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Knee Osteoarthritis: Guidelines for Surgery

Knee Osteoarthritis: Guidelines for Surgery

According to current estimates, 27 million adults in the United States—or more than 10% of the adult population—have clinical osteoarthritis, a condition that ranks among the leading causes of hospitalization. Recent estimates show that approximately 9.9 million adults have symptomatic osteoarthritis (OA) of the knee. With life expectancy rates continuing to rise, it is anticipated that the prevalence of knee OA will increase in the coming years. The number of people older than age 65 is expected to increase to more than 77 million by the year 2040. The burden of OA of the knee is largely attributable to the effects of disability, comorbid disease, and the expense of treatment. OA is the most frequent cause of disability among U.S. adults, and the burden is increasing due to the rising disease prevalence as well as higher expectations among patients to receive effective treatment. OA is the leading indication for joint replacement surgery. About 905,000 knee and hip replacements were performed in 2009, costing the healthcare system $42.3 billion. These estimates factor together direct medical, long-term medical, home modification, and nursing home costs.   OA Risk Factors & Disease Clinical studies have identified several factors that increase risks for developing OA of the knee to the point that surgery is required. These include joint degeneration over time due to hereditary vulnerability, large body mass, certain occupations, past joint traumas, and prior intraarticular damage. Knee OA also takes an emotional and physical toll on patients. Older adults with OA of the knee tend to visit their physicians more frequently and experience more functional limitations than others in the same age group....
Guidance on Treating Unexplained Chronic Cough

Guidance on Treating Unexplained Chronic Cough

Previous studies indicate that unexplained chronic cough—persistent cough with no identifiable cause after investigation and therapeutic trials—occurs in up to 10% of patients seeking medical assistance for chronic cough. “Although cough is just a symptom, it’s a sign of something that can be serious,” says Kenneth W. Altman, MD, PhD, FACS. “Determining the cause can be challenging because an entire spectrum of factors could play a role, ranging from cancer to neurologic causes to smoking.” With the National Ambulatory Medical Survey indicating that 3% of physician office visits in 2005 were for cough and physicians seeing about 1 billion patients each year in the United States, Dr. Altman says the economic impact of cough is significant. “Beyond its high prevalence and burden on the healthcare system,” he says, “the potential seriousness of the disease causing the underlying cough is the most important reason why addressing unexplained chronic cough needs to be better understood and treated.”   A Systematic Review Dr. Altman and a group of experts from the American College of Chest Physicians (ACCP) published a guideline and expert panel report in CHEST on the treatment of unexplained chronic cough. The team first conducted a systematic review of randomized controlled trials among patients older than 12 years with a chronic cough that was unexplained after systematic investigation and treatment and lasted longer than 8 weeks. “We found that the highest-quality trials didn’t have uniform criteria for defining unexplained chronic cough,” says Dr. Altman. “Diagnostic workup, descriptors, and assessments to identify unexplained chronic cough varied among studies. The takeaway message here is that standardization of our approaches to patients with...
Managing Candidiasis: Updated Guidelines

Managing Candidiasis: Updated Guidelines

The Infectious Diseases Society of America (IDSA) last updated their guideline on the management of candidiasis in 2009. Since that time, new data have emerged on the diagnosis, prevention, and treatment of this major cause of morbidity and mortality, leading to an update to IDSA’s recommendations that was recently released. “Among the most important studies during this time were those that assessed first-line therapy with echinocandins versus azoles,” says Peter G. Pappas, MD, lead author of the guideline update. This new research shows that echinocandins—which kill the fungus—are more effective than azoles—which prevent the fungus from growing—in treating invasive infections. “The data support our key recommendation to start most patients with candidiasis on echinocandins and then step down to an azole.” Judicious Prophylaxis The updated guideline also addresses the importance of judiciously using prophylaxis. It is important to understand which patient populations are mostly likely to benefit from prophylaxis, including ICU patients and transplant recipients. ICU patients who stand to benefit most from prophylaxis include patients: Who have been on antibiotics. Have central venous catheters. Are on a ventilator. Have pancreatitis or recent abdominal surgery. Are immunosuppressed. Have skin burns. “Transplant patients who would benefit most from prophylaxis include high-risk liver transplant recipients, those with modified renal function, and those with prolonged operations who require blood products,” adds Dr. Pappas. Clinicians are also advised to suspect candidiasis in patients who are deteriorating without an obvious reason, have unexplained fever, and have elevated white blood cell counts.   The Importance of Early Care A key theme throughout the guideline update is the importance of early recognition and initiation of therapy...
New Guidelines on Pelvic Exams Raise Controversy

New Guidelines on Pelvic Exams Raise Controversy

The American College of Physicians (ACP) has issued new controversial clinical guidelines recommending against screening pelvic examinations in asymptomatic, nonpregnant, adult women. Just published in the Annals of Internal Medicine, the authors reviewed the evidence and decided that the harms associated with screening pelvic exams outweigh the benefits. The new recommendations set off a lot of strong reactions among physicians and women’s health groups, including well-respected experts in the industry who are split on the recommendations. The ACP guideline was established after a systematic review of the published literature in the English language from 1946 through January 2014 identified using MEDLINE and hand-searching. The outcomes under evaluation included morbidity, mortality, and harms (ie, overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain, and discomfort). Researchers found that the yield of pelvic examination for identifying cancer or other treatable disease in nonpregnant women without symptoms was low and not associated with improved health outcomes. However, the ACP guidelines are not being met with widespread praise. A recent press release by the American College of Obstetricians and Gynecologists (ACOG) states that it stands by its current guidelines for well-women visits, which includes pelvic examinations. “We continue to urge women to visit their health care providers for annual visits, which play a valuable role in patient care,” said John C. Jennings, MD, president of ACOG, in a news release. “An annual well-woman visit can help physicians to promote healthy living and preventive care, to evaluate patients for risk factors for medical conditions, and to identify existing medical conditions, thereby opening the door for treatment. Annual well-woman visits are important for quality care of...
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