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The CMG Voice

Diagnosis of Slipped Capital Femoral Epiphysis (SCFE) often delayed in children

Posted Monday, July 16, 2018 by Tyler Goldberg-Hoss

Slipped Capital Femoral Epiphysis (SCFE or “Skiffy”) is a condition where a teen or preteen’s hip is fractured at the growth plate. This results in the femur slipping off the neck of the epiphysis (the round end or ball which sits in the socket of the hip).

A recent study found that over 3/4s of patients under 16 with a SCFE diagnosis had multiple primary care contacts with symptomatology before the actual diagnosis is made. Researchers noted that front line providers like primary care doctors need to be on the lookout not only for children with hip pain, but also for knee pain, which can be caused by SCFE. In addition, overweight and obese adolescents are at greater risk, as are children living in lower socioeconomic situations.

Delays in diagnosing SCFE can be serious, including a loss of blood flow to the epiphysis (necessitating a hip replacement), or a permanent pinning of the femur in a suboptimal anatomic position to prevent further slipping.

You can find the full study here:

A nationwide cohort study of slipped capital femoral epiphysis

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Health care continues trying to solve Sepsis

Posted Monday, July 9, 2018 by Tyler Goldberg-Hoss

Sepsis is a killer: over 250,000 people a year die from the blood infection each year. It is the third leading cause of death, behind cancer and heart disease.

Sepsis occurs when an infection somewhere in the body finds its way into the blood stream. Once there, the immune system recognizes the infection. Unfortunately, in an effort to combat sepsis, the immune system itself can cause serious symptoms by overwhelming the body with inflammatory chemicals.

Without identifying and addressing the cause of the infection, AND treating the serious symptoms, sepsis can lead to death. Early intervention appears to be very important in preventing this from occurring.

Recently, the FDA approved a new test that will more quickly identify the bacteria causing the infection from a blood sample, rather than having to culture it for days in a lab dish. This not only promises to allow earlier antibiotic treatment but also the right antibiotic treatment.

Today, patients typically receive a broad-spectrum antibiotic because clinicians don’t know what bacteria are causing the infection. Hopefully, with an earlier identification system, patients can avoid the sometimes dangerous side effects of a broad spectrum antibiotic and be given the right drug for the right bug.

Another avenue for speeding up detection and treatment come from the clinical practice in hospitals. Changes such as replacing catheters earlier than usual to avoid infections in the first place, starting patients on antibiotics in 15 minutes instead of an hour through the use of a “sepsis alert” system, and creating an acronym – “TIME” – to help clinicians remember the signs of sepsis: Temperature (too high or too low); Infection; Mental decline (confusion/sleepiness); and Extreme illness (including severe pain/discomfort).

To what extent these additional efforts reduce deaths from sepsis remain to be seen. If they are successful, hopefully they will be quickly adopted nationally as the standard of care in treating this deadly disease.

You can read more on this important topic, and see a great short video on what sepsis is, here:

Sepsis is the third leading cause of death. Can a new blood test change that?

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Robots Versus Humans in Mitral Valve Surgery

Posted Friday, July 6, 2018 by Morgan Cartwright

Mitral valve repair is an operation designed to fix the valve on the left side of an individual’s heart. Some mitral valve diseases include mitral valve regurgitation (valves don’t close tightly, causing blood to leak backward) or mitral valve stenosis (the leaflets become thick or stiff, and may fuse together). To repair or replace mitral valves often requires surgery.

Mitral valve surgery can be either open-heart or minimally invasive (known as mini-thoracotomy). The mini-thoracotomy surgery involves small incisions in the chest to operate on the heart. New technology has provided a robot-assisted method, but human minimally invasive surgery is still more common.

A recent study between human and robot-assisted mini-thoracotomies showed that human operations resulted in fewer transfusions (5% vs. 15%), lower atrial fibrillation rates (18% vs. 26%), shorter surgery time (60 min vs. 83 min), and shorter average hospital stay (1 day shorter). However, the overall outcomes were very similar although the robotic arm had fewer discharges to a facility than a home (7% vs. 15%).

The study does note that patients who had robot-assisted surgery were generally lower risk, lower comorbidity burden, but higher degenerative mitral valve disease. While the researchers did attempt to baseline the imbalances, the study was not causative.

For Mitral Valve Surgery, Mini-Thoracotomy May Trump Robotic Approach

Minimally Invasive Cardiac Surgery

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Identifying the Appropriate Amount of VTE Prophylaxis in Hospitals

Posted Tuesday, July 3, 2018 by Morgan Cartwright

Venous thromboembolism (VTE) is a medical condition that occurs when a blood clot forms in the deep veins of the leg, groin or arm. It is also known as deep vein thrombosis (DVT). If the clot breaks off and travels in the circulation, it can block a blood vessel in the lungs, known as a pulmonary embolism (PE). It is treated through VTE prophylaxis, which refers to both pharmacological (blood thinners typically) and/or non-pharmacological (such as compression stockings) interventions to prevent VTE.

VTE can occur after major general surgery. However, the risk of VTE is different depending on the patient and procedure. PE has been shown to be one of the most common identifiable causes of death in hospitals in the United States. This creates a need for hospitals to recognize the level of risk and order the appropriate amount of VTE prophylaxis.

A recent study suggests that hospitals have been overusing VTE prophylaxis by giving too much to patients. Lower risk patients – those who are not recommended to get any prophylaxis – were giving blood thinners 57.1% of the time, and 77.9% were given at minimum a compression device such as compression stockings.

Higher risk patients have also been systematically given too much prophylaxis. 32.3% of such patients without a contraindication to blood thinning medication (a factor suggesting withholding) were given too much, and 26.9% for those with a contraindication to pharmacological treatments were given too much.

Hospitals have been overusing VTE prophylaxis to various degrees, which can be dangerous. The consequences of overuse include bleeding, impaired mobility, falls, discomfort, and other adverse effects.

Without properly identifying the appropriate amount of VTE prophylaxis, hospitals unnecessarily risk the safety of their patients.

Sources:

What is Venous Thromboembolism (VTE)?

Venous Thromboembolism Prophylaxis

Study: Hospitals Overuse VTE Prophylaxis

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From Hospital to Nursing Home to Hospital

Posted Friday, June 29, 2018 by Morgan Cartwright

The elderly end up in hospitals due to falls, disease, stroke, and illness. Often, patients are forced to nursing homes sooner than may be ideal for their health. Unfortunately, many of these homes fail to live up to provide the needed care. This includes not heeding or receiving accurate hospital/physician instructions and creating new problems. Many are potentially preventable conditions, including dehydration, infections, and medication errors.

As a result, the elderly patients often arrive to the nursing home from the hospital and are sent back shortly thereafter. Federal records show that one in five Medicare patients sent to a nursing home from the hospital are sent back to the hospital within 30 days. Further, out of the nation’s 15,630 nursing homes, one out of five send 25% or more of their patients back to the hospital. This is largely a result of financial coverage of these patients for both the hospitals and nursing homes, including variable rates according to hospital treatment time, higher nursing home insurance coverage upon return from hospital, and bed-hold insurance.

However, even the fifth of nursing homes with the lowest overall readmission rates were at about 17%. As a result, the government has stepped in to try to address this readmission problem. In 2013, the government began fining hospitals for high readmission rates to discourage premature discharges and encourage referrals to good nursing homes. Starting this October, the government will start giving nursing homes bonuses or penalties on their Medicare rehospitalization rates.

While the government’s readmission policies are just beginning to take form, there seems to be progress. The rate of potentially avoidable readmissions dropped to 10.8% in 2016 from 12.4% in 2011. However, there are some who worry the effect will be that bad nursing homes will stop sending patients to the hospital.

Medicare Eyes Hospital Readmissions from Nursing Homes

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