OSF St. Francis Hospital & Medical Group

BACKGROUND: Antibiotics are often prescribed for viral respiratory infections. The goal of our study was to determine the factors associated with antibiotic prescribing for acute respiratory infections in primary care. METHODS: We performed an observational study in 15 primary care practices in Michigan using patient and physician surveys distributed during visits for acute respiratory infections. We included patients 4 years or older presenting with symptoms of an acute respiratory infection (n=482). The main outcome measures were prescriptions of antibiotics, signs and symptoms associated with antibiotic prescribing, and clinician-reported reasons for prescribing an antibiotic. RESULTS: We found that patients who were older than 18 years, sick for more than 14 days, and seen in urgent care clinics were more likely to receive antibiotics. Patients expected antibiotics if they perceived that the drug had helped with similar symptoms in the past. In an adjusted model, the variables significantly associated with antibiotic prescribing were physical findings of sinus tenderness (odds ratio [OR]=20.0; 95% confidence interval [CI], 8.3-43.2), rales/rhonchi (OR=19.9; 95% CI, 9.2-43.2), discolored nasal discharge (OR=11.7; 95% CI, 4.3-31.7), and postnasal drainage (OR=3.1; 95% CI, 1.6-6.0). The presence of clear nasal discharge on examination was negatively associated (OR=0.3; 95% CI, 0.2-0.5). CONCLUSIONS: Several physical signs play an important role in clinicians' decisions to prescribe antibiotics for respiratory infections. This information will be useful in designing interventions to decrease inappropriate antibiotic prescribing for upper respiratory infections.

A 5-year-old boy was evaluated for a left retrotympanic mass found at otoscopy. Subsequent petrous bone CT and MR angiographic examinations demonstrated bilateral aberrant internal carotid, bilateral stapedial artery persistence, and bilateral duplicated internal carotid arteries. Imaging findings and their clinical relevance are discussed. A second case of unilateral aberrant internal carotid artery with a persistent stapedial artery is included for comparison.

Abstract The goal of this project was to evaluate an innovative educational program for women with type 2 diabetes facilitated by trained lay health advisors from the local university extension service. The program focused on adherence to behaviors recommended to achieve optimal blood glucose control. We evaluated whether primary care physicians would refer to this program, whether the program would reach diabetic women in rural areas, and whether the program improved health behaviors and glycemic control. Women over 40 with type 2 diabetes were recruited through their primary care physician's offices. Eligible participants were randomly assigned to intervention (program) or control (usual care) groups. The six-session educational program focused on encouraging behavior change through instructor and group support, learning specific behavior change skills, and developing a confident attitude about self-management of diabetes. Physicians supported referral to the program, and the utilization of a lay health advisor for delivery of the program in rural areas was feasible. At 6-month follow-up the mean change in hemoglobin A1c and body mass index did not differ significantly between the intervention (n=67) and control (n=65) groups. However, participants felt better about their ability to control their diabetes and demonstrated an improvement in behaviors related to control.

Heart failure is a common, progressive, complex clinical syndrome with high morbidity and mortality. Coronary artery disease is its most common cause. The evaluation of symptomatic patients with suspected heart failure is directed at confirming the diagnosis, determining the cause, identifying concomitant illnesses, establishing the severity of heart failure, and guiding therapy. The initial evaluation should include a focused history and physical examination, a chest radiograph, and an electrocardiogram. The presence of heart failure can be confirmed by an echocardiogram. Heart failure is highly unlikely in the absence of dyspnea and an abnormal chest radiograph or electrocardiogram. Radionuclide angiography or contrast cineangiography may be necessary when clinical suspicion for heart failure is high and the echocardiogram is equivocal. Patients with confirmed heart failure should undergo additional testing, including a more detailed history and physical examination; a complete blood count; blood glucose measurement; liver function tests; serum electrolyte, blood urea nitrogen, and creatinine measurements; lipid panel; urinalysis; and thyroid-stimulating hormone level. A serum ferritin level, human immunodeficiency virus test, antinuclear antibody assays, rheumatoid factor test, or metanephrine measurements may be required in selected patients. Patients with coronary artery disease, hypertension, diabetes mellitus, exposure to cardiotoxic drugs, alcohol abuse, or a family history of cardiomyopathy are at high risk for heart failure and may benefit from routine screening.

Hypertension is arbitrarily defined as diastolic blood pressure (DBP) of 90 mm Hg or higher, systolic blood pressure (SBP) of 140 mm Hg or higher, or both, on 3 separate occasions. Essential hypertension is hypertension without an identifiable cause. Essential hypertension, also known as primary or idiopathic hypertension, accounts for at least 95% of all cases of hypertension. According to the third National Health and Nutrition Examination Survey (NHANES III), approximately 60% of the 50 million Americans with hypertension are at increased risk for cardiovascular disease resulting from uncontrolled hypertension. This is because only 53% of hypertensive patients are being treated and only 24% have their hypertension under control. Physicians must play an active role in identifying and treating hypertension. In an earlier Applied Evidence article, an approach to the diagnosis of hypertension was presented. This article reviews the treatment of essential hypertension in adults and the prognosis of untreated hypertension. Risk stratification, alternative therapies, lifestyle modification, drug therapy, and prognosis will each be reviewed sequentially.

Background and Aims: In the REALM (Randomized, Observational Study of Entecavir to Assess Long-Term Outcomes Associated with Nucleoside/Nucleotide Monotherapy for Patients with Chronic HBV Infection) study, 12,378 patients with chronic hepatitis B virus (HBV) infection received up to 10 years of randomized therapy with entecavir or another HBV nucleos(t)ide analogue. Monitored clinical outcome events (COEs) included malignant neoplasms, HBV disease progression events, and deaths. An external event adjudication committee (EAC) was convened to provide real-time review of reported COEs to optimize data quality, and minimize potential adverse effects of the large cohort, interdisciplinary outcome assessments, geographic scope, and long duration. Methods: The EAC comprised an international group of hepatologists and oncologists with expertise in diagnosis of targeted COEs. The EAC reviewed and adjudicated COEs according to prospectively defined diagnostic criteria captured in the EAC charter. Operational processes, including data collection and query procedures, were implemented to optimize efficiency of data recovery to maximize capture of adjudicated COEs, the primary study outcome measure. Results: A total of 1724 COEs were reported and 1465 of these events were adjudicated by the EAC as reported by the investigators (85.0% overall concordance). Concordance by COE type varied: deaths, 99.6%; hepatocellular carcinoma (HCC), 83.3%; non-HCC malignancies, 88.0%; non-HCC HBV disease progression, 68.2%. Reasons for lack of concordance were most commonly lack of adequate supporting data to support an adjudicated diagnosis or evidence that the event pre-dated the study. Conclusions: The REALM EAC performed a critical role in ensuring data quality and consistency; EAC performance was facilitated by well-defined diagnostic criteria, effective data capture, and efficient operational processes.

Nurses as healthcare professionals are in key positions to identify trafficked persons. Assessment of nurse knowledge shows the benefit of using asynchronous human trafficking education as a means for learning. Recommendations from this study for professional development educators include garnishing nurse executive support and use of case-study, evidence-based approaches. Support for state-mandated human trafficking education requirements for initial and ongoing licensure of nurses is necessary as human trafficking knowledge may decrease over time.

BACKGROUND: Michigan is facing a Medicaid budget shortfall. Evidence suggests that the underlying factors causing reliance on Medicaid and cost of treatment to increase are getting worse. A tax on Michigan physicians has been proposed by legislators to meet the budget demands of Michigan's Medicaid program. QUESTIONS/PURPOSES: This paper looks at the legal basis of such a tax, studies the successes and failures of other states that have implemented similar taxes, and attempts to assess the effect this tax would have on Michigan doctors and patients. CONCLUSION: With current Medicaid rules, such a tax would increase federal matching funds and potentially reimbursement rates. However, the cost of a tax on physicians would not be born equally, and there are no guarantees that the revenue would provide a funding solution.

To the Editor, I thank Dr. Yu for his comments on my paper [1]. Dr. Yu correctly reiterates some of the reasons why aging surgeons should consider retirement. These reasons include time since completion of education, experience, physical and cognitive decline, and the need for assurance of competence [1]. In addition, Dr. Yu adds two conflicting considerations that may be almost unique to China. The first is crimes and threats against health professionals. The second is the traditional Chinese cultural preference for older health professionals. I have been to Shanghai several times and I have conversed with many Chinese surgeons, mostly orthopaedic surgeons. I have heard their stories of surgeons who, unfortunately, had a bad surgical result, and were then threatened, beaten, and even murdered. Such occurrences might make me want to retire early. I learned of another wedge driven between Chinese orthopaedic surgeons and their patients. In most cases in China, the orthopaedic surgeon actually sells the implants to the patients. We all know how expensive those implants can be. I was told that in that setting, the patient may feel that the surgeon is profiteering. In the United States, in most cases, the hospital sells the implants to the insurance carrier. The patient does not pay personally for the implants, the patient does not think that the surgeon is the implant supplier, and the patient does not believe that the surgeon is profiteering. In China, third-party medical insurance is not common. Self-pay, including self-pay to the surgeon for the orthopaedic implants, is the common practice, and this acts to drive a wedge between the surgeon and the patient. On the other hand, the traditional Chinese veneration of age and wisdom might make a surgeon want to retire later. In fact, I retired on December 31, 2018 at 1:00 PM EST. I felt that I had to take my own advice from my 2009 paper [1] and retire before I began hurting patients due to a loss of my skills. Otherwise I would have become a hypocrite. I think I succeeded; the results of my last operations were as good as ever.