David Litaker

Returning to the Bedside: Using the History and Physical Examination To Identify Rotator Cuff Tears

OBJECTIVES: To determine the value of elements of the bedside history and physical examination in predicting arthrography results in older patients with suspected rotator cuff tear (RCT).

Implementing ACC/AHA guidelines for the preoperative management of patients with coronary artery disease scheduled for noncardiac surgery: effect on perioperative outcome

STUDY OBJECTIVE To review the new consensus guidelines for cardiac testing for the patient with cardiac disease scheduled for elective, noncardiac surgery, and their impact on cardiac functional testing. DESIGN Retrospective chart review study. SETTING Tertiary care medical center. PATIENTS 181 patients scheduled for elective, major surgery who met American College of Cardiology/American Heart Association (ACC/AHA) criteria for a preoperative stress test. INTERVENTIONS A variety of tests were ordered, including treadmill stress testing, persantine-thallium imaging, dobutamine echocardiography, and exercise stress echocardiography. MEASUREMENTS The numbers of and outcome of the stress tests and the cardiac outcome of the patients who underwent cardiac testing and surgery were recorded. MAIN RESULTS Abnormal tests occurred in 27 patients. Two patients declined treatment, eight patients had primary medical management, and the remainder (17) had cardiac catheterization. Results included no lesion (2 patients), angioplasty (4 patients), angioplasty plus stenting (1 patient), coronary artery bypass grafting (CABG) (4 patients), and delineated lesions treated with medical optimization (6 patients). One patient had CABG and declined further surgery. One patient had myocardial infarction 6 months after surgery that was treated by medical management after cardiac catheterization. The other 23 patients had surgery without cardiac complication within 1 year of surgery. Only 15% (27/180) of the patients with indications for a stress test had a positive result. Even fewer patients had any alteration of the perioperative period. Despite this finding, cardiac morbidity was very low. CONCLUSIONS The guidelines for stress test may be over-sensitive, and further prospective clinical studies are indicated.

DEVELOPING BETTER CRITICAL PATHS IN HEALTHCARE : COMBINING 'BEST PRACTICE'AND THE QUANTITATIVE APPROACH

Critical paths are tools to manage healthcare delivery and ensure favorable patient outcomes. Unfortunately, many of these paths are not evaluated or revised after their initial development. One potential problem faced by nursing managers is that critical paths may lose relevance in a rapidly changing healthcare environment. The authors suggest one strategy to strengthen existing critical paths in a way that is responsive to these changes.

Impact of Sumatriptan on Clinic Utilization and Costs of Care in Migraineurs

Background.—Although migraine headaches affect a large segment of the population, no objective measure of therapeutic success is currently available. Comparing visit frequency and associated costs of care before and after introduction of a new therapy represents an important surrogatemeasure of success.

The Impact of Drug Therapy on Quality of Life in Headache and Migraine

SummaryAlthough headache is among the most common and costly disorders in primary care, our understanding of its direct impact on the quality of life of affected individuals is incomplete. While studies evaluating the role of headache on health-related quality of life and healthcare economics are starting to appear in the medical literature, the effect of pharmacotherapy in improving quality of life is only beginning to be studied.At present, studies evaluating health-related quality of life in patients with migraine who are undergoing treatment are limited to 3 agents: sumatriptan, flurbiprofen and diclofenac. Several studies have consistently indicated that these drugs benefit patients by improving key dimensions of health-related quality of life or patients’ sense of well-being to a significant extent.Given the magnitude of functional and emotional impairment associated with chronic headache disorders, assessing patients’ perceptions of their quality of life makes a useful contribution to the evaluation of therapeutic interventions and should supplement traditional clinical endpoints in determining the effectiveness of new drugs.

Targeting Lead Screening: The Ohio Lead Risk Score

Objective. Annual blood lead (BPb) screening is recommended for children ≤2 years of age residing in high-risk areas. Strategies for identifying these areas exist but lack specificity. We sought to develop an efficient method for identifying risk factors for undue lead exposure in children by using community variables. Design. Logistic regression for model development in one half of the sample followed by validation of the model in the remaining half. Methods. The association between selected census tract characteristics from 19 Ohio counties and the BPb test results of children living in those census tracts was evaluated. The dependent variable, high-risk status, was defined as a census tract with ≥12% of BPb test results ≥10 μg/dL. Results. Data from 897 census tracts were available. Higher risk for lead toxicity existed in areas where: 1) ≥55% of houses were built before 1950 (adjusted odds ratio [AOR]: 10.9 [6.1,19.6]); 2) ≥35% of residents were black (AOR: 3.5 [2.0,6.3]); 3) ≥35% of residents had less than a high school education (AOR: 6.1 [3.6,10.4]); and 4) ≥50% of housing units were renter-occupied (AOR: 3.6 [2.1,6.2]). Receiver operator characteristic (ROC) curves demonstrated no significant differences after applying the model in a second dataset. Conclusions. Several community characteristics predict risk for lead toxicity in children and may provide a useful approach to focus lead screening, especially in communities where public health resources are limited. The approach described here may also prove helpful in identifying factors within a community associated with other environmental public health hazards for children.

Factors influencing the selection of general internal medicine fellowship programs: A national survey

Although criteria are available to guide the selection of general internal medicine (GIM) fellowship programs, the factors actually used in this process are unclear. Using a survey of current GIM fellows, we determined that most received information from their residency advisors, and many viewed them as the most important source of fellowship information. Program location was the top selection factor for fellows, followed by research opportunities, availability of a mentor, and the reputation of the program. This information may be useful to both fellowship candidates as an additional selection guide and to program directors seeking to best structure and market their fellowships.

Using pretreatment quality of life perceptions to predict response to sumatriptan in migraineurs

Quality of life perceptions vary for individuals with similar medical conditions and reflect disease impact. When correlated with subsequent response to treatment, such data may contribute useful insights in understanding the determinants of therapeutic effectiveness in selected medical conditions.

Ending A Nurse Practitioner-Patient Relationship: Uncovering Patients' Perceptions

DATA SOURCES Seventy-nine patients assigned to the care of a nurse practitioner (NP) were interviewed to explore reactions to ending a yearlong therapeutic relationship at the conclusion of a clinical trial. Three researchers identified, reviewed and CONCLUSIONS Of the total 79 patients, 22 (28%) spontaneously discussed perceptions and feelings about the termination of their relationship with the NP, Qualitative analysis of their statements identified future concerns about continuity of care and emotional themes ranging from gratitude, regret, and anxiety to grief. IMPLICATIONS FOR PRACTICE Changes in health care coverage often result in abrupt termination of patient-provider relationships. The involuntary termination of a patient-provider relationship may have significant negative consequences on patients with substantial influence on physical and emotional health. Awareness and anticipatory counseling may be useful in stemming these effects.

Factors Influencing the Selection of General Internal Medicine Fellowship Programs

Although criteria are available to guide the selection of general internal medicine (GIM) fellowship programs, the factors actually used in this process are unclear. Using a survey of current GIM fellows, we determined that most received information from their residency advisors, and many viewed them as the most important source of fellowship information. Program location was the top selection factor for fellows, followed by research opportunities, availability of a mentor, and the reputation of the program. This information may be useful to both fellowship candidates as an additional selection guide and to program directors seeking to best structure and market their fellowships.