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Conference Highlights: 2016 Critical Care Congress

Conference Highlights: 2016 Critical Care Congress

New research was presented at the 2016 Critical Care Congress, the Society of Critical Care Medicine’s annual meeting, from February 20 to 24 in Orlando. The features below highlight some of the studies emerging from the conference that focused on emergency medicine. Sedation, Analgesia, & RSI in the ED The Particulars: The appropriate use of sedation and analgesia are crucial to optimizing the management of patients undergoing intubation. However, studies suggest that this management is often inadequate, particularly after performing rapid sequence intubation (RSI) in patients with paralysis. Use of a prescribing pathway in the ED may improve the time from intubation to sedative and analgesic administration. Data Breakdown: Researchers compared sedation and analgesia administration in patients undergoing RSI in the ED before and after implementation of an electronic prescribing pathway for a study. The average time from RSI to sedation administration was 28.7 minutes for the pre-intervention group, compared with a time of 24.0 minutes in the post-intervention group. The average time from RSI to opioid analgesic administration decreased from 78.0 minutes before the intervention to 40.2 minutes after. Take Home Pearl: Adding an electronic prescribing pathway in the ED does not appear to decrease time to sedation administration among patients undergoing RSI, but does appear to significantly decrease the time from RSI to analgesic administration. —————————————————————-   Recognizing CIRCI in the ED The Particulars: The treatment of critical illness-related corticosteroid insufficiency (CIRCI) remains controversial, but data suggest that corticosteroid administration during early septic shock may improve 28-day survival. Little is known about how well EDs recognize patients with possible CIRCI. Data Breakdown: For a study, medical records...
CME: Examining Information Sharing Preferences

CME: Examining Information Sharing Preferences

Research has shown that older patients often share control over decision-making and personal health information with family members or friends in order to manage medical care issues. However, it can be challenging for clinicians to balance helping patients and their caregivers work collaboratively to manage health information and decision-making while simultaneously respecting the preferences, privacy, and priorities of patients. To help patients manage their healthcare, patient portals have been developed that connect patients with their healthcare records and oftentimes directly with their clinicians through secure messaging. While portals can be helpful, they may not account for all privacy preferences and offer little guidance on when patients would like to bring their families or caregivers into the fold. Examining Attitudes & Needs In previous research, studies have shown that older patients often want control over the privacy of their health information in electronic medical records, but little is known about how this control relates to family dynamics and the use of patient portals. As reported in  JAMA Internal Medicine, Bradley H. Crotty, MD, MPH, and colleagues sought to identify how elderly patients (older than 75) and their family caregivers approached sharing of health information. “This is an issue that many physicians will encounter, but there has not been much research on the topic,” says Dr. Crotty. For the study, investigators recruited participants from the Information Sharing Across Generations (InfoSAGE) Living Laboratory. InfoSAGE is an ongoing study of the information needs of elderly patients and families within a network of senior housing in the Massachusetts area. Participants joined one of 10 discussion groups to explore the issues. Group discussions were then...
Conference Highlights: ISC 2016

Conference Highlights: ISC 2016

New research was presented at ISC 2016, the International Stroke Conference, from February 17 to 19 in Los Angeles. The features below highlight some of the studies emerging from the conference that are relevant to emergency medicine. Analyzing Telestroke Consultations The Particulars: Telestroke consultations have been widely available for several years in the United States. However, large-scale outcomes data on the ability of telestroke to improve acute treatment in rural systems of care are lacking. Data Breakdown: For a study, researchers reviewed data from more than 3,000 acute ischemic stroke (AIS) patients who were treated via tele-emergency consults at 46 U.S. hospitals between 2012 and 2015. Among participants who received tPA, nearly three-quarters were treated within 180 minutes from being last seen normal (LSN). Almost 17% of patients received tPA within 4.5 hours of LSN. The average door-to-needle time was 83 minutes, with 22% receiving tPA within 60 minutes. The average time from patient arrival to telestroke call initiation was 44 minutes, and the average call to video consult time was 20 minutes. Take Home Pearls: Access to telestroke consultations in rural hospitals appears to result in relatively high levels of treatment with tPA among AIS patients. While teleconsultation physician response times appear to be quick, patient arrival to telestroke call times tend to be much longer. —————————————————————-   Hypertension Not Linked With ICH The Particulars: Recent research suggests that intracerebral hemorrhage (ICH) often occurs shortly after an acute rise in blood pressure. However, whether patients discharged from the ED with hypertension are at increased risk for ICH in subsequent weeks has not been well studied. Data Breakdown: American...
CME: Opioid Misuse, Abuse, & Addiction

CME: Opioid Misuse, Abuse, & Addiction

In recent years, clinicians have changed their attitudes regarding the use of opioids in light of the growing public health issue surrounding the potential of these drugs to be misused and abused. Risks associated with opioid use include overdose, drug dependence and subsequent withdrawal, addiction, and a negative impact on physical functioning. “For many years, the United States went through a stretch when opioids were prescribed increasingly for pain relief,” explains Kevin E. Vowles, PhD. “Recent research, however, has indicated some potential problems associated with increases in opioid prescription rates. As a result, the prescribing of opioids is leveling off, but there is still a segment of the population that stands to benefit from using these medications.” Experts have endorsed the notion that there is a need to differentiate and identify types of problems that may occur when using prescription opioids among patients with chronic pain. Some studies have attempted to calculate rates of problematic opioid use behavior, but these trials often suffer from imprecise and poorly defined terminology. “We’re lacking high-quality evidence on the identification of patients who are at risk for misusing and abusing opioids,” Dr. Vowles says. An Updated Review For a study published in Pain, Dr. Vowles and colleagues performed an updated review of problematic opioid use among patients with chronic pain. “Because previous reviews have indicated substantial variability in this literature,” says Dr. Vowles, “we took several steps to enhance precision and utility.” The authors gathered data from 38 studies and explicitly coded the terms for rates of problematic opioid use in the available literature. They referred to different patterns of use, such as...
Doctor Curmudgeon®: Patient Entitlementiasis with Insurance

Doctor Curmudgeon®: Patient Entitlementiasis with Insurance

By Doctor Curmudgeon® This week, the old Curmudgeon had a mental bloppo. I seemed to remember that great gentleman, Ben Franklin, saying something about insurance not meant to cover every penny of everything. After fruitless hours of searching, I could not find that quote. I did know that, in addition to being one of our Founding Fathers, he was the Father of mutual insurance. I was hoping that, being a certified curmudgeon, I could channel him on that point, but he must have been busy as there was a huge waiting line.  I did meet a few other curmudgeons, but that’s for another column Serendipity is an interesting muse because in the course of searching, I found an unrelated quote, which I feel compelled to post here:   “No man’s life, liberty or fortune is safe while our legislature is in session”   My door was partially open.  As I sat in my office, getting chocolate crumbs on my keyboard, I heard goings-on at the front desk. Assistant (a smile and gentleness in her voice):  “Ms. Difficult, your co pay is twenty dollars.  Would you prefer to pay by cash or credit card? Patient (with no smile and no gentleness in her voice):  “What? Twenty dollars?  I thought my insurance paid for everything?  I don’t have time for this.  I’m catching a plane for my vacation.” There are many, many, many who believe that insurance must cover everything.  But, to insure is to cover against catastrophe, not every single dime or penny or pence or ha’penny. Where did we lose this concept? I do remember my parents having insurance...
First Black Female Physician in the US honored by alma mater

First Black Female Physician in the US honored by alma mater

As the Civil War raged in 1864, Rebecca Lee marked her place in history when she became the first Black female to graduate medical school in the United States. She received an M.D. degree from the New England Female Medical College (now Boston University School of Medicine). This month my alma mater BUSM will celebrate the life of this pioneering Black woman physician as the exhibit established in her honor is unveiled. Raised by an aunt who provided care to the sick, an imprint was made. At 21, young Rebecca moved to Massachusetts and worked for eight years as a nurse. Physicians noted her dedication, skills and intellect. Replete with their letters of recommendation, in 1860 Rebecca Lee applied, and was admitted, to the New England Female Medical College.   “I early conceived a liking for, and sought every opportunity to be in, a position to relieve the suffering of others.”  – Rebecca Lee Crumpler, MD (1831-1895)   Dr. Lee graduated medical school, married Arthur Crumpler and worked for the Freedmen’s Bureau in Richmond, Virginia. The Bureau was established by Congress in 1865 to help repair Civil War-torn communities. Among other services, it provided food, built housing and provided physician services. Dr. Crumpler provided medical care to thousands of recently-freed slaves who were routinely denied medical care by White physicians. Dr. Crumpler endured very harsh conditions, disparaging comments and intense discrimination by most fellow physicians. Some administrators would not readily grant her hospital privileges, and many pharmacists would not honor her prescriptions. Some people wisecracked that “the M.D. behind her name stood for nothing more than ‘Mule Driver.'” The couple returned...
Osteoporosis & Fractures in Men

Osteoporosis & Fractures in Men

As the United States population continues to live longer, the incidence of osteoporotic fragility fractures is expected to increase substantially in both men and women over the next 30 years. Osteoporosis is primarily thought of as a disease that affects older women, but estimates show that more than 2 million men also have the condition. Current estimates show that as many as 25% of men older than age 50 will suffer a fracture due to osteoporosis. Wrist fractures currently rank as the third most common fragility fracture and the leading upper extremity fracture in older adults, but data are lacking on the characteristics of men who sustain these fractures. Comparing Characteristics In a study published in the Journal of Bone & Joint Surgery, Tamara D. Rozental, MD, and colleagues compared fracture characteristics, treatment, and osteoporosis evaluations among men and women who had sustained a distal radial fracture. The research team retrospectively reviewed medical records of 95 men and 344 women aged 50 and older and were treated for a wrist fracture between 2007 and 2012. According to the results, fewer men than women underwent bone mass density (BMD) testing before they sustained their fracture. Overall, men were 10 times less likely to be screened for osteoporosis and almost 16 times less likely to be treated than women, according to Dr. Rozental. Men were also less likely to be started on treatment with calcium and vitamin D supplements within 6 months of their injury. In addition, 3% of men started taking bisphosphonates to increase bone mass, compared with a 22% rate that was seen in women. The study used the...
CME – Wanted: Older Adults in Cancer  Trials

CME – Wanted: Older Adults in Cancer Trials

Studies have shown that older adults account for most of the cancer diagnoses and deaths that occur in the United States and make up the majority of cancer survivors. More than 50% of cancers in the U.S. occur in people aged 65 and older, a demographic that is expected to grow exponentially in the coming years. However, the evidence base for treating this patient group is lacking. In addition, few policy initiatives have targeted the lack of evidence on older adults with cancer. “Older adults are largely underrepresented in clinical trials, and it’s rare when these trials are designed specifically for older adults,” says Arti Hurria, MD. “This patient population tends to have different experiences and outcomes with cancer treatment than younger counterparts. We’re also expecting a doubling of the U.S. population that is 65 and older, and we project a 67% increase in cancer incidence among this age group. These data emphasize the importance of involving older adults in clinical trials so that we can optimize treatment for these patients.” In response to this issue, the American Society of Clinical Oncology (ASCO) recently released landmark recommendations to improve the evidence base for treating older adults with cancer. The call-to-action statement was developed by ASCO’s Cancer Research Committee and published in the Journal of Clinical Oncology. It made five overarching recommendations to improve the evidence base for treating older adults with cancer (Table). Improving Trial Designs The first recommendation from ASCO is to use clinical trials to improve the evidence base for treating older adults. There is growing recognition that eligibility criteria in clinical trials could be relaxed without...
Doctor Operates on the Wrong Child

Doctor Operates on the Wrong Child

A newborn in Tennessee had an operation to correct a “tongue tie.” Except for the procedure being performed on the wrong baby, things went well. According to reports, a nurse came into the mother’s room and took the baby. The mother assumed that the child was having some routine nursing care and was understandably upset when the nurse returned and said the baby was fine after the operation. The frenulum is a fold under the front part of the tongue [see photo of a normal frenulum]. When it is too short, tongue tie results. It can cause immediate problems with feeding and with speech and alignment of the teeth later in childhood. The surgery is usually done without anesthesia and consists of simply cutting the shortened frenulum to release the tongue. This link from Stanford University has before and after photos of a newborn with tongue tie. Tongue tie is common, occurring in 4% to 10% of babies, and serious complications of the corrective surgery are extremely rare. How could this mix-up have happened? It appears that the doctor accidentally sent for the wrong patient. The nurse who fetched the baby either did not ask anyone why he was having a procedure and/or did not know the baby’s history very well. Before starting any invasive procedure in most hospitals, a “timeout” is done. It consists of a checklist with the following: 1) the correct patient is confirmed by using at least two separate identifiers; 2) the procedure to be done is agreed upon by all participating medical personnel; 3) a consent form signed by the patient or a legal...
CME: Updated Guidance for STDs

CME: Updated Guidance for STDs

The CDC recently published an update to its 2010 sexually transmitted disease (STD) treatment guidelines in order to address key questions regarding the treatment and clinical management of these diseases. Published in the Morbidity and Mortality Weekly Report (MMWR), the guideline addresses several key updates, including: Alternative treatment regimens for Neisseria gonorrhoeae. The use of nucleic acid amplification tests for the diagnosis of trichomoniasis. Alternative treatment options for genital warts. The role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications. Updated HPV vaccine recommendations and counseling messages. The management persons who are transgender. Annual testing for hepatitis C in individuals with HIV infection. Updated recommendations for diagnosing urethritis. Retesting for chlamydia, gonorrhea, and trichomoniasis to detect repeat infections. A Focus on Risk Assessment As the guideline indicates, primary prevention of STDs should include behavioral and biologic risk assessment. As part of the clinical encounter, the CDC recommends that clinicians routinely obtain sexual histories and address risk reduction using the “Five Ps” approach (Table). “Regarding partners, clinicians should ask patients if they have sex with men, women, or both,” explains Kimberly A. Workowski, MD, FACP, FIDSA, lead author of the guideline update. “They should also ask about how many partners they’ve had in the last 2 and 12 months and whether it’s possible that their partners have other partners.” In terms of practices, Dr. Workowski says it is important to know if patients are engaging in vaginal, oral, or anal sex because certain infections can reside in certain anatomic sites of exposure and, in many instances, may infect patients without symptoms. Additional questions pertain to past history of sexually transmitted...

Neurosurgeon Predicts 90% Success of Head Transplant

Dr. Sergio Canavero, Director of the Turin Advanced Neuromodulation Group, announced that he would perform the world’s first human head transplant, scheduled for December 2017, if preparations beforehand goes according to plan. The eager volunteer? A 30-year-old Russian man, Valery Spiridonov, who suffers from a rare motor neuron disease known as Werdnig-Hoffman Disease. There is currently no treatment for the disease, and he has hopes of improving his quality of life. “The chances of this working is 90%,” claims Dr. Canavero.“…of course there’s a marginal risk. “But for him Western medicine has nothing to offer; “western medicine has failed.” Along with the risk and uncertainties that accompany any surgery, there is the obvious hitch: no doctor has ever successfully reconnected a spinal cord. And if the reconnection was successful, would the head reject the new body? Dr. Xiaopin Ren, a neurosurgeon from China’s Harbin Medical University, will partner up with Dr. Canavero in this endeavor. Dr. Ren has performed head transplants in over 1,000 different mice…unfortunately, while the mice were able to breathe, drink, and see, none of them survived for longer than a few minutes. The duo will spend the next 2 years prepping for the 36-hour surgery. Dr. Canavero will attempt to reconnect the spinal cord with polyethylene glycol—a compound known for its ability to fuse fatty cell membranes. If ever a success—in 2 years or 200—the procedure could address the <> of the severely disabled. Is it worth the risk? Source: Forbes Source:...
CME: Guidelines for Treating First Seizure

CME: Guidelines for Treating First Seizure

According to current estimates, about 150,000 American adults present with an unprovoked first seizure each year. Studies show that even one seizure can be a traumatic physical and psychological event for patients. They can have major consequences for patients, including loss of driving privileges, employment limitations, a higher risk for falls, and fears of having another seizure in public. Recurrent seizures can be even more serious and costly. Unprovoked first seizures are difficult to for clinicians to diagnose and treat. In 2007, practice guidelines were released to help clinicians evaluate an unprovoked first seizure in adults. In 2015, the American Academy of Neurology and the American Epilepsy Society issued evidence-based guidelines on prognosis and therapy for first seizures. This guideline, published in Neurology and available for free at www.neurology.org, clarifies when risk factors put individuals at greater risk for seizure recurrence. Prevention of seizure recurrence with antiepileptic drug (AED) therapy is also discussed. “Evidence-based approaches are needed to evaluate and manage adults after a first seizure,” says Allan Krumholz, MD, who was lead author of the guideline. “This guideline is a valuable tool because it could change approaches to treating first seizures, enabling clinicians to possibly improve outcomes and quality of life in patients.” Conveying Recurrence Risk The guidelines offer recommendations regarding the risk of seizure recurrence among patients who have an unprovoked first seizure. “Adults who have an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years,” Dr. Krumholz says. Studies show that recurrence risks vary between 21% and 45%, depending on a variety of factors (Figure). Several...
Fighting the Dr. Oz World

Fighting the Dr. Oz World

As 2016 rolls out, many resolutions spring to life and others already lay broken underfoot. Everyone wants to be healthy, fit and lean but that goal is difficult for most. And as we grow attuned to easy fixes in our culture, we search for quick health and fitness cures as well. We want magic pills to help us sleep and lose weight. We desire supplements that build muscle without the hassle of going to the gym. While most doctors and medical professionals do not support the safety of these products, celebrity doctors like Dr. Oz profit hugely from them. It certainly seems like we are living in an Oz world. Frequently, I am amazed at the “natural” products and supplements my patients buy into. There is no evidence to support their effectiveness, and research is needed to prove their safety. Yet, when a celebrity supports such products, people buy it. And then doctors in the exam room fight tooth and nail to explain why these may not be the best or safest treatment for them. Sure, there are some alternative medications that do work. I am sure that over time we will discover more and find that some of them we are hesitant to support have some use. But, until then we are fighting against the Oz-world of healthcare: fast solutions with no proven benefit at high costs. “As we grow attuned to easy fixes in our culture, we search for quick health and fitness cures as well.”   Companies that produce supplemental products need doctors to support them otherwise they will not see any profits. I delete 3...
Examining Low HPV Vaccination Rates

Examining Low HPV Vaccination Rates

Human papillomavirus (HPV) vaccination among adolescents aged 11 or 12 has been shown to be effective and is recommended as a routine primary prevention strategy to reduce many HPV-related cancers. However, data indicate that HPV vaccination coverage is low for adolescents. Examining Coverage To better understand HPV vaccination coverage rates in the United States, the CDC partnered with the National Committee on Quality Assurance (NCQA) to evaluate the rate of vaccination among more than 626,000 girls at age 13 who were enrolled in commercial health insurance plans or Medicaid in. “NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) houses data on performance measures for important healthcare issues that are reported by health insurance plans,” explains Shannon Stokley, MPH. “The HEDIS HPV Vaccine for Female Adolescents performance measure evaluates how many members of a given health plan have received the complete, three-dose HPV vaccination series by the age of 13.” Stokley and colleagues found that although health plan performance on HPV coverage varied by plan type, overall performance was low. Commercial plans provided all three doses of the HPV vaccine to a median of 12% of adolescent girls by age 13, with rates ranging from 0% to 34%. The authors observed little difference in performance by plan size, and the highest-performing plans were health maintenance organizations. Although Medicaid plans reported a significantly higher rate of coverage, these plans provide all three doses of the vaccine to only 19% of girls by age 13, with coverage ranging from 5% to 52% among the various plans. Next Steps “Other reports have shown that vaccination coverage rates for the tetanus, diphtheria, and pertussis...

Human Papillomavirus Vaccination Coverage Among Female Adolescents in Managed Care Plans — United States, 2013

Abstract Human papillomavirus (HPV) is the most common sexually transmitted infection, with a reported 79 million persons aged 15–59 years in the United States currently infected with HPV, and approximately 14 million new cases diagnosed each year. Although most HPV infections are asymptomatic, transient, and do not cause disease, persistent HPV infection can lead to cervical, vulvar, vaginal, anal, penile, and oropharyngeal cancer. In the United States, approximately 27,000 HPV-attributable cancers occur each year. HPV vaccination is an effective primary prevention strategy that can reduce many of the HPV infections that lead to cancer, and is routinely recommended for adolescents aged 11–12 years. To determine whether the recommended HPV vaccination series is currently being administered to adolescents with health insurance, CDC and the National Committee for Quality Assurance (NCQA) assessed 2013 data from the Healthcare Effectiveness Data and Information Set (HEDIS). The HEDIS HPV Vaccine for Female Adolescents performance measure evaluates the proportion of female adolescent members in commercial and Medicaid health plans who receive the recommended 3-dose HPV vaccination series by age 13 years. In 2013, in the United States, the median HPV vaccination coverage levels for female adolescents among commercial and Medicaid plans were 12% and 19%, respectively (ranges = 0%–34% for commercial plans; 5%–52% for Medicaid plans). Improving HPV vaccination coverage and understanding of what health plans might do to support HPV vaccination are needed, including understanding the barriers to, and facilitators for, vaccination coverage. Free full...
A Qualitative Look at AMI in Younger Women

A Qualitative Look at AMI in Younger Women

Each year, more than 15,000 women younger than age 55 die from heart disease, ranking it among the leading causes of death in this age group. “Young women have twice the risk of dying during hospitalization for an acute myocardial infarction (AMI) as similarly aged men,” says Judith H. Lichtman, PhD, MPH. Research suggests that delays in recognizing AMI symptoms and seeking medical care may contribute to poorer outcomes for women, but most of these studies involve patients older than 55. Few studies have examined the perceptions and actions of women younger than 55 who experience AMI symptoms. “With a better understanding of the perspective of these women with regard to AMI symptoms and their interactions with healthcare providers, clinicians can gain valuable insights into factors that influence prompt care-seeking behaviors,” Dr. Lightman say. To address this research gap, Dr. Lichtman, and colleagues had a qualitative study published in Circulation: Cardiovascular Quality and Outcomes in which 30 younger women (aged 30 to 55) who were recently hospitalized with AMI described their experiences with AMI symptoms and their decision-making process to seek medical care. The purpose was to identify factors that may contribute to delays in recognizing symptoms and engaging the healthcare system. Important Themes According to the results, five themes characterized the experiences of women. First, prodromal symptoms varied substantially in both nature and duration. Second, women inaccurately assessed their personal risk of heart disease and commonly attributed symptoms to non-cardiac causes. Third, it appeared that competing and conflicting priorities influenced decisions about seeking acute care. Fourth, the healthcare system was not consistently responsive to women, which resulted in...
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