Two months ago, IHI partnered with four hospitals in Ghana and trained their staff to use improvement methods in testing practical ways of making care safer.  Within a few weeks of this training, pictures surfaced on social media of staff from one of the hospitals in patient safety-branded t-shirts conducting what seemed to be a patient safety campaign within their hospital. When asked where the funding for the T-shirts came from, staff explained that the organizers reached into their own pockets and used their transportation reimbursement funds which had been provided for transportation to and from the IHI training.

The patient safety project in Ghana is still a fairly new concept, but, judging from the fact that the hospital staff campaigned to change their own organizational culture, it seems that the introduction of these patient safety improvement concepts was life changing to the team at La General Hospital. 

Author: Susan L. Hendrix, DO

Article: "Effects of Estrogen with and Without Progestin Therapy on Urinary Incontinence"

Summary Points:

• Hormone replacement therapy (HRT) should not be the treatment of choice for post-menopausal women with urinary incontinence.
• Post-menopausal women taking HRT should be regularly monitored for signs and symptoms of urinary incontinence.
• Post-menopausal women on HRT who develop urinary incontinence should be weaned off HRT.
• Post-menopausal women who elect to start HRT should be warned about the risks of developing urinary incontinence.

Author: Jackson T. Wright, Jr., MD, PhD, FACP

Article: "Outcomes in Hypertensive Black and Nonblack Patients Treated With Chlorthalidone, Amlodipine, and Lisinopril"

Summary Points:

• Thiazide-type diuretics are safe and effective for the treatment of blood pressure in both blacks and non-blacks.
• The effects of thiazide-type diuretics in reducing blood pressure and clinical outcomes overwhelm the observed adverse metabolic affects of those medications.
• A standardized and inexpensive approach to initial blood pressure management is possible and should be adopted.
• Methods of monitoring and improving antihypertensive use are warranted

Author: Alex R. Kemper, MD, MPH, MS

Article: "Follow-up Testing Among Children with Elevated Screening Blood Lead Levels"

Summary Points:

• About half the children (six years and younger) with elevated blood lead levels did not receive follow-up testing.
• Non-white children, and those living in urban as well as high-risk lead settings, were less likely to receive follow-up testing compared to their counterparts.
• Follow-up testing for children with high blood lead levels is essential for managing lead poisoning and for maximizing cognitive development.
• Interventions are needed to overcome disparities in care.

Author: Henry M. Blumberg, MD

Article: "Update on the Treatment of Tuberculosis and Latent Tuberculosis Infection"

Summary Points:

• Tuberculosis is a public health problem. The responsibility for prescribing an appropriate regimen and ensuring that treatment is completed is assigned to the public health program or the treating physician, not the patient.
• Directly observed therapy is recommended for all patients being treated for active TB. This will necessitate the need for greater collaboration between the treating physician and the public health department.
• Initial therapy for newly diagnosed patients with tuberculosis consists of a 4-drug regimen, including isoniazid, rifampin, pyrazinamide and ethambutol.
• Testing for latent TB infection should be targeted at those who are at increased risk of progression to active TB.
• Despite its limitations, the tuberculin skin test remains the most commonly used test for the diagnosis of latent TB infection; newer diagnostic tests for latent TB infection are on the horizon.
• Active tuberculosis should be excluded before beginning treatment for latent tuberculosis infection.
• Nine months of isoniazid is the preferred therapy for the treatment of latent TB infection.

Author: Michael E. Pichichero, MD

Article: "Combined Tetanus, Diphtheria, and 5-Component Pertussis Vaccine for Use in Adolescents and Adults"

Summary Points:

• The combined tetanus, diphtheria, and 5-component pertussis vaccine is needed.
• There has been a 300 percent increase of pertussis among US adolescents in the last three years.
• The combined tetanus, diphtheria, and 5-component pertussis vaccine is safe, as the reactions are the same as the tetanus vaccine.
• Universal use recommended: On June 30, 2005, the American Academy of Pediatrics (ASAP), America Academy of Family Physicians (AFAR), and the Advisory Committee on Immunization Practices (ACID) all recommended the universal use of the combined tetanus, diphtheria, and 5-component pertussis vaccine or its competitor vaccine for adolescents.

Authors: Judith Ockene, PhD, MEd, and David H. Barad, MD, MS

Article: "Symptom Experience After Discontinuing Use of Estrogen Plus Progestin"

Summary Points:

• Of the women who stopped estrogen plus progestin (E+P), 21.2 percent had menopausal symptoms (hot flashes or night sweats) after stopping study medication compared to 4.8 percent of women who were on placebo.
• Of the women who had menopausal symptoms when they started the study (about 12 percent) and were in the active hormone group, over 50 percent had a recurrence of symptoms after they stopped MHT compared to 21 percent of placebo users who had a recurrence of symptoms.
• Women in the E+P group reported higher rates of pain or stiffness (36.8 percent) after they stopped study medication compared to women who had been on placebo (22.2 percent).
• Women who had symptoms after they stopped study medication reported using a wide range of strategies to manage symptoms and a large proportion found the strategies to be helpful.

Authors: Rafael Harpaz, MD, MPH, and Fangjun Zhou, PhD

Article: "Impact of Varicella Vaccination on Health Care Utilization"

Summary Points:

• Varicella can be severe and at times life threatening, however, since the introduction of varicella vaccine in 1995, varicella hospitalizations have declined significantly, as have outpatient visits.
• Herd immunity is protecting unvaccinated persons from varicella. Since varicella can be more severe in adults, it is particularly important that patients are screened for evidence of immunity to varicella and anyone susceptible is vaccinated, so that children and adolescents do not remain susceptible at adulthood. The federal government's Advisory Committee on Immunization Practices (ACIP) provides new recommendations regarding screening patients for evidence of immunity to varicella and vaccinating those at risk of the disease.
• The diagnosis of varicella has become challenging as rates have declined and since the disease is highly modified among those vaccinated. Laboratory testing will play an increasing role in diagnosis of varicella.
• Providers should report varicella to the local health department so that public health authorities can act to control outbreaks and can monitor for development of problems in the vaccination program

During the Author in the Room teleconference, Dr. Harpaz mentioned that the Centers for Disease Control (CDC) has some photo images of more attenuated forms of varicella.

Additionally, the featured authors of "Impact of Varicella Vaccination on Health Care Utilization" are happy to be emailed with any follow-up questions. Dr. Rafael Harpaz can be reached at rzh6@cdc.gov, Dr. Fanjun Zhou can be reached at FAZ1@cdc.gov.

Author: Charles N. Ford, MD

Article: "Evaluation and Management of Laryngopharyngeal Reflux"

Summary Points:

• Differentiating between gastroesophageal reflux and laryngopharyngeal reflux
• Making and confirming laryngopharyngeal reflux diagnosis
• Resolution of laryngopharyngeal reflux findings may require aggressive and prolonged treatment

Author: David R. Flum, MD

Article: "Early Mortality Among Medicare Beneficiaries Undergoing Bariatric Surgical Procedures" 

• Patients 65 years or older have a much higher risk of early death than younger patients after bariatric (obesity) surgery.
• Already a high-risk population, Medicare medically disabled patients have a higher risk of early death after bariatric (obesity) surgery is performed than previously reported.
• Older patients of more experienced bariatric surgeons had a much lower risk of death than those older patients whose surgeons had less experience performing the surgery.

• Repetitive use of a diagnostic and treatment algorithm to ingrain new prescribing habits was a valuable part of this practice change intervention.
• Clinical decision support systems (CDSS) are feasibly implemented in practice settings that lack electronic medical records, including rural communities.
• CDSS needs to be integrated with tools that save clinicians' time to be sustainable

Author: Sandra Dial, MD, MSc

Article: "Use of Gastric Acid-Suppressive Agents and the Risk of Community-Acquired Clostridium difficile-Associated Disease"

• Acid suppressive therapy use was associated with an increased risk of community-acquired Clostridium difficile-associated disease (CDAD), with PPIs appearing to be associated with a higher risk than H2 blockers. These agents, particularly PPIs, are being prescribed with increasing frequency to patients, including situations where the benefits may be small.
• Although the rate is lower than in the hospital, CDAD is occurring in the community and is being diagnosed more frequently. 
• Prior antibiotic exposure appears to be less frequent in patients diagnosed in the community as compared to patients diagnosed in hospital.

Author: Olga Jonasson, MD

Article: "Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men"

• Men, and men only, who have few if any symptoms from their inguinal hemia can safely delay having it fixed.
• When symptoms develop, especially if the symptoms worsen suddenly, they should visit a surgeon and request a repair.
• If the hernia suddenly becomes incarcerated, painful, and signs of a bowel obstruction develop (vomiting, abdominal cramps), an operation should be done immediately. In 2006, even this emergency operation is safe and mortality rates are low.

• Infants feel pain during central line placement and this pain can be reduced with analgesics.
• IV morphine used alone or in combination with Tetracaine Gel is more effective than Tetracaine alone or no treatment.
• IV morphine and Tetracaine Gel are associated with expected side effects; IV morphine causes mild respiratory depression and Tetracaine causes reddening discoloration of the skin. 

Authors: Donald Berwick, MD, MPP, FRCP, and Thomas Nolan, PhD

Article: "All-or-None Measurement Raises the Bar on Performance"

• All-or-none measurement more closely reflects the interests and likely desires of patients than other approaches to measurement such as composite or item-by-item.
• All-or-none measurement forces a system perspective.
• All-or-none measurement offers a more sensitive scale for assessing improvements

• Embedded in experts’ recommendations for colorectal cancer screening are nearly impossible demands on primary care clinicians to discuss the pros and cons of various modalities for screening with each patient and to assess risk even to the detail of learning the pathology of the biopsy of relatives’ colonoscopies (e.g., adenomatous vs. hyperplastic polyps).
• The complex set of components involved in the decision to screen (or not) for colon cancer includes input from both the doctor (e.g., data about what might happen and how likely the possibilities are) and the patient (e.g., how the patient weighs the relative desirability of the various possible outcomes that result from the possible decisions).
• The decision to undertake a preventive maneuver involves weighing the risks, cost, and inconvenience of an intervention now for a potential benefit in the future.

• Primary care practices have standard protocols to offer a patient with Alzheimer Disease and their caregivers.
• The quality of care of many geriatric syndromes, including Alzheimer Disease, can be improved by implementing a collaborative care model.
• Similar to many geriatric syndromes, medication may be useful, but it is not enough. Medications are one part of a package of care.

• Raloxifene is as effective in reducing the risk of invasive breast cancer in postmenopausal women who are at increased risk of the disease.
• The safety profile of raloxifene is more favorable than tamoxifen with fewer hysterectomies, uterine malignancies, serious thrombotic events, and cataracts.
• Both physicians and patients are familiar with raloxifene and its use for preventing and treating osteoporosis, and there is a long experience with its use in healthy women.

Authors: David Gonzales, PhD, and Stephen Rennard, MD

Article: "Helping Patients Stop Smoking: Varenicline vs. Bupropion"

Summary Points:

• There is a new and novel pharmaceutical approach to treating nicotine addiction that helps smokers quit by specifically targeting nicotine receptors.
• Efficacy for varenicline was three to four times that of placebo and twice that of bupropion at the end of 12 weeks of treatment, but abstinence rates in all groups declined after drug treatment ended.
• The launch of a new smoking cessation medication will likely drive patient demand for smoking cessation services. Medical practices should be prepared to respond to this demand by having a clear, systematic approach to smoking cessation.

• Even though we have long assumed that clinicians should ask patients directly about intimate partner violence, this study shows that self-complete methods for soliciting such information are preferred by women and may be more efficient.
• The prevalence rate for intimate partner violence differs by setting and population and varies significantly from approximately 4 percent to approximately 18 percent.
• While this study provides evidence on the best methods to solicit information on intimate partner violence, it doesn’t tell us if collecting this information improves outcomes for women exposed to such violence. A randomized controlled trial evaluating the effectiveness of screening women for intimate partner violence in health care settings is currently underway.

​

Author: David Mark Spiro, MD, MPH

Article: "Wait-and-See Prescription for the Treatment of Acute Otitis"

Summary Points:

• Wait-and-See Prescription (WASP) is a viable approach to managing children with acute otitis media. Compared with the standard prescription group, the WASP group filled the antimicrobial prescription much less frequently and had equivalent clinical outcomes.
• Within the WASP group, fever and ear pain were associated with filling the prescription, demonstrating that parents are able to make appropriate care decisions when given clear guidance.
• In the management of acute otitis media, important points for clinicians are first to make right diagnosis and then to provide sufficient analgesia. Adequate pain control allows parents to better manage their sick child and use antimicrobials judiciously while also reducing the risk of medical side effects and antibiotic resistance.

• For the general population, the health benefits of fish intake far outweigh the risks.
• Women of childbearing age, nursing mothers and young children should eat up to two servings of fish per week as the benefits of fish intake still outweigh the risks.
• Given the magnitude of the benefits, physicians should regularly give dietary advice to patients for cardiovascular disease prevention.

• Most cancer screening guidelines do not recommend screening elderly persons in poor health who have limited life expectancies because the harms of screening (which occur immediately) outweigh the potential benefits (which occur many years in the future).
• PSA screening rates among elderly men with limited life expectancies should be much lower than current practice to avoid harming these men with unnecessary tests and procedures.
• Guidelines should be more explicit about how life expectancy is defined and provide tools to help clinicians identify men with poor prognoses who are most likely to be harmed by PSA screening, considering both age and the presence of severe disease.

• The long-term use of alendronate for up to 10 years is safe.
• Those who discontinued treatment at 5 years lost bone mass compared to those who continued, but the bone loss was only moderate. Rates of fracture were similar among those who continued versus those who discontinued except for clinical vertebral fractures which, although relatively uncommon, were higher in those who discontinued treatment.
• Results suggest that after 5 years of alendronate, many women may discontinue therapy for up to 5 years. Although, those at high risk of clinical vertebral fracture may benefit by continuing.

• Screening for falls is as simple as asking the patient if she's fallen in the past year. For patients who have not fallen, ask about gait or balance problems (e.g., "Do you have a walking or balance problem?").
• Most older patients who have a history of falls in the past year, or a gait/balance problem, have at least a 50 percent chance of falling in the coming year. You may want to do a more thorough evaluation on these patients.
• To make screening easy for new patients, add into your pre-visit questionnaire questions that ask about a history of falls and/or gait/balance problems. Or, have your office staff ask these questions routinely when patients are being checked in.

Author: Paul M. Ridker, MD, MPH

Article: "Development and Validation of Improved Algorithms for the Assessment of Global Cardiovascular Risk in Women: The Reynolds Risk Score"

Summary Points:

• Half of all heart attacks and strokes occur among those with normal cholesterol levels and 15 percent to 20 percent occur among those with no major risk factors at all.
• The major breakthroughs in understanding cardiovascular disease over the past decade include insights about inflammation and genetics. Each of these can easily be ascertained with either a simple blood test (hsCRP for inflamamtion) or a simple question about parental history of myocardial infarction.
• By incorporating these two new measures into how we think about risk, a new risk tool was derived known as the Reynolds Risk Score. 
• This is a win-win for everyone as it allows us to better target therapies, avoid toxicity, and improve overall prevention strategies for heart disease.

• Screening and other prevention approaches involve subjecting very large numbers of people to an intervention, with the expectation that a few will benefit, but most will not (as they would have never developed the condition anyway). 
• In general, screening for diseases such as cancer will uncover some reservoir of abnormalities that appear to be precursors to clinical disease but are not yet causing disease.
• We really have no evidence to support screening for lung cancer right now with any technology.
• We really should be advocating for our patients to help them understand why they shouldn't have this test until we know that it is more likely to hurt them or help them.

Author: Jan L. Brandes, MD

Article: "Sumatriptan-Naproxen for Acute Treatment of Migraine"

• Evidence from two replicate RDBPC trials showed sumatriptan-naproxen as a fixed dose combination was superior in treating an attack of migraine when compared to sumatriptan alone, naproxen alone, or placebo.
• Most importantly, given that migraine attacks in adults are 4 to 72 hours in duration, the fixed dose combination of suma-naproxen was significantly more effective that sumatriptan monotherapy or naproxen monotherapy in providing a 24 hour sustained pain free response.
• Patients using the fixed dose combination therapy were less likely to use rescue medication or to have headache recurrence, and did not experience any penalty in side effects using the combination.

Author: Steven R. Steinhubl, MD

Article: "Aspirin Dose for the Prevention of Cardiovascular Disease"

• While aspirin is generally a safe drug, and extremely effective, with over 50 million US adults taking it everyday for cardiovascular disease prevention, even a very small incidence of side-effects can have major implications. Consistent with this, one study found that the most common medication leading to an adverse event requiring hospitalization was aspirin for cardiovascular disease prevention.
• In terms of preventing heart attacks, strokes or cardiovascular deaths, no clinical trial has identified an aspirin dose more efficacious than 75 to 81mg daily.
• Although there is no dose of aspirin that doesn't increase the risk of GI toxicity or bleeding, greater doses of aspirin are consistently associated with a greater risk. For example, in the US alone, if everyone took 325mg of aspirin daily instead of 81mg, based on observational data, this could translate into nearly 1 million additional major bleeding complications a year.

Authors: Bernard Cole, PhD, and Robert S. Sandler, MD

Article: "Folic Acid for Prevention of Colorectal Adenomas"

• Folic acid supplementation is not useful for preventing colorectal adenomas.
• Folic acid supplementation may be harmful through increasing colorectal adenomas.
• Practitioners and patients should wait for strong evidence before initiating therapies given the potential for waste and unintended adverse consequences.

Author: Roy C. Ziegelstein, MD

Article: "Acute Emotional Stress and Cardiac Arrhythmias"

Summary Points:

• Episodes of emotional stress, especially when sudden, severe, and unexpected, may have significant adverse effects on the heart.
• Acute emotional stress can increase sympathetic stimulation of the heart and can alter brain activity in a way that makes the heart more susceptible to rhythm disturbances.
• Since episodes of emotional stress are almost inevitable in life, part of a healthy lifestyle is learning how to deal effectively with stress.

Author: Douglas R. Lowy, MD

Article: "HPV Vaccine in Young Women with Preexisting Infection"

Summary Points:

• The HPV vaccine has been shown to work very well in preventing new (incident) infection and disease caused by the HPV types targeted in the vaccine.
• This study shows that HPV vaccination does not hasten clearance of existing (prevalent) infection with the HPV types targeted by the vaccine (HPV16 and 18).
• It is most cost-effective to administer the vaccine before patients are exposed to HPV, because the vaccine is effective in preventing new infection but does not appear to be effective in treating established infection.

• Quality improvement (QI) curricula are often effective in improving learners’ QI-related participation, attitudes, and knowledge.
• QI curricula are less often associated with clinical improvements.
• Clinical improvements occur more often when learners engage in multiple small cycles of change, and when they have individualized coaching in QI, access to their performance data, and access to predeveloped QI tools.

Author: Monina Klevens, DDS, MPH

Article: "Invasive Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in the United States"

• The magnitude of MRSA infection is significant, demonstrating that it is a major health care and public health issue.
• The majority of invasive MRSA infections are healthcare-associated; hospitals and other health care facilities should make MRSA prevention a priority.
• MRSA skin infections are common in the community and rarely become life threatening or invasive.

Author: Dena M. Bravata, MD, MS

Article: "Using Pedometers to Increase Physical Activity and Improve Users' Health"

• Pedometer users increase their physical activity. They walked 2000 steps per day more than people who do not use a pedometer.  2000 steps is equivalent to about 1 mile per day or about 100 calories per day.
• Having a daily step goal is important for increasing physical activity with a pedometer. Pedometer users with any goal — either 10,000 steps per day or an individualized step goal — increase their physical activity whereas those pedometer users without a goal do not.
• Pedometer users lose weight and lower their blood pressure. 
• Pedometer interventions that take place in the workplace are less likely to result in improvements in physical activity than interventions that took place in non-workplace settings. This is because the people who chose to participate in workplace interventions already had relatively high baseline physical activity which suggests that workplace interventions should target sedentary employees.

Author: Ian George Williamson, MD

Article: "Antibiotics and Topical Nasal Steroid for Treatment of Acute Sinusitis"

• Antibiotics are not so effective in the routine treatment of cases of acute sinusitis even when of probable bacterial origin, and should therefore be used more judiciously and with greater caution.
• Expectations should not necessarily be for antibiotics but balanced risk assessments and symptom advice are still important.
• Findings of lack of efficacy for antibiotics should drive a research agenda which aims to identify subgroups that might benefit from their use and/or other types of treatment.

Author: Mark J. Pletcher, MD, MPH

Article: "Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments"

Summary Points:

• Doctors appear to prescribe opioids less often to blacks and Hispanics/Latinos than they do to whites in the emergency department. 
• These differences do not appear to be explained by differences in type or severity of pain.

• To make real progress in patient safety will require redesigning the underlying system of care such that health care professionals and institutions providing a continuum of services from prevention to hospice can address multiple conditions and episodes over time. A "culture of systems" must be established.
• Competing priorities, professional autonomy, solo and small physician practices, disciplinary silos, misaligned financial incentives, and inadequate feedback about performance all undermine efforts to create safe health care systems.
• A number of strategic, cultural, technical, and structural barriers need to be addressed to ensure safer care. This includes the need for patient safety organizations to gather information across the continuum of care and provide both rapid feedback to practitioners and analyze trends over time.

• Weight loss is feasible and long-term weight loss is possible.
• Ongoing personal contact and technology-based interventions were effective but the overall benefits were small.
• The role of providers is to reinforce the message that weight loss can prevent and treat multiple chronic conditions. Even small amounts of weight loss can lead to significant health benefits.  
• Our focus should be on long-term healthy life style changes rather than dieting, which is by its very nature short term.

• Reducing LDL-C and SBP to lower targets resulted in regression of carotid atherosclerosis and decrease in LV mass in individuals with type 2 diabetes.
• Clinical event rate was low in both groups and did not differ longer term follow-up. It will be necessary to determine whether the aggressive targets result in favorable risks or benefits.
• More emphasis should be placed on reaching conventional targets for both LDL-C and SBP in diabetic patients.
• More trials are needed to evaluate targets for lipids and BP rather than specific treatment regimens.

• Adding a single screening ultrasound examination to screening mammography in women at increased risk of breast cancer with at least heterogeneously dense breasts increases the cancer detection rate from 50 percent to 78 percent.
• The risk of a biopsy for a benign lesion in our series was 1 in 40 for women undergoing mammography versus 1 in 10 for women undergoing mammography combined with ultrasound screening.
• Using the standardized technique and interpretive criteria developed for this study, other radiologists and facilities with similar equipment and experience should expect similar results.​

• People with symptoms of depression are more likely to engage in diabetes-producing health behaviors, including eating more, exercising less, and smoking more. As a consequence, they were more obese.
• People with elevated symptoms of depression had a 42 percent increased risk of developing Type 2 diabetes over 3 years. This was partially explained by unhealthy behaviors.
• People with treated Type 2 diabetes had a 52 percent increased risk of developing depressive symptoms over 3 years. This suggests that individuals with diabetes should be monitored for development of depression.

Author: Beverly Beth Green, MD, MPH

Article: "Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control: The e-BP Randomized Controlled Trial"

• If blood pressure (BP) control could be improved, many deaths from cardiovascular and renal disease could be prevented. 
• The Chronic Care Model was used to design an intervention that empowered patients to be more involved in their own care using home BP monitoring, a patient shared electronic medical record, and Web-based pharmacist assistance.
• The group of patients that received BP monitors and training to use an existing patient website (with encouragement to send their BP numbers to their physician) had a modest decrease in systolic blood pressure, but BP control did not significantly improve. The group that received BP monitors, web training, and web-based pharmacy assistance had greater decreases in BP and were almost two times as likely to have controlled BP.

Author: H. George Numberg, MD

Article: "Sildenafil Treatment of Women with Antidepressant-Associated Sexual Dysfunction: A Randomized Controlled Trial"

Summary Points:

• Emergent sexual dysfunction (SD) is a principal reason for a three-fold increased risk of non-adherence that leads to increased relapse, recurrence, and poor disease management outcomes.
• Selective phosphodiesterase-type 5 inhibitors (PDE5Is), limited to studies in men, have demonstrated evidence based data to support broad-based and clinically meaningful treatment efficacy.
• In an intention-to-treat analysis, women treated with sildenafil showed significant improvement in adverse sexual effects compared with those taking placebo.
• Evidence shows that selective phosphodiesterase type 5 inhibitors are effective in both sexes for patients who have been effectively treated for depression but need to continue on their medication to avoid relapse or recurrence.

Author: Ingrid E. Nygaard, MD, MS

Article: "Symptomatic Pelvic Floor Disorders in Women"

• The three primary pelvic floor disorders include urinary and fecal incontinence, and pelvic organ prolapse.
• In a national population-based sample, nearly one-quarter of US women reported at least one symptomatic pelvic floor disorder: overall, 15.7 percent experienced moderate to severe urinary incontinence, 9.0 percent experienced fecal incontinence at least monthly, and 2.9 percent experienced symptomatic pelvic organ prolapse (a bulge in the vagina they could see or feel). 
• Older women, overweight and obese women, and multiparous women were more likely to report a pelvic floor disorder.

• A majority (55.5 percent) of Medicare patients with stable coronary artery disease who underwent an elective percutaneous coronary intervention (PCI) did not have a recommended stress test performed to document ischemia.
• The rate of stress testing before elective PCI shows significant geographic variation, from a low of 22 percent in Fresno, California, to a high of 71 percent in Rochester, Minnesota.
• Patient characteristics (female sex, age of 85 years or older, and having co-existing illnesses) and physician characteristics (physicians who performed a higher volume of PCI procedures) were associated with lower rates of stress testing.

Authors: Brett D. Thombs, PhD, and Roy Ziegelstein, MD

Article: "Depression Screening for Patients with Cardiovascular Disease"

Summary Points:

• Depression is a common and serious condition in patients with heart disease; therefore health care workers should inquire about symptoms of depression in their heart disease patients.     
• Our recent systematic review shows that there is not sufficient evidence at this time to call for routine screening for depression in patients with heart disease.
• Additional research is needed to determine the optimal model(s) of care that will allow depression to be appropriately diagnosed and treated in patients with heart disease, particularly at times when these patients are being cared for primarily by heart disease experts rather than by experts in depression diagnosis and treatment.

Author: David J.A. Jenkins, MD, PhD

Article: "Effect of a Low Glycemic Index or a High Cereal Fiber Diet on Type 2 Diabetes: A Randomized Trial"

• Drugs such as the alpha glucosidase inhibitor, acarbose, which reduce the rate of digestion and absorption of carbohydrate and so flatten the post-prandial glycemic response have been shown to improve diabetes control, reduce the risk of developing hypertension and lower the risk for cardiovascular disease.
• Can a selection of more slowly digested carbohydrate foods achieve qualitatively similar benefits to drugs? Current data suggest that selection of diets containing low glycemic intake foods have modest benefits in reducing HbA1C even in type 2 diabetes patients treated with one to three antihyperglycemic medications.
• Foods with a low glycemic index include many traditional study foods such as dried peas, beans, lentils, intact grain breads, pasta, oats, barley, parboiled rice, and temperate climate fruits and berries. Low glycemic index starchy foods are digested less readily in vitro.
• Other effects include a tendency for higher HDL, lower CRP values and greater weight loss in the per protocol completers (i.e., those who completed the study with no change in medications).

• Supervised treadmill exercise improves walking performance for patients with peripheral arterial disease (PAD), whether or not the patient has classic symptoms of intermittent claudication.
• Supervised lower extremity strength training improves quality of life, stair climbing ability, and treadmill walking performance for PAD patients with and without intermittent claudication.
• Supervised treadmill walking exercise improves brachial arterial flow mediated dilation in patients with PAD, suggesting a global cardiovascular health benefit.

• Smoking is extremely common among persons with mental illness and exerts a huge toll in terms of morbidity and mortality.
• We are now in the midst of a culture change. Formerly smoking was an integral part of the mental health culture and smoking cessation was not deemed pertinent. Now it is evolving into an important component of mental health and wellness.
• Most smokers who have mental illness would like to quit, and many are able to do so using the standard smoking cessation techniques used for the general population. There is still much more to know, but we know enough to encourage persons with mental illness to stop smoking and to provide them the tools to do so.

• Burnout and compassion fatigue are fundamentally different phenomena. Understanding the difference is helpful for effective intervention.
• Investments in self-awareness and self-care are sound business strategies that can be expected to reduce staff turnover and increase patient satisfaction.  
• Mindfulness meditation and reflective writing have both been shown to increase self-awareness and self-care. They are among a number of strategies that can be built into clinical practice to prevent burnout and compassion fatigue.  

• Cardiovascular disease accounts for 35 percent of the excess mortality in African Americans, in large part because of hypertension.
• Racial disparities in physicians’ clinical decision making and in quality of care for cardiovascular disease have been documented extensively; studies also show racial differences in patient-physician communication, particularly when the patient and physician come from different racial backgrounds, and unconscious racial biases among physicians.
• A categorical approach that lumps patients of particular cultural backgrounds into groups and outlines their characteristics values, customs, and beliefs may lead to over-simplication and stereotyping. Instead, an understanding of broad cultural concepts and skills that emphasize a patient-centered approach are preferred. This approach takes into account the individual patients’ explanatory model, illness agenda and behaviors, and social context, and attitudes and skills with regard to negotiating treatment. It also includes participatory behaviors such as asking open-ended questions, using reflective listening, and avoiding arguments in which one tries to change the patient’s views.
• Systematic reviews of interventions to improve patient adherence to treatments for hypertension show that simplifying dosing regimens is most effective; using motivational strategies such as home monitoring, small-group training, counseling by a nurse or other professional, and reminder calls for patients are somewhat effective; and patient education alone is not effective. Quality improvement strategies for hypertension management show team change interventions that include assignment of some responsibilities to a health professional other than the patient’s physician (such as a nurse or pharmacist) are associated with the largest reductions in blood pressure. Improvement in patient-physician communication is linked  to improved outcomes for mental health; more studies are needed that examine how patient-physician communication may improve hypertension control and other physiologic measures.

Author: Peter Hwang, MD

Article: "Diagnosis and Treatment of Acute Rhinosinusitis"

Summary Points:

• There are now published consensus guidelines for the diagnosis and treatment of acute rhinosinusitis.
• Acute viral rhinosinusitis and acute bacterial rhinosinusitis can be difficult to distinguish in the first 10 days of symptoms.
• Radiologic imaging is often “positive” in both viral and bacterial etiologies of acute sinusitis and therefore cannot be used to distinguish the two.
• Oral antibiotics, when prescribed appropriately, confer a higher rate of partial or complete resolution of acute sinusitis symptoms compared to placebo. However, it should be noted that the spontaneous rate of resolution of acute bacterial rhinosinusitis may be as high as 40 percent to 60 percent.
• Adjunctive therapies such as topical and oral decongestants may offer symptomatic relief but have not been proven to shorten the duration of illness.

• Cognitive Behavioral Therapy (CBT) is an effective treatment for chronic insomnia and can help reduce medication treatment for this condition.
• Clinicians can be successfully trained in CBT.
• CBT works well alone for insomnia and, while medication treatment may help early in the course of this condition, it does not have advantages for long-term use.

• At an individual level, combining healthy lifestyle factors may substantially reduce the risk of developing hypertension; according to the findings of the study, women who followed 6 healthy factors had nearly an 80 percent reduction in risk.
• At a population level, a large fraction of all new cases of hypertension could hypothetically be prevented if all individuals in the population followed combinations of healthy lifestyle factors; according to the findings of the study, this fraction may is 78 percent.
• Given that hypertension is a leading cause of preventable death in the population, and given that the majority of hypertension may be preventable through lifestyle modification, efforts should be intensified to improve lifestyle as a means of improving public health.

• Errors and adverse events are common, and disclosure of these events to patients is recommended but often does not take place.
• Physician fear of litigation inhibits disclosure, but so does physicians’ lack of confidence in their communication skills and concern that disclosure might be harmful to the patient.
• Important future developments in the field include linking disclosure with offers of compensation, and using performance improvement tools to enhance the disclosure process.

• Since quadrivalent HPV vaccine was licensed in June 2006, more than 23 million doses have been administered nationally.
• There were a total of 12,424 reports to the Vaccine Adverse Event Reporting System (VAERS) of adverse events following HPV vaccination through December 2008. The vast majority (94 percent) of adverse events reported to VAERS after receiving this vaccine have not been considered serious. The findings of this first published post-licensure safety review were generally not different from what is seen in safety reviews of other vaccines recommended for 9- to 26-year-olds.
• The most common events reported were syncope, local reactions at the site of immunization (pain and redness), dizziness, nausea, and headache.

Author: Michael S. Krasner,  MD

Article: "Burnout, Empathy, and Attitudes of Physicians After A Mindful Communication Program"

Summary Points:

• Burnout is prevalent among physicians, and has untoward effects not only on the physicians themselves but also on the quality of the care they provide to their patients.
• Mindful communication training among a group of primary care physicians resulted in not only improvements in burnout and measures of well-being, but also improvements in markers of relationship-centered care to their patients.
• Mindful communication should be considered among a menu of continuing medical education opportunities available for physicians to enhance well-being, meaning, and interpersonal relationships in the practice of medicine.

Author: Laura Essermand, MD, MBA

Article: "Rethinking Screening for Breast Cancer and Prostate Cancer"

Summary Points:

• The effectiveness of screening depends on the underlying biology of cancer. Routine mammographic screening works best for slow to moderate growth tumors, most common in women 50-74 and explains why the preventive services guidelines actually make sense.
• There are ways that we can improve screening today. Trained mammographers find the most cancers and have the fewest false positives. Offering follow up as an option for  low risk mammographic lesions will decrease false positives. Screening the populations who benefit most will also avoid false positives and overdiagnosis in those who benefit less from screening. The prostate cancer risk calculator is a good tool to use to determine whether to do a biopsy.
• We can and must do better. Mammography and PSA testing can detect very low risk cancers, and these cancers can be less aggressively treated. Tools are available to distinguish these low risk cancers. The most aggressive cancers often present between normal screens, so women with new masses, regardless of a recent normal mammogram should be evaluated. Men and women at high risk to develop breast and prostate cancer, should consider prevention interventions. Future screening should be developed to reduce mortality from the highest risk cancers

Author: Hussein Hollands, MD

Article: "Acute Onset Floaters and Flashes: Is This Patient at Risk for Retinal Detachment?" Summary Points:

• The most likely cause of acute onset monocular floaters or flashes is posterior vitreous detachment and if left untreated vitreous detachment complicated by retinal tear can progress to vision-threatening retinal detachment.
• A minimum approach to evaluating a patient with suspected posterior vitreous detachment should include a history of change in vision or curtain of darkness, measurement of visual acuity and assessment of confrontational visual fields.
• High-risk features for retinal tear in the setting of acute posterior vitreous detachment are subjective or objective visual acuity loss, monocular visual field loss (or curtain of darkness), and vitreous pigment or hemorrhage on slit-lamp examination and patients with any of these clinical findings should be referred for same day ophthalmology assessment. 

• For a conventional evidence-based approach is modified by three important caveats: prognosis, insufficient evidence, and patient goals and preferences.
• Conceptually, the care of older persons can be divided into three time frames: short-term, which focuses on remediating the current problems; mid-range, focusing on preventive and foreseeable problems; and long-range, which focus on eventual decline and living arrangements.
• Individual providers need to structure their practices to efficiently and comprehensively accommodate the diverse needs of elderly patients.

• A clinical trial is a powerful tool for showing whether an intervention works, but the heterogeneity of trial participants means it’s a mistake to assume that the overall (or group) benefit of an intervention found in such a trial is the same for every participant
• The absolute benefit of an intervention is greater for trial participants — and for patients, generally — whose baseline risk for a bad outcome is high than it is for those whose baseline risk is low
• A quality improvement program in any one organization is like an individual patient, in the sense that it’s highly complex, is unstable (i.e., changes over time), and its local circumstances are unique, all of which make it hard — although not impossible — to judge whether a quality improvement program in any particular setting actually works, and to know whether it would work elsewhere.

• Falls are common health events that cause discomfort and disability for older adults and stress for caregivers. Previous falls; strength, gait and balance impairments; and medications are the strongest risk factors for falling.
• The most effective strategy for reducing the rate of falling in community-living older adults may be intervening on multiple risk factors including strengthening and balance exercises through physical therapy, medication reduction, environmental modifications to reduce fall hazards, cataract surgery. Vitamin D has strong evidence of benefit for preventing fractures among older men at risk and probably of preventing falls in all at risk older adults.
• While challenges and barriers exist, fall prevention strategies can be incorporated into clinical practice.

• A small proportion of patients with acute low back pain (LBP) go on to develop chronic LBP; these patients account for a very high proportion of costs, services, and suffering.
• The most helpful items to predict persistent disabling low back pain are presence of maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.
• Early identification of patients with these risk factors could help guide early use of psychological therapies and exercise therapy to reduce the likelihood that they will go on to develop chronic disabling low back pain.​

• Know how to assess a cognitively impaired older driver in the office setting
• Know how and where to refer at-risk cognitively impaired older drivers
• Know how to counsel cognitively impaired older drivers in regards to driving retirement

Author: Kenneth J. Mukamal, MD, MPH, MA

Article: "A 42-Year-Old Man Considering Whether to Drink Alcohol for His Health"

Summary Points:

• Careful alcohol histories are needed for all patients, particularly to identify binge drinking, which is frequent among moderate and especially younger drinkers.
• Even moderate alcohol consumption has important and plausible health effects based on short-term trials and observational studies, including lower risk of heart disease presumably via higher HDL-cholesterol and higher risk of breast cancer (presumably via higher levels of estrone and DHEA sulfates).
• Given these points, even controlled alcohol consumption is unlikely to benefit younger drinkers, but is a reasonable point of discussion for middle-aged and older adults, especially as a launching point for education about problem drinking and the potential risks and benefits of including alcohol as part of a healthy diet in older age.