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HFSA 2015

HFSA 2015

New research was presented at HFSA 2015, the annual scientific meeting of the Heart Failure Society of America, from September 26 to 29 in Washington, DC. The features below highlight some of the studies that emerged from the conference.   Cognitive Impairment in HF Patients The Particulars: Researchers have hypothesized that significant cognitive impairment could be a contributing factor in the disease course of patients with heart failure (HF), as these patients often require multiple and complex lifestyle and pharmacologic interventions. However, few studies have explored the detection of cognitive impairment in HF patients. Data Breakdown: For a study, the prevalence of cognitive impairment among patients with HF was compared with that of patients without HF. Despite similar Mini-Mental Status Exam (MMSE) scores, HF patients had higher prevalence of moderate-to-severe cognitive impairment than age-matched controls across multiple domains. Take Home Pearl: Stable patients with chronic HF and normal MMSE results appear to have a high prevalence of moderate-to-severe cognitive impairment.   CPR Outcomes in Hospitalized HF Patients The Particulars: Data indicate that CPR preferences among patients hospitalized with heart failure (HF) may be influenced by beliefs about the success of CPR. However, the frequency and outcomes of CPR following in-hospital cardiac arrest in patients with HF are not well known. Data Breakdown: The outcomes of nearly 16,000 patients hospitalized for HF who underwent CPR for in-hospital cardiac arrest were assessed for a study. Among participants, 16% were eventually discharged directly home, among whom 44% required home healthcare. Nearly 10% of patients were transferred to a skilled nursing facility, and 73% died prior to discharge. Take Home Pearl: Survival following...
CME: Opioid Use in Chronic Non-Cancer Pain

CME: Opioid Use in Chronic Non-Cancer Pain

The management of chronic non-cancer pain (CNCP)—defined as pain lasting beyond 3 months—has emerged as a significant challenge for healthcare providers throughout the United States. In recent years, some studies have suggested that opioids can be taken safely to manage several CNCP conditions for long periods of time and with few severe problems as long as they are well-selected. However, there is little specific guidance on the dosing of opioids for CNCP in any statutes, regulations, or clinical guidelines. “Many pain specialists believe that the best way to manage CNCP is to increase the dose of opioids, a trend that has been increasingly prevalent throughout the U.S.,” explains Gary M. Franklin, MD, MPH. “But as this trend has continued, we’re seeing more frequent reports of deaths from accidental poisonings as well as problems with opioid abuse, dependence, and addiction. The CDC and other public health agencies have stated there has been an epidemic of opioid prescribing and adverse consequences from these practices since the late 1990s. Between 1999 and 2010, there were more than 100,000 opioid-related deaths in the U.S., which far exceeds the approximate 58,000 military casualties that the country endured during the Vietnam War.” In the journal Neurology, the American Academy of Neurology (AAN) published a position statement, written by Dr. Franklin, to help physicians manage CNCP. The AAN is the first national professional medical association to adopt such a statement. “The evidence of harm associated with long-term opioid use is high while the evidence of effectiveness of this approach is low,” Dr. Franklin says. He notes that clinicians need to recognize this imbalance and weigh the...
CME: Mental Health & Diabetes

CME: Mental Health & Diabetes

Studies have shown that patients living with diabetes are at increased risk for developing depression, anxiety, and eating disorders, among other mental health problems. “Mental health comorbidities of diabetes can compromise adherence to diabetes treatments, which in turn can increase risks for serious short- and long-term complications,” says Mark Peyrot, PhD. Failure to adhere to diabetes medication regimens can result in the development of cardiovascular disease, stroke, blindness, amputations, and cognitive decline. It can also decrease quality of life and increase risks for premature death. When mental health comorbidities of diabetes go undiagnosed and untreated, the financial cost to society and healthcare systems is substantial and health outcomes for patients are also impacted. “Among the wide-ranging comorbidities associated with diabetes, mental health issues are among the most overlooked,” Dr. Peyrot says. “This remains true despite the potential of mental health problems to compromise self-management and increase risks for serious complications.” Studies indicate that only about one-third of patients with these coexisting mental health conditions receive a diagnosis and treatment for them. Depression, Anxiety, & Eating Disorders Major depressive disorder affects nearly 7% of all adults in the United States and is more likely to be diagnosed in people with diabetes. “Diabetes is a risk factor for depression and depression is a risk factor for diabetes,” Dr. Peyrot says. Depression among patients with diabetes has been linked to poor self-care, poor glycemic control, more long-term complications, and a decreased quality of life. Fortunately, depression can be successfully treated in people with diabetes using collaborative care models that involve psychotherapy and antidepressants. These treatments can improve depressive symptoms and may have...
Concussion Season: Why We Need to Do Better

Concussion Season: Why We Need to Do Better

The NFL season kicked off this month but with it, we return back to concussion season. Most people know of the controversy of the concussion cover-up in the NFL and how pro-players suffer long-term brain damage from concussions they suffered. There is increasing evidence that demonstrates long-term brain damage from prior concussions. The NFL first recognized the problem of concussions in 1994 and formed the Mild Traumatic Brain Injury Committee. However, many felt there was little help derived from this. In 2002, a former Steelers center, Mike Webster, died at the age of 50. He suffered from CTE (chronic traumatic encephalopathy). He was the first identified of a host of other players suffering CTE. There are six former NFL players living with Lou Gehrig’s Disease, nine have committed suicide, and an unknown number are living with CTE. What is even more frightening is the fact that 50% of players who have suffered a concussive blow do not show symptoms. It has been estimated a pro player will be hit with 900-1500 blows to the head every year. 1 In 2013, more than 4500 players sued the NFL for failing to warn of the dangers of concussion and rushing them back to play. Many of these players were suffering the sequalae of TBI. An agreement was reached outside of court for $765 million, agreeing to compensate victims, pay medical bills, and fund research. 2 “There is a rising incidence of concussions in high school athletes. We need to heed the lessons learned in the NFL.”   But why do most doctors need to care about what happens in the NFL?...

ED Revisits & Mortality After Falls

Researchers in Boston indicate that more than one-third of older adult ED fall patients appear to revisit the ED revisit within 1 year and are at greater risk of death. Among patients who were an average age of 78.6 years old, ED revisit rates increased from 2% at 3 days to 25% at 1 year. Death rates increased from about 1% at 3 days to 15% at 1 year. More than 50% of patients revisited the during the 7-year study. Source: American Journal of Emergency Medicine, August...

Trends in Syncope-Related Resource Utilization

The amount of resources used for ED visits with syncope appears to have increased in recent years despite substantial efforts to optimize this utilization, according to a study. Between 2001 and 2010, admission rates ranged from 27% to 35%. The analysis showed no significant downward trend during the study period. Advanced imaging rates increased from about 21% to 45% during the study. Source: American Journal of Emergency Medicine, August...

Patient Perspectives on Acute Pain Management in the ED

Patients discharged from an urban ED after presenting with acute pain from fractures, renal colic, or musculoskeletal back injuries appear to receive little communication from ED providers regarding opioid dependence or alternative pain management options. A survey of these patients found that those with negative experiences from their pain management described deficiencies in communication that lead to misunderstanding of clinical diagnoses. They also reported fragmentation of care among their providers and a desire to be involved in decisions made about their pain management. Source: Annals of Emergency Medicine, September...
An Update on Poisonings Presenting to EDs

An Update on Poisonings Presenting to EDs

In the United States, deaths from drug overdose have become a leading cause of injury-related mortalities. According to current estimates, drug misuse and abuse causes about 2.5 million visits to the ED. “Drug-related deaths now exceed motor vehicle accidents as the leading cause of accidental death in the U.S.,” says Richard C. Dart, MD, PhD. “This is an important issue for EDs because they are typically the first to encounter these cases.” Despite being familiar with managing patients suspected of being poisoned, emergency physicians are continually challenged by the emergence of new types of poisoning. “Every year, emergency physicians encounter a new wave of poisoning agents that range from household products to drugs that are intended for recreational use,” Dr. Dart says. “Each newly identified poisoning agent may require a new approach to diagnose and manage.” Examining Recent Trends The National Poison Data System (NPDS) collects information from poison centers throughout the U.S. in order to recognize emerging poisonous hazards early. “This system can provide real-time advice while collecting data on a variety of poisonings, including those that may be new or unfamiliar to emergency physicians,” Dr. Dart says. Considering the challenges that come with managing new types of poisonings, the NPDS can play an integral role in helping EDs respond to dangerous substances. Dr. Dart and colleagues had a study published in Annals of Emergency Medicine that summarized data from U.S. poison centers about new emerging chemicals and drugs that ED personnel may confront. Specifically, the research used 2012 data to explore trends in poisonings involving opioids, laundry detergents, bath salts, synthetic cannabinoids (eg, Spice), and energy drinks. According...

Internet Use, Anxiety, & Cardiomyopathy Risk

Study results indicate that patients with or at risk for cardiomyopathy appear to experience less anxiety when they the internet as a source of health information. Among the study patients, 85% used the internet to obtain non-specific information about health in general. Another 65% used it to search specifically for heart disease-related information. Online health information seeking was associated with substantially lower state anxiety levels. Source: American Heart Journal, July...

Few Heart Failure Patients Receive Cardiac Rehab

About 10% of patients who are eligible to receive cardiac rehabilitation (CR) at discharge following hospitalization for heart failure actually follow through with CR, according to a large study. The authors reported that a significant increase in CR referral rates was observed between 2005 and 2014. However, additional strategies are needed to improve physician and patient awareness of the benefits of CR in order to increase CR referral among heart failure patients. Source: Journal of the American College of Cardiology, August 2015....

Comparing Approaches to Severe Aortic Stenosis

A Korean research team suggests that early aortic valve replacement (AVR) and watchful observation appear to have similar survival rates in symptomatic patients with normal flow, low-gradient severe aortic stenosis and preserved left ventricular ejection fraction. The study authors recommend that watchful observation with timely performance of AVR be considered a therapeutic option for this patient population. Source: Heart, September 2015.   An abstract of the study is available at...
Counseling Young Adults With Hypertension

Counseling Young Adults With Hypertension

Published studies show that about 9% of men and 7% of women who fall in the young adult age range—defined as ages 18 to 39—have hypertension. “Although young adults have lower rates of hypertension when compared with those aged 40 and older, only about 38% of these individuals have their hypertension under control,” explains Heather M. Johnson, MD, MS. Recent guidelines have identified lifestyle modifications as a critical first-line step to controlling hypertension. Several strategies are recommended, including losing weight for overweight and obese individuals; adopting the Dietary Approaches to Stop Hypertension (DASH) plan; reducing dietary sodium; increasing physical activity; consuming alcohol in moderation; and quitting smoking. “Lifestyle modifications have been shown to be effective in improving hypertension control, reducing cardiovascular risk, and enhancing the efficacy of antihypertensive medications,” says Dr. Johnson. Despite these benefits, research suggests that adults with hypertension receive little physician education about lifestyle modifications. Few studies have assessed lifestyle education among patients who develop incident hypertension. Examining Current Patterns An understanding of lifestyle education patterns and the influence of such counseling are needed to develop targeted hypertension interventions. In a study published in the Journal of General Internal Medicine, Dr. Johnson and colleagues sought to determine the presence of any documented lifestyle education in an electronic health record system for young adults with incident hypertension. The study also aimed to identify patient, provider, and visit predictors of receiving documented education. “Our study results showed that only 55% of the 500 participants received documented lifestyle education from a clinician within 1 year of presenting with incident hypertension,” Dr. Johnson says. Just 23% of participants received an...

Religious & Spiritual Considerations Infrequently Discussed

Discussions of religious or spiritual considerations appear to occur infrequently with the surrogate decision makers of ICU patients who have relatively high degrees of religiosity. Study investigators found that these discussions occurred in only about 16% of cases. Healthcare professionals rarely explored the patient’s or family’s religious or spiritual ideas. Source: JAMA Internal Medicine, August 31, 2015...

Daytime Procedures Following Night Shift Work

Adverse outcomes of elective daytime surgery appear to be similar, regardless of whether or not surgeons have provided medical services after midnight. The compilation of death, readmission, or complication was associated with a rate of about 22%, regardless of whether surgeons had worked the night before the procedure. Source: New England Journal of Medicine, August 27,...

The Vicious Cycle of Ventral Hernia Repair

Study results suggest that patients with multiple previous hernia repairs appear to be more likely that those with no previous repairs to undergo subsequent reoperations. These patients also tend to have a longer operative duration, are at greater risk for developing surgical site infections, and have higher risks for recurrence. After 140 months of follow-up, 37% of primary ventral hernias and 64% of incisional hernias had recurred among patients with previous hernia repairs. The highest recurrence rate (73%) was observed among patients undergoing at least a third repair. Source: Journal of the American College of Surgeons, August...

Comparing Revascularization Methods

Hybrid coronary revascularization (HCR)—which combines minimally invasive left internal mammary artery to left anterior descending bypass with PCI of non-left anterior descending vessels—appears to have a quicker recovery and similar outcomes when compared with conventional CABG. A study found that mortality rates at 3 years were similar for both approaches. However, HCR was associated with lower in-hospital morbidity, a reduced need for blood transfusion use, and decreased needs for chest tube drainage. It was also associated with shorter postoperative lengths of stay. Source: Journal of the American College of Surgeons, August...
Managing Atrial Fibrillation in Thoracic Surgery

Managing Atrial Fibrillation in Thoracic Surgery

Perioperative atrial fibrillation (AF) and flutter (POAF) is among the most common cardiac arrhythmias occurring in patients undergoing thoracic surgical procedures. POAF has been linked to longer ICU and hospital stays and is associated with higher morbidity from strokes and neurologic events. Recently, the American Association for Thoracic Surgery (AATS) convened a task force of cardiologists, electrophysiologists, anesthesiologists, intensive care specialists, and thoracic and cardiac surgeons to develop a guideline for managing POAF in patients undergoing thoracic surgeries. A Helpful Blueprint “We wanted to provide a blueprint for managing POAF that can be used to develop standardize practices and to help with teaching,” explains George Frendl, MD, PhD, FCCM, who led the AATS task force that developed the guideline. The evidence-based guideline was published in the Journal of Thoracic and Cardiovascular Surgery and is available at www.aats.org. According to Dr. Frendl, one of the most important recommendations is that both electrophysiologically-documented AF and clinically diagnosed AF should be included in clinical documentation and reported in trials and studies. The guideline also provides standards for ECG monitoring when managing patients at risk for POAF and offers management and treatment strategies for the condition. These strategies are important because managing antiarrhythmic medications and perioperative anticoagulation may pose challenges during thoracic surgeries. Preventive Strategies Recent evidence suggests that several prevention strategies may help reduce the incidence of POAF, such as avoiding β-blocker withdrawal for those taking these agents chronically and correcting serum magnesium levels when they are abnormal. For patients at higher risk for developing POAF, use of preventive medications (eg, diltiazem or amiodarone) may be reasonable, but the guidelines note that...
Preventing Postoperative Pneumonia

Preventing Postoperative Pneumonia

Pneumonia is a common nosocomial infection that accounts for approximately 2.7% to 3.4% of complications among surgical patients. Nosocomial pneumonia has been linked to high morbidity, mortality, and costs, and is among the complications used to assess readmission rates for hospital profiling and reimbursement. “In recent years, greater attention has been given to improving the quality of patient care, with an emphasis on infection control,” says Sherry M. Wren MD, FACS. “This has spurred the development of several guidelines for nosocomial pneumonia prevention.” Throughout the United States, some hospitals have developed multidisciplinary quality improvement (QI) programs that aim to reduce postoperative risk for pneumonia. Most of these programs have been initiated in critical care and ICU settings, but few have explored their effect in surgical wards. To address this research gap, Dr. Wren and colleagues at the VA Palo Alto Health Care System developed a pneumonia prevention QI program for surgical ward-acquired pneumonia prevention strategies that consist of several important steps (Table 1). The study group published long-term results of the program in JAMA Surgery. “We focused our research entirely on patients hospitalized on the surgical ward to evaluate the long-term effectiveness of our program,” Dr. Wren says. “It’s important to see if we can achieve sustained reductions in postoperative pneumonia in the surgical ward and to assess how effective it has been to adopt of our pneumonia prevention program.” The study revealed results of the program over a 5-year period since the intervention was implemented. Profound Results According to findings, between 2008 and 2012, there were just 18 cases of postoperative pneumonia among the more than 4,000 at-risk...

Costs of ABIM Maintenance of Certification

Researchers in California suggest that the 2015 version of the American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program will generate considerable costs, mostly due to demands on physician time. The study team estimated that internists will incur an average of $23,607 over 10 years, ranging from $16,725 for general internists to $40,495 for hematologists/oncologists. Time costs were estimated to account for 90% of MOC costs. Source: Annals of Internal Medicine, July 28, 2015...

Improving Survival After Pediatric In-Hospital Cardiac Arrest

Delays in epinephrine administration appear to decrease survival and worsen outcomes among children with in-hospital cardiac arrest who experience an initial non-shockable rhythm, according to a study. The longer amount of time that it took to administer epinephrine further reduced odds of survival to hospital discharge, return of spontaneous circulation, 24-hour survival, and survival to hospital discharge with a favorable neurologic outcome. Source: JAMA, August 25,...
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