Andrew M. Davis

A Comparison of Osteopathic Spinal Manipulation with Standard Care for Patients with Low Back Pain

BACKGROUND The effect of osteopathic manual therapy (i.e., spinal manipulation) in patients with chronic and subchronic back pain is largely unknown, and its use in such patients is controversial. Nevertheless, manual therapy is a frequently used method of treatment in this group of patients. METHODS We performed a randomized, controlled trial that involved patients who had had back pain for at least three weeks but less than six months. We screened 1193 patients; 178 were found to be eligible and were randomly assigned to treatment groups; 23 of these patients subsequently dropped out of the study. The patients were treated either with one or more standard medical therapies (72 patients) or with osteopathic manual therapy (83 patients). We used a variety of outcome measures, including scores on the Roland-Morris and Oswestry questionnaires, a visual-analogue pain scale, and measurements of range of motion and straight-leg raising, to assess the results of treatment over a 12-week period. RESULTS Patients in both groups improved during the 12 weeks. There was no statistically significant difference between the two groups in any of the primary outcome measures. The osteopathic-treatment group required significantly less medication (analgesics, antiinflammatory agents, and muscle relaxants) (P< 0.001) and used less physical therapy (0.2 percent vs. 2.6 percent, P<0.05). More than 90 percent of the patients in both groups were satisfied with their care. CONCLUSIONS Osteopathic manual care and standard medical care had similar clinical results in patients with subacute low back pain. However, the use of medication was greater with standard care.

Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Clinical spectrum, therapeutic management, and follow-up of ventricular tachycardia in infants and young children

We reviewed 40 infants and young children with VT. Median maximum VT rate was 214 beats/min (range 152 to 375 beats/min). A cause was defined in 20 (50%), the most common being cardiomyopathy or myocarditis in 8 (20%). There were six deaths (15%) related to VT, three of which occurred at diagnosis and in patients less than 1 week old. In 5 of 6 deaths related to VT, a cause was defined. At follow-up, 31 (91%) of 34 survivors did not have VT. The presence of symptoms was a predictor of death related to VT. The outlook for asymptomatic patients and those who survived more than 6 months after diagnosis and who do not have progressive myocardial disease appears good.

The use of quality improvement and health information technology approaches to improve diabetes outcomes in African American and Hispanic patients.

Differences in rates of diabetes-related lower extremity amputations represent one of the largest and most persistent health disparities found for African Americans and Hispanics compared with Whites in the United States. Since many minority patients receive care in underresourced settings, quality improvement (QI) initiatives in these settings may offer a targeted approach to improve diabetes outcomes in these patient populations. Health information technology (health IT) is widely viewed as an essential component of health care QI and may be useful in decreasing diabetes disparities in underresourced settings. This article reviews the effectiveness of health care interventions using health IT to improve diabetes process of care and intermediate diabetes outcomes in African American and Hispanic patients. Health IT interventions have addressed patient, provider, and system challenges in the provision of diabetes care but require further testing in minority patient populations to evaluate their effectiveness in improving diabetes outcomes and reducing diabetes-related complications.

Management of Sepsis and Septic Shock

of the Clinical Problem Sepsis results when the body’s response to infection causes lifethreatening organ dysfunction. Septic shock is sepsis that results in tissue hypoperfusion, with vasopressor-requiring hypotension and elevated lactate levels.1 Sepsis is a leading cause of death, morbidity, and expense, contributing to one-third to half of deaths of hospitalized patients,2 depending on definitions.3 Management of sepsis is a complicated clinical challenge requiring early recognition and management of infection, hemodynamic issues, and other organ dysfunctions.

Patient acuity rating: Quantifying clinical judgment regarding inpatient stability

BACKGROUND New resident work-hour restrictions are expected to result in further increases in the number of handoffs between inpatient care providers, a known risk factor for poor outcomes. Strategies for improving the accuracy and efficiency of provider sign-outs are needed. OBJECTIVE To develop and test a judgment-based scale for conveying the risk of clinical deterioration. DESIGN Prospective observational study. SETTING University teaching hospital. SUBJECTS Internal medicine clinicians and patients. MEASUREMENTS The Patient Acuity Rating (PAR), a 7-point Likert score representing the likelihood of a patient experiencing a cardiac arrest or intensive care unit (ICU) transfer within the next 24 hours, was obtained from physicians and midlevel practitioners at the time of sign-out. Cross-covering physicians were blinded to the results, which were subsequently correlated with outcomes. RESULTS Forty eligible clinicians consented to participate, providing 6034 individual scores on 3419 patient-days. Seventy-four patient-days resulted in cardiac arrest or ICU transfer within 24 hours. The average PAR was 3 ± 1 and yielded an area under the receiver operator characteristics curve (AUROC) of 0.82. Provider-specific AUROC values ranged from 0.69 for residents to 0.85 for attendings (P = 0.01). Interns and midlevels did not differ significantly from the other groups. A PAR of 4 or higher corresponded to a sensitivity of 82% and a specificity of 68% for predicting cardiac arrest or ICU transfer in the next 24 hours. CONCLUSIONS Clinical judgment regarding patient stability can be reliably quantified in a simple score with the potential for efficiently conveying complex assessments of at-risk patients during handoffs between healthcare members.

Part I. Noise exposure

Abstract The auditory and nonauditory effects of noise can be quite profound, affecting approximately 15 to 20 million Americans. As with most occupational toxins, recognition and careful assessment of noise exposure are the foundation on which preventive measures and treatment are based. Dosimeters can measure noise exposure over specific time periods. Pure tone air conduction audiometric monitoring should be performed on an annual basis in workers at risk for significant noise exposure. Occupational infectious disease involves far more than hepatitis and turberculosis. Periodic fever, dermatologic manifestations and other symptoms peculiar to a specific disease may be important clues to an occupationally related exposure. Whereas strict attention to hand washing and isolation are cornerstones of prevention, use of protective gear is mandated in certain situations. Zoonotic disease, agriculture exposure, water transmission, and biologic contaminants in buildings can be important but subtle exposures sources. Recognition of these infections often depends on the alertness of the primary care giver.

Lung Cancer Screening

of the Clinical Problem Lung cancer is the leading cause of cancer-related mortality in the UnitedStates,with159 000deathsestimatedin2014.Ageolderthan 55 years and smoking are the strongest risk factors for lung cancer. Smoking cessation is the main intervention to prevent lung cancer in the 20% of Americans who continue to smoke, but only 15% of cessation efforts succeed. Outcomes in lung cancer depend crucially on the stage of diagnosis, with 5-year survival for non–small cell lung cancer estimated at 71% to 90% for stage IA and 42% to 75% for stage IB cases, compared with less than 10% for those diagnosed with stage IV.1 Currently only 15% of lung cancer cases are diagnosed at stage I, and large trials have not supported the value of chest radiography or sputum cytology for screening.2 Low-dose computed tomography (CT) has emerged as a potentially useful screening method, with 55% to 85% of detected cancers found to be stage I.3,4 Approximately 9 million Americans would potentially be eligible for this screening guideline, divided roughly equally between current smokers and former smokers who have quit within the past 15 years.

IBCD: Development and Testing of a Checklist to Improve Quality of Care for Hospitalized General Medical Patients

BACKGROUND Several studies have demonstrated the usefulness of medical checklists to improve quality of care in surgery and the ICU. The feasibility, effectiveness, and sustainability of a checklist was explored. METHODS Literature on checklists and adherence to quality indicators in general medicine was reviewed to develop evidence-based measures for the IBCD checklist: (I) pneumococcal immunization, (B) pressure ulcers (bedsores), (C) catheter-associated urinary tract infections (CAUTIs), and (D) deep venous thrombosis (DVT) were considered conditions highly relevant to the quality of care in general medicine inpatients. The checklist was used by attending physicians during rounds to remind residents to perform four actions related to these measures. Charts were audited to document actions prompted by the checklist. RESULTS The IBCD checklist was associated with significantly increased documentation of and adherence to care processes associated with these four quality indicators. Seventy percent (46/66) of general medicine teams during the intervention period of July 2010-March 2011 voluntarily used the IBCD checklist for 1,168 (54%) of 2,161 patients. During the intervention period, average adherence for all four checklist items increased from 68% on admission to 82% after checklist use (p < .001). Average adherence after checklist use was also higher when compared to a historical control group from one year before implementation (82% versus 50%, p < .0001). In the six weeks after the checklist was transitioned to the electronic medical record, IBCD was noted in documentation of 133 (59%) of 226 patients admitted to general medicine. CONCLUSION A checklist is a useful and sustainable tool to improve adherence to, and documentation of, care processes specific to quality indicators in general medicine.

The impact of race/ethnicity on baseline characteristics and the burden of coronary atherosclerosis in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial.

OBJECTIVES We aimed to test the impact of race/ethnicity on coronary artery disease (CAD) after adjusting for baseline risk factors. BACKGROUND Whether race/ethnicity remains an important determinant of the burden of CAD even among patients with long-standing type 2 diabetes (diabetes mellitus) and established CAD is unknown. METHODS Analysis of baseline data from the BARI 2D trial (January 1, 2001, to March 31, 2005) was performed. Myocardial jeopardy index (MJI) was evaluated by a blinded core angiographic laboratory. Multivariate regression analysis was performed to determine the independent association of race/ethnicity on the burden of CAD after adjusting for baseline risk factors. Data were collected from US and Canadian academic and community hospitals. The baseline analysis was performed on patients with long-standing diabetes and documented CAD with no prior revascularization at study entry (n = 1,331). The main outcome measure was MJI, which represents the percentage of myocardium jeopardized by significant lesions (≥50%). The secondary outcome measure was ≥2 lesions with ≥50% stenosis. RESULTS Risk factors varied significantly among racial/ethnic groups. Blacks were significantly more likely to be women, have no health insurance, be current smokers, have higher body mass index, have hypertension, have a longer duration of diabetes, a higher hemoglobin A(1c) level, and were more likely to be taking insulin. Their mean total, low-density lipid, and high-density lipid cholesterol levels were higher, whereas their triglycerides were lower than others. After controlling for baseline risk factors, blacks had a significantly lower burden of CAD; the adjusted MJI was 5.43 U lower (95% CI -9.13 to -1.72), and the adjusted number of lesions was 0.53 fewer (95% CI -0.88 to -0.18) in blacks compared to whites. CONCLUSIONS In the BARI 2D trial, self-reported race/ethnicity is associated with important differences in baseline risk factors and is a powerful predictor of the burden of CAD adjusting for such baseline differences. These findings may help direct medical intervention and resources and further investigation into the basis of racial/ethnic differences in CAD burden.