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Improving Pediatric Asthma Care

Improving Pediatric Asthma Care

The current rate of childhood asthma in the United States is at a historically high 10%, according to recent research. Clinical practice guidelines recommend that clinicians provide parents and caregivers of children with asthma a regularly updated written asthma management plan. They are also recommended to administer annual influenza immunization for all children with asthma, prescribe daily controller medications in high-risk children, and screen for environmental tobacco exposure. Few studies have assessed compliance with recommendations that have been set forth by national medical societies and associations. It has been speculated that population-level surveys may provide such information and help identify social determinants of health and unique considerations that may benefit from tailored interventions. Learning From California For a study published in Population Health Management, Ulfat Shaikh, MD, MPH, MS, and Robert S. Byrd, MD, MPH, sought to determine the quality of life and healthcare utilization of children with asthma. “We used 2011-2012 data from the California Health Interview Survey because it is well collected and the sampling procedure used is excellent,” explains Dr. Shaikh. “The data are quite likely generalizable to the rest of the country because the population of California does not have significantly different rates of asthma than other states. We also wanted to use these data from 44,000 households to help identify ways in which pediatric asthma care could be improved.” Gaps Observed Dr. Shaikh says she and Dr. Byrd found several gaps between current practice and national recommendations for asthma care. “We found that children with asthma tended to use the emergency room more than they should,” she says. One-third of children in the study...
Examining Dietary Supplement Use

Examining Dietary Supplement Use

According to data from the 2012 National Health Interview Survey, approximately 18% of American adults take dietary supplements, amounting to more than 40 million people. The CDC recently reported that the most commonly used dietary supplements are vitamins and minerals. Other supplements that are frequently used by patients include herbs, amino acids, or other substances. “Many people use muscle building supplements, but they often do not disclose that they use these products to their healthcare providers,” says Paula M. Gardiner, MD, MPH. Research suggests that some patients may not disclose this information because they are unaware that physicians need to know about it. Other studies have revealed that patients may be reluctant to tell their healthcare providers for fear of being judged. A Significant Issue According to the Joint Commission, dietary supplements should be viewed by clinicians in the same context as they view prescription medications. “Just like prescription drugs, dietary supplements can have an impact on patient’s health outcomes and hence influence how clinicians manage their patients,” Dr. Gardiner says. These supplements can affect physiological processes in the body and may have an impact on medical procedures, such as surgery, chemotherapy, blood work, and other treatments or procedures. Dr. Gardiner notes that many over-the-counter products contain dietary supplements and have many active chemical properties that can be addictive or counteract the effects of the prescription drugs. “If clinicians don’t know all of the therapies that their patients are taking, they can’t do their job properly,” says Dr. Gardiner. Exploring the Issue A study published in Patient Education and Counseling by Dr. Gardiner and colleagues explored inpatient reconciliation of...
COPD Research: The Present & Future

COPD Research: The Present & Future

While research has made large strides in the assessment and treatment of patients with COPD in recent years, a number of important questions remain to be answered. The American Thoracic Society and European Respiratory Society have teamed up to publish a joint statement that describes current evidence on the diagnosis, assessment, and management of COPD; identifies gaps in knowledge; and makes recommendations for future research. Current Needs Perhaps the biggest need that spans all areas of COPD research is to determine which outcomes matter most to patients and then to ensure that research studies measure these outcomes. “Understanding what patients care about is the basis of patient-centered care,” says Kevin C. Wilson, MD, co-author of the statement, which was published in the American Journal of Respiratory and Critical Care Medicine. Physiological and/or anatomical outcomes are used frequently in studies because they tend to be easier to measure. Such surrogate outcomes, however, should strongly correlate with patient-centered outcomes if they are used in clinical research. Examples of patient-centered outcomes include quality of life, dyspnea, and frequency and severity of exacerbations. Determining the optimal method for diagnosing COPD based on spirometry is another important research need according to Dr. Wilson. It is undetermined whether the diagnosis of COPD should be based upon a fixed threshold or the lower limit of normal for the FEV1/FVC ratio. A post-bronchodilator FEV1/FVC ratio of less than 0.7 has traditionally been the criterion for airflow limitation. However, this threshold may result in more frequent identification of airflow limitation among the elderly and less frequent diagnoses among patients younger than 45 when compared with a threshold based...
Identifying Smoking-Related Disease

Identifying Smoking-Related Disease

Among current and former adult smokers, symptoms like productive cough, dyspnea, and exercise intolerance may be viewed as a part of normal aging, particularly among older former smokers. Smoking cessation may reduce respiratory symptom severity and slow the rate of lung function decline, but it does not eliminate progressive lung disease risk. Few studies have assessed the effects of smoking on patients without COPD. A group of researchers has suspected that spirometry may be insensitive to early disease or subclinical lung pathology and that current and former cigarette smokers without spirometric evidence of COPD may have impairments in physical function, quality of life, and respiratory symptoms that can go untreated. High-resolution CT scanning in this patient population may demonstrate significant lung disease, but comprehensive data has been lacking. Finding Hidden Lung Disease “There are no disease-modifying treatments for patients identified with smoking-related lung disease,” explains Elizabeth A. Regan, MD, PhD, “but there are many treatments that improve their symptoms, allow them to breath better, enable them to exercise, and improve quality of life.” For a study published in JAMA Internal Medicine, Dr. Regan and colleagues set out to determine whether or not patients with a heavy smoking history, but who did not meet spirometric criteria for COPD, had hidden lung disease. Dr. Regan and colleagues completed evaluations on more than 10,000 current and former smokers aged 45 to 80 with at least a 10 pack-year smoking history and a comparison group of more than 100 never smokers of similar ages. Evaluations included high-resolution chest CT scans, spirometry, 6-minute walking tests, and multiple questionnaires about respiratory symptoms, comorbidities, and quality...
Terrible Chest Pains

Terrible Chest Pains

“I think, if you loosen your belt a little, you won’t be experiencing those terrible chest...
Advances in Managing Multiple Sclerosis

Advances in Managing Multiple Sclerosis

According to recent estimates, about 400,000 people in the United States live with multiple sclerosis (MS). There are other conditions that are now known to be distinct from the disease but may be misdiagnosed as MS. Typically, MS can be associated with fatigue, impaired vision, problems with balance and walking, numbness or pain, tremor, and other sensory and physical changes. “With MS, the symptoms are unpredictable and vary from person to person,” explains Mark S. Freedman, MD. “Some patients may experience abnormal fatigue and episodes of numbness and tingling, whereas others lose balance and muscle coordination. All patients with MS will have unique characteristics and symptoms, making treatment challenging.” Disease-Modifying Therapy Some drugs treat symptoms of MS whereas others modify the disease by altering the course of its progression, Dr. Freedman says. “With disease-modifying therapy, the goal is to reduce MS attacks, decrease the number of lesions seen on MRI, and slow or prevent disease progression.” Several therapies have been approved by the FDA to treat MS, some that are taken orally and others that are injected. The National Multiple Sclerosis Society recommends that patients diagnosed with relapsing MS and those whose disease is currently active consider beginning treatment with disease-modifying therapy as early as possible, as these medications lose efficacy as the disease advances. “It can be challenging for patients to take disease-modifying medications over a long period of time,” Dr. Freedman says, “but it’s important that they understand the role of these therapies in their overall MS treatment plan.” Patients must also be made aware of the obstacles that can interfere with adherence to treatment plans. The...
Like a Duck

Like a Duck

“You look like a duck, you walk like a duck, you smell like a duck … I’m gonna refer you to a specialist.”      ...
Blindfolded

Blindfolded

“This is a common procedure. So to keep things interesting, I’m going to attempt it...
Cough

Cough

“When I said ‘cough’ I meant you, not him!”                    ...
Green Thumb

Green Thumb

“It’s green all right, but it’s not because you’re a gardener. Let’s get you into surgery.”...
Wanted: Older Adults in Cancer Trials

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...
Examining Information Sharing Preferences

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...
The CDI Burden in Surgery

The CDI Burden in Surgery

Despite increased national attention, the incidence of Clostridium difficile infection (CDI) and its associated financial and human costs continue to grow. In fact, the problem has become so critical that CMS would no longer reimburse hospitals for claims associated with this potentially preventable infection if it is acquired during the hospital stay. There are also concerns that new strains of the infection may cause resistance to traditional antibiotic regimens. Recent data have also shown that the burden of CDI is increasing among surgical patients. This is concerning given that surgical care accounts for about 40% to 50% of all hospital stays and healthcare dollars. “Surgery patients frequently receive prophylactic antibiotics and have longer inpatient hospital exposure,” explains Zaid M. Abdelsattar, MD, MSc. Previous reports on how CDI affects surgical patients has been limited by the use of administrative data and failure to capture cases diagnosed after discharge, and reports from single-center studies. A Large-Scale Analysis In a study published in Infection Control & Hospital Epidemiology, Dr. Abdelsattar and colleagues conducted a large-scale analysis of patients with postoperative CDI after 40 different surgeries at 52 academic and community hospitals for a period of about 1 year. The purpose of the analysis—which included more than 35,000 patients in total—was to identify CDI risk factors and determine the impact of the infection on resource utilization. According to the results, only about 0.5% of the study group developed CDI after surgery, but postoperative CDI rates varied significantly between surgical procedures. Three surgical groups had higher adjusted odds ratios (aOR) of postoperative CDI: Lower-extremity amputations: aOR,3.5. Gastric or esophageal operations: aOR, 2.1. Bowel resection...
Opioid Abuse Screening in the ED

Opioid Abuse Screening in the ED

Using screening tools for various substance use problems in the ED can be powerful but can also be time consuming and costly and may require additional staff resources. Some studies suggest that computerized screening may be a solution to this dilemma because they require less staff time and allow scores to be calculated with fewer errors. As tablet computers have become lighter and less expensive and have a longer battery life, screening ED patients with these devices may improve delivery of care. Over the past decade, opioid prescription abuse in the United States has increased exponentially, with deaths from overdose rising to epidemic proportions. In a study published in the Western Journal of Emergency Medicine, Scott G. Weiner, MD, MPH, and colleagues evaluated the feasibility of using an electronic tablet version of a screener for opioid prescription abuse potential in the ED. The authors used the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), a proprietary screening measure that was previously developed and validated in pain clinic patients. Promising Results For the study, 93 adults being considered for ED discharge with a prescription for an opioid were approached and 82 consented to participate. “All patients completed the screening without assistance and no additional staff resources were required,” says Dr. Weiner. “The median time to completion was just 148 seconds, and 95% completed the screening in less than 5 minutes. In addition, 93% of patients rated the ease of completion as very easy. Our results demonstrate that it is feasible to electronically administer a screening tool for opioid abuse potential to ED patients in a time-efficient manner.” Important...
Smoking Cessation After PCI

Smoking Cessation After PCI

It has been well-documented in clinical studies that smoking cessation after patients undergo PCI can improve outcomes. Some research has identified certain predictors of smoking cessation after PCI, including previous cigarette consumption and the number of coexisting coronary artery disease risk factors. Few studies, however, have assessed current trends in smoking cessation after PCI and looked at the potential impact of smoke-free policies that are being enacted throughout many parts of the United States. “Historically, patients who undergo PCI are a group that has more difficulty quitting smoking than others,” says Randal J. Thomas, MD, MS. The Effect of Smoke-Free Policies In a study published in the February 15, 2015 issue of the American Journal of Cardiology, Dr. Thomas and colleagues assessed trends and predictors of smoking cessation after PCI in Olmsted County, Minnesota. The investigators conducted the research at a time when local and statewide smoke-free public policies were enacted in Olmsted County. The study followed 2,306 patients who underwent their first PCI from 1999 to 2009 for 12 months. The researchers conducted structured telephone surveys at 6 and 12 months after PCI to assess smoking status and quit rates during the 10-year period. The authors paid particular attention to quite rates around two dates when three smoke-free ordinances were implemented to reduce secondhand tobacco exposure in Olmsted County. The first date was January 1, 2002, when an ordinance was passed requiring restaurants to be smoke-free. The second was October 1, 2007, when ordinances required both workplaces and the entire state of Minnesota to be smoke-free. The data were then analyzed according to three time periods: 1991 to 2001, 2002...
A Novel Approach for TMJ Dislocation 

A Novel Approach for TMJ Dislocation 

Anterior temporomandibular joint (TMJ) dislocations are among the most common non-traumatic dislocations of the jaw. Although non-traumatic TMJ dislocations are infrequent in the ED, it is important to find useful methods for managing these patients in order to improve patient outcomes in a safer and more effective manner. The traditional approaches to managing TMJ have numerous disadvantages, including the risk of bite injuries, which in turn increases the risk of transmitting diseases like hepatitis and HIV. Traditional approaches also require procedural sedation because the application of additional force to manually manipulate the mandible can be difficult and painful. In addition to these disadvantages, repeated attempts may be necessary before successfully reducing the dislocated TMJ. Another complication with traditional approaches is that they may inadvertently fracture the mandibular or condyle. Other techniques for reducing TMJ have also been tested, but these strategies still require procedural sedation and manual reduction. “Traditional approaches to TMJ can be time consuming, difficult, and sometimes ineffective,” explains Julie A. Gorchynski, MD, MSC, FACEP, FAAEM. “They can also be risky to patients and emergency physicians because it involves intraoral manual manipulation of the mandible as well as procedural sedation.” A New Technique In a prospective study published in the Journal of Emergency Medicine, Dr. Gorchynski and colleagues evaluated a simple and novel syringe technique for reducing acutely non-traumatic TMJ dislocations using a hands-free approach. The technique requires that a syringe be placed between the posterior molars as they slide over the syringe to glide the anteriorly displaced condyle back into its normal position. Over the 3-year study period, researchers collected information on demographics, mechanisms, duration of...
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