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“Spare Tire”

“Spare Tire”

“You need to diet. You’re getting love handles on your spare tire.”            ...
Pharmacist’s Reaction

Pharmacist’s Reaction

“Don’t be alarmed by the pharmacist’s reaction when you show him this prescription.”                  ...
Opioid-Induced Constipation in Cancer Patients

Opioid-Induced Constipation in Cancer Patients

Cancer patients who receive opioid therapy for the management of persistent pain commonly experience opioid-induced bowel dysfunction. Constipation is one of the most frequent manifestations. Other symptoms include nausea, bloating, and reflux. According to studies, the prevalence of opioid-induced constipation (OIC) among people with advanced cancer varies from 25% to 90%. “OIC is a complex and potentially serious problem,” says Lara K. Dhingra, PhD. “In addition to the physical effects from both OIC and the treatments used to manage it, OIC is associated with an emotional burden for patients.” Constipation may impair quality of life (QOL) and can potentially have serious complications, including bowel obstruction and severe anorexia. OIC can also lead to time missed from work, more healthcare utilization, and changes in opioid regimens. Despite the growing recognition of adverse consequences that have been linked to OIC, little is known about the nature of psychological distress and the burden associated with this problem. There is a lack of systematic research on the affective and cognitive burden of OIC, particularly among cancer populations, a group that may be at higher risk for physical and psychological distress due to OIC. “Studies show that cancer patients are more likely to rate constipation as a cause of severe symptom distress than pain,” adds Dr. Dhingra. “This highlights the importance of developing effective treatment strategies and finding ways to reduce distress.” A Qualitative Analysis A study published in Palliative Medicine by Dr. Dhingra and colleagues used qualitative research methods to better understand the psychological distress and burden associated with OIC and its treatment in advanced cancer patients. “This type of design is ideal...
A Little Pinch

A Little Pinch

“You’ll feel a little pinch, then another pinch, and then a few more because I’m pretty bad  at this.”...
Symptomatic Knee OA on the Rise

Symptomatic Knee OA on the Rise

Throughout the United States, the rate of knee replacement operations has surged in recent years. Experts have speculated that the increased prevalence of knee pain or of symptomatic knee osteoarthritis (OA) is due to an aging and increasingly obese U.S. population, which in turn may be the cause for the increase in knee surgeries. However, formal assessments of the secular trend of knee pain and symptomatic knee OA have been lacking. In the Annals of Internal Medicine, David T. Felson, MD, MPH, and colleagues addressed this void when they conducted a study examining whether a change in the prevalence of knee pain and symptomatic OA could be attributed to age, BMI, and radiographic knee OA. “It’s largely unknown if the increase in knee replacements was due to patients seeking the procedure more often,” explains Dr. Felson. “We also don’t have a great deal of data on the trends in knee OA.” Key Findings For their study, Dr. Felson and colleagues collected data from six National Health and Nutrition Examination Surveys (NHANES) conducted between 1971 and 2004 and from three examination periods in the Framingham Osteoarthritis (FOA) study between 1983 and 2005. “We wanted to see if the prevalence of knee OA had increased over time,” Dr. Felson says. In all samples studied, the age-adjusted prevalence of knee pain and symptomatic knee OA increased substantially over time. Between 1974 and 1994, the prevalence of knee pain—with adjustment for age and BMI—increased by about 65% among Caucasian and Mexican men and women and among African-American women in NHANES (Figure 1). In FOA, the age and BMI-adjusted prevalence of knee pain and...
Preventing SSIs: An Evidence-Based Update

Preventing SSIs: An Evidence-Based Update

According to recent data, surgical site infections (SSIs) are common complications in acute care facilities, occurring in 2% to 5% of patients undergoing inpatient surgery. Approximately 160,000 to 300,000 SSIs occur each year in the United States, making these infections one of the most common and costly healthcare-associated infections (HAIs). “As society continues to age, older patients are increasingly undergoing surgical procedures,” says Keith S. Kaye, MD, MPH. “These patients are particularly vulnerable to SSIs. As surgical advances continue to evolve, we must continue to find ways to further improve our ability to prevent SSIs.” Studies have shown that as many as 60% of SSIs are preventable if clinicians follow evidence-based guidelines. SSIs account for about 20% of all HAIs in hospitalized patients, and each case is associated with at least 7 days of prolonged hospitalization. Research has indicated that SSIs account for $3.5 billion to $10 billion annually in healthcare expenditures. Dr. Kaye notes that the outcomes and costs attributable to SSIs vary depending on the type of operation and the type of infecting pathogen. A Welcome Update In 2008, the Society for Healthcare Epidemiology of America (SHEA) and Infectious Disease Society of America (IDSA) released their Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. The document was designed to help healthcare institutions prioritize and implement strategies to reduce the number of infections. Recently, SHEA and IDSA released an update of these guidelines and published them in Infection Control and Hospital Epidemiology. The updated evidence-based recommendations are broader and more inclusive than other clinical guidelines that are currently available. They include 15 strategies for prevention...
Hip Fracture Surgery: Costs & Benefits

Hip Fracture Surgery: Costs & Benefits

According to current estimates, more than 300,000 patients—mostly people aged 65 and older—sustain a hip fracture each year in the United States, and the annual incidence is expected to exceed 500,000 by 2040. Hip fractures often result in nursing home stays, higher mortality, and lower quality of life. The expected rising incidence will place a significant financial burden on patients, families, insurers, and other key stakeholders. Surgery is the primary treatment strategy for hip fractures because it can reduce mortality risk and improve physical function, but less is known about the societal cost implications of hip fractures. New Data Little is known about the return on investment of surgery for hip fracture patients, says Lane Koenig, PhD. “Policymakers and payers are increasingly focusing on value, making it critical to understand the return from healthcare spending,” he says. To investigate this further, Dr. Koenig and colleagues conducted a study—published in Clinical Orthopaedics and Related Research—that estimated the impact of surgical and nonsurgical treatment in patients aged 65 and older. The research team reviewed published literature and expert opinions to examine a comprehensive set of outcomes, including long-term medical costs, home modification costs, and costs associated with long-term nursing home care. For the study, Dr. Koenig and colleagues developed a predictive tool to account for various possible outcomes so that they could measure the cost and potential savings of repairing hip fractures with surgery. “Our results showed that surgery provided a significant societal benefit and value by returning patients to active, independent living,” Dr. Koenig says. The average lifetime societal benefits in the U.S. reduced medical and nursing home costs of...
Cardiometabolic Risk, Type 2 Diabetes, & Heart Disease

Cardiometabolic Risk, Type 2 Diabetes, & Heart Disease

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

Malpractice Reform’s Effect on ED Care

It is often claimed that “defensive medicine” is a major source of wasteful medical spending. One report estimated that $210 billion is spent each year on needless care that is motivated by fear of lawsuits. Despite this widespread belief, few previous studies have directly measured the effect of malpractice reform laws on clinical practice. Emergency care may be at particular risk for accruing high costs from defensive medicine practices. “Emergency physicians operate in an information-poor, high-risk environment that would seem to be as prone to defensive practice as any other,” says Daniel A. Waxman, MD, PhD. Most changes to tort law have focused on limiting the size of awards, such as putting a cap on noneconomic damages. ED care, however, has been a focus of a new kind of reform that might be expected to offer a stronger sense of protection to emergency physicians. About 10 years ago, Texas, Georgia, and South Carolina changed their malpractice standard for emergency care from the usual “deviation from the standard of customary practice” to “willful and wanton negligence” (in Texas) and “gross negligence” (in Georgia and South Carolina). Those two standards are essentially synonymous. The three states’ laws, which also have other provisions that apply outside the ED, are summarized in Table 1. “The gross negligence standard is widely acknowledged to be an incredibly high bar for plaintiffs to meet, and the laws therefore offer very strong protection to emergency physicians,” Dr. Waxman says. “For example, plaintiffs must prove ‘conscious indifference,’ meaning that a physician knew that an action would probably cause serious injury and then took the action anyway.” New Research...
Updated Guidelines for NSTE-ACS

Updated Guidelines for NSTE-ACS

Recently, the American College of Cardiology and American Heart Association (ACC/AHA) updated their guideline on the management of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). “This guideline is the first full revision of previous recommendations since 2007,” says Ezra A. Amsterdam, MD, FACC, who co-chaired the ACC/AHA writing committee. The other co-chair was Nanette Wenger, MD, of Emory University, and the writing group included 18 clinicians from multiple specialties involved in the care of patients with NSTE-ACS. “The ACC/AHA update offers a new name and terminology that reflects current ways of thinking about the condition,” says Dr. Amsterdam. “The terminology now emphasizes the pathophysiologic continuum of unstable angina and NSTEMI and their frequently indistinguishable clinical presentations.” The update incorporates both established and new evidence from published clinical trials and information from basic science and comprehensive review articles. Dr. Amsterdam notes that there have been major advances since 2007 with regard to enhancing the care of these patients. Although still extensive and comprehensive, the document is now more direct and succinct. Important Changes “A significant change in the guideline was to replace the term ‘initial conservative management’ with ‘ischemia-guided strategy,’” says Dr. Amsterdam. “This was done to more clearly convey the physiologic rationale of this approach.” When treating NSTE-ACS, the guideline notes that an early invasive strategy for those with high-risk coronary artery disease has been successful. However, low-risk patients can benefit substantially from guideline-directed medical therapy (GDMT), an approach that has not always been optimally used. Advances in cardiac troponin testing should help clinicians detect patients with NSTE-ACS, according to Dr. Amsterdam. “Advances in non-invasive assessment of prognostic risk...
An Update for Preventing MRSA

An Update for Preventing MRSA

In 2008, the Society for Healthcare Epidemiology of America and Infectious Diseases Society of America—partnering with the American Hospital Association, Association for Professionals in Infection Control and Epidemiology, and the Joint Commission—published the “Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals,” a collection of recommendations focused on common hospital-acquired infections. With new research emerging and the need for up-to-date information, the organizations recently released an update to the compendium. As part of the compendium, updated recommendations were made on the prevention of MRSA infection and transmission. Getting to the Basics Published in Infection Control and Hospital Epidemi-ology, the recently updated compendium recommendations provide a roadmap for prioritizing and implementing strategies to help prevent MRSA infection and transmission. These strategies are broken down into basic practices (Table 1) and special practices. “Based on evidence, expert opinion, and experience, the basic practices are recommended for all hospitals, regardless of the burden of MRSA,” explains lead author David P. Calfee, MD, MS. “These are good, basic infection control practices. Many would be useful in preventing a wide variety of healthcare-associated infections (HAIs) and preventing transmission of various pathogens, including MRSA.” When considering MRSA control practices, conducting a risk assessment is important. This should include an analysis of infection rates, the basic practices that have and have not been implemented already, and whether implemented practices are adhered to consistently, according to Dr. Calfee. “Writing a policy and making sure it’s actually being followed are two different things,” he adds. “A good understanding of the epidemiology of MRSA within your facility is really the first step.” He notes that all providers...
Heart Rhythm 2015

Heart Rhythm 2015

New research was presented at Heart Rhythm 2015, the Heart Rhythm Society’s annual scientific sessions, from May 13 to 16 in Boston. The features below highlight some of the studies that emerged from the conference. Physical Activity, AF, & Gender The Particulars: Results of previous studies on the impact of physical activity on the risk of atrial fibrillation (AF) have been inconclusive in many investigations. Few analyses have assessed the effect of intensity of physical activity on AF, particularly with regard to gender. Data Breakdown: Researchers performed a systematic review of 14 studies involving nearly 400,000 patients that reported on the relationship between physical activity and AF incidence. Among men, vigorous exercise increased the risk of AF, whereas moderate exercise lowered AF incidence. For women, moderate and high intensity physical activity both reduced subsequent risks of AF. Take Home Pearls: Moderate exercise appears to reduce the risk of AF in men and women. However, vigorous exercise appears to reduce the risk of AF in women but increase this risk in men. Measuring Activity in Patients With ICDs The Particulars: Implantable cardioverter defibrillators (ICDs) automatically collect physical activity data in order to provide quantifiable and easily accessible measures of functional status. However, few studies have assessed the relationship of these measures with survival in this patient population. Data Breakdown: More than 98,000 patients with ICDs were followed in a study to examine the association between survival and increments of 30 minutes of physical activity per day. After 4 years, the survival rate was about 90% among the most active patients when assessed at baseline, compared with a rate of 50%...
Assessing Aspirin Use for CVD Prevention

Assessing Aspirin Use for CVD Prevention

Aspirin is used as a primary strategy to help prevent a first occurrence of cardiovascular disease (CVD). It can also be used as secondary prevention for survivors of heart attacks and strokes to prevent additional cardiovascular events. The American Heart Asso­ciation recommends daily low-dose aspirin for people at high risk of heart attacks and regular use of low-dose aspirin for heart attack survivors. “Preventing CVD events is particularly important,” says Arch G. Mainous, PhD. “Understanding physician recommendations for aspirin therapy is critical to the delivery of quality care.” Few studies, however, have evaluated patient use of aspirin and reported physician recommendations of aspirin therapy for CVD prevention. Suboptimal Use In a study published in the Journal of the American Heart Association, Dr. Mainous and colleagues analyzed data from the National Health and Nutrition Examination Survey, 2011–2012 and examined aspirin use for preventing CVD. The study showed that only about 41% of high-risk individuals reported being told by their physician to take aspirin, and just 79% of these patients actually complied with the recommendation. Among low-risk patients, 26% were told by their physician to take aspirin, with nearly 77% complying. Age, access to a regular source of care, education, and insurance status were identified as significant predictors of a physician recommendation for aspirin use as primary prevention. Among high-risk patients, significant predictors were age, race, and insurance status. Age, education, obesity, and insurance status were significant predictors among low-risk patients. Overall, the analysis indicated that there were persistent problems with access to care. The rates of patients being recommended to take aspirin to prevent CVD are not ideal, says Dr....
Social Support After AMI

Social Support After AMI

Studies have shown that social support is an important prognostic predictor in older people who have suffered an acute myocardial infarction (AMI). Patients with low perceived social support have worse outcomes after their AMI, including higher mortality, more cardiac events, and lower quality of life (QOL). However, most studies have focused on older men, and few analyses have looked at the role of social support in younger AMI patients, especially women. “Younger AMI survivors are at an entirely different stage of life and often have different social connections and support structures,” says Emily M. Bucholz, MD, PhD MPH. “While older people tend to rely on their immediate family for help, younger individuals are more likely to include fewer family members and more friends and coworkers in their support networks. Younger people may also experience more stress from work, raising their family, or social obligations, which can compromise their support structures. As a result, social support may be a particularly important predictor of AMI prognosis in these patients.” Examining Younger AMI Patients In a study published in the Journal of the American Heart Association, Bucholz and colleagues used data from the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study to examine social support in younger patients after they had an AMI, particularly women, from the United States and Spain. VIRGO contains detailed socio-demographic and psychosocial information as well as data on mental health, depression symptoms, and QOL during follow-up. Data from VIRGO were used to investigate both the physical and mental health consequences of low social support after AMI. The investigators evaluated self-reported social...
Outlaw Motorcycle Gangs: Lessons for ED Personnel

Outlaw Motorcycle Gangs: Lessons for ED Personnel

Outlaw motorcycle gangs (OMGs) are an iconic element of the criminal landscape in the United States. “When an injured member of an OMG is brought to the ED, other members and associates are likely to come to the ED to support him,” say Anand N. Bosmia and colleagues. “The arrival of injured outlaw bikers and their associates can be concerning to ED personnel because of their potential for aggression and violence. Increasing knowledge on the symbols, values, and hierarchy of OMGs may help ED personnel understand the mentality of outlaw bikers and thereby optimize management strategies.” In a study published in the Western Journal of Emergency Medicine, Bosmia and colleagues discuss various aspects of the culture of OMGs to inform ED personnel about outlaw bikers. The study notes that OMGs pose a challenge for ED personnel because they are well-organized, have an intricate intelligence network, and are capable of mobilizing members quickly to assist injured comrades. Important Characteristics Many outlaw bikers refer to their organizations as “one-percenter” motorcycle clubs (MCs) rather than gangs. The term “one-percenter” originated from a statement made in 1947 by the American Motorcycle Association, which proclaimed that 99% of the motorcycling public abides by the law and the remaining 1% does not. Outlaw bikers wear the diamond-shaped “1%” patch if their MC is immersed in criminality and large enough to defend itself against all rivals. OMGs are divided into four categories (Table 1), with the larger one-percenter MCs topping the criminal hierarchy. Almost all OMGs in the United States are entirely Caucasian, and many of these one-percenter MCs are racist and have strong links to...
Guidelines for Metastatic Castration-Resistant Prostate Cancer

Guidelines for Metastatic Castration-Resistant Prostate Cancer

According to current estimates, prostate cancer is the second leading cause of cancer deaths among North American men, with more than 33,000 dying from the disease in 2013. For men with androgen-sensitive metastatic disease, continuous androgen-deprivation therapy is considered the current standard of care, but many of these individuals will go on to develop castration-resistant prostate cancer (CRPC). When this occurs, patients will need additional lines of treatments to support their androgen-deprivation therapy. These additional therapies have the potential to improve survival and quality of life (QOL). A Welcome Guideline Recently, the American Society of Clinical Oncology (ASCO) and Cancer Care Ontario (CCO) released a joint clinical practice guideline for treating men with metastatic CRPC. Published in the Journal of Clinical Oncology, the guideline builds upon previous ASCO/CCO recommendations based on a systematic review of 28 randomized clinical trials published between 1979 and 2004. Since the previous guideline was released, an additional 28 trials on systemic therapies have been identified for treating metastatic CRPC, including analyses involving targeted therapies and immunotherapies. These additional randomized trials helped inform the current recommendations. The updated guideline includes recommendations on systemic therapies indicated for use along with androgen deprivation. They address survival and QOL benefits, side effects, and cost considerations for each of these therapies (Table). The expert panel also recommends that palliative care be offered to all patients, particularly for those exhibiting symptoms or QOL decrements. Recently, there has been significant progress in the care of advanced prostate cancer, with several new treatments gaining FDA approval over the last few years, says Ethan Basch, MD, MSc, who co-chaired the ASCO/CCO expert writing...
Decision Aids & Difficult Choices

Decision Aids & Difficult Choices

With advance care planning, clinicians can help honor patient preferences and goals in cases of incapacitating illness or when injuries prevent adequate communication. These tools are designed to help prioritize treatment goals, but each person’s personal care goals will vary with regard to life-sustaining interventions. Some will prioritize living longer, whereas others may not wish to be kept alive when it is unlikely that they will have a meaningful recovery or better quality of life. Studies show that religious and spiritual values and beliefs may also affect goals of care. Research suggests that less than half of severely or terminally ill patients have advance directives in their medical record. Compounding the problem is that physicians are accurate only about 65% of the time when predicting patient preferences for intensive care. Decision aids for advance care planning support three key components of the process: 1) learning about anticipated conditions and options for care; 2) considering these options; and 3) communicating preferences for future care. “The type of decision aid that will be most useful for decision makers depends on the patient’s current health status and the predictability of illness trajectories,” says Mary Butler, PhD, MBA (Figure). For example, healthy people may benefit most from general decision aids that focus on choice-of-healthcare proxies and goals of care for hypothetical situations. For patients with life-threatening illnesses, decision aids may focus on decisions to accept, withhold, or terminate specific treatments. Analyzing Current Decision Aids In a review published in Annals of Internal Medicine that was commissioned as a technical brief by the AHRQ Effective Health Care Program, Dr. Butler and colleagues provided an...
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