Showing papers in "Southern Medical Journal in 2013"

Major sleep disorders among women: (women's health series).

Abstract: Disruption of sleep causes adverse health outcomes and poor quality of life. People with sleep disruption have higher levels than people without disrupted sleep of depression and anxiety and increased rates of cardiovascular diseases. Women have a higher incidence than men of insomnia and depression related to poor sleep. The types of complaints differ significantly between the sexes. Women are more likely than men to complain of insomnia, headache, irritability, and fatigue than the "typical" symptoms of loud snoring and breathing cessation during sleep. Hormones play an important role in sleep in women. Reproductive hormones were found to have a protective effect on sleep apnea in women of premenopausal age. Pregnancy is another period when the prevalence of sleep apnea and restless leg syndrome increases from hormonal effect. Cardiovascular mortality is high in women with obstructive sleep apnea. Continuous positive airway pressure therapy improves outcomes in most cases of obstructive sleep apnea. The epidemiology, risk factors, diagnostic criteria, and therapies for the three most common sleep disorders (insomnia, obstructive sleep apnea, and restless leg syndrome), along with effects of menopause, pregnancy, and social factors on sleep in women, are key considerations for clinicians caring for female patients across the adult life span.

Kidney disease in pregnancy: (Women's Health Series)

Abstract: Kidney disease and pregnancy may exist in two general settings: acute kidney injury that develops during pregnancy, and chronic kidney disease that predates conception. In the first trimester of pregnancy, acute kidney injury is most often the result of hyperemesis gravidarum, ectopic pregnancy, or miscarriage. In the second and third trimesters, the common causes of acute kidney injury are severe preeclampsia, hemolysis-elevated liver enzymes-low platelets syndrome, acute fatty liver of pregnancy, and thrombotic microangiopathies, which may pose diagnostic challenges to the clinician. Cortical necrosis and obstructive uropathy are other conditions that may lead to acute kidney injury in these trimesters. Early recognition of these disorders is essential to timely treatment that can improve both maternal and fetal outcomes. In women with preexisting kidney disease, pregnancy-related outcomes depend upon the degree of renal impairment, the amount of proteinuria, and the severity of hypertension. Neonatal and maternal outcomes in pregnancies among renal transplant patients are generally good if the mother has normal baseline allograft function. Common renally active drugs and immunosuppressant medications must be prescribed, with special considerations in pregnant patients.

Cheating in medical school: the unacknowledged ailment.

Abstract: The reported prevalence of cheating among US medical students ranges from 0% to 58%. Cheating behaviors include copy- ing from others, using unauthorized notes, sharing information about observed structured clinical encounters, and dishonesty about per- forming physical examinations on patients. Correlates of cheating in medical school include prior cheating behavior, burnout, and inade- quate understanding about what constitutes cheating. Institutional re- sponses include expulsion, reprimands, counseling, and peer review. Preventing cheating requires establishing standards for acceptable behavior, focusing on learning rather than assessment, involving medi- cal students in peer review, and creating a culture of academic integrity. Cheating in medical school may have serious long-term consequences for future physicians. Institutions should develop environments that promote integrity.

Home food environment, dietary intake, and weight among overweight and obese children in Southern Appalachia.

Abstract: OBJECTIVES This study examined the relation of multiple aspects of the home food environment to dietary intake and body weight among overweight and obese children in southern Appalachia. METHODS The study used baseline data from a cluster-randomized controlled trial, Parent-Led Activity and Nutrition for Healthy Living, evaluating a parent-mediated approach to treating child overweight and obesity in the primary care setting in southern Appalachia. Sixty-seven children ages 5 to 11 years were recruited from four primary care clinics. Multiple linear regression was used to estimate the relation between multiple aspects of the home food environment to dietary intake (fruit and vegetable intake, fat and sweets intake), and standardized body mass index (zBMI), adjusted for baseline family characteristics (education, smoking status during the past month, BMI) and child characteristics (sex, age, Medicaid/TennCare). RESULTS Findings showed greater parental restriction and pressure in feeding were associated with greater fruit and vegetable intake in children (β = 0.33, β = 0.30, respectively; both P < 0.05). The availability of chips and sweets in a child's home and parental inappropriate modeling of eating were associated with an increased risk for consumption of fats and sweets by children (β = 0.47, β = 0.54, respectively; both P < 0.01). Parental monitoring of the child's eating was associated with a reduced risk for fat and sweets intake (β = -0.24; P < 0.01). Finally, parental responsibility for feeding the child was associated with lower zBMI (β = -0.20; P < 0.05). CONCLUSIONS The home food environment, including food availability and parenting behaviors, was associated with overweight and obese children's dietary intake and weight. This study adds to evidence suggesting that programs aimed at improving overweight and obese children's eating patterns may target both aspects of the physical home environment and parental behaviors surrounding eating.

Laboratory diagnosis of antiphospholipid syndrome.

Abstract: Antiphospholipid syndrome is an intriguing clinical entity encountered by all physicians because of the wide range of clinical manifestations involving every organ system. Ordering a single test under the name "antiphospholipid antibody" does not rule out this entity. There are overlapping but distinct autoantibodies, and a positive result in one assay is conclusive despite a negative result in another. Laboratories continue to conduct several nonstandard tests as part of integrated kits and physicians should be familiar with them for proper interpretation of the results. Lupus anticoagulant testing is an integral part of every thrombophilia workup and should be performed regardless of the screening activated partial thromboplastin time or mixing study.

Four-year trends of inappropriate proton pump inhibitor use after hospital discharge.

Abstract: Background Several hospital-based studies have determined that physicians often inappropriately prescribe acid-suppressive medications for stress ulcer prevention in hospitalized patients and continue these drugs after discharge. We sought to determine the frequency of inappropriate proton pump inhibitor (PPI) use continued at discharge within our geographic region. Methods We undertook a retrospective review of the medical records and pharmacy prescription database of a large regional insurance carrier from January 2005 through December 2008 (total hospital admissions 96,669). The primary inclusion criterion was hospital-initiated PPI therapy and continuation on hospital discharge without an appropriate indication. Patients receiving a PPI at the time of admission were excluded from the analysis. Results The number of patients per year discharged on a PPI decreased during the study period: 876 (2005), 763 (2006), 562 (2007), and 485 (2008). Of the patients discharged on a PPI, the number (%) of patients receiving PPIs inappropriately were 695 (79%; 2005); 627 (82%; 2006), 441 (78%; 2007), and 397 (82%; 2008). The annual number of PPI prescriptions and PPI doses dispensed decreased from 2015 to 1263 and from 60,608 to 38,742, respectively, during the study period. The estimated 4-year cost of inappropriate PPI use was $595,809, although cost savings from the absolute reduction in inappropriate PPI use over time was $65,598. Conclusions We report a significant decrease of 39% in the number of inappropriate discharge prescriptions for PPIs during the study period; however, the percentage of inappropriate use of PPIs remains high. There is room for improvement in cost-effective use of PPIs.

Osteoporosis in Postmenopausal Women: Considerations in Prevention and Treatment

Abstract: Osteoporosis, the most common human bone disease, affects 8 million American women and has significant morbidity and mortality. Screening is important in older women and younger postmenopausal women with additional risk factors for osteoporosis/fracture. Preventive measures include avoiding smoking, excessive alcohol/caffeine intake, and falls in addition to maintaining adequate calcium/vitamin D intake and exercise. Estrogen/hormone therapy may be considered in some patients. Various medications have proven efficacy in treating postmenopausal osteoporosis; however, potential adverse effects such as hypocalcemia, worsening of renal impairment, and osteonecrosis of the jaw must be considered. The optimal duration of therapy requires further investigation.

Factors influencing consumer purchasing patterns of generic versus brand name over-the-counter drugs.

Abstract: Objectives US consumers spend more than $20 billion/year on over-the-counter (OTC) drugs. Although generic and brand name OTC drugs share the same active ingredients and undergo the same rigorous Food and Drug Administration approval process, brand name formulations continue to lead the OTC drug market with a higher market share. There is a limited amount of publicly available information regarding consumer perceptions and awareness about generic and brand name OTC drugs. The main objective of this research was to understand what factors influence US consumers to purchase generic versus brand name OTC drugs. Methods The researchers used a 20-question, self-administered, multiple-choice survey to collect data on the factors influencing consumers' preferences for generic versus brand name OTC drugs. Results Results revealed that the single most influential factor for participants when purchasing OTC drugs was lower cost. Conclusions Although economic factors play an important role in influencing consumers to choose generic formulations, a variety of other factors including advertisements, duration of the OTC effectiveness, severity of sickness, preferable form of OTC medication, safety of the OTC, relief of multiple symptoms, and preferred company will persuade others to pay more for brand name drugs. Ultimately, increased awareness and use of generic OTC drugs may result in substantial cost savings for consumers.

Perceptions and attitudes about preexposure prophylaxis among seronegative partners and the potential of sexual disinhibition

Abstract: Objectives Preexposure prophylaxis (PrEP) is a promising strategy to prevent human immunodeficiency virus (HIV) infection, especially among high-risk individuals such as seronegative partners; however, many caveats such as the potential risk of sexual disinhibition and noncompliance need to be considered. We explored the sociodemographic and behavioral factors associated with the adoption of PrEP among HIV seronegative men who have sex with men and heterosexual partners. Methods A prepiloted self-administered survey was conducted among seronegative partners in a Ryan White HIV/AIDS Clinic in South Carolina from 2010 to 2011. Bivariate and multivariable analyses were used to explore the data. Results The survey was completed by 89 seronegative partners. The median age was 42 years (interquartile range 32-50) and a majority was men (56%), black (70%), and heterosexual (74%). A majority (94%) was willing to use PrEP if available; however, 26% of subjects suggested that they would be more likely to have unprotected sex with an HIV-positive partner while using PrEP, and 27% suggested that it would be difficult to take a daily dose of PrEP and consistently use condoms. The multivariable results suggest that the belief that a condom is no longer needed while taking PrEP was more likely among those who did not use a condom during their last sexual intercourse (adjusted odds ratio 7.45; 95% confidence interval 1.57-35.45) and among those with a higher HIV knowledge score (adjusted odds ratio 0.43; 95% confidence interval 0.23-0.78). Conclusions Overall, these results suggest high acceptability of PrEP among seronegative partners to lower the risk of HIV transmission; however, there is a substantial risk of sexual disinhibition and noncompliance while using PrEP that may be reduced by ongoing education.

Healthcare access and disparities in chronic medical conditions in urban populations.

Abstract: Objectives The purpose of this study was to identify barriers and disparities in healthcare access and the factors associated with them in an urban population. Methods Eligible patients were consented and enrolled randomly from the inpatient internal medicine unit at Truman Medical Center, Kansas City, Missouri, a 250-bed hospital recognized for its broad range of acute and chronic diseases seen in its inpatient and outpatient care. They had one or more of the following chronic medical conditions (CMCs): congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, chest pain, or cirrhosis. One hundred patients were interviewed regarding challenges they have encountered as consumers and their understanding of CMCs. Results Interview results indicate patients' understanding of their CMC, the associated needs for self-management, and the potential health consequences are contributing factors leading to repeated visits to the emergency department. Conclusions Our study suggests that access to the following health-focused services has the potential to reduce the rate of emergency department visits and hospitalizations, morbidity, mortality, and the burden of cost. These services include adequate access to and utilization of primary care characterized by preventive care, early detection of acute illness, ongoing chronic disease management through easy access to primary providers, and adequate health literacy about CMC.

Sharpening the tandem walking test for screening peripheral neuropathy.

Abstract: Objective: Few tests of functional motor behavior are useful for rapidly screening people for lower extremity peripheral neuropathy. The goal of this study was to improve the widely used tandem walking (TW) test. Methods: We tested ‘‘normal’’ (control) adult and ambulatory patients with peripheral neuropathy (PN) with their eyes open and eyes closed while they performed TW on industrial carpeting in sockcovered feet. Each subject wore a torso-mounted inertial motion unit to measure kinematic data. The data of subjects with PN also were compared with historical data on patients with vestibular impairments. Results: The normal and PN groups differed significantly on TW and on the number of steps completed. PN and vestibular impairments data also differed significantly on both visual conditions. Kinematic data showed that patients with PN were more unstable than normal patients in the group. For the number of steps taken during the eyes open condition, receiver operating characteristic (ROC) values were only 0.81 and for the number of steps taken during the eyes closed condition, ROC values were 0.88. Although not optimal, this ROC value is better. Sensitivity and specificity at a cutoff of two steps were 0.81 and 0.92, respectively, and at a cutoff of three steps were 0.86 and 0.75, respectively. ROC values for kinematic data were G0.8, and when combined with the ROC value for the number of steps, the total ROC value did not improve appreciably. Conclusions: Although not ideal for screening patients who may have PN, counting the number of steps during TW is a quick and useful clinical test. TW is most sensitive to patients with PN when they are tested with eyes closed.

Anemia in general medical inpatients prolongs length of stay and increases 30-day unplanned readmission rate.

Abstract: BAObjectives: Anemia, either chronic or newly developed in the hos-pital as a result of underlying disease and/or phlebotomy, is seencommonly among general medical inpatients, and its impact on thequality and efficiency of care is unknown.Methods: This study investigated the relation among hemoglobinlevel, length of stay, and 30-day unplanned readmission rates in acohort of 314 general medical inpatients 18 years old and older ad-mitted to a teaching hospital during a period of 4 months in a largeurban academic medical center, using retrospective chart review ofthe electronic health record.Results: Anemiawas common among this cohort of general medicalinpatients (44.6%), and therewas a statistically significant decrease inhemoglobin levels during their hospitalization. Anemic patients, ascomparedwithnonanemicpatients,hadsignificantlylongermeanandmedian length of stay. More important, the admission hemoglobinlevel and its change during hospitalization were significant predictorsof increased length of stay. For every 1-U increase in admissionhemoglobin level, the median length of stay was reduced by 0.5 days.For every 1-U increase in the level of hemoglobin change, the medianlength of stay was extended by 1.5 days. Likewise, the dischargehemoglobinlevelpredictedtherateof30-dayunplannedreadmission.For every 1-U decrease in discharge hemoglobin level, the read-mission rate increased by nearly 4%. These relations remained afteradjusting for common demographic and clinical variables, includingage, sex, nutritional status, and number of comorbidities.Conclusions: Anemia is common among general medical inpatientsand adversely affects their length of stay and 30-day unplannedreadmission rate.Key Words: anemia,generalmedicalinpatients,lengthofstay,30-dayunplanned readmission rate

Does ambulance response time influence patient condition among patients with specific medical and trauma emergencies

Abstract: OBJECTIVES: The relation between patient outcome and ambulance response times is unknown. We sought to measure the influence of shorter response times on patient outcomes. The objective of the study was to determine whether ambulance response time makes a difference in the outcomes of emergency medical services (EMS) patients with specific traumatic and medical emergencies. METHODS: This study was conducted in a metropolitan EMS system serving a population of 800,000, including urban and rural areas. Cases were included if the private EMS service was the first medical provider on scene, the case was priority 1, and the patients were 13 years old and older. A 14-month time period was used for the data evaluation. Four diagnoses were examined: motor vehicle crash injuries, penetrating trauma, difficulty breathing, and chest pain complaints. Data collected included ambulance response times, initial vital signs, and the number of vital signs out of range. Cases seen at the single major trauma center were selected for evaluation of hospital outcome. Correlation coefficients were used to evaluate interactions between independent and outcome variables. RESULTS: Of the 2164 cases we reviewed, the EMS service responded significantly faster to trauma complaints at 4.5 minutes (n = 254) than medical complaints at 5.9 minutes (n = 1910). In the trauma center sample of 559 cases, response time was not related to hospital days (P = 0.5), admissions (P = 0.7), intensive care unit admissions (P = 0.4), or deaths (P= 0.3). CONCLUSIONS: This study showed that in cases seen at a major trauma center, longer response times were not associated with worse outcomes for the diagnostic groups tested. Language: en

Caring for elderly adults during disasters: improving health outcomes and recovery.

Abstract: Elderly adults are faced with many unique health challenges during disasters and public health emergencies. The healthcare system can mitigate the risks to vulnerable elders by recognizing the variations in the environment in which they live and receive care and the likelihood of financial and social isolation and creating disaster medical care plans that address these issues. Healthcare providers and systems can improve health outcomes for older adults following disasters via specific predisaster-planning steps that engage not only the older patient but also the community. Resources are available to help augment geriatric patient care knowledge and formulate best practices for eldercare during disasters.

Comparison of breast-feeding knowledge, attitudes, and beliefs before and after educational intervention for rural Appalachian high school students.

Abstract: Objectives Breast-feeding rates in rural and southeastern regions of the United States are lower than national rates and Healthy People 2020 targets. The objectives of this study were to understand current breast-feeding knowledge, attitudes, and beliefs among rural southern Appalachian adolescents and to explore whether a high school educational intervention designed to address the five tenets (knowledge, attitudes, intentions, perceived behavioral control, and subjective norms) of the theory of planned behavior may be effective in increasing future rates of breast-feeding in this population. Methods An educational session including an interactive game was developed and administered to occupational health science students during a single class period in two county high schools. A presurvey and a postsurvey administered 2 weeks after the intervention were completed by students. Pre- and postsurveys were analyzed using paired t tests and Cohen d and potential differences based on sex and grade were explored. Results Both pre- and postsurveys were completed by 107 students (78%). Knowledge, attitudes about breast-feeding benefits, subjective norms, and intentions significantly improved following the intervention. Baseline knowledge and attitudes about breast-feeding benefits for mothers were low and demonstrated the greatest improvement. Conclusions Offering breast-feeding education based on the theory of planned behavior in a single high school class session was effective in improving student knowledge, attitudes, and beliefs about breast-feeding and intention to breast-feed.

Sexual abuse history and pelvic floor disorders in women.

Abstract: Objectives Sexual abuse rates in the general female population range between 15% and 25%, and sexual abuse is known to have a long-term impact on a woman’s health. The aim of this study was to report the prevalence of sexual abuse history in women presenting to clinicians for pelvic floor disorders (PFD) and to determine whether a history of sexual abuse is associated with a specific type of PFD.

Considerations in women with hypertension.

Abstract: Cardiovascular disease is the most common cause of death in women in the United States, and hypertension is a major contributor to cardiovascular mortality. The incidence of hypertension in women is steadily increasing, paralleling the epidemics of obesity and diabetes. Blood pressure control rates among women are suboptimal, even when secondary causes are identified and treated. There are few high-quality data describing specific hypertension-related outcomes in women. Some data comparing hypertensive women to age-matched men suggest advantages to sex-specific strategies, but further study is needed to determine optimal regimens for women throughout their lives. Pregnancy and menopause present unique, complex challenges in hypertension management.

Effect of patients' awareness of CVD risk factors on health-related behaviors

Abstract: Objectives: In 2010, the American Heart Association unveiled a strategic plan to reduce cardiovascular deaths by targeting seven components of ideal cardiovascular health. Although education is a sensible first step, it is not known whether awareness correlates with healthy behavior. The objective of the study was to examine the association between awareness of risk factors and ideal cardiovascular health behavior. Methods: We surveyed patients 40 years and older at five ambulatory clinics. The survey measured demographics, health management behaviors, comorbidities, and awareness of five modifiable cardiac risk factors (smoking, obesity, high cholesterol, hypertension and diabetes mellitus) and one protective factor (exercise). Healthy behavior was defined as follows: diabetes, hemoglobin A1c G8.0%; hypertension, systolic blood pressure G140 mm Hg), high cholesterol, medication adherence; obesity, attempting to lose weight; smoking, abstinence; and exercise, Q30 minutes/day, Q3 times per week. Results: For five modifiable risk factors, awareness was positively associated with healthy behavior in multivariable models: obesity, hypertension, exercise, cholesterol, and diabetes. Awareness was inversely associated with smoking abstention. Conclusions: Awareness that a specific factor increases the risk for cardiovascular disease was positively associated with healthy behavior regarding most risk factors; however, the association was modest, suggesting that awareness alone does not motivate behavior.

Disaster-Related Injuries and Illnesses Treated by American Red Cross Disaster Health Services During Hurricanes Gustav and Ike

Abstract: OBJECTIVE: To describe the injuries and illnesses treated by the American Red Cross (Red Cross) during Hurricanes Gustav and Ike disaster relief operations reported on a new Aggregate Morbidity Report Form. METHODS: From August 28 to October 18, 2008, 119 Red Cross field service locations in Louisiana, Mississippi, Tennessee, and Texas addressed the healthcare needs of people affected by the hurricanes. From these locations, individual client visit data were retrospectively collated per site onto new 24-hour Aggregate Morbidity Report Forms. RESULTS: A total of 3863 clients were treated. Of the clients, 48% were girls and women and 44% were boys and men; 61% were 19 to 64 years old. Ninety-eight percent of the visits occurred in shelters. The reasons for half of the visits were acute illness and symptoms (eg, pain) and 16% were for routine follow-up care. The majority (65%) of the 2516 visits required treatment at a field location, although 34%, or 1296 visits, required a referral, including 543 healthcare facility transfers. CONCLUSIONS: During the hurricanes, a substantial number of displaced evacuees sought care for acute and routine healthcare needs. The capacity of the Red Cross to address the immediate and ongoing health needs of sheltered clients for an extended period of time is a critical resource for local public health agencies, which are often overwhelmed during a disaster. This article highlights the important role that this humanitarian organization fills, to decrease surge to local healthcare systems and to monitor health effects following a disaster. The Aggregate Morbidity Report Form has the potential to assist greatly in this role, and thus its utility for real-time reporting should be evaluated further. Language: en

Mediastinoscopy: trends and practice patterns in the United States.

Abstract: Lung cancer staging is essential to selecting the most effective therapy and assessing a prognosis. Since the 1950s, mediastinoscopy has been the gold standard in evaluating the presence of mediastinal nodal metastases in patients with lung cancer. Carlens first performed mediastinoscopy in the 1950s and his technique is still in use today.1 By 1964, patients were selected for the procedure if x-ray imaging demonstrated central tumors, atelectases, or oat-cell carcinoma. By that time, physicians had discovered that with mediastinoscopy, the resection rate had increased to 90%.2 By 1969, mediastinoscopy was suggested for every case of operable bronchogenic cancer because it offered histopathological evidence and reduced higher-risk thoracotomy.3 By 1976, researchers had determined that available radiographic techniques were insufficient to select patients for mediastinoscopy because of the prevalence of occult cancers.4 As a result, it was determined that histology was more important than location in diagnosing metastasis. The incidence of mediastinoscopy has increased over time, with 16% of patients undergoing the procedure from 1986–1992, 32% of whom undergoing the procedure from 1993–2001.5 In 1989, Lerut and colleagues developed video-assisted mediastinoscopy,6 which was expanded in a clinical setting by Sortini and colleagues.7 In addition to its utility in staging lung cancer, mediastinoscopy is mandatory for lung resection in some medical centers. When compared with advances in minimally invasive procedures and imaging technology, mediastinoscopy is perceived by many surgeons to be exceedingly invasive. Many practitioners believe that advances in new technology and minimally invasive techniques can replace mediastinoscopy. The present study was undertaken to assess and evaluate contemporary practices in the staging of lung cancer by describing current trends and practice patterns of mediastinoscopy usage. In addition, regional variation in usage was assessed nationally, as was practice-based learning and patient care. The hypothesis is that lessons learned during surgeries performed on patients with lung cancer and new advances can be universally applied to improve surgeons' management of patient care. We expect that our findings will be relevant to both clinical practice and practice guidelines.

Integrated Models of Education and Service Involving Community-Based Health Care for Underserved Populations: Tulane Student-Run Free Clinics

Abstract: A lack of insurance and underinsurance in the United States constitutes a significant national public health problem.1 In the United States, 50.7 million individuals, 16.7% of the population, are uninsured and many more experience barriers to obtaining health care.2,3 Certain population subgroups have a low amount of health insurance coverage, including ethnic minorities, residents of southern and urban locations, and low-income households.3 In Louisiana, 17.4% of the population is uninsured and the highest uninsured rate for the state is in Orleans Parish (24.3%).3 There is a substantial need for safety-net services to provide care for uninsured individuals in the United States and Louisiana in particular. Many medical students are exposed to the safety-net healthcare environment for underserved populations, either on a volunteer basis or as part of their education. Approximately half of US medical schools have at least one student-run clinic, with most serving poor and uninsured patients.4 In addition to providing a needed service to patients, these clinics have the potential to teach students clinical skills, medical humanism, systems-based practice, collaborative and multidisciplinary approaches to medicine, and leadership skills.4–6 Participating in community-based, student-run clinics has the added advantage of potentially influencing students’ choice to practice in primary care.7 The purpose of this article is to describe the clinic models, patient demographics, and services provided by four student-run clinicsVBridge House Wednesday Clinic, Ozanam Inn Weekend Clinic, Fleur de Vie at Covenant House, and Fleur de Vie in New Orleans East—and to examine the relevance of these clinics for medical education and healthcare service delivery for underserved populations in New Orleans.

Minimally invasive drainage of subcutaneous abscesses reduces hospital cost and length of stay.

Abstract: OBJECTIVE We compared outcomes among pediatric patients managed with minimally invasive (MI) packing techniques with those managed with traditional packing techniques for drainage of subcutaneous abscesses. METHODS After institutional review board approval, medical records of children requiring drainage of subcutaneous abscesses between January 2010 and June 2011 were reviewed. Data were collected on patient demographics, abscess location, surgical procedure, microbiology cultures, and hospital length of stay (LOS). The hospital accounting system was queried for direct and indirect costs. We compared LOS and cost data among groups managed with MI versus traditional packing techniques. RESULTS Incision and drainage was performed on 329 children (57.8% girls, 72% white, mean age of 43 months [range <1 to 218]). Of the total abscesses 198 (60.2%) were located in the groin/buttocks/perineum. Methicillin-resistant Staphylococcus aureus was identified in 74% of culture specimens. A total of 202 patients (61.4%) underwent packing and 127 (38.6%) underwent MI drainage. MI drainage ranged from 0% (0/110) in January to June 2010 to 34.6% (44/127) in the July to December 2010 transition period and reached 90.2% (83/92) in 2011 (P < 0.001). Median LOS decreased from 2 days (interquartile range 1-2) in the packing-only period to 1 day (interquartile range 1-2) in the predominantly MI period (P < 0.001). Hospital costs decreased with the transition to the MI technique (P < 0.001). MI drainage was associated with a $520 reduction in median direct costs and a $385 reduction in median indirect costs (P < 0.001). CONCLUSIONS Soft tissue infections requiring incision and drainage are common in the pediatric population, with the majority caused by methicillin-resistant Staphylococcus aureus. Infections requiring drainage most frequently occurred in the diaper area of girls younger than 3 years old. Changing to an MI technique significantly decreased the hospital costs and LOS in our patient population.

Surgical treatment of lung cancer in octogenarians.

Abstract: BACKGROUND As the population ages, octogenarians are becoming the fastest growing patient demographic for non-small-cell lung cancer. We examined lobectomies and 30-day outcomes in this group compared with younger patients to gain insight into the optimal treatment for this challenging group. METHODS We analyzed data from the American College of Surgeons National Quality Improvement Program for patients with lung cancer undergoing lobectomy during calendar years 2005-2010. We compared clinical risk factors, intraoperative factors, and 30-day operative mortality and major morbidity in octogenarians versus younger patients undergoing either open traditional thoracotomy (OPEN) or video-assisted (VATS) pulmonary lobar resection. RESULTS Of 2171 patients who had lobar resections for lung cancer, 245 (11%) were octogenarians. Six hundred eight lobectomies (28.0%) were VATS procedures and 1563 (72.0%) were OPEN procedures. The VATS rate increased as patient age increased (34% VATS for octogenarians vs 27% for patients younger than 80 years; P = 0.01). Thoracic surgeons performed VATS with greater frequency compared with general surgeons, especially in octogenarians (41% VATS for thoracic surgeons vs 29% for general surgeons; P < 0.001). Univariate analysis suggests significantly increased major morbidity (pulmonary, renal, and sepsis), but not operative mortality in octogenarians; however, multivariate predictors of major morbidity include OPEN procedures, preoperative decreased functional status, history of chronic obstructive pulmonary disease, preoperative sepsis, prior radiation, diabetes, and dyspnea on exertion (all P < 0.05), but they do not include advanced age. CONCLUSIONS Comorbidities predict most increased morbidity in octogenarians, and advanced age per se is not an important multivariate predictor of postoperative morbidity or mortality. The frequency of VATS lobectomy increased with increasing patient age, and VATS predisposes to decreased morbidity in octogenarians.

Reducing high BMI in African American preschoolers: effects of a behavior-based physical activity intervention on caloric expenditure.

Abstract: OBJECTIVES Overweight and obesity in young children are increasing concerns for medical professionals. Lack of sufficient physical activity may be the primary cause; therefore, the development and testing of a theory-based intervention for preschoolers is a priority. METHODS A 30-minutes/day preschool-based intervention (Start For Life), with a foundation in social cognitive theory that emphasizes the use of self-regulation skills and feelings of mastery (self-efficacy), was administered for 9 months to 4- and 5-year-old African American children. RESULTS Findings indicated a significant increase in accelerometer-measured moderate-to-vigorous and vigorous physical activity during the 7-hour school day. Reductions in body mass index (BMI; kg/m) were significant, with greater effects found in participants with an initially higher BMI. Further analyses indicated that the kilocalories expended through physical activity explained approximately 87% of the weight lost. Participants' sex did not affect the identified changes in BMI. CONCLUSIONS A brief theory-based physical activity intervention (Start For Life) was associated with increased moderate-to-vigorous and vigorous physical activity and reduced overweight/obesity in 4- to 5-year-old preschoolers. Because of its practical format, opportunities for widespread dissemination may be possible.

Prevalence and impact of anemia in hospitalized patients.

Abstract: OBJECTIVE: The prevalence of anemia is increasing in the general population similarly to other comorbidities and is associated with high mortality in a variety of settings. Most studies, however, have analyzed older adults or specific comorbidities, and the independent impact of anemia on outcomes in a general population of hospitalized patients has not been clearly defined. METHODS: Retrospective analysis of a medical records database of all consecutive patient discharges (aged 18 years or older) admitted to our institution from January 1, 1999 through December 31, 2008. RESULTS: A total of 179,516 admissions were included. Of these, 18,589 patients were diagnosed as having anemia (10.4%). There were 123,586 patients younger than 65 years. The prevalence of anemia among all of the discharges was characterized by a significant linear increase across the 10-year time frame, from 8.7% (1999) to 12.8% (2008), as was the average number of comorbidities. Over time, anemic patients were characterized by increasing comorbidity. Anemia was significantly associated with mortality (6.5% vs 2.5%; P < 0.001, odds ratio 2.68). This association remained significant after additional adjustment for demographic characteristics and comorbidities. The risk of mortality was significantly higher in patients younger than 65 years than it was in patients older than 65 (odds ratio 3.2 vs 2.1, respectively). CONCLUSIONS: The prevalence of anemia increased during a 10-year time frame, as did the average number of associated comorbid conditions. With adjustment for time, demographic factors, and additional comorbidities, anemia remained independently associated with mortality. This association was stronger in younger patients.

Intrauterine device knowledge and practices: a national survey of obstetrics and gynecology residents.

Abstract: Objectives: The primary objective of this study was to assess the current intrauterine device (IUD) knowledge and counseling practices of US obstetrics and gynecology chief residents. The secondary objective was to evaluate the current IUD experience of obstetrics and gynecology residents. Methods: A Web-based survey about IUD knowledge and practices was sent to US obstetrics and gynecology residents in January 2010. An analysis of responses by postgraduate year was completed using descriptive statistics. Results: We received 699 surveys (36%) from a pool of 1922 residents in 96 different residency programs. A total of 654 respondents (94%) had placed an IUD during residency and 88% had received formal teaching about IUDs during residency. Only 53% of respondents knew that the copper IUD could be used for emergency contraception. Less than 65% of respondents would routinely recommend the IUD to adolescents or immediately after first trimester abortion. Conclusions: Many US obstetrics and gynecology residents lack knowledge about IUD benefits and do not counsel all eligible women to use IUDs. We should continue to evaluate our training and educational programs to ensure that women’s health providers do not act as a barrier to IUD use.

Burn disaster preparedness and the southern region of the United States.

Abstract: Disasters with significant numbers of burn-injured patients create incredible challenges for disaster planners. Although not unique to burn care, high-intensity areas of specialty such as burns, pediatrics, and trauma quickly become scarce resources in a disaster.All disasters are local, but regional support is critical in burn disaster planning. On a day-to-day basis, burn bed capacity can be problematic. A review of the literature and our experiences, including mathematical modeling and real events, reaffirm how rapidly we can overwhelm our resources.This review includes the Southern Burn Plan, created by the burn centers of the American Burn Association's Southern Region, should there be a need for additional hospital burn beds (capacity) and burn care (capability) in response to a disaster. This article also explores planning and preparedness developments and describes options to improve our efforts, including training and education.It is incumbent upon everyone in the healthcare profession to become comfortable managing burn-injured patients until the patients can be moved to a burn center. Understanding the regional capacity, capability, and when a surge of patients may require the practice of altered standards of care is essential for those involved in medical disaster preparedness.

Utilization of counseling services at one medical school

Abstract: Objectives The purpose of this study was to assess the usage of mental health counseling services by medical students. Medical students experience high rates of burnout, depression, and suicidal ideation. Our medical school (Baylor) provides free professional counseling services. Methods The authors administered a survey that included a burnout scale; a depression screen; and questions about demographics, usage of counseling services, and helpful coping mechanisms for 526 first-through third-year students (336 respondents) at one school. Results Approximately 24% of students with high rates of burnout and 24% of students with depressive symptoms took advantage of counseling services at least once. Of the students who had not used counseling services, approximately 49% were found to have high rates of burnout in the domain of emotional exhaustion. Similarly, of the students who had not accessed counseling services, 56% had depressive symptoms. Conclusions A large percentage of medical students across three classes did not use mental health counseling services provided by the school. Students should be clearly informed about the availability of counseling services and their potential utility. In addition, specific barriers to attendance should be identified and reduced.

Relationship of vitamin D monitoring and status to bladder cancer survival in veterans.

Abstract: Objectives: Veterans of the armed forces, like most population groups, have a high prevalence of vitamin D deficiency, which may be associated with adverse outcomes in several types of cancer. Ultraviolet irradiation is inversely linked with the risk of bladder cancer, presumably through enhanced vitamin D synthesis. We hypothesized that variations in vitamin D status and monitoring predict adverse outcomes in bladder cancer among veterans. Methods: A retrospective analysis of data in the Veterans Integrated Service Network-9 (southeastern United States) was performed for patients diagnosed between October 1, 1999 and February 29, 2008. Age, tobacco exposure, body mass index, and latitude and seasonality of sampling were included as variables in addition to serum vitamin 25(OH)D levels. Results: Monitoring of vitamin D and vitamin D levels and status were closely linked to survival in bladder cancer. Both the chances of survival and longevity improved with enhanced vitamin D status and monitoring. Veterans with bladder cancer had better outcomes if the initial vitamin D level was higher and had more monitoring of the vitamin. Initial vitamin D levels were more strongly related to outcomes than follow-up levels. The link between vitamin D and outcomes remained after adjusting for background variables such as age, body mass index, latitude, seasonality, and tobacco exposure. Conclusions: Findings suggest that adequate vitamin D levels early in the course of the disease provide the best opportunity to improve outcomes. Ensuring that veterans with bladder cancer have adequate vitamin D reserves with appropriate monitoring may play a role in improving outcomes in bladder cancer.