Facility fees added to patient bills have some crying foul

Elliott VS – The news that the Cleveland Clinic started billing patients facility fees for visiting physicians at some outpatient offices as of March 1 stirred up shock waves. At a time when health care costs are increasing and many families are under economic strain, this practice may increase out–of–pocket costs that patients see only when they get the bill.

Type 2 diabetes in children and adolescents: Screening, diagnosis, and management

Von V et al. – The multifaceted approach to management of type 2 diabetes in children and adolescents is similar to that used in adults with the disease. First, patients and their families must acknowledge that lifestyle modifications such as eating a balanced diet, maintaining a healthy weight, and exercising regularly are essential. Health care providers should encourage all patients to adhere to these principles, but this is especially important for those patients at higher risk for developing this disease. Screening those children who are at increased risk for developing type 2 diabetes can lead to earlier recognition of its onset and intervention, which can slow down or even halt progression to a clinical diagnosis. Type 2 diabetes in the pediatric population is a growing problem. The subtle differences in risk factors, screening and diagnosis protocols, and management of younger patients with this disease present a challenge for clinicians. As further studies provide a better understanding of the effects of type 2 diabetes and its longterm treatment in pediatric patients, it is important for PAs to keep up to date with the evolving protocols for diagnosis and treatment.

Drug and herb interactions – Searching the web

Wong FWS et al. – There are misconceptions that most herbs are ‘natural’ and ‘safe’. It is not surprising, given this misconception of safety, that potentially up to billions of dollars are spent by patients on complementary medicines (CM). All herbs have actions that may interact with drugs patients may be taking. The risk of drug and herb interactions may be especially severe for the elderly, frail or those taking multiple medications for chronic diseases. There are many reports, papers and websites that discuss information on drug and herb interactions. This article looks at current internet resources that can assist GPs to answer patient questions about interactions between prescribed and complementary medicines. Many of the websites found in this study provided limited information and limited searchability. The authors found seven webistes out of 100 that met the authors’ selection criteria. A web portal, with risk categorisation of mild, moderate and severe for drug–herb interactions, can assist doctors in clinical decision making. Maximum benefits could be obtained by working corroboratively with the Therapeutic Goods Administration.

Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease: A Scientific Statement from the AHA and AAP Pediatrics

Mahle WT et al. – CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on–site pediatric cardiovascular services incurs very low cost and risk of harm.

Dronedarone for atrial fibrillation: a new therapeutic agent

Patel PD et al. – Atrial fibrillation is the most common of the serious cardiac rhythm disturbances and is responsible for substantial morbidity and mortality. Dronedarone is a multichannel blocker and, like amiodarone, possesses both a rhythm and a rate control property in atrial fibrillation.

What’s new in prostate cancer screening and prevention?

Klein EA – Prostate cancer is extremely common but causes death in only a minority of men in whom it develops, facts that raise issues regarding screening and treatment morbidity. Two large trials of screening with prostate–specific antigen (PSA) measurements came to seemingly opposite conclusions. Furthermore, a large trial of selenium and vitamin E found that these agents have no value as preventive agents.

* An elevated PSA level lacks specificity as a test for prostate cancer, but PSA measurements can be useful in combination with clinical risk factors or to measure changes in PSA over time.
* Rather than relying on PSA screening alone, we should stratify the risk of prostate cancer on the basis of race, age, PSA level, family history, findings on digital rectal examination, whether the patient has ever undergone a prostate biopsy, and whether the patient is taking finasteride (Proscar). A simple online tool is available to do this.
* There is no PSA level below which the risk of cancer is zero.
* Finasteride has been found in a randomized trial to decrease the risk of prostate cancer, but vitamin E and selenium supplements have failed to show a benefit.
* In spite of some recent studies, or perhaps because of them, we still are unsure about how best to screen for and prevent prostate cancer. Two large trials of screening with prostate–specific antigen (PSA) measurements came to seemingly opposite conclusions.1,2 Furthermore, a large trial of selenium and vitamin E found that these agents have no value as preventive agents.

How menopause affects oral health, and what we can do about it

Buencamino MCA et al. – After menopause, women become more susceptible to periodontal disease. The authors believe the problem is due in large part to estrogen deficiency with resulting bone loss and inflammatory processes. Osteoporosis and periodontal disease are best diagnosed early so that treatment can be started sooner and fractures and tooth loss can be prevented. This article reviews the published studies of the association between menopause and periodontal disease, specifically, the effects of hormonal changes, osteoporosis, and bisphosphonate use on the periodontal status of postmenopausal women. The authors will highlight the interrelationship of dental health and postmenopausal health and underscore the need for cross–communication and patient referral between physicians and dentists.

Current trends in the treatment of hepatic encephalopathy

Al Sibae MR et al. – More recent data supports the benefits of rifaximin used solely and as an additional agent with fewer side effects than neomycin or metronidazole. Newer therapies being investigated in humans with clinical promise include nitazoxanide, the molecular adsorbent recirculating system (MARS), L–ornithine phenylacetate, sodium benzoate, and/or sodium phenylacetate and Kremezin.

Ventilator Associated Pneumonia – an Overview

Wagh H et al. – Ventilator Associated Pneumonia (VAP) is pneumonia occurring in a patient within 48 hours or more after intubation with an endotracheal tube or tracheostomy tube and which was not present before. It is also the most common and fatal infection of ICU. VAP increases length of ICU stay by 28% and each incidence of VAP is estimated to generate an increased cost of £6000– £22000. Eliminating or reducing the unnecessary use of antibiotics should be the primary goal in reducing antibiotic–resistant nosocomial infections.

Glucose Control and Cardiovascular Disease in Type 2 Diabetes

Kelly TN et al. – This review of 5 large trials found that, compared with conventional control, intensive glucose control reduced the risk for some cardiovascular disease (such as nonfatal myocardial infarction), did not reduce the risk for cardiovascular death or all–cause mortality, and increased the risk for severe hypoglycemia. Health care providers should focus their efforts on combining elements of lifestyle modification, glucose control that minimizes hypoglycemia, blood pressure reduction, and lipid lowering to optimally curtail the risk for CVD in patients with type 2 diabetes.

Effects of Pay for Performance on the Quality of Primary Care in England

Campbell SM et al. – Against a background of increases in the quality of care before the pay–for–performance scheme was introduced, the scheme accelerated improvements in quality for two of three chronic conditions in the short term. However, once targets were reached, the improvement in the quality of care for patients with these conditions slowed, and the quality of care declined for two conditions that had not been linked to incentives. Continuity of care was reduced after the introduction of the scheme.

A combined role of calcium channel blockers and angiotensin receptor blockers in stroke prevention

Wang JG – Dihydropyridine calcium channel blockers, such as amlodipine, and angiotensin receptor blockers, such as valsartan, represent the two antihypertensive drug classes with the strongest supportive data for the prevention of stroke. Therefore, when combination therapy is required, a combination of these two antihypertensive classes represents a logical approach.

Ziprasidone vs clozapine in schizophrenia patients refractory to multiple antipsychotic treatments: The MOZART study

Sacchetti E et al. – This trial indicates that both ziprasidone and clozapine, having comparable efficacy coupled with satisfactory general safety and tolerability, may be regarded as valuable options for the short–term treatment of difficult–to–treat schizophrenia patients with a history of multiple resistance and/or intolerance to antipsychotics. The more favorable metabolic profile of ziprasidone may represent an added value that could guide clinicians, at least in the presence of patients at high risk for metabolic disorders.

Vinegar

Sego S – A vinegar cocktail each morning may not sound appealing, but growing evidence indicates it has impressive qualities and might make a big difference in the current obesity and diabetes epidemics. Although not appropriate for every patient, the idea certainly bears consideration.

Use of dexamethasone and prednisone in acute asthma exacerbations in pediatric patients
Canadian Family Physician, 07/15/09

Shefrin AE et al. – Short courses of systemic corticosteroids are indicated in the treatment of moderate and severe asthma exacerbations as well as mild exacerbations unresponsive to increased doses of beta-agonist therapy and inhaled corticosteroids. Prednisone (1 to 2 mg/kg daily for 5 days) and dexamethasone (0.3 to 0.6 mg/kg daily for 1 to 5 days) are appropriate choices, with some evidence suggesting that dexamethasone might be better tolerated and requires shorter duration of therapy. Side effects of short corticosteroid treatments appear minimal and clinically insignificant. More studies are needed to ascertain the optimal dose, duration, and choice of systemic steroids, especially in the ambulatory care setting.

Osteoarthritis: Managing without surgery
APCToday, 07/16/09

Crosby J – Osteoarthritis (OA) is a common, almost expected, part of getting old. Some patients require no treatment or have symptoms that are easily controlled with over-the-counter analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) and lifestyle modifications. Others are so debilitated that surgery is the only way to go. Where does that leave elderly patients in between—those who don’t make good surgical candidates or find little relief from basic interventions and want to “try everything” before surgery? The best way to answer this question is to utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) format, a helpful mnemonic for an objective way to evaluate drugs or medical therapies. The recommendations, strength of recommendation (SOR) ratings, and summaries that follow are presented in this format, and draw upon recent reviews, focused studies, and scholarly analysis provided by the Osteoarthritis Research Society International (OARSI). The interventions are divided into 3 categories: over-the-counter remedies, nonpharmacologic interventions, injections/prescription drugs.

The CATIE and CUtLASS Studies in Schizophrenia: Results and Implications for Clinicians.
CNS Drugs, 07/16/09

Naber D et al. – CATIE and CUtLASS suggest that SGAs do not live up to all the previous expectations. However, even if most of these advantages are debatable, the lower risk of tardive dyskinesia and the better subjective effects should be strong enough reasons to favour these drugs.
Methods

* CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness)
* CUtLASS (Cost Utility of the Latest Antipsychotic drugs in Schizophrenia Study).
* 1493 patients participated in CATIE, an 18-month, double-blind trial comparing the SGAs olanzapine, quetiapine, risperidone and ziprasidone with the FGA perphenazine.
* If efficacy or tolerability was insufficient, patients were re-randomized to a medication other than the one they previously received.
* In CUtLASS, a 12-month open-label trial, 277 patients were randomized to receive an FGA or a SGA.

Results

* Improvement of psychopathology and of quality of life was only moderate.
* Overall, 74% of patients discontinued study medication before 18 months, and the median time to discontinuation was 4.6 months. from olanzapine (time to discontinuation 9.2 months), the other SGAs did not differ from each other or from perphenazine.

Glucose Control and Cardiovascular Disease in Type 2 Diabetes
Annals of Internal Medicine, 07/21/09

Kelly TN et al. – This review of 5 large trials found that, compared with conventional control, intensive glucose control reduced the risk for some cardiovascular disease (such as nonfatal myocardial infarction), did not reduce the risk for cardiovascular death or all–cause mortality, and increased the risk for severe hypoglycemia. Health care providers should focus their efforts on combining elements of lifestyle modification, glucose control that minimizes hypoglycemia, blood pressure reduction, and lipid lowering to optimally curtail the risk for CVD in patients with type 2 diabetes.