My wife is a Primary Care Nurse Practitioner. She works with a very good Internist who gives her a lot of independence in managing her patients, but always backs her up when she needs advice. She is well respected by the specialists she refers to and has always been able to discuss a patient with any one of them. Yes, there is an element of selection there, since she tends to refer to the specialists who are willing to talk to her in the first place, but that is true for any Primary Care Practitioner, NP, or MD. Today she needed a Hematology consultation on a woman she’d been following for several months. The patient has a refractory anemia and all of the usual lab evaluations have been inconclusive. She felt the patient needed a bone marrow biopsy and possibly more sophisticated lab evaluations. Her patient was enrolled in a health plan run by BigHealth, the local healthcare juggernaut in our area. BigHealth owns seven local hospitals and another ten or so in other states. They have aggressively expanded their market share both through purchasing hospitals and practices and through exclusivity in their BigHealth insurance plans. What I have seen is a longer referral process, significant delays in starting treatment, confused patients, and a serious lack of approachability in the oncologists employed to deliver the care. – See more at: http://dev.physiciansweekly.com/cancer-care-business-decision/#sthash.rm5o6Vsp.dpuf Recently they started a joint venture with FamousName, a well-known cancer hospital from another state, to run the BigHealth/FamousName Cancer Center. There really wasn’t a need for another oncology center in our area. The market was pretty well...

Every day, we are hearing about new genetic discoveries, from finding the loci of various diseases to the discovery of new diagnostic tests to detect these. Yet, we are not seeing this new science being brought into the exam room and having much clinical relevance. If we look further, it is not because the patient lacks health insurance or financial means for these tests, whether the test is a genotype panel, a whole exome or transcriptome sequence, or a whole genome sequence. Why are new discoveries not being utilized in medicine? 1. Some data is simply not actionable. It still needs aggregation and interpretation. We truly do not know what all the data means. Data is published daily that may yield clinically valuable information on associations between discrete gene somatic mutations or germline variants (collectively, “genomic events”), and prevention, diagnosis, prognosis, or treatment of certain diseases. The number of new sources of data each year runs in the hundreds of thousands. But the data is spread across conference abstracts, FDA reports, clinical trials, other scientific literature, and proprietary databases. In the case of cancer genomics, arguably the most important field in genomic medicine, there is currently no universally accepted, open-access database that efficiently enables genome analysts to retrieve all of the available data potentially related to various genomic events in given cancer patients. Thus is the analyst’s work of interpreting and reporting the patient’s clinically associated genomic event—the last step before a physician recommends prophylaxis, or makes a cancer diagnosis or prognosis, for a patient—made of longer duration, or otherwise more challenging. [1] 2. The data that is...

1. An article in Time magazine is headlined “It’s Not You, Doctors Are Just Rude.” The first sentence of the article is “Doctors-in-training are in need of a dose of compassion.” It describes a paper from Johns Hopkins and the University of Maryland about intern communication behaviors. Interns were watched by trained observers. Although interns were pretty good about touching patients and asking open-ended questions, they only introduce themselves 40% of the time and explained their roles only 37% of the time. They also sat down with patients just 9% the time. Observations were made on 732 patient encounters, but only 29 first-year internal medicine trainees were involved. The abstract did not explain whether these first-year interns had received any training in communication (“interpersonal skills and communication” is one of the 6 ACGME core competencies), nor did it state at what point in their first year the study was done. The headline of the piece in Time is a bit misleading since it suggests that all doctors are rude. Similarly, the first sentence of the article somehow brings in compassion. The study was not about rudeness or compassion; rather it was about communication. 2. An article from a website called iMedicalApps gushes with excitement about the fact that Google Glass can be used by a surgeon to view continuous vital signs while operating. It could be that Google Glass is going to revolutionize medical care, but I don’t think it’s going to be useful in the context of a surgeon looking at vital signs while she is operating. You cannot concentrate on the operation and look at a Google...

The development of cardiac imaging technologies has revolutionized cardiovascular medicine by allowing for routine, non-invasive assessments of myocardial perfusion and anatomy. “Despite these advances, little evidence exists regarding the impact of radiation exposure on cardiac patients,” says Andrew J. Einstein, MD, PhD. In November 2012, a symposium sponsored by the NIH/National Heart, Lung, and Blood Institute and the National Cancer Institute was conducted to address these knowledge gaps. Dr. Einstein and other symposium participants identified key components of a framework to target critical radiation safety issues for patients, laboratories, and patients with known or suspected cardiovascular disease. Key Recommendations Several important recommendations resulted from the symposium and were published in the Journal of the American College of Cardiology. The overriding theme is to use shared decision making between providers and patients when disclosing the use of ionizing radiation. According to the recommendations, use of ionizing radiation during an imaging procedure should be disclosed to all patients by the ordering provider at the time of ordering and reinforced by the performing provider team. The recommendations also provide measures to ensure the safety and effectiveness of these imaging procedures. “A cardiac imaging procedure with an effective radiation dose of 3 mSv or less is associated with a low risk of adverse events from radiation exposure,” says Dr. Einstein. “This doesn’t require a detailed discussion from ordering physicians or written consent from patients. However, if the effective radiation dose exceeds 20 mSv, ordering physicians should have a discussion with patients about their specific radiation exposure risks and any projected cancer risks or get written informed consent from patients.” Justification for using cardiac...

Throughout the medical community, the “July effect” or “July phenom­enon” is a well-known entity in which it is believed that the month of July is a poor time to be cared for in the hospital because trainee doctors are beginning their new roles. As medical students move up the ranks in July, their amount of collective experience in the hospital is less than the months before this time. “Anecdotal evidence suggests that the July effect may be responsible for higher rates of errors, resulting in poor outcomes,” explains Christine Riguzzi, MD. Previous studies have looked at morbidity and mortality, surgical outcomes, hospital length of stay (LOS), and hospital charges early in the academic year as compared with other times of the year, but these investigations have yielded mixed results. “The July effect has been examined in various clinical settings, such as surgery, but little is known about it with regard to the ED setting,” Dr. Riguzzi says. A Retrospective Analysis Dr. Riguzzi and colleagues conducted a study to assess if LOS varied throughout the year at teaching and non-teaching EDs. Published in the Western Journal of Emergency Medicine, the retrospective analysis involved a nationally representative sample of 283,621 ED visits from 2001 to 2008. The study compared July to the rest of the year, July to June, and July and August to the remainder of the year. According to the results, there was no significant difference in the average LOS for the month of July versus the rest of the year, July and August versus the rest of the year, or July versus June at teaching hospitals with residents....

ICU telemedicine uses audiovisual technology to provide critical care services remotely, typically with fixed installations that can be used continuously or during nighttime hours. “Research has shown that telemedicine can potentially improve ICU outcomes by increasing access to expert physicians,” explains Jeremy M. Kahn, MD, MS. “It can also potentially facilitate the early recognition of physiological deterioration and prompt providers to implement routine evidence-based practices at the bedside.” However, studies that have evaluated the effects of telemedicine on ICU outcomes have yielded mixed results. Complicating the matter is that adoption of ICU telemedicine is associated with major organizational barriers to overcome, such as high technological and staffing costs. Clinicians also lack consensus about how to best use this technology and where it is best applied. Considering these potential barriers, it is important to understand the patterns of ICU telemedicine adoption and implementation in the United States. “Research is needed to examine the pace of adoption and the degree to which telemedicine has been adopted in smaller, rural hospitals, where it may have the greatest potential to improve outcomes,” Dr. Kahn says. Use & Patterns In Critical Care Medicine, Dr. Kahn and colleagues published a study that examined the extent of use and patterns of adoption of ICU telemedicine in the U.S. from 2003 to 2010. The retrospective analysis combined a systematic listing of ICU telemedicine installations with hospital characteristic data from Medicare. According to the findings, the number of hospitals using ICU telemedicine increased from 0.4% in 2003 to 4.6% in 2010, resulting in an average annual increase of 61.0% per year (Figure). However, most of that growth occurred...

Studies indicate that newborns and children who undergo surgery in environments with pediatric expert resources have better outcomes, fewer complications, and shorter hospital stays when compared with those cared for at non-specialized centers. “Millions of children undergo surgery in the United States each year, but some of these patients receive surgical care in environments that are not matched to their needs,” says Keith T. Oldham, MD, FACS. “This can affect how children fare after operations.” In 2014, the Task Force for Children’s Surgical Care published an article that defined the resources U.S. surgical facilities need to perform surgery effectively and safely in infants and children. The document, published in the Journal of the American College of Surgeons, was approved by the American College of Surgeons (ACS), the American Pediatric Surgical Association, and the Society of Pediatric Anesthesia. “The intent of these standards is to ensure that all infants and children receive care in a surgical environment that matches their individual medical, emotional, and social needs,” says Dr. Oldham, who chaired the task force that developed the document. Important Definitions The proper surgical environment for children was defined as one that offers all of the facilities, equipment, and—most importantly—access to providers who have the appropriate background and training to optimize care. “To accomplish this mission, clinicians must balance the issues of access, available manpower, and the need to improve value,” Dr. Oldham says. Levels of resources are designated similarly to how ACS has done for trauma centers, with the goal of prospectively defining optimal training and experience. To achieve Level I status, hospitals must have adequate resources to provide comprehensive...

Obesity is now recognized as one of the leading causes of many diseases. There are also other impor-tant factors to consider, such as the medical costs associated with obesity and obesity-related comorbidities. “It’s essential to improve our treatment strategies for managing obesity so that we can effectively reduce the rate of obesity-related conditions, most notably type 2 diabetes,” says Louis J. Aronne, MD, FACP. Shifting the Approach According to Dr. Aronne, much of the focus on managing patients with diabetes is to get A1C levels within a normal range. “While this is an important part of caring for patients with diabetes, it’s also paramount that clinicians recognize that many commonly used diabetes therapies can cause weight gain as a side effect,” he says. Patients can gain a significant amount of weight in a relatively short period after initiating diabetes medications. Drug-induced weight gain can have many consequences, including patient non-compliance with treatment regimens once weight gain occurs and health complications associated with weight gain itself. “If patients gain weight from taking their diabetes drugs,” Dr. Aronne says, “it’s possible that this can mitigate control of their diabetes. Although effective glucose control remains important, it cannot come at the expense of worsening obesity. A paradigm shift is needed in which physicians use a weight-centric approach to managing diabetes rather than a glucose-centric model.” Even modest weight loss can improve multiple cardiovascular risk factors while simultaneously improving glycemic control. Published guidelines have supported the concept of shifting treatment plans for diabetes toward a weight-centric approach. “Weight loss via lifestyle modifications and pharmacotherapy are now encouraged earlier in the treatment of diabetes...

According to recent data, more than one-third of American adults were obese in 2010, and studies continue to show that obesity prevalence is rising throughout the United States. Research has shown that obesity negatively impacts the risks and outcomes of various diseases, including knee osteoarthritis, and leads to higher healthcare expenditures. Total knee arthroplasty (TKA) is increasingly being performed in obese patients. In fact, studies suggest that obese patients represent at least half of all patients undergoing TKA. “Obesity does not seem to interfere with the effectiveness of TKA, but evidence is lacking as to whether overweight or obese patients undergoing these procedures assume higher costs than their normal-weight counterparts,” says Hilal Maradit Kremers, MD, MSc. She notes that obesity may be associated with higher costs in TKA because of the increased prevalence of obesity-related comorbidities. It may also be due to the higher risk of short-term TKA complications, such as infections or thrombovascular events. Previous analyses have had mixed results in establishing patterns in the relationship between obesity and TKA costs in terms of complication and readmission rates. Discrepancies in these studies may be the result of methodological differences or from variations in the way researchers have adjusted for comorbidities. Costs from comorbidities and complications can theoretically be considered attributable to obesity too. “It’s important to examine the effect of obesity on costs in patients undergoing TKA and the impact of the higher prevalence of comorbidities and complications among obese individuals,” says Dr. Maradit Kremers. Analyzing New Data To explore the issue further, Dr. Maradit Kremers and colleagues had a study published in the Journal of Bone &...

In clinical research, sleep disordered breathing conditions like obstructive sleep apnea (OSA) have been associated with insulin resistance and glucose intolerance. OSA is typically characterized by loud snoring and pauses in breathing while sleeping. Excess weight is often considered the cause of OSA because fat deposits around the upper airways obstruct breathing. Obesity has been identified as a significant risk factor for OSA as well as diabetes, but studies suggest that obesity status is not the only determinant. Also, diabetes itself is a major risk factor and complication of OSA. In addition to causing poor sleep quality and daytime sleepiness, OSA has other important clinical consequences, including an increased risk of hypertension and cardiovascular disease (CVD). Despite the significant burden that OSA and other sleep disorders has on patients, these health problems are not well recognized by clinicians. “OSA is commonly found in people with type 2 diabetes, but clinicians need to ask their patients about daytime drowsiness, snoring, and impaired sleep symptoms in order to identify the problem,” says Daniel Einhorn, MD, FACP, FACE. He notes that the link between OSA and type 2 diabetes has important clinical, epidemiologic, and public health implications. “When OSA is treated appropriately, it’s possible to prevent serious health problems,” he says. “This is particularly relevant in the context of coexisting type 2 diabetes, when patients are already at significant risk of CVD.” Understanding the Clinical Picture Sleep-disordered breathing encompasses several characteristic complications (Table 1). Other symptoms and associated clinical disorders are seen more commonly in those with OSA than would be expected by chance. “Sleep apnea can decrease quality of life,” says...

People have commented on some of my posts, expressing appreciation for my ‘patient advocacy.’ I hate that term. Let’s get something straight. I am not a patient advocate. Patient advocates are nurses and social workers with a Mother Teresa complex who see their mission as protecting the patient from evil uncaring doctors who would subject them to unnecessary pain and indignity. I have little tolerance for such people. If I am anything, I am an honest craftsman. When a patient comes to my office seeking surgical care, I am making a pact with them, a contract if you will. I pledge my honor as a surgeon, as an honest man, that I will do the right thing for them. The right operation for the right reason at the right time. I will be conscientious in the operating room and will do my utmost to give them a smooth and uneventful recovery. To the extent that I do these things, my patient will do well and recover. If there is a complication, the first question I ask is “What did I do wrong?” Note that in all of that, the real issue is my personal duty and integrity. If I do all those things right, the patient will recover and do well. But in the end, it’s not about the patient—it’s about the integrity of the work. The patient’s recovery is a happy side effect. It is the work that is the real motivation. My personal integrity is at stake each time I go to the operating room. I have pledged to that patient to do my best. I don’t...

Each year nearly a million people in Europe suffer from a cardiac arrest. A mere 8% survives due to slow response times of emergency services. The ambulance drone is capable of saving lives with an integrated defibrillator. The goal is to improve existing emergency infrastructure with a network of drones. This new type of drones can go over 100 km/h and reaches its destination within an average of 1 minute, which has the potential to increase the chance of cardiac arrest survival from 8% to 80%! This drone folds up and becomes a toolbox for all kinds of emergency supplies. Future implementations will also serve other cases such as drowning, diabetes, respiratory issues, and traumas.Source: TU...

The Particulars: Comparisons of open and endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) are lacking in patients with abdominal compartment syndrome. Data Breakdown: Researchers compared several important characteristics among patients with and without abdominal compartment syndrome following RAAA repair. These included mode of transport, time taken for transfer, modality of treatment, transfusion requirements, discharge disposition, length of stay, survival, Glasgow aneurysm score, and Hardmans’s index score. No differences were observed between groups with regard to age, gender, mode of transportation, distance travelled, or length of stay. However, patients with abdominal compartment syndrome underwent more open repairs, received more transfusions, and were less likely to be discharged home. They also had a higher mortality rate, higher Glasgow aneurysm scores, and higher Hardman index scores. Take Home Pearls: Abdominal compartment syndrome appears to be a significant predictor of mortality following RAAA repair. Patients who undergo open repair or have poor physiological indices appear to be at risk for developing abdominal compartment...

The Particulars: Few studies have assessed the safety of iliac vein stenting in office-based settings, particularly among patients in their 80s and 90s. Data Breakdown: For a study, investigators analyzed data on patients younger than 80 (group 1), octogenarians (group 2), and nonagenarians (group 3) who underwent iliac vein stenting at an office-based surgery center. Among 646 treated limbs, only nine complications developed: group 1 had six complications, group 2 had 2, and group 3 had 1. Complications included one hematoma and eight cases of DVT. Researchers observed no surgical site infections, pseudo-aneurysms, arteriovenous fistulas, or femoral artery injuries. No patients required postoperative transfusion, and no 30-day mortalities were reported. Take Home Pearl: Iliac vein stenting performed in an office-based surgery center appears to be safe among octogenarians and...

The Particulars: Thoracic endovascular aneurysm repair (TEVAR) can be performed either electively or urgently. Data are lacking on the differences in outcomes for TEVAR procedures performed electively or urgently. Data Breakdown: For a study, researchers compared demographics, intraoperative parameters, follow-up data, complications, endoleak rates and types, reinterventions, and mortality rates between patients who underwent elective or urgent TEVAR. Complication rates were three times higher in the urgent group when compared with the elective group. Length of stay was twice as high for the urgent group when compared with the elective group. Patients aged 70 or older had a two-fold greater rate of all-cause mortality when compared with those who were younger than 70. However, no differences were observed between the elective and urgent groups with regard to 30-day aneurysm-related and all-cause mortality rates. Take Home Pearls: Patients who undergo urgent TEVAR appear to have a significantly higher rate of complications and longer lengths of stay when compared with those who undergo elective TEVAR. When compared with younger individuals, those aged 70 and older appear to have a higher risk of...

The Particulars: Data suggest that women have been under-represented in studies that set guidelines for managing aortic aneurysms. Some studies have observed worse outcomes in women following endovascular aneurysm repair (EVAR). However, the relationship between gender and outcomes following EVAR is not well understood. Data Breakdown: Postoperative variables by gender were analyzed for nearly 1,400 patients who underwent EVAR between 1992 and 2012 for a study. Women had more arterial reconstructions, perioperative complications, and in-hospital days than men. Perioperative mortality, aneurysm-related deaths, and overall survival were equivalent between genders during an average of 30 months follow-up. Although women were more likely to develop endoleaks, no difference was observed between genders in rates of arterial re-interventions. Take Home Pearls: Among patients who undergo EVAR, women appear to have more perioperative complications, adjunctive arterial procedures, and endoleaks. However, these differences do not appear to affect long-term re-interventions or...

The Particulars: Patients with atrial fibrillation (AF) often have comorbid cardiovascular disease that prompts the need for long-term exposure to both warfarin and antiplatelet agents. It has yet to be determined if overuse of anticoagulants among these patients can increase risks for developing dementia. Data Breakdown: More than 1,000 patients with AF who were on warfarin therapy and antiplatelet treatment participated in a study. Patients were classified as using out-of-range anticoagulation if their International Normalized Ratio (INR) was higher than 3 more than 25% of the time. Patients using out-of-range anticoagulation had about a 6% risk of developing dementia during an average of 4 years. Those using out-of-range anticoagulation less than 10% of the time had a 4-year dementia risk of almost 3%. Take Home Pearls: Overtreatment of patients with AF with out-of-range anticoagulation appears to slightly increase the risk for dementia. More research is needed to better understand the relationship between anticoagulation and dementia...

The Particulars: Coronary artery disease (CAD) has been shown to be a major cause of cardiovascular morbidity and mortality in patients with diabetes. However, CAD is often asymptomatic prior to patients suffering a myocardial infarction (MI) and coronary death. Routine CAD screening with coronary CT angiography (CCTA) in patients with diabetes who are at high cardiac risk and subsequently using CCTA-direct therapy may reduce the risk of death and non-fatal coronary outcomes. Data Breakdown: For a study, patients with diabetes and no symptoms of CAD were randomized to CAD screening with CCTA or to standard optimal diabetes care based on national guideline recommendations. At an average of 4 years follow-up, the composite rates of all-cause mortality, non-fatal MI, or unstable angina requiring hospitalization were not significantly different between the two groups. Rates of ischemic major adverse cardiovascular events also did not differ between the groups. Take Home Pearl: Among asymptomatic patients with diabetes, use of CCTA to screen for CAD does not appear to reduce the rate of all-cause mortality, non-fatal MI, or unstable angina requiring hospitalization at 4 years when compared with standard optimal...