Surveys from more than 37,000 adults between 1999 and 2012 and looked at time trends data in 2-year blocks. “The prevalence of hypertension changed very little over this period,” says Dr. Egan. “However, hypertension treatment and the proportion of treated adults who got their BP under control increased significantly.” Hypertension control—defined as reaching a BP of less than 140/90 mm Hg—increased every 2 years from 1999-2000 to 2009-2010 before leveling off slightly to just over 51% in 2011-2012. Identifying Strong Predictors Several modifiable risk factors were found to be strong predictors of BP control. Patients who visited their healthcare provider at least twice a year were 3.2 times more likely to keep their BP under control than those who saw their providers less frequently. Patients who had healthcare insurance and received treatment for high cholesterol also had a greater likelihood of keeping...
IAS 2015

IAS 2015

New research was presented at IAS 2015, the International AIDS Society Conference, from July 19 to 22 in Vancouver, Canada. The features below highlight some of the studies that emerged from the conference. Benefits Seen With Widespread ART Access The Particulars: Widespread HIV screening and access to highly active antiretroviral therapy (ART) have been shown to be cost effective in mathematical models. However, the costs, value, and feasibility of complete access to ART have yet to be determined. Data Breakdown: For a study, Canadian researchers assessed the cost-effectiveness of universal ART access in British Columbia from 1997 to 2010 and compared it with hypothetical scenarios of constrained treatment access. The study team estimated savings of 65.5 million Canadian dollars by 2035, based on the difference between a 100% probability of accessing ART and a 50% probability. Savings based on a 75% probability would be $25.1 million by 2035. Take Home Pearl: Universal access to ART appears to result in substantial cost savings over the long term. ART Halts HIV Transmission in Heterosexual Couples The Particulars: Data are lacking on the ability of antiretroviral therapy (ART) to stop HIV transmission from an infected person to their partner among heterosexual discordant couples. Data Breakdown: For a study, infected patients were randomized to immediate ART treatment or to wait until their CD4 count fell below 250 cells/mm3. Transmission of HIV was reduced by 93% among couples in which the infected partner received ART. Transmission only occurred when HIV was not fully suppressed or when treatment had failed. Take Home Pearl: Effective ART appears to prevent the vast majority of HIV transmission among...
Analyzing the Appropriate Use of Statins

Analyzing the Appropriate Use of Statins

Recently, the recently American College of Cardiology (ACC) and the American Heart Association (AHA) updated their cholesterol guidelines, which shifted away from a focus on treating to target LDL cholesterol levels and toward minimizing global cardiovascular risk. The updated ACC/AHA guidelines substantially broadened the number of people for whom statins are recommended, primarily by enlarging the eligible population to those with lower levels of cardiovascular risk. Examining Patterns While previous studies have shown that statin use is increasing in the United States, others have shown that use of these medications is suboptimal, even among high-risk individuals. “We have few data that have looked at how cardiovascular risk and specific risk factors contribute to the actual prescribing of statins,” says Michael E. Johansen, MD, MS. In an effort to address this research gap, he and his colleagues conducted a study—published in Annals of Family Medicine—that looked at the relationships between statin use and cardiovascular risk as well as diagnosed hyperlipidemia and other specific risk factors using a nationally representative sample. The study by Dr. Johansen and colleagues analyzed data from the 2010 Medical Expenditure Panel Survey and involved more than 16,000 patients aged 30 to 79. Those who reported filling at least two statin prescriptions were classified as statin users. “Overall, only about 50% to 60% of people at high cardiovascular risk were prescribed statins,” says Dr. Johansen. The study revealed that slightly more than 58% of individuals with coronary artery disease (CAD) and 52% of those with diabetes older than 40 were statin users. After adjusting for cardiovascular risk and sociodemographic factors, the probability of being on a statin...
Illustrating the Importance of Cholesterol

Illustrating the Importance of Cholesterol

The Foundation of the National Lipid Association, the Preventive Cardiovascular Nurses Association, and Mended Hearts recently launched Cholesterol Counts, a program designed to accumulate internet-based information on how much people in the United States know about their cholesterol. “The program gathers data on how much patients care about their cholesterol and whether they are treated if their cholesterol levels are high,” says Ralph M. Vicari, MD, FACC. “The goal of the program is to get a pulse of cholesterol knowledge in the U.S. and find where gaps may exist. The program is also designed to help determine whether healthcare professionals are discussing cholesterol levels with patients.” The Cholesterol Counts program has surveyed more than 12,000 adults, including approximately 200 adults in each of the 50 states. The poll, which is available online at www.CholesterolCounts.com, was conducted online by Harris Poll on behalf of Sanofi and Regeneron Pharmaceuticals. The results are weighted demographically and attitudinally so that they are representative of the national population and the population of each state. Concerning Results Initial results from the Cholesterol Counts poll were released in 2015, and showed that 71% of Americans surveyed are not sure of or do not recall their LDL cholesterol levels despite the fact that this is a critical health factor that can increase risks for heart attack and stroke (Figure). “This finding is concerning because patients need to know their cholesterol levels and goals so that they talk to their physicians to help manage it and assess their risk for potential cardiac events,” says Dr. Vicari. He recommends that clinicians make a concerted effort to write down cholesterol...
Ethical Pain Management in the ED

Ethical Pain Management in the ED

According to published reports, up to 75% of ED patients present with pain-related complaints, and more than half come to the ED with severe or moderate pain. Pain management is a fundamental component of emergency medicine, but there are barriers to providing effective pain control in the ED. “There is growing tension between the ethical and professional obligations of emergency physicians (EPs) to treat pain and their reluctance to contribute to the growing problems of opioid abuse and diversion,” explains Arvind Venkat, MD. A more in-depth understanding of how to resolve issues surrounding ethical pain management in the ED may help EPs in their efforts to treat pain. In an article published in Academic Emergency Medicine, Dr. Venkat and colleagues proposed an ethical framework to address the clinical dilemmas surrounding the management of pain in ED patients. “Given the frequency of ED patients presenting with pain and the barriers to effective pain relief, it’s important to recognize the ethical issues that can affect the treatment of pain in this setting,” says Dr. Venkat. Key Considerations According to Dr. Venkat, EPs often get little training in addiction problems. “It’s important for EPs managing pain to not assume that all patients are at risk for addiction to prescription drugs like opioids,” he says. “We need to recognize narcotic seeking behaviors, but we must also keep the patient’s health foremost in mind,” he says. “If patients are suspected of narcotic seeking behavior, we should treat them but also direct them to resources where they can get more appropriate care for their pain and potential dependency issues.” A framework needs to be in...
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