Advertisement

Conference Highlights: ACEP 2015

New research was presented at ACEP 2015, the American College of Emergency Physicians’ annual meeting, from October 26 to 29 in Boston. The features below highlight some of the studies emerging from the conference. —————————————————————-   Reducing Pediatric Head CT Use The Particulars: Prior research suggests that head CT may be over-utilized in pediatric patients with mild head injuries. A program focused on physician education, shared decision making, and clinical decision support tools may help reduce unnecessary head CT use and associated radiation exposure. Data Breakdown: For a study, researchers compared the year before with the year after the implementation of a quality improvement project to reduce inappropriate head CT use. The project included ED nurse and physician leadership engagement, physician education, a parent-patient shared decision-making model, a clinical decision support tool embedded into the electronic medical record, and importation of all data into clinical notes to reduce keystrokes and drive compliance. Prior to the intervention, head CT was used in 28% of pediatric patients presenting to the ED with mild head injuries, compared with a rate of 21% observed during the year after implementation of the intervention. Take Home Pearl: Shared decision making and decision support tools appear to significantly reduce head CT utilization in pediatric patients presenting to the ED with mild head injury. —————————————————————-   Streamlining ICU Admissions The Particulars: Studies indicate that boarding of patients in the ED increases ED congestion, length of stay (LOS), and use of limited resources. Boarding can also worsen patient and family satisfaction as well as outcomes. Streamlining the admission of critically ill trauma patients to the ICU may help...

Conference Highlights: ACS 2015

New research was presented at ACS 2015, the American College of Surgeons’ annual clinical congress, from October 4 to 8 in Chicago. The features below highlight some of the studies emerging from the conference. —————————————————————-   Metastatic Melanoma Resection The Particulars: Melanoma that has metastasized to the abdomen has been considered incurable and seldom received surgical resection in the past. Recent advances in medicine may allow for successful resection of this cancer type, but few studies have assessed outcomes in this patient population. Data Breakdown: For a study, the outcomes of melanoma patients with abdominal metastases were compared based on whether or not these individuals underwent surgical resection of the metastases. The surgical patient group had an average survival of 18 months, compared with an average survival of 7 months for the non-surgical group. Take Home Pearl: Among patients with melanoma and abdominal metastases, surgical resection of the metastases appears to more than double the length of survival when compared with receipt of medical therapy alone.   —————————————————————-   Poor Recall in Colonoscopy Patients The Particulars: Little is known regarding the ability of colonoscopy patients to recall details regarding their last colonoscopy, including when and where it was performed. Data Breakdown: Colorectal surgeons grouped participants in a study based upon whether it had been 2 months, 1 year, 2 years, or 4 years since their last colonoscopy and compared the results. The table below summarizes key findings:   Time since colonoscopy 2 months 1 year 2 years 4 years Remembered date of last scope within 1 month 94% 42% 30% 28% Knew about presence of polyps on last scope...
CME: An Update on Poisonings Presenting to EDs

CME: 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...
Conference Highlights: TCT 2015

Conference Highlights: TCT 2015

New research was presented at TCT 2015, the Cardiovascular Research Foundation’s Transcatheter Cardiovascular Therapeutics annual meeting, from October 11 to 15 in San Francisco. The features below highlight some of the studies that emerged from the conference.   Estimating Fractional Flow Reserve With CT The Particulars: Comparisons of diagnostic angiography with fractional flow reserve derived from CT (FFR-CT) in patients with chest pain are lacking. Data Breakdown: For a study, researchers looked at patients who were either undergoing planned invasive testing with diagnostic angiography or planned noninvasive testing. Participants were assigned to usual care or a strategy guided by FFR-CT. Average costs were 32% lower for patients in the FFR-CT arm than for the invasive testing group. The difference in costs was driven mostly by the lower costs of invasive procedures. In addition, 61% of angiograms were canceled after FFR-CT data were obtained by physicians. Only 12% of patients who underwent angiography following FFR-CT did not have obstructive coronary disease, compared with 73% of those assigned directly to diagnostic angiography. Take Home Pearl: A diagnostic strategy with FFR-CT among chest pain patients suspected to have coronary artery disease appears to reduce the number of patients requiring invasive diagnostic angiography, resource utilization, and associated costs.   —————————————————————- Improving Care With Mitral Valve Teams The Particulars: Patients with mitral valve disease require complex care from cardiologists and surgeons. A team approach to this care could increase coordination and collaboration. Data Breakdown: David L. Brown, MD, FACC, FACP, FSCAI, founder of the Heart Hospital Baylor Plano and president and chairman of the medical staff, suggests that cardiologists and surgeons must work together...
CME: Counseling Young Adults With Hypertension

CME: 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...
CME: Preventing Postoperative Pneumonia

CME: 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...

Is CDI Overdiagnosed?

Researchers at the University of California, Davis suggest that reliance on only molecular tests to diagnose Clostridium difficile infection (CDI) without tests for toxins or host responses appears to result in overdiagnosis, overtreatment, and increased healthcare costs for CDI. For the study, all CDI-related complications and deaths among hospitalized patients occurred in those with toxin immunoassay results. Patients with positive molecular test results but negative toxin immunoassay results had outcomes similar to those without CDI. Source: JAMA Internal Medicine, September 8, 2015 (online)....

Trends in Breast Cancer

A study of 16 million women aged 40 and older who were followed for 10 years suggests that more breast cancer screenings led to a greater incidence of cancer diagnoses. However, increased screening did not result in decreased breast cancer-associated mortality. The incidence of small breast cancer diagnoses increased as screening increased, but the incidence of larger breast cancers did not decrease with increased screening. The authors suggest that there may be widespread overdiagnosis of breast cancer. Source: JAMA Internal Medicine, September 2015....

Alternative Dementia Screening Tests

Chinese investigators suggest that there are multiples alternatives to the Mini-Mental State Examination that have comparable diagnostic capabilities for detecting dementia. The Mini-Cog test and the Addenbrooke’s Cognitive Examination-Revised were deemed the most effective alternative screening tests for dementia. The Montreal Cognitive Assessment was determined to be the optimal alternative for detecting mild cognitive impairment. Source: JAMA Internal Medicine, September 2015....

TAVR Referral & Use: Predicting Mortality

Patients with severe symptomatic aortic stenosis who go untreated following referrals for transcatheter aortic valve replacement (TAVR) appear to have a 1-year mortality rate of almost 40%, according to a study. Among this patient population, those with advanced heart failure, renal dysfunction, low albumin levels, and/or left ventricular dysfunction were at increased risk for mortality. Source: American Journal of Cardiology, September 15,...
CME: The Demand for Emergency Care

CME: The Demand for Emergency Care

The CDC’s most recent National Hospital Ambulatory Medical Care Survey revealed that EDs in the United States saw more than 136 million patient visits in 2011, representing the highest number ever recorded. “It’s important to look at how EDs are being utilized on a national level,” says James J. Augustine, MD, FACEP. “By assessing ED utilization, we can document trends and set the course for what will be needed in order to continue providing high-quality care to more patients in the U.S.” From 1992 to 2011, there was a steady growth of about 3% in the number of patients visiting EDs. Experts project that the number of emergency visits will probably reach about 140 million by the next time the CDC compiles this data. “With Americans living longer than ever before,” says Dr. Augustine, “it’s expected that they will require more medical care from EDs in the future.” Non-Urgent Conditions: Changes in Trends The percentage of patients who visited EDs with non-urgent medical conditions decreased from 2010 to 2011 by about 50%, according to the survey. “More patients are seeking care for non-urgent conditions from other healthcare facilities, most notably for minor injuries, illnesses, and routine medical issues,” says Dr. Augustine. “This is helping EDs devote their resources to treating those who truly need emergency care. These findings reveal some of the successes occurring in EDs throughout the country.” The National Hospital Ambulatory Medical Care Survey found that although the highest number of ED visits was made by those between the ages of 25 and 44 (Figure 1), the highest utilization was by those over age 75 especially those...

The Costs of Fatal Injuries

Combined medical and work-loss costs for fatal injuries exceeded $214 billion in 2013, according a report from the CDC. Available for free at www.cdc.gov, the report states that costs from fatal injuries represented approximately one-third of the total $671 billion in medical and work-loss costs associated with all injuries in 2013.   Source: Morbidity and Mortality Weekly Report, October 2, 2015. For the full report, visit...
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...
CME: Cardiac Biomarker Testing in the ED

CME: 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...

Diabetes Prevalence Continues to Rise

The prevalence of diabetes appears to have increased in the United States and in all subgroups of Americans evaluated in a study from 1988-1994 to 2011-2012. During the study period, the overall prevalence increased from 9.8% to 12.4%. Diabetes prevalence increased significantly in every age group, both genders, and every racial and ethnic group. Its prevalence also increased significantly among patients from all education levels and in all poverty income ratio tertiles. Source: JAMA, September 8,...

Resuscitation Training Improves Outcomes

A statewide educational intervention on resuscitation training appears to have increased the proportion of patients who received bystander-initiated CPR and defibrillation by first responders. The combination of bystander CPR and first responder defibrillation increased from 14.1% before the intervention to 23.1% after. Survival with favorable neurological outcomes increased from 7.1% to 9.7% and was associated with bystander-initiated CPR. Source: JAMA, July 21,...

Tobacco Screening & Counseling in the Pediatric ED

Previous studies have shown that the pediatric ED tends to underuse parental tobacco screening and brief cessation counseling. Recently, a study was conducted to look at the attitudes and perceived barriers regarding the implementation and adoption of tobacco screening and cessation counseling of parental smokers among pediatric ED practitioners. The analysis also solicited suggestions for improving the sustainability and maintenance of these practices. For the study, investigators conducted 30 interviews to identify relevant data, patterns, and themes. Reach factors included targeting parental smokers with children with respiratory diseases, having adequate training of practitioners, and providing “prearranged” counseling packages. Effectiveness factors included practitioner desire for outcomes data about intervention effectiveness, such as changes in children’s secondhand smoke exposure and parental quit rates. Solutions to increase the adoption of interventions included quick electronic health record prompts and the provision of onsite tobacco cessation experts. Financial support and alignment of strategic plans were also viewed as important factors. Maintenance factors included institutional and technical support, as well as specifically identifying intervention “champions” in the pediatric ED. By highlighting these viewpoints, the researchers concluded that their findings can help guide and direct the development and evaluation of sustainable interventions for treating tobacco use in the pediatric ED. Source: Journal of Emergency Nursing, July...
CME: Dealing With the Aging Surgeon

CME: 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...
Page 1 of 212
[ HIDE/SHOW ]