northeast florida medicine - summer 2010 - resident research
DESCRIPTION
Our Summer 2010 issue on Resident Research was guest edited by DCMS member Dr. J. Bracken Burns Jr. It offers CME credit on Managing Physician Stress. CME is available on our website: http://bit.ly/DCMSCMETRANSCRIPT
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www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 3
Features9 LikeTallPines,ResidentsReachforHighGoals
11 ResidentScholarlyActivityFocusesonthePursuitofKnowledge J.BrackenBurns,Jr.,DO,GuestEditor
12 AbstractCategory1-Prospective
17 AbstractCategory2-Retrospective
21 AbstractCategory3-CaseStudy27 FromaResident’sPerspective SpecialArticles35 HighRiskStressinHighRiskCareers:ManagingPhysicianStress(CME)KamelaK.Scott,PhDandDavidJ.Chesire,PhD
44 SpecialCaseStudy-IsEarlyTPNinHyperemesisGravidarumWorththeRisk? KarishmaRamsubeik,MD,etal
45 UpdateonHaitiReliefEfforts
VOLUME 61, NUMBER 2ResidentResearchSummer2010
EDITOR IN CHIEFJoanL.Huffman,MD
MANAGING EDITORLeoraLegacy
ASSOCIATE EDITORSRaedAssar,MDHernanChang,MDKathyHarris(Alliance)JoanHarmon(Alliance)SunilJoshi,MDJamesJoyce,MDNeelKarnani,MDSenthilMeenrajan,MDTimothySternberg,MD
Executive Vice PresidentJayW.Millson
DCMS FOUNDATION BOARD OF DIRECTORSBenjaminMoore,MD,PresidentToddL.Sack,MD,VicePresidentKayM.Mitchell,MD,SecretaryJ.EugeneGlenn,MD,TreasurerGuyI.Benrubi,MD,ImmediatePastPresidentMohamedH.Antar,MDRaedAssar,MDAshleyBoothNorse,MDJ.BrackenBurns,DOMalcolmT.Foster,Jr.,MDJeffreyL.Goldhagen,MDJeffreyM.Harris,MDMarkL.Hudak,MDJoanL.Huffman,MDSunilN.Joshi,MDDanielKantor,MDNeelG.Karnani,MDJohnW.KilkennyIII,MDSherryA.King,MDHarryM.Koslowski,MDEliN.Lerner,MDR.StephenLucie,MDJesseP.McRae,MDSenthilR.Meenrajan,MDNathanP.Newman,MDMobeenH.Rathore,MDRonaldJ.Stephens,MDJeffreyH.Wachholz,MDAnneH.Waldron,MDDavidL.Wood,MD
Northeast Florida Medicine is pub-lished by the DCMS Foundation,Jacksonville,Florida,onbehalfoftheCountyMedicalSocietiesofDuval,Clay,Nassau,Putnam,andSt.Johns.Except for official announcementsfromtheCountyMedicalSocieties,nomaterialoradvertisementspublishedinNEFMaretobeseenasrepresent-ingthepolicyorviewsoftheDCMSFoundationoritscolleagueMedicalSocieties.AlladvertisingissubjecttoacceptancebytheEditorinChief.Ad-dresscorrespondenceandadvertisingto:555BishopgateLane,Jacksonville,FL32204(904-355-6561),oremail:[email protected].
COVER: Photograph of pine trees in Guana River State Park, Ponte Vedra Beach, FL by a resident, Dr. Adithya Suresh.
Inside this issue of
Departments4 FromtheEditor’sDesk5 FromthePresident’sDesk8 DCMSHistoryBook34 Ole’TimeReunionPhotos
Northeast Florida Medicine
4 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
From the Editor’s Desk
Solidarity Needed to Improve Patient CareOnMarch23,2010,PresidentBarackObamasignedintolawthePatientProtectionandAffordableCareAct(PPACA-H.R.
3590).Thenewlaw,themostsweepinghealthcarereformsince1965,willimpactpatients,employers,insurancecompa-nies,healthcarefacilitiesandproviders.MuchhueandcryaccompaniedthebillonitswaybackandforththroughtheHouseandSenate,andcontinuestocarryaburdenofcontroversy;however,therearemanypositive,long-neededchangesasaresultofitspassage.
Physicianswillfeeltheimpactofthebillinapersonalwaythatmanyotherprofessionalsmaynotexperience.ButbeforeyoubegintowaveyourTeaPartyflag,CoffeePartybanner,ordragoutyourDemocrat,RepublicanorIndependentpodium, let’sexaminethepositivebeforewethrowtheinfantlegislationoutwiththebathwaterofrejection.Wecanthenintelligentlytalkabouthowwecanbandtogetherasphysicianstomaximizeourimpactonimprovingthecurrentlaw.
OftheAmericanMedicalAssociation’s(AMA)sevenessentialelements,fivewerefulfilled:thefirst two, expandedhealth insurance coverage andwellness andprevention initiatives,willhelppatientswithimprovedaccess,aswellas,bothphysiciansandinstitutionswiththeoverwhelmingburdenofuncompensatedcare.Thethird,removalofpre-existingconditionslimitations,will aidpatientswithchronicdiseaseand/orcancerdiagnosesand the fourth,qualityimprovementincentives,willrewarddoctorsforprovidingexcellentevidencedbasedmedicalcare.Finally, thefifth, simplified insuranceclaimsprocessing,will reducecostsofbillingandcollections.
Severalseriousareasofconcernfordoctorsare:TortReform,theSustainableGrowthRate(SGR),IndependentPaymentAdvisoryBoard(IPAB)andPhysicianWorkforceExpansion.Physiciansneedtobeprotectedfromfrivolousandastronomicalsuitswhichcolortheirpracticewithdefensivemedicinethatinturnelevateshealthcarecost.TheSGRmustbeaddressedwithapermanentfixratherthananannualpush-back.TheAMAopposestheinstitutionof
theIPAB,anindependentcommissionthatcouldmandatepaymentcutsforproviders.Andfinally,withincreasedaccesstocare,morephysicianswillberequiredtotreatthelargernumberofpatients.
Whilemostdoctorsagree inprinciplethatreformwasneeded,manydisagreewiththestrategyandtacticsutilizedtoachievetheresultantproductandthechallengerequiredforimplementation.Inresponsetotheconcernsandvariedopinionsoflocaldoctors,theDCMSBoardofDirectorshasinitiatedabipartisanHealthSystemReform(HSR)TaskForce.AttherecentvisitofCecilB.Wilson,MD,President-ElectoftheAmericanMedicalAssociation,theAMA’sposi-tionwaselucidated;andattheMayBi-AnnualPhysicianTownHallmeetingmanyofourmembers’thoughtswereaired.Uponthisfoundation,theTaskForcecanmoveforwardtoproduceasummaryDCMSpositionstatementthatbridgesourdifferencesandleadstotheformulationofanon-polarizingactionplan.Welookforwardtoworkinginacollabora-tivemannerthatgivesvoicetoallsidesofthematterandaddressesareasofspecificconcerntoourprofession.PleasecontinuetocommunicateyourconcernsandideasregardingPPACAwithDCMSExecutiveVicePresidentJayMillsonatjmillson@dcmsonline.org.
Let’sworktogetherinacommonbonddedicatedtoimprovingpatientcareandshareourthoughtsinaunifiedvoiceaboutwhatsuccessofamendedhealthcarereformwouldlooklikeforbothpatientsandphysicians.Wehaveanopportu-nitytostrengthenthelawbyaddressingtheissuesthatarenotinourbestinterestsandbybecomingpartofthesolution,nottheproblem.
JoanL.Huffman,MD,FACSEditor-in-ChiefNortheast Florida Medicine
Update on Haiti Relief EffortsAn“UpdateonHaitiReliefEfforts”byDCMSmembersandJacksonvillemedicalgroupsbeginsonp.45ofthisissueand
continuesonpp.48&49.Dr.HuffmanmadeasecondtriptoHaitiApril9-17,andshereportsonthesituationinHaitiin“How’sHaiti”(p.45&p.48)
TheCrudemFoundationthatsupportstheSacredHeartHospitalinMilot,Haitineedsortho/scrubtechs,ORnurseswithorthopaedicexperience,orthoPAs,anesthesiologistsandphysicaltherapiststovolunteertheirservicesinHaiti.LearnmoreabouttheFoundationatwww.crudem.organdifinterestedinvolunteering,[email protected].(ThisisthehospitalwhereDr.JohnLovejoydonateshistimeandservices.Seepp.48-49)
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 5
From the President’s Desk
The Times They Are A-Changin’*AswemullovertherecentlyenactedlawthatmanyknowastheHealthSystemReformLegislation,itisapparentthat
ourresponsesfallacrossawidespectrum.Atoneendistheratherobstructionistviewthatisopposedtotheveryessenceoftheproductaswellastheprocessthatwasusedincraftingit.Attheotherextremeistheoverlyoptimisticviewthatourmedicalsystemwoesaresoontobesolved.Aswe’dexpect,thesediametricallyopposedextremesarethepurviewofthosewithpolitical‘axestogrind’.Whenqueriedobjectively,thesestiltedreviewsharborlittleconcernforusorourpatients.
Manyaspectsofpatientcarewillbechanged,thoughtheactualregulationsthatwillbedefinedfromthislegislationarestillbeingformulated.Thisispreciselythepointintime,whereweasorganizedphysicianscanhavethemostimpactonhowthislawwillultimatelyaffectourpatientsandourrelationshipswiththem.Wehaveseenthedifficultyof‘mixingitup’withtheprimaryplayersofthisrecentlyenactedlegislation:theindustriesofinsurance,drugs,hospitalsandmedical
devices.Wehaverecoiledatthesightofbackroomdealsandbemusedlyobservedlargepre-negotiationconcessionsresultingingenerousfavoritisminthefinishedproduct.
ThreeareasindireneedofrectificationaretheSGRfiasco,tortreformandphysicianshort-ages.I’dliketofocusonthelatter.Inpreviouscolumns,Ihaveoutlinedtheominousstatisticsfromourownstate,groundedinathought-provokingsurveybyourcolleaguesinPalmBeachCountylastyear.Lookingtothefirststatetoenactsignificanthealthsystemreformonitsown,Massachusetts,therearesimilarnumbersofconcern.AccordingtotheMassachusettsMedicalSociety,inthenextdecade,one-thirdofthestate’spracticingdoctorsenterretirementage,andonly13percentofthestate’spracticingphysiciansare35oryounger.
Primarycarespecialistsaretheveryfoundationuponwhichourentirehealthcaresystemrelies.Itisherewherethefocusisondiseasepreventionratherthantreatment.Inaddition,thisiswherepatientswithchronic,complexdiseasesaremanaged.Inmostareasofthiscountry,thisisalsowheresubstance-abuseandmental-healthproblemsareaddressed.Researchhasshownthatgeographicareaswithmoreprimary-carephysicianshavebetterhealthoutcomesatalowercost.
Thenumberofmedicalstudentsgoingintofamilymedicineresidencieshasdroppedover50%inthelastdecade.Duringthepastthreeyears,only15percentofU.S.medicalschoolgraduateschosecareersinprimarycare.Atthesametimethatthefederalgovernmentismandatingmedicalinsurancecoveragefortensofmillionsofourcitizenry,itisalsorestrictingthenumbersoftheverysameprimarycarephysiciansthatarerequiredfortheircare.Overthelastdecadetherehavebeendrasticcuts(55%inrecentyears)inthefundingoffederalgrantsforthetrainingoffamilypracticephysicians(Section747ofaprogramcalledTitleVII).
Thecomplexityofcaringfortheincreasingnumbersofaging‘babyboomers’,diminishingreimbursementratesinthefaceofproliferatingregulationsandtimeconsumingpaperwork,andeverspiralingstudentloandebtshaveonlyexacerbatedtheproblem.Onanannualbasis,ithasbeenestimatedthatphysiciansinprivatepracticespendthreeweeksoftheirtimeand$68,000worthofstaffingcostsinordertodealwiththeadministrativeconstraintsofthevariousthird-partypayersofhealthinsurance.Witheachpolicy’spermutations,itbecomesmoreandmoredifficultforaphysiciantodeviseacareplanthatwillcomplywithapatient’sparticularcoverage,e.g.,uniquedrugformularies.
Istherestof‘thehouseofmedicine’readytoconformandchangetotheconceptsthatarerequiredtoamelioratethisconundrum?Althoughhigherremunerationforprimarycareisrequired,therehasalreadybeenunderstandableresistancefromspecialiststotakepaycutsaspartofanyzerosumformulation.Butpaymentisonlypartoftherevampingthatisneeded.Primarycarephysicianswillneedlargerteamsof‘midlevelproviders’toassistthemincaringfortheseburgeon-ingpopulationsofpatientsintheir‘medicalhomes’.Theseentitieswillneedtobeequippedwithsystemssuchastrulyfunctionalelectronicmedicalrecordsthatwillhelpthemmanagethefloodofinformationthatthey’realreadyconfrontedwithonadailybasis.
Inordertoprovidethehighestqualitycareforourpatients,howarewetoremedythisimpendingcrisisofbeingwoe-fullyshort-handedinprimarycare?AfteryearsofsteadfastlyopposinganynumberofScopeofPracticeintrusionsinourLegislature,arewewillingorabletoadapttothesentimentthatlargeportionsofprimarycarecanbedeliveredbynon-physicianteammembersinafarmoreexpandedfashionthanwepresentlyhave,albeitoverseenbythephysicianteamleader?Yourrepresentatives,medicalandlegislative,needtoknowyouropinionsbeforethedecisionsaremadeforyou.
(*Song title by Robert Allen Zimmerman)
John W. Kilkenny III, MD2010 DCMS President
6 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
Brooks Rehabilitation has been a leading provider of physical rehabilitation services in Northeast and Central Florida for more than 35 years. With expertise in treating stroke, spinal cord injury, hip fracture/orthopedics, pediatrics, and brain injury, Brooks offers a full continuum of services to support patients, including:
• One of the largest inpatient rehabilitation hospitals in the Southeast• An extensive network of more than 25 outpatient centers• An established home health services division and• A cutting-edge research facility currently conducting over 20 clinical trials.
With an extensive array of preventive, educational, and community-based services such as adaptive sports, Brooks is deeply committed to improving the health of the community, especially for those living with a disability.
Offering the most comprehensive care possible so our patients can achieve the most complete recovery possible.
Rehabilitation hospital • home health CaRe • outpatient theRapy • sub-aCute CaRe
BrooksRehab.org
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 7
Isn’t It Time You Called The Med Mal Experts?
Jacksonville Office: 904.215.7277www.dannagracey.com
Delray Beach • Jacksonville • Orlando • Miami
Danna-Gracey is an independent insurance
agency with a statewide team of specialists
dedicated solely to insurance coverage
placement for Florida’s doctors.
With offices located throughout Florida,
Danna-Gracey works on behalf of physicians –
well beyond managing their insurance policy.
By speaking, writing and educating, we hope
to effect positive change in the healthcare
industry. We make it our practice to genuinely
care about yours. For more information, please
contact Stephanie Johnson at 904.215.7277 or
Ask us about our Workers’ Comp dividend program for Duval County Medical Society members!
8 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
Recognize These Physicians?
Abel S. Baldwin, MD had a town named after him because of his reputation as a physician and community leader. E. Thomas Sellers, MD had the medical society lecture hall named after him (Sellers’ Auditorium - first “permanent home” of the DCMS) because of his influential leadership. Emmet F. Ferguson, Jr., MD had many young surgeons who revered his name because he mentored them and was a model of a “good man and good physician.”
The impact of these physicians (and many others) on the DCMS and surrounding area will be forgotten and lost unless the DCMS updates its published history. So DCMS is chronicling 157 years of medicine in a coffee table book. Two thirds of the book will include significant events that left a lasting impression on Northeast Florida and the local medical community. The remainder of the book will feature physician and practice histories and profiles, purchased by physicians, families, and groups who want to chronicle their footprint in Jacksonville’s storied history.
Be a Part of History!Contact Mr. John Compton, Publisher
at 904-355-6561 x110 [email protected]
If you do, it is because these DCMS Past Presidents helped shape medicine in Duval County.
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 9
Like Tall Pines, Residents Reach for High GoalsAdithyaSuresh,MD,isthephotographerwhosnappedthisissue’scovershotofthetallpinetreesatGuanaRiverStatePark
isinSt.JohnsCountyalongAIAbetweentheFloridacitiesofSt.AugustineandJacksonville.Thesepinesreachtowardtheskyjustasresidentsstretchthemselvesmentally,emotionallyandphysicallytoreachhighprofessionalgoalstheyhavesetforthemselvesandtheirmedicalcareers.
Dr.Suresh,aPGY-3residentintheDepartmentofSurgeryattheUniversityofFlorida,CollegeofMedicineinJacksonville,hasacareergoalofbeingasurgeonandpursuingfurthertraininginminimallyinvasivesurgery.
Alongwiththisambition,heenjoysphotographybecauseashesays,“Agreatpictureisonethatcapturesthemoodoftheset-tingandcreatesmemoriesthatcanberevisitedmanytimesover.Forexample,thecoverphotographwastakeninGuanaRiverStateParkinPonteVedraBeach,Florida,oneofmyfavoriteplacestovisit.Photographyalsogivesmeachancetoexplorethecreativesideofmyself,andthishasprovedtobeaveryenjoyableoutlet.”
Hetookthecoverphotointhespringof2008.Herecalls,“Iwasstill‘new’toJacksonville,andIwouldspendmyfreetimeexploringthecityanditssurroundingparksandnaturepreserves,mycamerainhand.Thisparticularlocationsoonbecameoneofmyfavoriteplacestovisit,andIreturntoitateveryopportunityIhave.”
Besidesaninterestinmedicine,photographyhasbeenapassionforDr.Sureshsincehishighschoolyears.Hesaid,“Igotinterestedat the time thefirstconsumerdigital camerasbecameavailable.What fascinatedme themostwasbeingable toinstantlyviewmy‘results.’WhenIwasincollegeIwasthechiefphotographerofthecollegenewspaper.Itwasagreatexperi-encethatnotonlyallowedmetocontinuetotakepicturesonaprofessionallevelbutalsoindulgemyhobbyoftakingpictureswheneverpossible.”
Inadditiontotalltrees,Dr.Sureshlikestophotographlandscapes,flora,fauna,buildingsand“sometimesevenpeople”.Withallofthesesubjects,hewantsto“capturetheessence”ofplaceshevisits,suchasthephotographofhiminKinderdijk,NetherlandsinOctober2009.(see below) Hesaid,“Ihavealwayshadaninterestintravelingaroundtheworld,andIhavebeenfortunateenoughtovisitmanyexoticlocations.Thisnaturallyfueledmydesiretocapturethebeautyofthoselocations.”
AsforGuanaRiverStatePark,heremembers,“Lookingupandseeingthetipsofthetalltreesandthescuddingcloudsabovethembroughtasenseofserenitythatwasrefreshinglydifferentfromthefreneticpaceatthehospitalandtherigorofatypicalworkday.EverytimeIamthereIexperienceabsolutepeaceandsolitude.”
10 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
Medical residents, students, and professionals
can increase the healthof many patients through the
Ask, Advise and Refer process.
The National Cancer Institute projects that if providers assisted even 10% of their tobacco-using patients in quitting, the number of tobacco users in the U.S. would drop by 2 million people annually.
Northeast Florida AHEC offers FREE training to help providers effectivelyAsk, Advise, and Refer patients to appropriate cessation programs.
Search for upcoming trainingsthroughout Florida at:www.ahecregistration.org
Northeast Florida AHEC
CONTACT:NE Florida AHEC Tobacco Training1107 Myra St., Suite 250Jacksonville, FL 32204Ph: (904) 482-0189 • Fax: (904) 482-0196www.northfloridaahec.org www.quitsmokingnowfirstcoast.com
NORTHEAST FLORIDA AHEC OFFERS A VARIETY OFTRAINING OPPORTUNITIES for current and future healthcare professionals to help increase your knowledge oftobacco-related issues, and develop your tobacco cessationcounseling skills. Topics such as Brief Intervention Training,Motivational Interviewing, NRT Options and others can expandyour expertise as well as provide reimbursement opportunities.Most trainings offer CE/CME's, and may be offered through:• On-site workshops• Conference presentations• Regional trainings• Online trainings
DCMS_QSN/AHEC Ad:DCMS_AskAdviseReferAd 5/13/10 7:58 AM Page 1
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 11
This Issue’s Focus: Resident Research
Resident Scholarly Activity Focuses on the Pursuit of Knowledge
Socratessaid“Theonlygoodisknowledgeandtheonlyevilisignorance.”InthisissueofNortheast Florida Medi-cine,werecognizethepursuitofknowledgeofindividualsinpost-graduatetraining.Inparticular,werecognizethepursuitofknowledgeintheformofscholarlyactivity.
Whatisscholarlyactivity?ConradWeiserinhis1996article“TheValueSystemofaUniversity–RethinkingScholarship”definesscholarshipas“creativeintellectualworkthisisvalidatedbypeersandcommunicated.”1Hefurtherdescribesfourformsofscholarship:discoveryofnewknowledge;developmentofnewtechnologies,methods,
materials,oruses;integrationofknowledgeleadingtonewunderstanding;andartistrythatcreatesnewinsightsandinterpretations.
In this issue, we feature articles that represent three distinct categories of residentscholarlyactivity:prospectivestudies,retrospectivestudies,andcasestudies.Eacharticlemakesitsowncontributiontothebodyofscholarlyactivityinexistence.Thisyearwearealsohighlightingresidentcommentariesonpublichealthin“FromaResident’sPerspec-tive.”Thefactthattheseworkswerecreatedwithinourregionisasourceofprideandatestamenttotheregionaldedicationtotheeducationalprocess.
Iamsuremanyoftheauthorsinthefollowingpageswouldagreeitischallengingtofindtimetodedicateandcompletescholarlyactivity.Scholarlyactivityisalsochalleng-ingtomanypotentialauthorsbecauseitisoutsidethenormalrealmofpatientcare,butitcertainlyhasitsplaceinboththeartandscienceofmedicine.Scholarlyactivitycan
beparticularlychallengingasastudent,resident,orfellowfacingpotentialobstaclessuchasscheduleissues,lackofsupport,andinexperienceintheprocessofcreatingsuchwork.Therefore,Icommendboththeauthorswhoarestillintrainingandtheirmentorswhohelpedthemproducethescholarlyactivityinthisissue.
Ithasbeenapleasure,anhonor,andachallengetoserveastheGuestEditorforthe2010ResidentScholarlyActivityissueofNortheast Florida Medicine.Reference:1Weiser,ConradJ.,“TheValueSystemofaUniversity–RethinkingScholarship.”1996.http://www.adec.edu/clemson/papers/weiserhtml.AccessedApril30,2010.
J. Bracken Burns Jr., DOAssistant Professor of Surgery,Division of Acute Care Surgery,University of Florida, Collegeof Medicine, Jacksonville, FL
J.BrackenBurns,DO,receivedthe2009PhilipH.GilbertYoungPhysicianLeadershipAwardatthe2010DCMSAnnualMeeting.Thisaward,createdtohonorthememoryandserviceofPhilipH.GilbertwhoservedasExecutiveVicePresidentoftheDCMSfrom1984untilhisdeathin2004,recognizesYoungPhysicianswithleadershiptraitsthatMr.Gilbertwouldhaveadmired.Candidatesmustmeetthefollowingeligibilitycriteria:A“YoungPhysician”fromNortheastFlorida,under40yearsofageorwithinthefirsteightyearsofprofessionalpracticeafterresidencyandfellowshiptraining,asdefinedbytheAMA;activeintheDCMSorotherorganizedmedicineservice;activeincivicservice;medicalstaff(orsimilar)leadershipexperience;andbeastrongadvocateformedicine.
(Left) Dr. Burns with Dr. John Kilkenny III, DCMS President. (Center) A special pencil sketch of Philip Gilbert. (Right) Dr. Burns receiving his award from Dr. R. Stephen Lucie, DCMS Immediate-Past President.
Pencil sketch by Alexander Braddock
12 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
High Recruitment Efficiency Associated with a Study Evaluating Health Literacy in Patients Hospitalized with Acute Ischemic Stroke
Kalina Sanders, MD1; LorettaSchnepel,ARNP1;KatryneLukens-Bull,MS2;NaderAntonios,MD1;DavidWood,MD3andScottSilliman,MD1
UniversityofFloridaCollegeofMedicine,JacksonvilleCampus,DepartmentsofNeurology1,OfficeofResearchAffairs2,andPediatrics3
Abstract Category 1 - Prospective
Background:Strokeisacommonandsignificantcauseofmorbidityandmortality.Approximately780,000casesofstrokearereportedintheU.S.eachyear,ofwhich180,000representstrokerecurrence.Healthliteracyisthepatient’sabilitytoobtain,process,andunderstandhealthinformationandservices.ImprovinghealthliteracyinstrokesurvivorsmayultimatelyreducethenumberofrecurrentstrokesintheU.S.viabetteradherencetomedicaltherapiesandhealthybehaviors.Theprevalenceofpoor,marginal,andgoodhealthliteracyamongU.S.strokesurvivorsisunknown.AtShands-Jacksonville,theStrokeProgramisconductingastudythatisevaluatinghealthliteracyinacohortofpatientswithacuteischemicstroke(AIS).Wereporttherecruitmentefficiencyassociatedwiththefirstfourmonthsofthisstudy.
Methods:ConsecutivepatientswithradiographicallyconfirmedAISwhohavebeenadmittedtotheShands-JacksonvilleStrokeUnithavebeenevaluatedforinclusionintothestudysinceSeptember8,2009.Allconsentedpatientsundergovalidatedteststoassesstheirhealthliteracyduringtheirhospitalization.Demographic,educational,stroke-specificandsocioeconomicinformationisprospectivelycollectedonallconsentedpatients.Reasonsforstudyexclusionarecollectedforallnon-consentablepatients.Thenumberofpatientsrefusingtoconsentisalsocollected. Aninterimanalysis evaluatingnumberofstudyrecruitsandnonrecruitswasconducted.
Results:BetweenSeptember8,2009andJanuary15,2010,89patientshadradiographicallyconfirmedAIS.Ofthese,34(38%)wereexcludedfromstudyparticipation.Theprimaryreasonsforexclusionwerelethargy(n=11),dysphasia(n=10),andhospitaldischargepriortorecruitment(n=7).Oftheremaining55patientsthatwereapproachedforstudyparticipation,40(73%)consentedtoparticipateinthestudy.Theaverageageofenrolleesis60yearsofage.Twenty(50%)ofthoseenrolledweremaleand25(62.5%)wereAfrican-American.
Conclusion:Duringthefirstfourmonthsofourstudy,recruitmentefficiencyhasbeenhighwithanaverageof9.5patientspermonthconsentingtoparticipate.Almostone-half(45%)ofalladmittedAISpatientshaveundergonehealthliteracyassessment.Thishighrecruitmentefficiencyisprimarilyduetoahighrateofconsentinstudy-eligiblepatients.OurinterimexperiencesuggeststhathospitalbasedstudiesevaluatinghealthliteracyinpatientswithAISisfeasibletoconductinanurbansetting.Inaddition,ourexperiencesuggeststhataraciallydiversestudycohortcanberecruitedintoahospitalbasedhealthliteracystudy.
ED Documentation Training in the Face of ED Overcrowding
Ben Lenhart, MD:KellyGray-Eurom,MD;andDavidCaro,MDUniversityofFloridaCollegeofMedicine,DepartmentofEmergencyMedicine
Editor’s Note: Due to production constraints, Figures 1 & 3 are not printed in the journal. They are available online at www.dcmson-line.org as a web illustration.
Background: ResidencytraininginthefaceofEmergencyDepartment(ED)overcrowdingcanpresentmanychallenges.UniquemethodsareoftenneededtomaintainaneducationalenvironmentconducivetopreparingemergencymedicineResidentstobecomecompetentpractitioners,especiallyineducationalareasidentifiedas“holes”inthemodelcurriculum.AnAmericanCollegeofEmergencyPhysicians(ACEP)sponsoredsurveyofnewEmergencyMedicine(EM)graduatesidentifieddeficienciesintrainingcustomerserviceconceptsandpracticemanagementcriticaltosuccessintheworkenvironment.AnACEPsponsoredsurveytomedicaldirectorsofnon-academicemergencydepartmentsregardingtheirperceptionofthedeficienciesseeninnewEMgraduatesidentifiedpracticemanagement,administrativefunctions,andcommunicationskillsasbeingareasinmostneedofimprovement.Ouremergencydepartmentisanacademicurbanprogramthatseesapproximately90,000patientsannually.
Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold
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EDandhospitalovercrowdingimpactsourdepartmentonadailybasis,withEDlengthofstaytimesofgreaterthan11hoursforadmittedpatients,andoverallturnaroundtimesfordischargedpatientsexceeding5.5hoursoverthepastyear.Ourdepart-mentidentifiedtheeducationalaspectofbusinessmanagement,andinparticularimprovingcodinganddocumentation,asoneofourtraininggoalsinNovemberof2008,asanincreaseindeficienciesindocumentationperformanceandchartcompletionwereidentifiedinconjunctionwiththelengthofstaydelays.Thedepartmentusesatemplateddocumentationsystem(XpressCharts,XPressTechnologies©2009) torecordemergencydepartmentdocumentation. CompletedEDtreatmentrecordsarescannedintoacomputerizedchartmanagementsystemafterpatientdispositionintheED.
Methods:Aneducationalpresentationwasgivenduringoneoftheresidency’splannedweeklydidacticsessions.Chartdocu-mentationeducationalreviewwastheninitiated.Departmentalbillingspecialistsforwardedcodingdowngradedchartstothedepartment’smedicaldirector.Abriefchartdocumentationeducationalreviewwasthenperformed,whichincludedmissingdocumentation,whatlevelthechartshouldhavebeenbilledascomparedtothelevelofmedicalserviceprovided,whatlevelthechartwasactuallybilledat,andwhatrevenuelossoccurredduetothisdowngrading. (Figure 1, www.dcmsonline.org) Thischartdocumentationeducationreviewwasthensenttotheresidentproviderforreassessmentandeducation,especiallyinsystemsbasedpracticeandpractice-basedlearningandimprovementcompetencies.ThisdatahasbeencollectedforqualityreviewandisanalyzedmonthlyduringEDoperationsanalysis.(Figure 2)
Results:DatarevealedthatdespitelengthofstayandoverallEDpatientvolumebeingrelativelyconsistent,theaveragechargeperresidentchartduringthefivemonthsbeforeandafterthiseducationalactivityincreasedfrom$313.44to$394.76.(Figure 3, www.dcmsonline.org) Residentsseemsatisfiedwiththiseducationalcomponentcoveringaneducationalaspectthatisofteninsufficientduringresidencybutexpectedaftergraduation.Thisreviewprovidesanothermethodoftrainingandassessmentfordepartmentswhoseattendingphysiciancoverageisattimesstretchedanddetailedanalysisofchartsanddiscussionofthedetailsofdocumentationfromabusinessperspectivecansometimesbedifficulttoperform.
Conclusions:Acombinationofdidactictrainingandreal-timeContinuousQualityImprovement(CQI)reviewbothimprovedresidentphysicianmeanchargesperchartandE&Mcodinglevels,eveninthesettingofextendedlengthofstayinacrowdedED.Thisprocessprovidesamethodofcompetency-basedtrainingandassessmentforemergencyresidenciesinthesettingofEDovercrowding,targetinganeducational“hole”intheEMModelCurriculumthatiscurrentlyinneedoffurthertraining.Inparticular,itfocusesonpractice-basedlearning,systemsbasedpractice,andwrittencommunicationskillcompetencies.
Figure 2 Monthly ED Operations Analysis
14 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
Pupillary Response After Neuromuscular Blockade
Steven Andescavage, DO; DavidCaro,MD;MohsenAkhlaghi,MD;ColleenKalynych,MSH,EdD;ChristinaHanna,BSandJackieBarzyk,BD
UniversityofFloridaCollegeofMedicine,DepartmentofEmergencyMedicine
Editor’s Note: Due to production constraints, Figure 1 is not printed in the journal. It is available online at www.dcmsonline.org as a web illustration.
Background:Neuromuscularblockers,bothnon-depolarizinganddepolarizing,arecommonlyusedintheEmergencyDepart-mentforintubationofcriticallyillpatientsviarapidsequenceintubation(RSI).RSIinvolvesadministeringasedative-inductionagentfollowedbyaneuromuscularblockingagenttorenderapatientsedatedandparalyzedtooptimizefirst-attemptintubationsuccess.Neuromuscularblockersworkspecificallyatnicotinicacetylcholinereceptorsattheneuromuscularendplateofstriatedmuscle,andthereforeshouldnotaffectthepupillarymuscleresponsetolightstimulation.Ciliarymuscleactivationandpupil-laryconstrictionismediatedbycholinergicreflex,andthereforeisprimarilycontrolledbymuscarinicreceptors(Figure 1, www.dcmsonline.org).Thelossofpupillaryresponsetolightisoftenusedforcriticalclinicaldecision-making,includingthedetermina-tionofpresenceofcriticalintracranialhypertensionintheemergencysetting,andbraindeathinthecriticalcaresetting.
Objective: Wesoughttodetermine ifpupillaryresponsetolightisaffectedbypharmacologicneuromuscularblockadeduringRapidSequenceIntubation(RSI)inanemergencysetting.
Methods:ThisInstitutionalReviewBoard(IRB)approvedprospective,observationalstudyconsistedofaconveniencesampleofpatientsina100,000patient/year,inner-cityemergencydepartment(ED)betweenFebruary2008andFebruary2009whoreceivedadepolarizingornondepolarizingneuromuscularblockadeforrapidsequenceintubation.Patientswereeligibleforthestudyiftheirpupilsdisplayedbrisk(<1second),>1mmconstrictiontolightchallengepriortointubation.Twophysicians(oneresident,oneattending)independentlyreviewedpupillaryreactivitypriortoandafterintubation.Datacollectedincludedthepatients’age,gender,weight,admittingdiagnosis,finaldiagnosis,RSIandParalyticmedication(s)givenwithdosages;Pupillaryresponsepriortoandpostintubation.
Results:Ofthe96patientswhometinclusioncriteria,90hadpupillaryactivityafterRSIconfirmedbybothphysicians.TwopatientshadphysiciandisagreementonreactivitypostRSIand4patientshadnopupillaryreactionconfirmedbybothphysiciansafterRSI.Grossagreementofpupilreactivityoftheobserverswas98%(95%CI93%-100%),with κ=0.82.Acombined,liberalmeasurementofreactivityafterparalytics(includingthetwopatientswithphysiciandisagreement,or92/96patients)yields96%(95%CI90%-99%),whereasconservativemeasurement(excludingthetwopatientswithphysiciandisagreementor90/96)yields94%(95%CI87-98%).
Conclusions:Todate,neuromuscularblockadewithdepolarizingornondepolarizingneuromuscularblockingagentsappearsnottoinhibitpupillaryreactivityinthevastmajorityofpatientswhosepupilsarereactivepriortoRSI.Asingularcaseofmiosisoccurredinanelderlywomanwhoreceivedmorethan2mg/kgofsuccinylcholine,whichsuggestsmuscarinicactivationbyanexcessivedose.AllpatientsintubatedforneurologicreasonsdemonstratednormalpupillaryactivityafterparalysisduringRSI.
Use of Broselow Tape to Determine an Optimal Dosing Weight in Overweight Patients
Jason Lowe, DO; RobertLuten,MD;ColleenKalynych,MSH,EdD;andChristineHanna,BSUniversityofFloridaCollegeofMedicine,DepartmentofEmergencyMedicine
Editor’s Note: Due to production constraints, Figures 1,2 & 3 are not printed in the journal. They are available online at www.dcmson-line.org as a web illustration.
Background:TheBroselowTape(BT)hasbecomewidelyacceptedasarapid,accuratemethodofapproximatingmedicationdosagesinthepediatricpopulation.(Figure 1, www.dcmsonline.org)Byestimatingapatient’sweightusinghis/herheight,valuabletimecanbesaved.SeveralstudieshavebeenpublishedquestioningthevalidityoftheBT;especiallyinatimewhenobesityratesareclimbingamongchildren.Findingsinthesestudiesarenotconclusive,yetauthorsimplythatpatients,especiallytaller/largerones,maybereceivinglowerdosesofmedicationsthanwhatwouldbeadministeredifthepatient’strueweightwasknown.Othersystems,particularlythedevisedweightestimationmethod(DWEM)attempttoadjusttheweightestimatedbythepatient’s
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lengthbyhavingthepractitionerdeterminethepatient’sbodyhabitus.ConsiderationtomakeasimilaradjustmentbasedonbodyhabitushasalsobeenmadefortheBT.Theaimsofthisstudyweretodeterminehowaccuratehealthcarepractitionerswereatestimatingbodyhabitus;todetermineifaddingbodyhabitusestimatesincreasestheaccuracyoftheBT;tocomparethedosagesderivedbytheBT,theBTadjustedforbodyhabitusandthepatient’sactualweightbaseddosage;andtore-evaluatetheoverallaccuracyoftheBroselowTapeanditsutilityinthefaceofrisingobesityrates.(Figures 2 & 3, www.dcmsonline.org)
Methods:AconveniencesampleofpatientspresentingtoUniversityofFlorida–Shands,Jacksonville’sPediatricEmergencyDepartmentfrom12/07to2/08wereenrolledintothestudywithparentalconsent.Thereweretwotypesofstudyparticipants.Thefirstsetwaschildrenaged0-12years.Studyinvestigatorsgatheredtheage,gender,race,weightandthepatient’sheight/lengthattriage.Oncedataonthepatientwasgathered,theinvestigatorsthenaskedhealthcareproviders(HCPs–secondtypeofstudyparticipant)toestimatethepatient’sbodyhabitusasnormal,underweightoroverweight.Healthcareproviderswereblindedtoallthepatient’sdata.Severalhealthcareproviderswereaskedtoevaluatethesamepatientasthegoalwastoachieve300encountersor“guesses”overall.Eachsubsequent“guesser”wasblindedtopreviousguesser’sanswer.Further,healthcareproviderswerenotgivenorremindedoftheclinicaldefinitionsofoverweight(95th%-ile)orunderweight(<3%-ile).
Results:Atotalof122patientswererecruitedduringthestudyperiod.Fromthese,441estimationsweremadeaboutpatients’bodyhabitusfrom59distincthealthcareproviders(residents,fellows,attendingsandphysicianassistants).Asa“test”,ourHCPshadasensitivityof67%andspecificity95%.Differencesbetweennon-adjustedweightsandadjustedweightswerecomparedbycalculatingpercentofweighterror(PE=((ActualWeight-BroselowWeight)/ActualWeight))100.APEof15%orlessisconsid-eredtobeacceptable.ThemeanPE(Table 1)was36.7%fornon-adjustedand17.17%forhabitusadjustedweights(P<0.0001).Non-adjusted,thetapeprovided60%ofweightswithin15%.Afteradjustment,weightswerewithin15%ofactual80%ofthetime.Wefoundthatthedifferences(Table 2, p.16) betweenAdjustedandNon-adjustedPEandalsoEstimatedWeightandActualWeightvaluesareonlysignificantinOverweightpatients(p<0.0001).Inter-observerreliabilitywasassessedwithakappascoreandshowntobeacceptablewithavalueof0.48.Despitethisseeminginaccuracy,wefoundthatallowingHCPstomakesuchadeterminationimprovestheaccuracyofthetapeby25%.Also,wefoundthat15%ofpatientswerefoundtobeoverweight,whichisinlinewithnationaldatafromtheNationalHealthandNutritionExaminationSurvey2004(NHANES),whichestimatedtherateofoverweightbeing~17%inchildren.DemographicdatashowsourstudypopulationtobesimilartoouroverallpatientpopulationatShandsJacksonville.(Table 3, p.16)
Conclusions:Recent literaturehasbeenpublishedcautioningusersoftheBroselowtape.Althoughadverseoutcomeswerenotnoted,authorswarnagainstpotentialunderdosingofobesepatientswhenusingtheBroselowsystem.Contrarily,othersnotethatoptimaldosingmaynotbebasedon“fatbodyweight”butmoreappropriatelybyidealbodyweight,whichiswhattheBroselowsystempresents.TheinitialstudiesoftheBroselowsystemdiscoveredthepotentialforunderestimatingweight,andinactuality,concurwithdatapresentedinthemorerecentstudies.Atthistime,ithasnotbeendeterminedwhetherthisunderdosingisdetrimental.Otherworkneedstobedone,butitappearsthataskinghealthcareproviderstomakeadjustmentstotheBroselowsystemwouldhelp,although30%ofthetime,anincreaseddosewouldnotbegiven.Thisisacceptable,because70%ofthetime,overweightstatusisdetectedandthisimprovestheBroselowtape’sabilitytoestimateweightby25%.Admit-tedly,ourkappavalueisnotoptimal;however,wehadabroadrangeoftraininglevelsamongourestimators,includinginterns.OurnextstepwillbetoimplementtheHealthCareProviders(HCP)bodyhabitusestimationsintoarealtimesettinganddetermineiftheyremainfeasibleandpracticalinapediatricER.
% Weight Error Adjusted % Weight Error
Patient Body Habitus N Mean Std Dev Mean Std Dev
Overweight 58 36.70 10.78 17.17 15.29
Normal 348 7.11 11.05 8.06 16.68
Underweight 32 -18.22 20.16 -5.68 32.32
Table 1 Mean % Weight Error versus Adjusted Mean % Error
16 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
Table 2 Difference Between Mean % Weight Error and Adjusted Mean % Error
Adjusted - Non-Adjusted Percent of Weight Error
Tape Weight - Actual Weight
Patient Body Habitus N Mean Std Dev Mean Std Dev
Overweight 58 -19.52 17.75 14.51 11.33
Normal 348 0.95 14.12 -1.32 2.57
Underweight 32 12.17 40.4 1.31 0.87
Number (n) Percentage (%)
Male 47 38.5
Female 74 60.7
Caucasian 12 9.8
Hispanic 2 1.6
AA 80 65.6
Asian 1 0.8
Unknown (not recorded) 25 20.5
0-4 years old 81 66.3
5-8 years old 21 17.1
9-12 years old 19 15.5
Overweight Body Habitus(BMI>95th%ile)
17 13.9
Underweight Body Habitus(BMI<3rd%ile)
4 3.3
Table 3 Study Demographics
Dr. Baker Receives the Philip H. Gilbert Award
StephenBaker,PhD.,JacksonvilleUniversityPoliticalScienceProfessor,receivedthe2010PhilipH.GilbertAwardfromtheNortheastFloridaHealthyStartCo-alitionforhisvolunteereffortsaschairoftheCommunityAdvocacyandPublicPolicyCommittee.Picturedat left isKarenWolfsen,ChairoftheCoalition,presentingtheawardtoDr.Baker.
Dr.Baker,aHealthyStartBoardmembersince2001,hastakenaleadershiproleindevelopinganadvocacystrategyfortheorganizationthatincludesvolunteertraining,developmentofissuepapersaddressinglegislativeprioritiesandannuallegislativevisits.Hehasalso recruitednewmembersandworked to link theCoalitiontothelargernon-profitcommunity.
Theawardwascreatedin2006tohonorPhilipH.Gilbert,thefoundingchairmanoftheCoalitionandalsoapastDCMSExecutiveVicePresident.
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 17
Abstract Category 2 - Retrospective
Background:Thisstudywasdesignedtoexamineindication,dosing,andoutcomesassociatedwithinhalednitricoxide(NO)useforacuterespiratorydistresssyndrome(ARDS)atShandsJacksonvilleMedicalCenter.
Methods: AdultintensivecareunitpatientsfromJanuary2006throughSeptember2008whoreceivedNOforARDSwereretrospectivelyassessedforindication,dosingandoutcomes.ActualuseofNOwascomparedtorecommendationsdevelopedatShandsJacksonvilleMedicalCenterinJanuary2009.Thosewhometalloftherecommendedcriteriaforindicationanddosewereconsideredcompliantandallotherswereconsiderednoncompliant.Therecommendedcriteriaforuseincludes:aninitialNOdoselessthanorequalto10ppm,PaO2/FiO2oflessthan200mmHg,anFiO2greaterthanorequalto80%,positiveend-expiratorypressure(PEEP)greaterthanorequalto12cmH2O,andNOdosesnotexceeding20ppmthroughoutthecourseoftherapy.Outcomesincludedin-hospitalmortality,mechanicalventilation(MV)days,andcostsofNOtherapy.
Results: Tenpatientsmetthecriteriaforuseanddosingrecommendationsandwereincludedinthecompliantgroup,withtheremaining63patientsallocatedintothenoncompliantgroup.In-hospitalmortalityoccurredin71%ofthosepatientsconsideredtobecompliantand56.3%ofthenoncompliantgroup(p=0.053).PatientsincompliancewiththepolicywereonMVforanaverageof28days(median,19.5days)comparedto10.8days(median,5days)forthosewhodidnotmeettherecommendations.ThedifferencebetweenMVdaysbetweenthegroupsisstatisticallysignificant(p=0.048).AveragehospitalacquisitioncostsforNOinthecompliantgroupwas$18,206(median,$9,687)and$13,802(median,$6,853)inthenoncompliantgroup(p=0.732).Sevenand32patientsinthecompliantandnoncompliantgrouprespectively,hadeitheraPaO2orSaO2valuerecordedwithin60minutesofNOinitiationand,therefore,providedenoughdatatoevaluateoxygenationresponse.Fivepatientsinthecompliantgroupand18patientsinthenoncompliantgroupachievedafullresponse(p=0.678),definedasgreaterthan20%increaseinPaO2orgreaterthan10%increaseinSaO2within60minutesofNOinitiation.
Conclusion:Themajorityofpatients(63of73)whoreceivedNOwouldnothavemetthenewcriteriaforuse;thosewhosatisfiedthesecriteriawereassociatedwithimprovedoxygenation,longerdurationofmechanicalventilation,andhighercostwithoutsignificantimprovementinpatientoutcome.
Nitric Oxide Use in Adults with Acute Respiratory Distress Syndrome
Nai Chao, PharmD; PaulTan,PharmD,FASHP;andAmyRockwell,PharmDShandsJacksonvilleMedicalCenter,DepartmentofPharmacy
Ibuprofen lysine: A Modified Dosing Regimen for Patent Ductus Arteriosus*
Stephen J. Tan, PharmD; RenuSharma,MD;WilliamH.Renfro,PharmD;LindaHastings,PharmD;andMarkSchreiber,PharmD
ShandsJacksonvilleMedicalCenter,DepartmentofPharmacy
Background:In2006anIVformofibuprofenlysinewasapprovedforpatentductusarteriosus(PDA)closure.Basedonrecentpharmacokineticstudies,dosingregimenshavebeendevelopedthatmayincreasethesuccessofPDAclosurewithibuprofenlysinewhiledecreasingadverseeffects.Therationaleofthisstudyistoobservetheeffectivenessofamodifieddosingregimeninaclinicalsetting.
Methods: Thiswasconductedasanobservational,retrospectivereviewofpreterminfantswithadocumentedPDAadmittedtotheNeonatalIntensiveCareUnit(NICU)serviceatShandsJacksonville.Inclusioncriteriaconsistsofpatientsbetweenthegestationalageof25and34weeks,postnatalageof1to11days,withmoderatetosevererespiratorydistressneedingmechanicalventilation,aechocardiograph(ECHO)documentedPDAandreceivingibuprofenlysinefortreatmentofPDA.TheprimaryoutcomewillbeECHOconfirmedclosureofPDAthroughcomparisonofamodifiedversustraditionaldosingregimenofibu-profenlysine.Secondaryoutcomeswillevaluatethesafetyofthemodifieddosingregimenthroughadverseevents.Theprimary
Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold.
18 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
objectiveofthisstudyistocomparetheefficacyandsafetyofamodifieddosingregimenwhencomparedtoatraditionaldosingregimenofibuprofenlysinewhenusedforPDAclosure.
Results: TherewasnostatisticaldifferenceinPDAclosure(p=0.443)orsafetyoutcomeswhencomparingamodifieddosingregimentoatraditionaldosingregimenofibuprofenlysinewhenusedinneonates.
Conclusion: ThisstudywasnotabletocollectenoughdatatostatisticallyshowadifferenceinPDAclosureorsafetyoutcomeswhenusingthemodifieddosingregimen.Currentlydatahasbeencollectedon22patientsinthetraditionaldosinggroupversus10patientsinthemodifieddosinggroup.Datacollectionisongoing.
*UnrestrictedEducationalGrantReceivedfromOvationPharmaceuticalsInc.
Effects of Severe Hypoglycemia on Trauma Patientsin an Intensive Care Unit
Nicole Scott, PharmD; PaulTan,PharmD;KathleenRottman,PharmD;andJulieOffutt,PharmDShandsJacksonvilleMedicalCenter,DepartmentofPharmacy
Background: Manyfactorsinfluencetheoutcomeofpatientsinintensivecareunits.Ageandseverityofthediseasestatehavebeenlongstandingfactorsthatleadtoincreasedmorbidityandmortality.Withinthelasttwentyyearsuncontrolledglyce-miclevelshavebeenassociatedwithanincreasedriskofadverseoutcomesincriticallyillpatients.Themainfocushasbeenonhyperglycemia,whichhasledtothemajorityofICUpatientsbeingplacedonaninsulininfusionandhavingtheirbloodglucoselevelstightlycontrolled.However,recentstudieshaveshownthatseverehypoglycemiamayplayaroleinpoorpatientoutcomes.Forthesereasonsthepurposeofthestudywastodeterminetheeffectsofseverehypoglycemiaontraumapatientsinanintensivecareunit.
Methods: Thestudywasaretrospective,singlecenter,observationalcohortstudyconductedbetweenJanuary2007–June2008.Onegroupconsistedoftraumapatientswhohavesufferedatleastoneepisodeofseverehypoglycemia(bloodglucoselevel<40mg/dL).Theothergroupconsistedoftraumapatientswithsimilarcharacteristicsbutwithatleastonebloodglucoselevel
Evaluation of Adequate Use of Antibiotics for Suspected Ventilator-associated Pneumonia in Critically Ill Trauma Patients
Claire Chan, PharmD; PaulTan,PharmD;ElainePoon,PharmD;NadiaShami,PharmD;andMarciDelossantos,PharmD
ShandsJacksonvilleMedicalCenter,DepartmentofPharmacy
Background:Currently,thereisgrowingevidenceontheimportanceofinitiatingappropriateantibioticsforsuspectedventila-tor-associatedpneumonia(VAP).ThisstudywillassesstheuseofantibioticsforsuspectedVAPintraumapatientsadmittedtothesurgicalICU(SICU)atShandsJacksonvilleMedicalCenter.
Methods:ThisisanIRB-approved,observational,retrospectivereviewofdatabasesthatincludedtraumapatientsintheSICUonaventilatorgreaterthan48hours,withsuspectedVAP,andwithabronchoalveolarlavage(BAL)completedbetweenAugust1,2006-2008.Fisher’sexactandT-testswereusedtoanalyzethedata.TheprimaryendpointwasfrequencyofadequateinitiationofantibioticsforsuspectedVAPbasedonBALresults.Secondaryendpointsinclude:appropriateantibioticdoseandduration,appropriatechangeintherapybasedonBALresult,outcomes(ICUdays,ventilatordays,andICUmortality),andappropriateantibioticde-escalation.
Results:Therewas94%frequencyofadequateinitiationofantibiotics.Oftheadequatelytreatedgroup,81%hadappropriatedose,8.5%hadadequateduration,and55%hadappropriateantibioticde-escalation.TheadequateandinadequatetreatmentgroupshadmeanICUlengthofstayof21.6daysversus12.7days(p=0.076),respectively.Theadequatetreatmentgrouphadmeanventilatordaysof15.7;whileinadequatehad12.7ventilatordays(p=0.608).Theadequatetreatmentgrouphad26%mortality;whileinadequatehad33%mortality(p=1.00).
Conclusion:Antibioticswereadequatelyinitiated94%ofthetime.TherewasnosignificantdifferencebetweentheadequatetreatmentgroupandinadequatetreatmentgroupsformeanICUlengthofstay,ventilatordays,ormortality.
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Comparative Study of the Clinical and Tumor Characteristics in Women with Breast Cancer of Different Age Groups
Atman U. Shah, MD; FauziaRana,MDandElenaM.Buzaianu,PhD(Statistician)UFShands,Jacksonville,DepartmentofMedicine
Background: Adjuvantchemotherapyforbreastcancerimprovessurvivalinpatientswithearlybreastcancerwithnodepositivedisease.Thegoaloftreatmentwithadjuvantchemotherapyistopreventcancerrecurrenceandreducecancerrelatedmortality.Thechoicetoadministeradjuvanttherapyisprimarilybasedonthepredictedbenefitsandrisksforthepatient.Alargeamountofliteraturedescribesage-dependentvariationsintreatment,showingthatolderwomenwithbreastcancerarelesslikelytoreceiveadjuvantchemotherapythanyoungerwomen.Wesoughttoidentifypatientandtumorcharacteristicsinwomenofdifferentagegroupswhoreceivedsystemicadjuvanttherapiesatourinstitution.
Methods: Wecollectedclinical,demographicandtreatmentdatafromelectronicdatasources,includingtumorregistrydataandpatients’medicalrecords.Dataof465womenwithbreastcancerwasreviewedandanalyzedusingSASstatisticalsoftwareversion9.1.ThesewomenreceivedadjuvantchemotherapyandwerefollowedattheUniversityofFlorida,ShandsHospitalfromJanuary2001toDecember2007.Theauthorsrandomlyselected465of1,265patientswithbreastcancerwhoreceivedadjuvantchemotherapyanddividedtheminto3groupsonthebasisofage.Eachgroupwasstudiedcloselyfordifferencesinsocialfactors(suchasraceandinsurancestatus),clinicalcharacteristics(hormonereceptorstatus,nodeinvolvement,tumorsize,typeofsurgeryperformed,andmortality)andpathologicalfactors(tumormorphology).
Results: Dataof465patientswasanalyzed.Womenwithagelessthan58wereplacedingroupA(n=155),ageswithin58-69ingroupB(n=155)andagegreaterthan70ingroupC(n=155).Therewasasignificantly(p=0.004)higherincidenceofin-filtrativeductalorlobularcarcinomainyoungerwomen(GroupA,BandChad80%,73%and60%respectively).Therewasnosignificantdifferencebetweenestrogenorprogesteronereceptorstatusbetweenthethreeagegroups.Youngerwomenhadasignificantlyhigherincidenceofnodeinvolvementthanolderwomen(p=0.001).Youngerwomen(groupA;53%)weremorelikelytoundergomastectomythanolderwomen(groupC;36%,P=0.02).Therewasnosignificantdifferencebetweentheproportionsofwomenwhoreceivedendocrinetherapies.Thelikelihoodofdevelopingasmalltumor(<2cm)increasedwithage.WomenwithsmalltumorsingroupA,BandCwere28%,34%and46%respectively(p=0.023).Olderwomenweremorelikelytohaveinsurancethanyoungerwomen(p<0.0001).
Conclusion: Theincidenceofbreast cancer increaseswithadvancingage, andalmosthalfof allnewbreast cancers in theUnitedStatesoccurinpatientsover65yearsofage.Somecliniciansarehesitanttoprescribeadjuvanttherapiestoolderbreastcancerpatients.Ourdatashowedthatelderlywomenhadsomefavorableprognosticfactors.Olderwomenwerelesslikelytohavelargetumors(>2cm)andlesslikelytohavepositivenodes.Infiltrativeductal/lobularcarcinomasweremorecommoninyoungerwomen.Therewerenodifferencesbetweenhormonereceptorstatuses.Olderwomenweremorelikelytohavemedicalinsuranceatourinstitution.
between70–150mg/dLbutwithnobloodsugarlessthan40gm/dL.Allpatientsenrolledinthestudywereplacedonaninsulininfusionperthestresshyperglycemiainsulininfusionprotocoltitratedtoatargetglucoselevelsbeing80-120mg/dL.Glucoselevelsweremonitoredhourlyuntiltargetlevelswereobtainedfor3consecutivetimesinarow.Thereafterbloodglucoselevelswerecheckedevery2-4hrs.
Results: Atotalof219patientswereincludedinthestudy,ofwhich73wereinthehypoglycemicgroupand146wereinthenon-hypoglycemicgroup.Mortalityoccurredin25%ofpatientsinthehypoglycemicgroupversus12%inthenon-hypoglycemicgroup(p=0.01).TheaveragetotalICUdaysforthehypoglycemicgroupwas28(2-152)and13(2-133)inthenon-hypoglyce-micgroup(p<0.0001).Inaddition,thehypoglycemicgrouphadlongeraveragetotalventilatordays(21vs.8;p<0.0001)andoverallhospitaldays(40vs.22;p=0.0002).Theinfectionratewasalsohigherinthehypoglycemicgroupascomparedtothenon-hypoglycemicgroup(75%vs.36%;p<0.0001).Whenanalyzingthemaincauseofthehypoglycemicevent,insulinwasthemostcommonagentused(64%).Thisisanimportantfactortonotesincetightglucosecontrolisalwaysatopicofdebate.DuringthestudyperiodthegoalglucoselevelforpatientsonaninsulindripinanICUwas80-120mg/dL.Havingthisnarrowglucoserangemayhaveincreasedthechancesforthehypoglycemicevent.Thereforeitcanbepostulatedthatraisingthetargetrangeto<180mg/dlcouldleadtofewerhypoglycemiceventsthusimproveoutcomeoftraumapatients.
Conclusion: Overallpatientsinthehypoglycemicgroupexperiencedpooreroutcomesascomparedtothenon-hypoglycemicgroup.Patientswithbloodglucoselevelslessthan40mg/dLappearedtohaveahigheracuitywithhigherinjuryscoresandhavemorehyperglycemicepisodes.Thiswasreflectedintheirworseningoutcome.Hypoglycemiawithbloodglucoselevellessthan40mg/dLappearedtobeapoorprognosticindicatorfortraumapatient.
20 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
2nd Annual Quality/Safety Forum Draws Crowd
John A. BeAls AwArdfor medicAl reseArch
G. shAhin AwArdfor reseArch By A physiciAn in trAininG in duvAl county
Articles submitted for the Beals Award must have been written by a member of the Duval County Medical Society, based on work done in Duval County. They must have been published between January 2009 and December 2009 in a peer reviewed periodical listed in the MEDLINE / PubMed journal database.
Articles submitted for the G. Shahin Award must have a resident or fellow in training in Duval County as the lead author. The majority of the work must have been done while the resident or fellow was training in Duval County. They must have been published between January 2009 and December 2009 in a peer reviewed periodical listed in the MEDLINE / PubMed journal database.
it’s time for the 2010 BeAls & shAhin AwArds!
Beals and Shahin Awards will be considered in three categories: Original Investigation • Clinical Observation • Review Articles
suBmission deAdline is August 6, 2010. All winners will be recognized and receive plaques at the DCMS / Navy Meeting in late September,
with the winners in the Original Investigation categories also receiving monetary awards. Please login to the DCMS website (www.dcmsonline.org) and follow the Beals / Shahin link (under “Quick Links”) to submit your article for consideration. You will be asked to complete a brief form with contact information, award category, and publication details, and if available, email a PDF file of your article as it appeared in print or electronically.
If you have questions, please contact Marigrace Doran at 355-6561 ext. 101 or [email protected].
The130attendeesatthe2ndAnnualQuality/SafetyForum,May7,2010attheUniversityofNorthFloridaUniversityCenter,heardKeynoteSpeakerDr.BrentJames(leftatpodium),theChief Quality Officer, Executive Director, oftheInstituteforHealthCareDeliveryResearch,IntermountainHealthcareinSaltLakeCity,Utahandseveralpanelists.
Panelistspicturedare(left,LtoR)DCMSmem-bersDr.RobertNussandDr.WilliamRupp,MichaelSpigelofBrooksHealthandDCMSmemberDr.JayCummingsonthe“CreatingaCulture toFosterOutstandingQuality andSafety”panel.
The forum focused on Creating a Culture ofQuality, Communication and Collaboration.Itwashostedby theUNFCenter forGlobalHealthandMedicalDiplomacyandtheDuvalCountyMedicalSociety.
(Farleft,LtoR)Dr.&Mrs.YankD.Coble,Jr.(Dr.CobleistheDirectorandDistinguishedProfessorof theCenter forGlobalHealth&MedicalDiplomacyattheUniversityofNorthFlorida) with Dr. David Moomaw. (Left, LtoR)DCMSExecutiveDirectorJayMillsonandDCMSPresidentDr.JohnKilkennychatduringabreak.
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Abstract Category 3 - Case Study
Editor’s Note: The following data are presented clearly and conclusions are consistent with the data. Because of space limitations, we are only publishing abstracts. It is, therefore, inherently difficult to determine if some conclusions may overstate the magnitude or causality of the relationships identified. Resident author names are in bold.
Molecular Analysis of Intravascular Large B-Cell Lymphoma with Paraneoplastic Neoangiogenesis
HanW.Tun,MDandChristina Saurel, MDMayoClinic,Jacksonville,FL,DepartmentofHematology/Oncology
Background:IntravascularlargeB-celllymphoma(IVLBCL)isararesubtypeofnon-Hodgkinlymphoma.InWesterncoun-triesIVLBCLhasapredilectionforthecentralnervoussystemandtheskin.Werecentlydiagnoseda77-year-oldwomanwhopresentedwithextensive,painfulcutaneousnodulesandspiderangiomasofthetorsoandlegs.Aleftthighnodulewasbiop-siedandleadtothediagnosisofIVLBCLwithassociatedangiomaandangiolipomaformation.FourothercasesofpatientswithasimilarpresentationhavebeenreportedintheEnglishliteraturebutthepathogenesisforthisneoangiogenesisremainsunknown.Weperformedanin-depthmolecularandpathologicanalysistoelucidatethemolecularbasisfortheparaneoplasticneoangiogenesis.
Methods:Theskinbiopsywasfixedinformalin,embeddedinparaffin,andsectionedat3-micrometerintervals.SingleantibodystainwasperformedforVEGF.Threeobserversevaluatedtheimmunohistochemicalresults.Dualimmunohistochemicalstud-ieswereperformedwiththecombinationofFactorVIII/CD20,FactorVIII/Osteopontin(SPP1),andCD20/SPP1.PresenceofmembranestainingforCD20,cytoplasmicstainingforFactorVIII,predominantnuclearstainingforSPP1,cytoplasmicstainingforVEGFwerescoredaspositive.TotalRNAfrombiopsyspecimenwasextractedusingRNeasyMiniKit,accordingtomanufacturer’sprotocol.ThecontrolgroupconsistedofdiffuselargeB-celllymphoma(DLBCL)tissuesamplesfromvarioussites.Nineprimersetstargetedthefollowinggenetranscripts:vascularendothelialgrowthfactor(VEGF)A,VEGF-B,VEGF-C,VEGF-D,VEGF-R1,VEGF-R2,VEGF-R3,andSPP1.
Results: Wereviewedtheslidesoftheskinexcisionalbiopsy.ThedualstainforfactorVIIIandCD20demonstratedCD20+neoplasticBcellswithinthevessels,highlightedbyfactorVIIIstaining,consistentwithIVLBCL.IntravascularneoplasticBcellsshowedstrongexpressionforSPP1.TheneoplasticintravascularlymphocytesalsoexpressedVEGF.qRT-PCRconfirmedtheelevatedexpressionofVEGF-A,VEGF-C,VEGF-D,andSPP1 inourcasecomparedtootherDLBCLs.
Conclusion:OurexperimentselucidateamolecularbasisforparaneoplasticneoangiogenesisincutaneousIVLBCL.LymphomacellsproducedproangiogenicagentssuchasVEGFandSSP1,whichhasbeenshowtopromoteangiogenesisinothercancers.Theseproangiogenicfactorsappearedtohaveaparacrineeffect,leadingtoangiomaformationintheskin.SPP1inIVLBCLhasnotbeenpreviouslyreported.Inthefuturetreatmentofpatientslikeours,theadditionofantiangiogenicagentsshouldbeexplored.However,itisnotcompletelycleartouswhetherantiangiogenictherapywouldhavehadaclinicallysignificantimpactonoutcome,asneoangiogenesismaynotbedirectlyinvolvedinthedevelopmentandmaintenanceofIVLBCL.
IleoSigmoid Knotting: Take a Second Look
Ainsley Freshour, MDandJ.BrackenBurns,Jr.,DOUniversityofFlorida-Jacksonville,DepartmentofAcuteCareSurgery
Introduction: IleoSigmoidKnotting(ISK)isararecauseofintestinalobstructionthatcarriesaveryhighmorbidityandmortal-ity.Awarenessofitsexistenceandpathogenesisincreasespromptrecognitionanddirectsappropriatesurgicaltherapy.
Case Description:A19-year-oldmalepresentedwithacuteperitonitis.ACTscanobtainedpriortosurgicalconsultshowedmarkedascites,air-fluidlevels,anda“whirl”signmid-abdomensuggestiveofvolvulus.Atlaparotomy,weencounteredacopi-ousamountofdarkbrownsero-sanguineousfluidandnecroticsmallandlargebowelthatwereintertwined.Partialsigmoidcolectomyandenterectomyoftheinvolvedsmallbowelwasperformed,andthepatientwasleftindiscontinuity,pendingasecond-lookoperation.AfteraggressiveresuscitationintheICU,asecondlookoperationwasperformed36hourslaterwhichrevealedviablebowelendsandtwoanastomoseswereperformedinahemodynamicallystablepatient.Thepatientunderwentanuneventfulrecoveryandwasdischargedhomeonpost-operativeday7/5.
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Discussion: With amortalityof40%andamorbidityofnearly100%,knowledgeofIleoSigmoidKnotting(ISK),itspatho-genesis, and itsappropriatemanagement is essential.Throughauniquemechanism,adouble-loopobstructioncanrapidlyprogresstogangreneofthesmallbowelandoftenthesigmoidcolonaswell.Therecanalsobeassociatedthrombosisofthesuperiorrectalvesselswhichcanleadtolaterectalnecrosis.Patientsfrequentlypresentwithacuteonsetperitonitisandoftenhaveaccompanyingshock.Atlaparotomy,darkbrownascitesandobviouslynecroticbowelisencountered.Thiscanbeconfus-ingforasurgeonwhohasneverheardofISKbecausetherearenecroticareasofbothsmallandlargebowelthataredifficulttountwistwithoutperforation.KnowledgeofISKisimportantbecausetherapyneedstotakeintoaccountthepossibilityoflaterectalnecrosis.Traditionally,ISKpatientshaveundergoneilealresectionwithentero-enterostomyandsigmoidcolectomywithcolostomy.Weproposeusing“damagecontrol”principlesandplanningasecond-lookoperation.Thisaccomplishesseveralthings:initialoperativetimeisshortened;questionablyviablebowelcanbeleftinthehopesofrecovery;thepatientcanundergoearlyaggressiveresuscitation;bowelviabilitycanbereassessedatthesecond-look;anyanastamosesperformedcanbedoneinacontrolledenvironmentonamorestablepatient;andtheneedforacolostomymaybeavoided.HopefullybyincreasingtheawarenessofIleoSigmoidKnottingandproposingthissurgicaltherapy,wecandecreaseboththemorbidityandthemortalityofthisrarecondition.
Spindle Cell Carcinoma: A Rare and Challenging Disease Entity
Atman U. Shah, MD; MuhammadA.Salahuddin,MD;LindaR.Edwards,MD; Elaine Salazar, MD andRonaldM.Rhatigan,MD
University of Florida, Health Science Center, Jacksonville, FL, Department of Medicine
Editor’s Note: Due to production constraints, Figure 3 is not printed in the journal. It is available online at www.dcmsonline.org as a web illustration.
Abstract: Spindlecellcarcinoma(SpCC)isararehistologicvariantofsquamouscellcarcinomawithanaggressivemetastaticcourseandahighpropensityforrecurrence.Thediagnosisismadehistopathologicallywiththehelpofimmunohistochemicalstains.Ourcaseexaminesthisrarecutaneousspindlecellcarcinomathatinvolvedtheperioralregioninourpatient.Ourgoalistoincreaseawarenessofthisraremalignancyandbrieflyreviewthecurrentlyavailableliterature.
Case Presentation: A44-year-oldCaucasiangentlemanwithamedicalhistorysignificantofHIV(CD4countof18)wasbroughttotheemergencyroomintubated,afterbeingfoundunresponsive.Hewassuccessfullyextubatedafterbecomingmorealertandoriented.Hecomplainedofgeneralizedfatigue,weightloss(20lbwithinthelast3months),leftupperarmweak-ness,aswellassevereneckpainthathadbeenongoingforalmostayear.Hissocialhistorywaspositivefora50packsperyearhistoryofsmoking.Onphysicalexamheappearedcachecticandpale,butnotinapparentdistress.Hehadnoticeablefingerclubbing.Thephysicalexamrevealeda2x3cmleftupperlip,exophyticulceratedlesionof1monthduration.Theremainderofthephysicalexamwasunremarkable.
Achestradiographrevealedacavitarylesionintherightupperlobe.CTscanofchestalsoshoweda3x5cmcavitaryrightupperlobelesion(Figure 1, p.23)aswellasmultiplelyticlesionspredominantlyinvolvingthethoracicspineandanassociatedcom-pressionfractureatT9consistentwithosseousmetastases.Thenon-contrastheadCTshowednoacuteinfarctorhemorrhagebutdidshowmultiplelyticlesionswithinthecalvariumandcervicalspine(Figure 2, p.23).
Initialdifferentialdiagnosisincludedmultiplemyelomaand/oraninfectiouspathology(tuberculosis,fungal)inthepulmonarysystem.Multiplemyelomawasruledoutbyabonemarrowbiopsythatwasnegativeforneoplasmorinfection.AbronchoalveolarlavageandaCTguidedbiopsyofthelunglesionwerebothnegativeforneoplasmorinfections,suchasPneumocystisCariniiPneumonia (PCP)andtuberculosis.
Duringthehospitalcourse,thepatienthadagradualworseningofleftupperextremityweakness.AnMRIofthespinerevealedseverecordcompressionatC3.Thepatientwasapoorsurgicalcandidateandwasstartedondexamethasoneinadditiontobeingplacedinacervicalcollar.Finallyinsearchofatissuediagnosis,abiopsyoftheupperliplesionwasperformedandpathologywaspositiveforspindlesquamouscellcarcinoma.Priortobeingtransferredtoanursinghome,thepatienthadanacuterespira-torydecompensationandexpired.
Discussion: Spindlecellcarcinoma(SpCC)isararehistologicvariantofSquamouscellcarcinoma(SCC)havinganaggressivemetastaticpotentialandahighrateofrecurrence.Itmayappearasanexophytictumororanulceratedmassonthesun-exposedskin.Spindlecelllesionsaremorelikelytooccurwithintheheadandneckregionswheresunexposureismostprominent.1,2
Westudiedthecasereportsinliteraturetobecomemorefamiliarwiththeapproachtoevaluationandtreatmentofthisrarediseaseentity.SpindlecellSCCwasinitiallyreportedbyMartinandStewartin1935.Itwasbelievedthatpreviousradiationwasthemostimportantcause,assixoftheeightpatientsinitiallyreportedbyMartinandStewart,hadahistoryofradiationand
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 23
halfofthemdiedofcancer.3In1972,Smithet.alproposedthatSpCChadamoreaggressivecoursewhentheyaroseatasiteofpreviousradiation.4SpCCwasalsobeenreportedbyHarwoodin1996,inacaseseriesofrenaltransplantpatients,ofwhich25%ofpatientsdevelopedmetastaticdisease.5
Histopathology: SpCCispartofagroupoftumorsthatreflectacontinuuminhistologicheterogeneityaswellasepithelialandmesenchymaldifferentiation.Inourcase,afinaldiagnosisofpoorlydifferentiatedspindledsquamouscarcinomawasreachedbycombiningcytopathologicandimmunocytochemicalinformation.
SpCCmustbedistinguishedfromspindlecell/desmoplasticmelanoma,cutaneousleiomyosarcoma,atypicalfibroxanthoma,andscartissue,allofwhicharehistologicalmimickers.Onobservation,thelesioniscompletelyintradermalwithnoepidermalinvolvement.Itiscomposedofverypleomorphicspindlecellsarrangedinawhorledpattern.Thespindlecellshaveprominentnucleoli,scanteosinophiliccytoplasmandindistinctcellborders(Figure 3, www.dcmsonline.org).Numerousmitoticcellsarepresent.
Inourcase,thetumorstainedpositiveforhigh-molecularweightcytokeratin(CK),vimentinandEMA.Thetumorstainednega-tivefordesmin,CD31,HHV8andS-100,thusrulingoutmelanomas(S-100positive)andatypicalfibroxanthomas(vimentinpositive).However,somepoorlydifferentiatedspindlecellsquamouscarcinomasmayshowlossofcytokeratinexpressionandaberrantvimentinexpression,makingthediagnosisevenmorechallenging.
Conclusion: Cutaneous spindle cell carcinoma is anuncommonmalignancymarkedbyboth local recurrence anddistantmetastases.Theincidenceofthiscancerisunknown,withonlyanumberofindexcasesreportedinliterature.Mostcommonsitesofthiscancerareonsunexposedareasoftheheadandneck.Somestudiesindicatethatpreviousradiationexposureisassociatedwithhigherriskofdevelopingspindlecellcarcinoma.Histologically,itsdominantcomponentshavebothepithelialandmesenchymaldifferentiationthatmimicsothercutaneouspathologies,makingadiagnosisbycytopathologyalonedifficult.Therefore,immunocytochemicalinformationisrequiredtoconfirmthisdiagnosis.
Noclearmanagementguidelinesexistforthisraremalignancy.Earlydiagnosisandsurgicalexcisionoflesionsaremostlikelyrelatedtoabetterprognosis.Unfortunately,nolargestudieshavebeenconductedregardingtheprognosisofSpCC,especiallycomparingdenovolesionswithradiation-associatedlesions.TheadoptionofacomprehensiveanduniversaltreatmentapproachtoSpCCwillhelpinunderstandingtheroleofsystemicchemotherapyinpatientswithmetastaticdisease.
References1. SomerenA,KarciogluZ,ClairmontAJr.Polypoidspindlecellcarcinoma(pleomorphiccarcinoma).Oral Surg 1976;42:474–89.
2. RandallG,AlonsoW,OguraJ.Spindlecellcarcinoma(pseudosarcoma)ofthelarynx.Arch Otolaryngol 1975;101:63–6.
3. MartinHE,StewartFW.Spindlecellepidermoidcarcinoma.Am J Cancer.1935;24:273-297.
4. SmithJL.Spindlecellsquamouscarcinoma.In:GrahamJH,JohnsonWC,HelwigEB,eds.Dermal Pathology.Hagerstown,Md:HarperandRow;1972:631-635.
5. HarwoodCA,ProbyCM,LeighIM,etal.Aggressivespindlecellsquamouscellcarcinomainrenaltransplantrecipients.Br JDermatol.
1996;135:23.
Figures 1 & 2 CT Scan of Chest and of Spine (L and R)
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An Unusual Case of Pancytopenia
Shimona Bhatia, DO, MPHUniversityofFlorida,CollegeofMedicine-Jacksonville,FL,DepartmentofPediatrics
Editor’s Note: Due to production constraints, Figures 1-5 are not printed in the journal. They are available online at www.dcmsonline.org as web illustrations.
History of Present Illness:Analmostthree-year-oldboypresentedtotheERinJuneof2008withathree-weekhistoryofweakness,decreasedactivity,fussiness,decreasedappetite.Healsohadatwo-dayhistoryoffever(Tmax=102.8F),drycoughandarunnynose.Healsohadafewepisodesofnon-bloody,non-biliousvomitinginthelastday.Hewasseenatanurgentcarecenterthedaypriortoadmissionandprescribedamoxicillin.Earlierintheday,hewasseenathisprimarycarephysician’sofficeatwhichtimehewas“ill-appearing”andhadsymptomsofrespiratorydistress.
Past Medical History: Hehasnosignificantpastmedicalhistory.Hisimmunizationswereup-to-date.Hismedicationsincludedmontelukastandamultivitamin.Therewerenoknownsickcontacts.Heeatsanormaltoddlerdiet.
Physical Exam:T:38.6C,Pulse:156,BP:112/80,RR:26,O2saturation:100%on2LO2,Weight:13.9kg,Height:98cm.General:pale,mildrespiratorydistress.HEENT:normocephalic,clearTMsandoropharynx,PERRLA.Heart:tachycardia,regularrhythm,nomurmurs.Lungs:poorairmovement,cleartoauscultationbilaterally.Abdomen:soft,nontender,mildsple-nomegaly,normoactivebowelsounds.Lymph:shottycervicallymphadenopathy.Extremities:peripheralpulses2+bilaterally,capillaryrefill=3seconds.Neuro:nofocaldeficit,normalgaitandsensation.Musculoskeletal:4/5strengthinbilateralupperandlowerextremities.
Laboratory Studies:Initiallaboratoryinvestigationrevealedamarkedpancytopenia.(Table 1)
Discussion:Duetothesevereanemia,hereceivedapRBCtransfusionandhadabonemarrowbiopsy.Sincehislaboratoryevaluationrevealedapancytopenia,hewasgiventhepresumptivediagnosisofleukemia.Bonemarrowbiopsyrevealedahyper-cellularmarrow,virtuallynoblasts,giantbandsandmegakaryocytes.Megaloblasticerythroidprecursorcellswerepresentwithcharacteristicsconsistentwithnuclearcytoplasmicasynchrony(largeimmaturenucleusinamaturecytoplasm).Themyeloidtoerythroidcellratio(M:Eratio)was1to2-3(normal=3:1).Furtherevaluationofhis initialCBCrevealedasignificantmacrocytosis.
Thework-upincludedmicroscopicevaluation,measurementofmarkersofrapidcellturnover(lactatedehydrogenase,uricacidandunconjugatedbilirubin)andanevaluationofthereticulocytecount.Thesimultaneouspresenceofincreasedmarkersofrapidcellturnover,lowreticulocytecount,highmeancorpuscularvolume,highredcelldistributionwidthandahypercellularmarrowindicatesineffectiveerythropoiesiswhichisconsistentwithmegaloblasticanemia.Megaloblasticanemiaischaracterizedbythepresenceofovalmacrocytesandhypersegmentedneutrophilsonaperipheralbloodsmear.(Figures 1-5, www.dcmsonline.org)
MegaloblasticanemiaiscausedbyeitheradeficiencyoffolateorvitaminB12(cobalamin).HisserumvitaminB12levelwasfoundtobemarkedlylow.Aendoscopywasperformedandrevealednormalgastricandduodenalmucosa.Hewasfoundtohaveserumantibodiestointrinsicfactor.HewastreatedwithIMB12for5-6days.HisrepeatB12levelwasnormal,sohewasdischargedhomewithoralhigh-doseB12.Hisfinaldiagnosiswasantibody-positivecongenitalperniciousanemia.Todate,intheliteraturetherearenoisolated,recordedcasesofcongenitalantibody-perniciousanemiainanotherwisehealthychild.”
Table 1 Laboratory Values
(Normal values) Initial Evaluation Post-Treatment Evaluation WBC 2.19 (6-17.5) 8.55 (6-17.5) Hg / Hct 2.8 (11.2-14.3) / 8.1 (34-40) 13.6 (11.2-14.3) / 39.4 (34-40) Plt 72 (150-450) 241 (150-450) MCV 109.2 (75-87) 79 (75-87) Reticulocyte count 6.1%/50,000 Not done B12 73 (190-914) >1500 (190-914) Folate 15 (3-17) Not done MMA 2.423 (0.073-0.376) 0.152 (0.073-0.376)
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 25
Olfactory Neuroblastoma with Hyponatremia
Altman U. Shah, MD; Jamie Woodcock, MD; andFauziaN.Rana,MDUniversityofFlorida,HealthScienceCenter,Jacksonville,FL,DepartmentofMedicine
Abstract: Olfactoryneuroblastoma(ONB),alsoknownasesthesioneuroblastoma,isararemalignanttumorofneuroectodermaloriginwithanestimatedincidenceof0.4permillion.Itrepresentsonetofivepercentofmalignantnasaltumors.Earlydiagnosisisuncommonbecauseofvaguesymptomatologyatpresentation.NoTNMstaginghasbeencreatedforthistypeoftumor.Imagingisusefulinassessinglocalinvasionoftumor,althoughisinsufficienttomakeadiagnosis.Definitivediagnosisrequiresexaminationofhistologyandconfirmationwithelectronmicroscopyandimmunohistochemistry.Wedescribeapatientthatpresentedwithuncommonfeaturesandreviewthecurrentavailableliterature.
Case Presentation: A26-year-oldCaucasianstudentwhopresentedtoclinicwitha2-yearhistoryofsinusitisandnasalconges-tionthatwasalsoassociatedwithchangesinsmell.Hehadnohistoryofbleeding,facialpain,discharge,recurrentinfections,headache,orvisualcomplaints.Hismedicalrecordsrevealedananxietydisorderandhypertension,aswellas,chronichypona-tremiaandSyndromeofInappropriateAntidiureticHormoneHypersecretionproduction(SIADH).HewasbeingtreatedwithDemeclocycline.Onevaluation,hewasfoundtohaveapolyp,left-sidedsino-nasalmasswithanotherwisenormalexam.
CTimagingrevealeda3.9cmexpansilemassoftheleftanteriorethmoidsinuswithextensionintotheleftsuperiormedialmaxillarysinusandsuperiorleftnasalcavity.AnMRIshowedscatteredwhite-matteredlesions.APETscanshowedmildlyhypermetaboliclymphnodeatoftheleftsuperiorjugularlymphnodechain,measuredabout1.3cminsizeandasinonasalmassthatwasencroachingontheleftmedialorbitaswellasseveralplaquesinthewhitematter.
Hewastakentotheoperatingroomwhereanendoscopicdissectionandbiopsywasperformed.Definitiveresectioncouldnotbeperformedduetomassivebleeding.Heunderwentlymphnodedissection,andalllymphnodeswerenegativeforneu-roblastoma.Leftmaxillarybiopsywasconsistentwithpigmentedolfactoryneuroblastoma.Thetumorinvolvedtheboneandsinonasalstructures.Itwascomposedofprimitivesmallcluecellswithfocalrosetteformation.Themitoticactivitywaslowandmoreconsistentwithlow-gradeolfactoryneuroblastoma.
Followingsurgeryhishyponatremiacompletelyresolved.Hereceivedpostoperativelow-doseCisplatin20mg/m2onaweeklybasisalongwithradiationtherapytwiceperday.After16monthsoffollowup,therewasnoevidenceofrecurrence.
Discussion: Olfactoryneuroblastoma(ONB)isanuncommonmalignanttumorthatrepresentsupto5%ofmalignantnasaltumors.Ithasnopredilectionforraceorsex.1Thereisawideagedistributionwithbimodalpeaksinincidencebetween11-20and51-60yearsofage.TherearenoknowngeneticmutationsoretiologicagentsforONBinhumans.ONBoriginatesfromthebasalolfactoryepithelialstemcellslocatedintheupperthirdofthenasalcavity.Grossly,itappearsasasmooth,hemorrhagic,andpolypoidmass.2Microscopically,itiscomposedofuniformcellswithscantcytoplasmandsmall,roundnucleilocalizedtonestorlobulesinthesubmucosaandstroma.3
Themostcommonpresentingsymptomsareunilateralnasalobstruction,epistaxis,andpersistentnasaldischarge.Lesscommonsymptomsincludeheadache,hyposmia,anosmia,visualdisturbances,proptosis,facialpainandswelling,andsyncope.4Inmostcasesthediagnosisisdelayedformonthsbecausethecommonsymptomsareoftenpassedoffasbenignsinonasaldisease.Di-agnosingONBrequireshistochemicalanalysisinordertoruleoutothersmallroundcellmalignantneoplasmsofthesinonasaltract.Thedifferentialdiagnosisincludesundifferentiatedcarcinoma,lymphoma,melanoma,embryonalrhabdomyosarcoma,andextramedullaryplasmacytoma.5-6
ThesetumorsaregradedbyHyam’sclassificationsystem,whichiscomprisedoffourgradesdifferentiatedbyhistologiccharacter-istics.Gradingisbasedonthepresenceofcertainhistologicfeaturessuchaslobulararchitecture,nuclearpleomorphism,rosettes,mitoticactivity,andcellularnecrosis.Thelessdifferentiationatumorshows,thehighergradeitreceivesonascaleof1through4.7StagingforthesetumorsusestheKadishsystem.Inthissystem,stageAisconfinedtothenasalcavity,stageBspreadstotheparanasalsinuses,andstageCextendsbeyondtheseregionstoincludetheorbit,intracranialcavity,skullbase,cervicallymphnodes,ordistantmetastases.Hightumorgradeanddiseasestagecorrelatewithapoorprognosisforthepatient.8
Conclusion: AdiagnosisofONBrequiresproper tumorgradingandclinical stagingwithradiologic imaging, followedbyrigoroustreatment.Aggressivesurgicalresectionfollowedbyadjuvantradiationtherapyisthemainstayoftreatmentforanyneoplasticstage.Thiscombinationtherapyhasbeenshowntohavethehighestcurerate.Chemotherapyisusuallyreservedforadvanceddiseaseduetoitslimitedsuccessasacurativemodality.
Five-yearsurvivalrangesfrom40%to80%dependinguponthestateandgrade.Patient’swithlow-gradetumorshave80%five-yearsurvival,butthosewithhigh-gradehave40%survival.About30%candeveloplocalrecurrenceusuallywithinthefirst2years,and15%havecervicallymphnodemetastasis,and10%willdevelopmetastasisatsomepointduringthecourseofthedisease.9
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References1. SheldonR,BrownSR.Esthesioneuroblastoma.Otolaryngology
Head and Neck Surgery 2007;137(5):835-6.
2. CastelnuovoP,BignamiM,DelùG,etal.Endonasalendoscopicresectionandradiotherapyinolfactoryneuroblastoma:ourexperience.Head Neck 2007;29:845–50.
3. Esposito,DFKellyandHVVinterset al.,Primarysphenoidsinusneoplasma:areportoffourcasewithcommonclinicalpresentationtreatedwithtranssphenoidalsurgeryandadjuvanttherapies,J Neurooncol76 (2006),pp.299–306
4. SampathP,ParkMC,HuangD,etal.Esthesioneuroblastoma(olfactory neuroblastoma) with hemorrhage: an unusualpresentation.Skull Base 2006;16(3):169-73.
5. PagniF,DiBellaC,BonoF,etal.A37-year-oldwomanwithepistaxis and unilateral nasal obstruction. Neuropathology 2007;27(6):609-11.
6. CapelleL,KrawitzH.Esthesioneuroblastoma:acasereportofdiffusesubduralrecurrenceandreviewofpublishedstudies.Journal of Medical Imaging and Radiation Oncology 2008;52(1):85-90.
7. HyamsVJ,Batsakis JG,MichaelsL (1988) Atlas of tumor pathology.ArmedForcesInstituteofPathology,Washington,pp240–248
8. KadishS,GoodmanM,WangCC.Olfactoryneuroblastoma:aclinicalanalysisof17cases.Cancer1976;37:1571–1576.
9. DulguerovP,AllalAS,CalcaterraTC.Esthesioneuroblastoma:ameta-analysisandreview.Lancet Oncol 2001;2:683–690.
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From a Resident’s Perspective
Editor’s Note: The opinions expressed in these essays are the personal perspectives of the resident authors and may or may not represent the views or ideology of the publisher, the University of Florida or Shands Jacksonville. Resident author names are in bold.
AnunfortunatecircumstanceaffectingthecityofJacksonville,FloridaandtheUnitedStatesistherisingnumberofgirlsinvolvedinthejuvenilejusticesystem.Inanationalsurveyconductedin2001,thedelinquencycasesforgirlshadincreasednationallyby83%,asignificantincreaseworthyofintervention.CurrentlyinFlorida,almostoneoutofeverythreejuvenilesarrestedisfemale.Girlsarethefastestgrowingsegmentofthejuvenilejusticesystem,anditistimetotakeactiontostopthisgrowingtrend.
Thereappearstobealinkbetweenvictimizationanddelinquencyamongthispopulation.InJacksonville,itwasnotedthatupto73%ofthegirlsinvolvedinthejuvenilejusticesystemreportedbeingvictimsofviolence,especiallysexualabuse,famil-ialsubstanceabuse,domesticandcommunityviolence.Emotionalfactorsalsoplayahugepartintheirdelinquentbehaviors.Seventy-ninepercent(79%)ofgirlsintheresidentialprogramsand84%ofgirlsinthenon-residentialprogramssufferedfromdepression,trauma,anger,self-destructivebehaviororothermentalhealth/clinicaldiagnoses.
Thefactremains,however,thatthetypesofoffensesforwhichgirlsarearrestedandincarceratedarelessseriousthanthoseforboys.Theiroffensesrangefromstatusoffenses(18%)totechnicalviolations(15%)andsimpleassault(15%).Detainedgirlsposelessofapublicsafetyriskcomparedtoboys,makingitmorebeneficialtoinvestinlessexpensivecommunity-basedservicesforthemratherthanthemorecostlyresidentialcommitment.
Duringmycommunityrotation,IwasabletointeractwithgirlsatthePACECenter.ThePACECenterforGirlsisafree,non-residentialprivateschoolforhigh-riskgirlswhohavenotyetenteredthejuvenilejusticesystem,butarefromhigh-riskenvironments.Thesegirlsexperienceanaverageoffiveriskfactorsincludingchronictruancy,learningdisabilities,documentedchildabuse,parentalincarceration,substanceabuse,runningaway,gangmembershipandabsenteeparents.Itisunfortunatetothinkthatthesechildrenwerealreadyatadisadvantagefrombirthbasedontheirenvironments.ThePACECenterofferssoundacademics, intensivetherapeuticcounselingandcasemanagement,familycarecoordination,healtheducationandremedialacademicattention.
Ihadtheopportunitytoobserveaone-on-oneinteractionbetweentheschoolnursepractitionerandoneofthePACEstudents.Thestudentcametotheschool-basedclinicatPACEfor“headaches”,acommoncomplaintamongthesegirls.Hersocialhistoryrevealedthatshehadbeensexuallyassaultednumeroustimesbyamaleadultfamilymember.WealsolearnedthatherunclehadjustdiedinIraqandwasbeingbroughthomeforfuneralservicesthatweekend.Thelistofstressesandproblemsexperiencedbythisyounggirlwerenumerous.Itwasdishearteningtohearthattheseso-calledheadacheswerequitecomplicatedandrequiredamorein-depthtreatmentthanjust2Tylenol.
PACECenterforGirlsinJacksonvilleisaverysuccessfulprogramwithextraordinaryoutcomes.AccordingtothePACECenterwebsite,100%ofthegirlsenrolledintheprogramhadnoinvolvementwiththejuvenilejusticesystemwithinayearofleavingPACE,100%wereinschooloremployedthreeyearsafterleavingPACEand97%improvedtheiracademicperformance(www.pacecenter.org).Thisprogramreallyhelpstoenhancethefutureofthesevulnerablegirls.
Ithinkitisimportantforpediatricianstoensurethatthesegirlsreceiveproperhealthcareinasafemedicalenvironment.Itisessentialtoadvocateforthesegirlsclinicallysotheydelaypregnancy,practicesafesexandliveinasafehome.Itisalsocriticalforpediatricianstoadvocateonthelocal,stateandnationallevelstopromotepublicpolicyforimprovedoutcomesforthesegirls.
Prescribing Justice for Girls: More Than 2 Tylenol
Monica Marcus, MDUniversityofFlorida,CollegeofMedicine,Jacksonville,FL
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Hostage Situation: Rescuing the Children of New Town
Ngozi Ogbuehi, MDUniversity of Florida, College of Medicine, Jacksonville, Department of Pediatrics
Eyesfixed,heartpounding,sweatdripping,Iwatchalovedonelingeringclosetodeath.Fearcapturesmybody.IwanttoscreamandIwanttoshout,butwhatdifferencewillmyvoicemake?Iamoneperson.WhatcanIdotostopthis?WheredoIevenbegintohelp?Iaminundatedwithfeelingsofhelplessness.YetallIcandoisstandandwatchasmylovedoneisheldhostageinthegripsofanattacker;onethathasnoothergoalbuttostripmylovedoneofdignity,strength,andeventuallylife.
Nowimaginethatthehostageisnotalovedonebutacommunityandtheattackerisnotdeathoramaskedgunmanbutwell-knownoffendersthathavebeenaroundforyears–povertyandcrime.
NewTown,aoncethrivingcommunityofJacksonville,isheldhostagebypovertyandcrime.Itisanareaofthecitynotmentionedintouristbrochures.Ninety-sevenpercent(97%)ofNewTownresidentsareAfricanAmericanand35%ofresidentsliveinpoverty.Roughlyhalfoftheadultsdonothaveahighschooldiplomaandtheeffectscanbeseeninpovertyandviolentcrimerates.ThehomiciderateinNewTownisthehighestinJacksonville.1,2
Thereareover1,500childrenlivingintheNewTowncommunity.Theyareresilientchildrenwhohavefacedstaggeringoddsfrombirth.Sixty-fourpercentoftheirfamiliesareheadedbysinglemothers.In2000,therewerenearly400birthsinNewTown,with23%ofthesebirthstoteenagemothers.1ThisisnotsurprisingsinceNewTownisnestledwithintheurbancoreofJacksonvillewhichhasthehighestrateofteenpregnancyinthecity.In2000,81per1000girls,ages15-19yearsold,becamepregnantinthisarea,comparedtothecountyaverageof51per1000girls.Theseteenmothersareamongtheadolescentsandyoungadults,ages15-24yearsold,withthehighestratesofsexuallytransmittedinfections(STIs)inDuvalCounty.Theco-factorsofyoungmothers,STIs,povertyandloweducationalattainmentcombinetoproducethehighestratesoflowbirthweightbabiesandinfantmortalityinDuvalCounty.Withaninfantmortalityrateof13per100,000livebirths,whichissignificantly
Asphysicians,weneedtowritetoourlegislatorstoencouragestableandongoingfundingforplaceslikethePACECenterforGirls.Wealsoneedtoadvocateforasafeenvironmentforthesegirlstogotoiftheyarenotbeingprovidedoneathome.
Programsthatofferspecializedmentalhealthservices,substanceabusetreatment,familyfocusedservices,specializedmedicalcare,educationalandvocationalservices,transitionalplacementsandservicesneedtobeappropriatelyfundedandmadeacces-sibletothesegirlsandtheirfamilies.
Itisimperativethatphysiciansstayinformedaboutandsupportprogramsthatpromotegender-specificstrategiesforatriskgirlsthatwillpreventthemfromenteringthejuvenilejusticesystem.OnesuchprogramistheNationalCouncilonCrimeandDelinquency(NCCD)CenterforGirlsandYoungWomen,anewlyformedorganizationinJacksonvillethatprovidescommu-nityandprofessionaleducationandtraining,assessment,research,evaluationandadvocacytoensurethecontinuedwell-beingofatriskgirls(www.justiceforallgirls.org).
Thetimeisnow.WemustadvocateforthelivelihoodandwellbeingofthesegirlsandtheprogramsthatservicetheirneedsTODAY!
References1. PatinoV,RavoiraL,WolfA.Arallyingcryforchange:chartinganewdirectioninthestateofFlorida’sresponsestogirls
injuvenilejustice.Focus Views from the National Council on Crime and Delinquency,2006,pp.1-62. Children’sCampaign,Inc.GirlsinFlorida’sjuvenilejusticesystem;dowetrulyseetheirpain?pp.1-3.http://www.iamforkids.org/promises/promise5/facts5.asp.Accessed4/29/10.3. Jacksonville’s Children’s Commission. 2009 state of Jacksonville’s children: racial and ethnic disparities report, pp.
76-87. http://www.coj.net/NR/rdonlyres/ehcqorshfk35wi27tk6n7isj4g5lxoq5rn25g76kgriokkozpqkfmxh356lnbwekyt3tjefzlhzlgijocfc5uto25yb/2009+Racial_Ethnic_Disparities_Report.pdf.Accessed4/29/10.
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 29
higherthanthecounty,stateandnationalrates,survivingbirthandlivingbeyondthefirstyearoflifeisadauntingtaskforNewTowninfants.2
ThechildrenofNewTownattendtheneighborhoodschools,S.P.LivingstonElementaryandEugeneButlerMiddleSchools.Livingstonisan‘F’gradeschoolandButlermiddleisa“C”gradeschoolbyFloridaDepartmentofEducationstandards.Over90%ofthestudentsareAfrican-Americanandparticipateinthefreeorreducedlunchprogram.3BothschoolsarechallengedbytheurgencytoimprovestudentFCATscoresandoverallacademicperformance.
OncethechildrenofNewTownleaveschool,theyencountertheotherfactorsthatimpactthetrajectoryoftheirlives.Theyseejoblessness,withunemploymentratesinthisareadoubletheDuvalCountyrate.Theyseetheirlovedonesdyingprematurelyfromand/orlivingwithcomplicationsofdiabetes,heartdisease,andHIV/AIDS,allofwhichhavethehighestratesinthisareaofJacksonville.HIV/AIDSrelateddeathsinthiscommunityoccurin42.4per100,000persons,whichisalmost4timesashighastheDuvalCountyrateof11.8per100,000persons.2ThisareaalsohasthehighestratesofasthmahospitalizationsinJacksonville.2
Whendrivingthroughtheneighborhood,itiseasytoseehowthephysicalenvironmentalsoaffectsthelivesofthechildren.Manyofthehomesareoldandindisrepair.Thereareseveralboarded-upshopsinthearea,areminiscentsignofatimewhenthiscommunitythrived.Childrenarerarelyseenplayingoutside.Theviolentcrimerateortheperceptionofhighcrimemayleadparentstokeeptheirchildrenindoors.Thereisanoticeableabsenceofgrocerystoresinthisneighborhood.Thechildrenhavenoaccesstofreshfruitsandvegetables,onlyfastfoodrestaurantsandconvenienceor“momandpop”storessellingprocessedfoodsandhigh-caloriesnacks.Howcanweexpectchildrentomaintainnormalweightsiftheyarenotabletoplayoutsideandtherearenohealthyfoodoptions?
Evenwithsomanyfactorsnegativelyaffectingthem,thiscommunityisresilient.Althoughtheyhavebeentakenhostage,theyarefightingback.In2008,agroupoflocalcivicleadersformedacoalitiontoimproveNewTown.TheNewTownSuccessZoneSteeringCommitteewasinspiredbytheprogressoftheHarlemChildren’sZoneinNewYorkCity.Thegroup,undertheleadershipoftheJacksonvilleChildren’sCommission,engagedtheJacksonvilleSheriff’sOffice(JSO)andnonprofitorganiza-tionsandgroupstocreateaconveyorbeltofservicestoimprovethelivesofchildreninNewTownfrombirththroughcollegegraduation.
Althoughstillinthebeginningphases,thegrouphasmadeprogress.Inthepastyear,policeofficersfromJSOhaveincreasedtheirpresenceintheneighborhoodandhaveworkedhardtostrengthentheirrelationshipwithresidentsinanefforttoreducecrimeandgaintrust.TheDepartmentofChildrenandFamiliesenlistedthefarmer’smarket,locatednearNewTown,tobegintakingFoodStampsasameanstoincreaseresidentaccesstofreshfruitsandvegetables.TheNortheastFloridaHealthyStartCoalitionincreasedservicesforpregnantwomenandalongwithotherorganizations,providesparentingandmaleinvolvementclassesinNewTown.BaptistHealthprovidesasthmaeducationforchildrenwithasthmawhoattendS.P.LivingstonElementaryandEugeneButlerMiddleschools.TheyrecentlycontractedwiththeHealthPlanningCouncilofNortheastFloridatoworkwithNewTownresidentstoconductathoroughcommunityassessmentofNewTown.
Afterschoolprogramsandactivitieshavebeenmadeavailableforthechildren,givingthemasafeplacetoplayandlearnoutsideofschool.EdwardWatersCollege,asmallhistoricallyblackcollegelocatedinthecenterofNewTown,openeditsdoorstothecommunity,volunteeringitsfacilitiesforcommunitymeetingsandavarietyofmuchneededcommunityservices.Thereishopethatbringingtheneighborhoodresidentsoncampuswillinspirethemtoexplorehighereducationandjobtrainingopportunities.
AlthoughtheSteeringCommitteehasmadegreatprogress,ongoingeffortstokeeptheresidentsinformedaboutprogramsandopportunitiesinthecommunityandinvolvetheminstrategiestoimprovetheirownneighborhood,iscritical.IftheNewTownresidentsareinvolved,feelempoweredandareabletomakedecisionsabouttheirowncommunity,thenthepositiveimpactthatiscurrentlybeingmadewillcontinue,longafterfundingendsandorganizationsmoveontotheirnextprojects.
WhenIfirstlearnedaboutNewTown,Ifeltlikethehelplesspersonwatchingalovedonebeingheldhostage.TheproblemsofNewTownarelarge,complexandoverwhelming.HowdoIhelp?WhatcontributionscouldImake?
NowthatIamlearningmoreabouttheimportantadvocacyroleofpediatriciansandallphysiciansinthecommunity,Iam
30 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
empoweredtojoinwiththeNewTownSuccessZoneSteeringCommitteetoimprovethelivesofthechildrenwithinNewTown.MyvoicewillnotbesmallwhenIjoinachorusofothersspeakingforthesameissue.
WhatI,asapediatrician,candotoaidinthemissionoftheNewTownSuccessZoneiswhatanyphysicianinJacksonvillecandotoadvocateforchildrenandthecommunitiesinwhichtheylive.
• Becomemoreknowledgeableaboutthecommunity,itsdemographics,anditsresidentsbyspendingtimevolunteeringwithvariousorganizationsandprogramsinthecommunity.
• Understandthesocialandenvironmentaldeterminantsofhealthmostaffectingchildren’shealthoutcomesandimplementevidence-basedstrategiesthathaveworkedtoimprovetheseoutcomeselsewhere.
• Formrelationshipswiththelocal,stateandnationalpolicymakerswhoareresponsibleforthisareainordertopromotemoreeffectiveadvocacyforthechildrenandfamiliesofthiscommunity.
ThechildrenandfamiliesofNewTownhavethepotentialtoovercomethehardshipsthathavebefallentheirpredecessorsandbecomethehostageswhosuccessfullybreakfromthegripsoftheirattackers–povertyandcrime.Thiscanbedonemoreeffectivelythroughthehelpandsupportofothers-peoplelikemeandyouwhoarenolongerafraidtofacetheattackersandconquerthem.
If you would like to support the activities of the New Town Success Zone Steering Committee, visit the website http://www.jaxkids.org/Departments/Childrens+Commission/Community+Information+and+Resources/New+Town+Success+Zone.htm for more information or contact Program Manager Irvin “Pedro” Cohen at (904) 630-6339 or [email protected]
References1. Jacksonville Children’s Commission. Success Zone Briefing Paper I http://www.jaxkids.org/NR/rdonlyres/
pxcnydddwn2uxrfihsipynstqkagfymuf/Success+Zone+Briefing+Paper+I.pdfAccessedMarch2010.2. DuvalCountyHealthDepartment.Health:Place Matters.2008;Issue1,7:1-10.3. FloridaDepartmentofEducation.SchoolGradesbyCountyhttp://schoolgrades.fldoe.org/default.asp.AccessedMarch2010.4. UnitedStatesDeptofAgriculture.IncomeEligibilityGuidelineforFreeandReducedLunch.http://www.fns.usda.gov/
cnd/Governance/notices/iegs/IEGs09-10.pdf.AccessedMarch2010.
The Problem with the American Health Care System
Nararjun Rayapudi, MD andJosephJ.TepasIII,MDUniversity of Florida, College of Medicine, Jacksonville, Department of Pediatrics
IntroductionAsaninternationalmedicalgraduate,IhadminimalexposuretotheAmericanhealthcaresystembeforestartingresidency
training.IgraduatedfrommedicalschoolinIndiaandrealizedthatIwasworkingandlearninginanunderdevelopedhealthcaresystem.Manypatientswerenotgettingadequatehealthcarebecauseoflackoffacilities,money,oravailableskilledperson-nel.Iwantedtopursuefurthereducationinwhatisrecognizedasoneofthebesthealthcaresystemsintheworld.ThisledmetotheUnitedStates.Inmytraining,Ipickeduptheclinicalaspectsofpatientcareveryquickly,however,Idevelopedseveralquestionsaboutthesystem.
My ProjectTogaindeeperunderstandingoftheAmericanhealthcaresystem,Ispentsixweeksonanelectiverotationinhealthadminis-
tration.IwasassignedtotheadministrationdepartmentofShandsJacksonville;a696bed,tertiarycare,teachinghospital.MyfacultymentoralsoarrangedaoneweekrotationatOrangeParkMedicalCenter,aHCAhospital.Thishelpedmeappreciatethedifferencesbetweenasafetynethospitalandaprivatehospital.MycolleaguesintheadministrationatShandshospitalin-cludedtworesidentswhohadfinishedMBAsinhealthcareadministrationandweredoingaoneyearinternshipatthisfacility.IfunctionedasthethirdresidentunderthementorshipofMr.SteveBlumberg,VicePresidentofBusinessDevelopmentandStrategicPlanning.
Asanadministrator,Iattendednumerousbusinessmeetings,interviewedpersonnelfromvariousdepartmentsofadministration
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 31
andlearnedtheirperspective.Iconductedone-on-oneinterviewswithpersonnelfromseveraldepartmentsincludinghumanresources,patientsafety,financialevaluation,quality improvement, infectioncontrol, labor,purchasing,pharmacy,andriskmanagement.
Impressions of a TraineeFirstandforemost,thereismindbogglingcomplexityintheAmericanhealthcaresystem.Itbecameincreasinglyapparent
thattheorganizedsystemofhealthcareisfragmentedandconfusing.Ifthisweremyperceptionasaprovider,Icouldonlywonderabouttheintensityofchallengeforsickpatientsandtheirfamilymemberstryingtodecipherthissystemintimesofneed.Perhapsasimportantly,thisincrediblecomplexityalsocontributestohighcostofhealthcareasisclearlyevidencedbythefactthatalmost25to33%ofU.S.healthcarespendinggoestoadministrativefunctions,notclinicalservices.
Thereisahugedifferenceinperceptionofthehealthcaresystembyadministratorsincomparisontohealthcareproviders.Throughinterviewsandobservations,Inoticedthatthefocusofmostadministratorswasimprovingthefinancialperformanceofthehospitalsandtryingtosurviveinachallengingeconomythatincludesintensecompetition.Clinicians,ontheotherhand,weremorefocusedonimprovingqualityofcareandpatientoutcomes.Itappearedtome,oftentimes,theclinicians’commitmenttoprovidingwhatisconsideredtobeoptimalcaredidnotincludeconsiderationofpotentiallycontrollablecosts.Conversely,administratorsconstantlystruggledwiththemandatetoprovideanappropriatemargintocontinuesupportoftheclinician’smission.Onsomeoccasions,thisdisconnectbetweenperspectivesseemedtoindicatethatthecliniciansandadministratorsareworkingagainsteachother.
Amajorcontributortothisdisconnectisthevariabilityofpayermixamongdifferenthospitals.Atmostsafetynethospitalsthepercentageofselfpay,mostlyuninsuredpatients,approached30%,whereasatprivatehospitalsapproximately10%ofpatientsareuninsured.Throughoutmyresidency,IhaveencounteredmanypatientswhowereseenandevaluatedatotherhospitalsandreferredtoShandsbecausetheylackedinsurance.Itappearsthatabsenceofinsuranceisabiggerproblemthancancer,coronaryarterydisease,ormanyotherpotentiallycatastrophicillnesses.ItisunfortunatethattheU.S.istheonlyindustrializednationthatdoesnotprovidesomeformofbasichealthcaretoitscitizens.Althoughqualitycareatahighcostisreadilyavailabletomany,almost50millionAmericansareuninsuredanddon’thavesuchaccess.Inaddition,16millionpeopleareconsideredunderinsured.Theseworkingpooraremorelikelytodiefrompreventableillnessesandpresentwithadvanceddiseasestatesbecausetheyhavenoaccesstoroutinemedicalcare.
Thethirdobservationthatispossiblyevenmorecompellingisthatourexcessivespendingdoesnottranslatetobetterhealthcomparedtoothernations.ThelifeexpectancyinUnitedStatesis78,whichranks50thintheworld,wellbehindSingapore,Japan,Bermuda,Greece,JordanandBosnia.TheInfantMortalityRateis6.26(per1000births)intheU.S.whichishigherthanmostofthedevelopedcountries.TheWorldHealthOrganization(WHO)rankedthehealthcaresystemof191nationsin2000.FranceandItalywerefirstandsecond:theU.S.wasinthe37thposition.
Finally,itappearsthatdespitetheaboveproblems,theU.S.spends16%ofitsGrossDomesticProduct(GDP)onhealthcare,whichisthehighestproportionamongallothernationsintheworld.Thenearestrival,Switzerland,spends11.5%ofitsGDP,followedbyGermany(10.6%ofitsGDP),andNorway(8.9%ofitsGDP).Theproblemisnotjustthatthecurrentspendingandcostsarehigh,butthattheyareprojectedtoincreasesignificantlyandmaybankruptAmericainthefuture.
ConclusionsMyillusionatthetimeofbeginningofmyresidencytrainingwasthattheAmericanhealthcaresystemisthebestintheworld.
Yet,thissystemhasmajorproblems.ItappearsthattheU.S.providesthebesthealthcareavailabletopatientsattheindividuallevelbutfailsatthesystemlevel.Thiscountrylagsbehindotheradvancednationsindeliveringqualityhealthcareinatimelyfashion.Healthcarehereisexpensiveandnotaccessibletoallpeople.Bothqualityandcoverageareinconsistent.Therecentlypassedhealthcarereformlegislationaddressessomeoftheproblemsbyexpandinginsurancecoverage,focusingoncostcontain-ment,andincreasingregulationofinsurancecompanies.Ibelievehealthcarereformisanecessarystepintherightdirection,butAmericaisstilldecadesawayfromparitywithmanyindustrializednationsintermsofhealthcaredeliveryatasystemlevel.
Thecurrenttrendisthattheresidentslearnabouttheadministrativeaspectsandbusinessofhealthcareaftertheygraduateandenterpractice.ItappearsthattheresidencytrainingcurriculumadequatelyaddressesmostoftheACGMEcorecompetenciesexceptconceptsofsystembasedpractice.Asachiefresidentonlymonthsawayfromenteringpractice,Ifindthatthisparticular
32 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
corecompetencyhasbeenthemostdifficulttoachieve.TheAmericanhealthcaresystemisincrediblycomplex,andIamreallygladIhadanopportunitytolearnabouttheadministrativeaspectsofthesystemduringmyresidencytraining.
Idecidedtopursuetraininginaspecialtythatinvolvesenormousamountsofphysicalandmentalefforttomaintaincon-tinuedexcellenceandcompetency.Duringtraining,Inoticedthatmanyresidentsspendcountlesshoursatthebedsideofthepatientlearningabouttheclinicalaspectsofthepatientcarebutdonotdedicateenoughtimefortheequallyimportantaspectoflearningaboutthesystemthatdeliversthepatientcare.
Asasurgeon,Iwillsoonhavetheprivilegeofopeningapatient’sabdomenandquicklyaddressingsevereorlifethreateningproblems.Withthisprivilegecomestheresponsibilitytolearnandbeanintegralpartofthesystemthatdeliversthecareforthepatientswhoplacetheirtrustinmyskillandjudgment.
ThejourneyoflearningaboutAmerica’shealthcaresystemistrulyalifelongprocessasthesystemcontinuestoevolve.Thisjourneyshouldideallystartinmedicalschoolandcontinuethroughresidencytrainingratherthanstartingafterresidencytrain-ing.Ibelievethatmandatoryeducationabouthealthcaresystemfunctioninmedicalschoolandresidencywillhelpadministra-torsandyoungcliniciansworktogethertoimprovethecareofallpatients.Iamcertainthatthehealthadministrationelectivedeepenedmyinsightintowhatgoesonbehind-the-scenesinthehospitalwhileIamtakingcareofpatients.
Acknowledgments - I could not have done this elective rotation without the mentorship of Dr. Joseph J. Tepas, III. He not only guided me through setting up this rotation but also encouraged and challenged me to explore and learn about the health care system. I also wish to thank Dr. Michael Nussbaum, Chairman of Surgery, for encouraging my efforts to learn about the system. And finally, I would like to thank the administration departments at Shands Hospital and Orange Park Medical Center for their support in making this rotation a great learning experience.
For more information, contact Shelly Hakes, Director
of Society Relations at (800) 741-3742, Ext. 3294.In a MEDICaL MaLPRaCTICE CLaIM:Be ready for anything and everything.
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Endorsed bySignificant discounts available for eligible DCMS members.
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Find it on the Website
Looking for the illustrations that accompany clinical articles in this issue?
GototheDCMSwebsiteatwww.dcmsonline.org.Click“NEFM”,“CurrentIssue”,andthen“TableofContents”.Allarticlesarelistedthere(withlinks)andthewebillustrationsaswell.
See the digital version of the journal! (followdirectionsabove)
2 1 Student Athletic Screenings
The DCMS needs YOUR help with the
Share your expertise at the JSMP Athletic Screenings
Saturday, August 7 – high school athletesSaturday, August 14 – middle school athletes
Nemours Children’s Clinic & Wolfson Children’s Hospital
JSMP coordinates free pre-participation athletic screenings for student-athletes in Duval County. Primary care physicians, orthopedic surgeons, cardiologists, pulmonologists, other medical specialists, physician assistants, and allied health professionals participate in the screenings. Physician and PA volunteers are coordinated through the DCMS.
These screenings are provided at no charge to student athletes, most from homes with limited means, and are not intended to replace annual physical exams performed by pediatricians and primary care physicians. Follow up care with individual physicians is encouraged when screenings indicate potential problems which may impact the athlete’s participation in sports activities.
Want to Help?Watch your email or fax for
registration forms, visit our website, or contact Barbara Braddock at [email protected]
or 355-6561 ext. 107.
Find it on the Website
Looking for the Post Test for the CME article in this issue or for other CME courses to complete?
GototheDCMSwebsiteatwww.dcmsonline.org.
Click“NEFM”,“CurrentIssue”,andthen“Tableof
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(withaPostTest link)ORclick“CMEArticles”
under“NEFM”andseealistofalltheCMEarticles
stillavailableforcredit.
See the digital version of the journal! (followdirectionsabove)
34 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
InFebruary,75attendedthe25thAnnualGood‘OleTime’ReunionforDCMSmemberswhopracticedduringthe“GoldenAge”ofmedicinepriorto1970.Onceresidentsandyoungpractitioners,theyarenowseasonedphysicians.Mostwhoattendthiseventareretired,andtheylookforwardtogatheringeachyearandreconnectingone-on-one.
(Left,toptobottom)Dr.GeorgeTrotterandDr.RossKrueger;Dr.&Mrs.JimDyer;Dr.RobertThrelkel,Dr.CharlesHayes,Dr.EugeneGlenn,&Dr.TaylorKing;andMrs.JerryFergusonandMrs.LindaMoseley.(Rightcolumn)Allattendeesenjoyhavingtabletalktimeandminglingwithfriends.CongratulationsandthanksgotoJerryFergusonfororganizing,yetagain,anothermemorableandenjoyableevent.
Once Residents...Now Good Ole’ Time Reunion Attendees
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 35
High Risk Stress in High Risk Careers: Managing Physician Stress
Background - Benefits that Matter!TheDuvalCountyMedicalSociety(DCMS)attemptstoprovideitsmemberswiththebenefitsthatconsistentlymeetyourprofes-
sionalneeds.OneexampleofhowthisisbeingaccomplishedisbyprovidingtoDCMSmembersfreeContinuingMedicalEducation(CME)opportunitiesinthesubjectareasmandated/andorsuggestedbytheStateofFloridaBoardofMedicinetoobtainandretainmedicallicensure.TheDCMSwouldliketothanktheSt.Vincent’sHealthcare(SVHC)CommitteeonCMEforreviewingandac-creditingthisactivityincompliancewiththeAccreditationCouncilonContinuingMedicalEducation(ACCME).HelenaKarnani,MD,ChairoftheCMECommittee;BetsyMiller,Director,MedicalStaff,QualityManagement;andCindyWilliamson,CMECo-ordinator,fromSVHCdeservespecialrecognitionfortheirworkonbehalfofDCMS.
ThisissueofNortheast Florida Medicine includesanarticle,“HighRiskStressinHighRiskCareers:ManagingPhysicianStress”au-thoredbyKamelaK.Scott,PhD,andDavidJ.Chesire,PhD(see pp. 37-41),whichhasbeenapprovedfor1.0AMAPRACategory1credit(s).™ForafulldescriptionofCMErequirementsforFloridaphysicians(MD/DO),pleasevisittheDCMSwebsite(http://www.dcmsonline.org/cme_requirements.aspx).
Faculty/Credentials: KamelaK.Scott,PhD,isanAssociateProfessorandDavidJ.Chesire,PhD,isanAssistantProfessor,DepartmentofSurgeryattheUniversityofFloridaCollegeofMedicine-JacksonvilleinJacksonville,FL.
Objectives for CME Journal Article
1. Beabletorecognizethephysiologicaleffectsofstress2. Beabletorecognizethepsychologicaleffectsofstress3. Beabletoidentifyminimallythreewaystoeffectivelymanageexperiencedstress
Date of Release: June 8, 2010 Date Credit Expires: June 8, 2011 Estimated time to complete: 1 hr.
Methods of Physician Participation in the Learning Process1.Readthe“HighRiskStressinHighRiskCareers:ManagingPhysicianStress”articleonpages37-41
2.CompletethePostTestandEvaluationonpage36
3.Cutout&faxthePostTestandEvaluationtoDCMS(FAX)904-353-5848ORmembersgotowww.dcmsonline.org&submittestonline
CME Credit EligibilityInordertoreceivefullcreditforthisactivity,aminimumpassinggradeof70%mustbeachieved.Onlyonere-takeopportunitywillbegrantedif
apassingscoreisnotmadeonthefirstattempt.DCMSmembersandnon-membershaveoneyeartosubmittheposttestandearnCMEcredit.Acertificateofcredit/completionwillbeemailed,faxedorUSPSmailedwithin4-6weeksofsubmission.Ifyouhaveanyquestions,pleasecontacttheDCMSat355-6561,ext.103,[email protected].
Faculty Disclosure InformationDr.ScottandDr.Chesirereportnosignificantrelationshipstodisclose,financialorotherwisewithanycommercialsupporterorproductmanufacturerassociatedwiththisactivity.
Disclosure of Conflicts of InterestSt.Vincent’sHealthcare(SVHC)requiresspeakers,faculty,CMECommittee,andotherindividualswhoareinapositiontocontrolthecontent
ofthiseducationalactivitytodiscloseanyrealorapparentconflictofinteresttheymayhaveasrelatedtothecontentofthisactivity.AllidentifiedconflictsofinterestarethoroughlyevaluatedbySVHCforfairbalance,scientificobjectivityofstudiesmentionedinthepresentationandeducationalmaterialsusedasbasisforcontent,andappropriatenessofpatientcarerecommendations.
Joint Sponsorship Accreditation StatementThis activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medi-
cal Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physicians.
The St. Vincent’s Healthcare designates this educational activity for a maximum of 1.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.
36 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
1.Stressisthecombinationofphysiologicalandpsychologicalvariablesthatleadapersontojudgeasituationas:
a.Threatening&requiringsomecopingmechanism b.Intolerableandbeyondone’scopingability c.Requiringprofessionalinterventiond.Seenas“eustress”,requiresactivecopingstrategy
2.Stressintheworkplacehasbeenassociatedwith: a.Hypertensionb.Highplasmafibrinogenconcentrations c.Highlevelsofcatecholamines d.Alloftheabove
3.Uniquesourcesofstressforphysiciansincludepatientvariablessuchas: a.Patientageb.Severityofillnessorinjuryc.Patientabilitytocope d.Alloftheabove
4.Generally,thetermusedtodescribewhenanindividualworking in a high-stress work environment becomesmoredetachedfromtheworkitselfis:
a.Isolation b.Burnoutc.Withdrawald.Disentanglement
HighRiskStressinHighRiskCareers:ManagingPhysicianStressCMEQuestions&Answers(CircleCorrectAnswer)Free-DCMSMembers/$50.00chargenon-members*
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5.Atermassociatedwiththebluntingintheabilityofacaregivertobearthesufferingofothersis:
a.Compassionfatigueb.Apathy c.Sufferingseclusiond.Dispassionateretreat 6.Greenbergadviseswhichofthefollowingsituationinterventions: a.Donottakeworkhome b.Workthroughlunchtomanagetimec.Discussbusinessoverlunchwithcolleaguesd.Ignoreyourfeelingsaboutoccupationalstress7.BensonandMagraith’sreviewonstressreductionadvises
whichofthefollowing:a.Notexpectingtoomuchofoneselfb.Maintainingagoodsenseofhumorc.Participatinginoutsidehobbiesd.Alloftheabove
8.Contributingfactorstomaritalstressinclude: a.Physiciansescapeintoworkthinkingitiseasiertosolveclinicaldilemmasthandomesticproblems b.Aphysician’s“need”tobeincontrolcanconveyalackofrespectfortheirpartnerasanequalc.Inabilityforthepartnertotrulyunderstandthepressuresofthejob d.AandB
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 37
High Risk Stress in High Risk Careers: Managing Physician StressKamelaK.Scott,PhD;KristinStaggs,MSandDavidJ.Chesire,PhD
AddressCorrespondence:KamelaK.Scott,PhD,AssociateProfessor,DepartmentofSurgery,UniversityofFloridaCollegeofMedicine,Jacksonville,FL.Email:[email protected]
Abstract: The medical field is one in which professionals expose them-selves to the physical and emotional pain of those they seek to help, and this exposure can lead to them experiencing their patient’s pain. Medical personnel are particularly vulnerable to suffering from the physical and psychological consequences of occupational stress. Ironically, there is a pervasive attitude in the medical profession that suggests practitioners should be invulnerable to the stress-related consequences of their field, and many practitioners neglect to effectively attend to their own needs. The fallout of such neglect may manifest itself as burnout and compas-sion fatigue and affects those close to the physician as well, including family members and patients. A review of the literature indicates a need for physicians to be mindful of their own well-being. Strategies are presented to help physicians avoid the negative effects of working in a high risk profession.
IntroductionFriday night, 2:13 a.m. – “Beep… Beep…,” the pager
goesoffyetagain,indicatingthependingarrivalofalevelone trauma. A 19-year-old driver, motor vehicle collision(MVC)intubatedinthefield,isactivelybeingresuscitated.Onarrival tothetraumacenter, it isapparentthepatienthasincurredalethalbraininjury,yettheteammakeseveryattempttocontinuetheresuscitationtosavethisyounglife.At2:51a.m.thecallismaderegardingtimeofdeath.Theattendingphysicianisinformedtheyoungboy’sparentsarewaitinginthefamilyquietroomforwordabouthisinjuries,andsheknowsshe’snowtaskedwithdeliveringthedevastat-ingnews.
InanEmergencyRoom,a15-year-oldgirlisbroughttothehospitalbyafriend.Shehasbeenthevictimofabrutalrapeandisseverelybeaten.Perprotocol,thesexualassaultteamisnotified,andanofficerapproachesthebedtoobtaincontactinformationforthegirl’sparents.Thepatientreachesoutandgrabsthephysicianbythecoat,pleading,“Pleasedon’ttellmydaddy!”Thephysicianishitwiththerealityhisowndaughterisnow14-years-old.Whatwouldhewant,asherfather?
Saturdayafternoonatthebaseballpark,ablond-haired,9-year-oldboyapproachesthe“on-deck”circle.Whilenothisfirstgameoftheseason,thisoneisspecial;it’sthefirstgamehisdadhasbeenabletoattend.He’sproudthathisdadisadoctor,andheunderstandsthatmanypatientscountonhim.Hewantstomakecertainhisdadseesagreatgame!Ashestandsondeck,helookstohisdadinthestands,smiling.Atthatmoment,hisfather’scellphonerings,andhisphysi-ciandadistoldheisneededatthehospitalbecauseofanemergency.Theboyapproachestheplate,buthisdadmissesthisimportantmomentbecausehehadtoleaveimmediately.Theboy’smothershuddersindisappointment.
Occupational Stress Thelifeworkofaphysicianyieldssignificantstressdueto
themyriadpressuresfacedinthelineofduty.Daily,physi-ciansareaskedto“domorewithless,”tomakelifeanddeathdecisions,andtohealandmendbattered,tornanddiseasedbodies. Medicine is, indeed,a“highriskcareer”thatcangenerateagreatdealofpersonalstress.Theartofmedicinealone,however,doesnotaccountforthisexperiencedstress;indeed,itmaybetheleaststressfulpartofbeingaphysician.Onecanlearn,practiceandmasterknowledgeandaction.Itistheemotionalsideofthepracticeofmedicinethatmaynotbesopreciseorsoeasy.Howdoesoneseparateouttheemotionalresponsewhenconfrontedwithhumananguishandpain?Howisonetobalancethedemandsoftheprofessionwiththeneedsoffamily–spouseandchildren?
Occupationalstressisnotconfinedtothemedicalprofes-sion,andjustasallindividualsintheworkplacearepotentiallyatriskforthenegativeeffectsassociatedwithstress,thereisnothinguniqueaboutphysiciansorothermedicalworkersthatinoculatethemfromstressreactions.Anargumentcanbemade,infact,thatmedicalprofessionalsareparticularlyvulnerabletooccupationalstressbecausetheywillinglyputthemselvesinharm’sway,directlyexposingthemselvestothepainandtraumaoftheirpatients.Infact,ithasbeendem-onstratedthatobservingothersinpainevokesactivationintheneuralnetworkoftheobserverthatisresponsibleforpaintransmissionandtheprocessingoffearandanxiety.1,2
Stressisthecombinationofphysiologicalandpsychologicalvariablesthatleadapersontojudgeasituationasthreaten-ingandasrequiringsomesortofcopingmechanism.3Oc-cupationalstressresultswhencharacteristicsofthejobandjobrolerequireanindividualtoemploycopingmechanismstodealwiththeoccupationaldemands.Stressitselfisveryindividualized.Whatmaybestressful tooneperson,maynotbetoanother.Perceivedstresscancomefromavarietyofsources,anditisnotalwaysevidentthatasituationmight,infact,bestressful.Forexample,earlyresearchonstressandstressmanagementsuggestedthatanxietyisabi-dimensionalconstructcomprisedof“facilitating”anxietyand“debilitat-ing”anxiety.Facilitatinganxietyactuallyimprovesoptimalperformance, while debilitating anxiety impedes optimalperformance.4Morerecently,stresshasbeenidentifiedascom-ingfrombothnegativesources(distress)andpositivesources(eustress).5Bothdistressandeustressmayresultinsimilarstressconsequences,andeachrequireeffectivecoping.
Symptoms and EffectsOccupationalstresscanresultinnegativephysiologicaland
psychologicaloutcomes.Therehavebeenseveralinvestigationsintothephysiologicaleffectsassociatedwithincreasedlevelsof stress.Stress in theworkplacehasbeenassociatedwith
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hypertension6,7,elevatedserumcholesterollevels8,increasesinleftventricularmass9,highlevelsofcatecholamines10,highplasmafibrinogenconcentrations11,andincreasedtobaccoandalcoholuse.12,13Highlevelsofstressintheworkplace,whenaworkerisfurtherexposedtounpleasantworkplacecondi-tions(suchassexualharassment),havealsobeenassociatedwithheadaches,gastrointestinaldisturbances,fatigue,sleepdisturbances,nausea,weightloss,lossofappetite,neckandbackpain,anddentalproblems.14-22Similarly,highlevelsofworkplacestressmaymanifestaspsychologicalandbehavioralissues. Stress may result in low self-esteem, increased jobtension,andlowerjobsatisfaction;23itmayresultinimpair-mentsintheabilitytostore,retain,andretrieveinformationfrommemory.24,25Stresscanalsonegativelyimpactdecisionmaking26andoverallgroupperformance27.
Acutestressinthemedicalworkplacehasalsobeenshowntohavenegativeimplicationsforpatientcare.28Forphysicians,uniquesourcesofstressinvolvesuchareasaspatientvariables(e.g.,patientage,severityofillnessorinjury,patientabilitytocope,etc.),settingvariables(e.g.,workhours,resources,collegialrelationships,autonomy,etc.),andpersonalvariables(physiciancopingstrategies,experience,individualpersonal-ity,etc.).Thisexperiencedstressmayalsospillovertothefamilyofthephysician,impactingapartner,children,andrelatives.Ironically,thecultureofmedicinetendstoperpetuatethenotionthatphysiciansshouldbeimmunetoworkplacestress;therefore,physiciansmaytendtoviewstress-reductionworkshopsandtechniquesashavinglittlevalue.29
Twoareasofparticularconcernforphysiciansandothermedicalproviders,whenworkinginahighstressenvironment,areburnoutandcompassionfatigue.Theterm“burnout”isgenerallyused todescribe theprocesswhenan individualworking within a high-stress work environment becomesmore and more detached from the work itself. Particularsymptomsassociatedwithburnoutincludelowworkermorale,increased absenteeism, job turnover, physical illness, drugandalcoholabuserates,andfamilydiscord.30 Individualsexperiencingburnoutgenerally exhibit a reduced senseofhumor, increased physical complaints, social withdrawaland isolation, decreased job performance, self-medication(includingillegaldrugabuse),andpsychologicalsymptomssuchasanxietyanddepression.
“Compassionfatigue”isatermthatisassociatedwiththebluntingintheabilityofacaregivertobearthesufferingofothers.Inessence,thetermreferstothesecondarytraumathat isexperiencedbyaprofessionalwhenhe/sheengageswith traumatized patients.31 Compassion fatigue, unlikeburnout,tendstobuildquickly,andtheeffectsusuallyleavetheprofessionalfeelingconfused,helpless,andisolated.32Ithasalsobeenproposedthatcompassionfatigueismoreac-curatelyviewedasaformof“moralstress”,wherethecaregiverrequiresoutletstodiscussthemoralimplicationsinherentincompassion fatigue.33 Together, burnout and compassionfatiguecanisolateaphysicianfromhis/herpeers,impairingoverallworksatisfactionandimpedingoverallpatientcare.Theeffectscan reachbeyondworkplace settingsandhave
devastatingeffectsonrelationshipswithfamilyandfriends,furtherisolatingtheindividual.
Stress Reduction Strategies Becauseoftheoveralldeleteriouseffectsofoccupational
stress on work performance, job satisfaction, mental andphysical health, and other areas, there have been manystrategiesproposedforidentifyingandcombatingnegativestresssymptoms.Greenbergdividedhisdiscussionofman-agingoccupationalstressintofourcategories:life-situationinterventions, perception interventions, emotional arousalinterventions,andphysiologicalarousalinterventions.34Forlife-situationinterventions,hemakesthefollowingrecom-mendations:Donottakeworkhome,takeafulllunchhour,donotdiscussbusinessoverlunch,anddiscussyourfeelingsaboutoccupationalstress.Forperceptioninterventions,hesuggestslookingforhumorinthestressorsatwork,tryingtoseetherealityofthesituationratherthanfocusingononlythenegative,distinguishingbetweenneedsanddesires,notbasingself-worthonthetaskathand,andemployingappropriatecopingstrategiesforappropriatesituations(e.g.,donotwastetimetryingtochangethingsthatcannotbechanged).Foremotionalarousalandphysiologicalarousal,Greenbergrecom-mendsrelaxationtrainingandphysicalexercise,respectively.Overall,theimplicationisthatanindividualneedstoseetohis/herownneeds,ensuringthathe/sheishealthyphysicallyandpsychologicallybeforeembarkingonattendingtotheneedsofothersoroftheinstitution.
In a similar report, Benson and Magraith identify thatprogramsdesignedtohelpphysiciansmanageoccupationalstress should focus collectively on personal, professional,andorganizationalissues.35Theirreviewonstressreductionadvisesontheimportanceofamaintainingagoodsenseofhumor,sharingofemotions,participatinginoutsidehobbies,andtheimportanceofnotexpectingtoomuchofoneself.Further,organizationally, it is important to engage in lesstraditionalworkactivities,inadditiontotheprimaryrole,suchasteachingorresearch.Professionally,theyrecommendtheparticipationinBalintgroupsandvaryingthenatureofone’swork.
The literature is rife with studies documenting similarstress theoriesanduniversal reductionstrategies. Mostofthesereportsdescribegeneraltechniquesdesignedtohelpallprofessions.However,inthecaseofBalintgroups,thisstressreduction technique isdirected specifically to themedicalprofessional. In Balint groups, physicians discuss variousphysician-patientencounterswiththeircolleagues,specifi-callyfocusingonthefeelingstheencounterevoked.Thegoalistofacilitateanenhancedawarenessandunderstandingofthephysician-patientrelationshipsothatthephysician’sownskillsinhandlingsuchencounters,whilecontrollingtheirownemotionalandpersonalinvestment,arestrengthened.Whileproposedtohavethepotentialtoaidinthepreventionofcompassionfatigueandburnoutingroupparticipants,Balintgroupsrequirealong-termcommitmentonthephysician’spartforatrueandsustainedeffect.Suchgroupsdoprovide
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aneffectiveforum,nonetheless,forphysicianstoexplorekeyprofessionalandpersonalvariablesnecessaryforstressreduc-tion,suchasprofessionalboundarykeeping,settingofrealisticexpectations,andlearningeffectivemeansof“nottakingworkhome.”36Anexamplemaybedevelopinganewroutineoflisteningtoaudiobooksduringthedrivehome,torefocusthemindonalternativestowork-relateddemands.
Personal Stress Reduction Whilereviewoftheliteratureprovidesmanysuggestions
foridentifyingandaddressingexperiencedoccupationalstress,therearesomecommonstrategiesthathealthcareproviderscanemploytomoreeffectivelytakecarethemselves.First,inthearenaofpersonalstrategiesformanagingstress,essentiallyalifeoutsideofmedicineneedstobecultivatedandappreci-ated.Formanyphysicians,thismayrequiretheyonceagain“learntoplay.”37Asstrategiesforaddressingstress,physiciansshouldutilizehumor,relaxation,physicalandmentalexercise.Theyshouldengageinhobbiesandoutsideinterests,respecttheirownlimits,maintaintimeforself-careactivities,propernutrition,andengageinspiritualandfamilyrelations.Somework sponsored programs have developed brief remindersheetstoberegularlydistributedtophysicianstaffadvisingthefollowing:
1. Getaway2. Seekhelp3. Manageburnout(makeitaprioritytogetadequate
sleep, daily physical exercise, to work reasonableamounts,andto“cutyourselfsomeslack”)
4. Renewyourrelationships5. Re-evaluateyourworksituation6. Feedyourspirit38
Zeckhausen similarly suggests additional strategies formanagingpersonalstresssuchasemphasizingtheimportanceofavoidingcynicismanddoingmorethancommiserating.39Alsosuggestedisdemystifyingpsychologicalsupportandcon-sideringtherapyorasupportgroupaspositiveresourcesratherthansignsofweakness.Ultimately,personalmanagementofstressrequiresbalance,whilealsoenhancingperceptionsof“meaning”inwork–physiciansmustfindmeaningintheirwork,andtheymustfindbalanceintheirlives.40
Intheorganizationalarena,thecruxofstressmanagementlies in the cultivationof a true cultureof caring,not justforthepatientbutalsoforthephysician.Thismayincludepoliciesthatpromotework-lifebalanceandrestorephysicianautonomy,andcultivateefficiency,autonomyandmeaninginworkthroughcontinuousqualityimprovementprocesses.Team-basedburnoutinterventionprogramscanfurtherpro-videaforumforphysicianstodiscusswork-relatedfeelingsandexperiencesandwork-relatedproblemsandwaysofsolvingthem.41Regular,interactiveprocessesofinquiryandfeedbackfromphysicianscanhelptoidentifyissuesthatnegativelyaf-fectoverallwellbeing,andalsocanidentifyobstacles,withintheorganization,tobringimprovement.Suchprocessesmayenhancephysicianjobautonomyandfeelingsofjobcontrol
andmayprovidephysicians’theperceptionofaloudervoiceinorganizationaldecision-making.42,43
Stress Impact on Relationships“Medicalmarriages”requirespecificattentionasexcessive
maritalstressmaybeexperiencedduetolackof“togethertime”,lengthyworkdays,fatigueandthesensethattheca-reeralwayscomesfirst–eitherbynecessityorbychoice.Itiswell-knownthatphysiciansnecessarilymustperformlongdutyhoursandthatoverwork isnormative;.Yethowthistranslatestothemaritalrelationshipiskey.Physiciansmayescapeintoworksinceitcouldseemeasiertosolveclinicaldilemmasthandomesticproblems.Also,aphysician’s“need”tobeincontrolcanconveyalackofrespectforthepartnerasanequal.Noboundaries,whereinworkandhomebecomeblurred(especiallywhenoncall)cancreatesignificantmaritalandfamilystress.Thecommonstanceofmakingmentalhealthalowpriorityand/orthe“personofsteel”mentalityoftenprevalentinmedicine,maymakethedecisiontoengageinmaritalcounselingverydifficult.Forinstance,adoctormaybereluctanttoacknowledgetoanotherdoctorthathis/herrelationshipisintrouble;fearfulitisasignofweakness.
Commonsensestrategiesforavoidingsuchpitfallsmayinclude:
1. Maketimeforoneanother2. Safeguard time for communication and fun in an
otherwiseverybusylife3. Keepasenseofhumor4. Trytofindothervenuesto“vent”thestressfromwork
otherthanwithinthehomesetting5. Developinterestsoutsidemedicineandwork6. Havefriendsoutsidemedicineandwork.
Additionally,considerconsistentlyreviewingdutyhoursandsettingboundarieswhenable;compromising;puttingthemarriagefirst,ensuringthattimetogetherisapriority,andidentifyingaproblemandthendoingsomethingaboutit.Challengethe“Icanhandleitalone”mentality.Mostim-portantly,monitorandeffectivelycarefor,notonlyoneself,butalsoone’spartner,givingthemarriagethesamedegreeofattentionthatisgiventhemedicalcareer.
Conclusion Medicineisindeeda“highriskcareer”inlightoftheinherent
highdegreeofexperiencedstress(“highriskstress”)thateachphysicianmusteffectivelymanage.Thiscareerchoiceembodiesaninordinatedegreeofpersonal,professional,organizationalandmaritaldemands,anditistheperceptionsofone’srole,ineachoftheseareas,thatdefineone’sexperiencedstress.Themannerinwhicheachindividualmanageshis/herownstressdictatestherolethatstressplaysin,notonlyone’sphysicalhealth,butalsoone’spsychologicalhealthandwellbeing,andoverallprofessionalism.
Physiciansmusttaskthemselveswiththeresponsibilityofself-care,inthesamemannersuchexpectationsareplacedupontheirpatients.Specificstrategiesmustbeemployedto
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promotetheeffectivebalancebetweenjobfunction,jobmean-ing,andoverallsenseofpurpose–bethatasaphysicianorsimplyasaperson,partner,colleague,orfriend.Thesocietalburdenplaceduponphysiciansstandsonlytoincreaseinthiseraofhealthcarereform,emphasizingthepersonalneedandprofessionalresponsibilityforselfcare.Patient-centeredcarerequires“person-centered”providersandmandatesphysicianself-careandattentiontostressandwell-being.Thesearethecornerstoneofoverallprofessionalism.
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42 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
DCMS Membership Applications
These physicians’ applications for membership in the Duval CountyMedical Society are now being processed. Any information or opinionsyoumayhaveconcerningtheeligibilityoftheapplicantslistedheremaybedirectedtoAshleyBoothNorse,MD,DCMSMembershipCommitteeChair(904-244-4106orBarbaraBraddock,MembershipDirector(904-355-6561x107).
Daniel J. Matricia, DOUrgentCare/OccupationalMedicine/EmergencyMedicineAmeliaUrgentCare510AirportCenterDr.MedicalDegree:DesMoinesUniversityCollegeofOsteopathicMedicineInternship:ITEADoctor’sHospitalResidency:ITEANorthlakeRegionalHospitalNominatedby:NassauCountyMedicalSociety
Patrick J. DeMarco, MDAllergy/ImmunologyAllergy&AsthmaSpecialistsofNorthFlorida3636UniversityBlvd.S.#A-3MedicalDegree:HahnemannSchoolofMedicineInternship/Residency/Fellowship:UniversityofSouthFloridaCol-legeofMedicineNominatedby:EdwardMizrahi,MD;PaulWubbena,MD;SunilJoshi,MD
Cheryl Lynn Dixon, MD AnesthesiologyJacksonvilleAnesthesiaCorporation,Inc.820PrudentialDr.#606MedicalDegree:MedicalCollegeofOhioatToledoResidency/Fellowship:UniversityofFloridaCollegeofMedicineNominatedby:FranciscoJimenez,MD;PamelaRama,MD;EdwardYoung,MD
Brian R. Emerson, MDAnesthesiologyUFAnesthesiology655W.8thSt.2ndFLClinicalCenterMedicalDegree:VanderbiltUniversityMedicalSchoolInternship:AustinMedicalEducationProgramResidency:MayoClinicFellowship:SeattleChildren’sHospitalNominatedby:UFJP
Ruple J. Galani, MDCardiology/InternalMedicineJacksonvilleHeartCenterPA14546St.AugustineRd.#103MedicalDegree:MedicalCollegeofOhioMedicalSchoolResidency:UniversityofFloridaCollegeofMedicineFellowship:OhioStateUniversityMedicalCenterNominatedby:JoelSchrank,MD;KennethAdams,MD;ShannonLeu,MD
Carol Mannings, MDPediatricsDuvalCountyHealthDepartmentMedicalDegree:UniversityofMiamiSchoolofMedicineResidency:UniversityofFloridaCollegeofMedicine/JaxNominatedby:UFJP
Jerry P. Matteo, MDDiagnosticRadiologyUFRadiology655W.8thSt.2ndFLClinicalCenterMedicalDegree:RossUniversityMedicalSchoolInternship:FlushingHospitalResidency:LongIslandCollegeHospital
Fellowship:MedicalUniversityofSouthCarolinaMedicalSchoolNominatedby:UFJP
Gabriel Paulian, MDInternalMedicine/Hospice&PalliativeMedicineShandsCommunityHealthCenter655W.8thSt.4thFLACCMedicalDegree:RossUniversityMedicalSchoolInternship:MountSinaiSchoolofMedicine/BronxVAMedicalCenterResidency/Fellowship:UniversityofFloridaHealthScienceCenterNominatedby:UFJP
Adil Shujaat, MDPulmonaryMedicineUFCriticalCare655W.8thSt.7thFLClinicalCenterMedicalDegree:KingEdwardMedicalCollegePunjabUniversityResidency/Fellowship:SaintLukes-RooseveltHospitalNominatedby:UFJP
Residents/Fellows - University of Florida, Jacksonville
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www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 43
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44 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
AddressCorrespondenceto:MohammadA.Khan,MD,MRCPI,UniversityofFlorida-Jacksonville,DepartmentofInternalMedi-cine,653W,LRC4,8thStreet,Jacksonville,FL32209.Phone:(904)343-3038.Email:[email protected].
Special Case Report
Is Early TPN in Hyperemesis Gravidarum Worth the Risk?KarishmaRamsubeik,MD;RavindraP.Maharaj,MD;
MohammadA.Khan,MD,MRCPIandShilpaC.Reddy,MD
Editor’s Note: Due to production constraints, Figures 1 & 2 are not printed in the journal. They are available online at www.dcmsonline.org as a web illustration.
Case ReportWereportacaseofbacterialendocarditisasacomplication
ofaperipherallyinsertedcentralcatheterinthetreatmentofapatientwithhyperemesisgravidarum.A26-year-oldAfri-canAmericanfemalegravida4,para3withanintrauterinepregnancy at 26 weeks was diagnosed with hyperemesisgravidarumduringherfirsttrimester.Aperipherallyinsertedcentralcatheter(PICC)linewasinsertedtoallowdeliveryof total parenteral nutrition due to non-tolerance of oralintake.ThePICClinewasremovedassoonasshetoleratedoralnutrition.Herhyperemesisrecurredaftersixweeks,andasecondPICClinewasplaced.ThepatientdevelopedfeverandthePICClinewasremovedandwasreplacedbyathirdPICCline.ThefeverreturnedafterthethirdPICClinewasinserted.Onexamination,shehadstablevitalsexcepttachy-cardiawithaheartrateof100beatsperminute.AgradeIIIsystolicmurmurwasaudibleattheleftsternalborder.Therestofherphysicalexamwaswithinnormallimits.Labora-toryinvestigationrevealedawhitebloodcellcountof19000permicroliter,Hemoglobin12.2g/dl,Hematocrit35%andplatelets273000permicroliter.Herchemistrywaswithinnormallimits.Thebloodculturesandfungalculturewerenegative.
Theechocardiogramrevealedmildlyreducedleftventricularfunctionwithanejectionfractionof55to60%.Therewasmildbiatrialenlargementwithmoderatemitralregurgitation.Mildtomoderatetricuspidregurgitationwithpulmonaryarterysystolicpressureof43mmHg(Figure 1, www.dcmsonline.org)wasnoted.Posteriortricuspidleafletvegetation,measuring1.8x2.9cmandaseptaltricuspidleafletvegetation,(Figure 2, www.dcmsonline.org)wasrevealed.Therewasnoevidenceofaperivalvularabscess.AntibiotictreatmentwasinitiatedwithintravenousNafcillin.AhighresolutionCTscanofthechestrevealedalargefillingdefectatthebifurcationoftherightmiddleandlowerlobepulmonaryarteriesconsistentwithanembolusandmultiplenodularopacitiesinbothlungs,suggestinganinfectiousorinflammatoryetiology.Basedonthehistoryandlaboratorydata,adiagnosisoftricuspidvalveendocarditiswithsepticembolismwasmade.
DiscussionHyperemesisgravidarumaffectsabout2%ofallpregnant
women1.Onemustfirstconfirmaviableintrauterinepreg-nancy.Supportivecareisthemainstayoftherapy.Lifestylemodificationsmaybeattemptedtohelpthepatienttolerate
oralintake,suchaseatingdry,blandcarbohydrates,havingsmallfrequentmealsandavoidingunpleasantsmells.Withincreasingsymptoms,antiemeticsmaybeinstituted.Correc-tionoffluidandelectrolytedeficitsshouldalsobeundertakenandintravenoustherapymaybeused.VanStuijvenbergetal1observedthatvomitingsubsidedin24hoursaftertreatmentofpatientswithhyperemesisgravidarumifgivenintravenousadministration,normalsalinesolutionandoneampuleofanintravenousmultivitaminpreparation.Hsuetal2dem-onstratedsuccessfuluseofnasogastric(NG)tubefeedinginpatientswithhyperemesisgravidarumandassociatednauseaandvomitingimprovingwithin24hoursafterNGtubeplace-ment.In2004,Folketal3comparedtheobstetricandmaternalcomplicationsinpatientswithhyperemesisgravidarumtreatedwithtotalparentalnutrition(TPN)versusthosewhodidnotreceiveTPN.Theyfoundthatthetwogroupsweresimilarregardingtheincidenceofpregnancy-relatedandmaternalmedicalcomplications;howevertheTPNgrouphadahigherincidenceofTPNassociatedcomplicationsincludingsepsis,bacterialendocarditisandpneumonia.In2008,Holmgrenetal4observedthatmaternalcomplicationsassociatedwithPICClineplacementweresubstantialdespitenodifferencein neonatal outcomes. In fact, there was a 66.4% rate ofinfectivecomplications,thromboembolismorbothduetoPICClineuseinhyperemesispatients.
Conclusion Theinfectivecomplicationsofcentralintravenousaccess
over peripheral intravenous access cannot be emphasisedenough.Thisyoungladyhasnowbeencommittedtolong-termendocarditismanagementwiththeadditionalrisknowaffecting the patient and her fetus. This could have beenavoidedbyconservativemeasuresandlessinvasiveintravenousaccess.Inaddition,aPICClinehastheadditionalcostburdencomparedwithsimpleperipheralIVaccessandconservativemanagement.TheriskofTPNinshort-termmanagementofnutritionalneedsfaroutweighsthebenefitsashighlightedbythiscase.TheuseofPICClinesforhyperemesisgravidarumisrarelyindicatedandshouldbeavoidedifpossible.
References1.VanStuijvenbergM.E,SchabortI,LabadariosD,J.TN,The
nutrionalstatusandtreatmentofpatientswithhyperemesisgravidarum. American Journal of Obstetrics and Gynecology 1995;172(5):1585-1591.
2. Hsu JJ, Clark-Glena R, Nelson DK, CH K. Nasogastricenteral feeding in hyperemesis gravidarum Obstet Gynecol. 1996;88(3):343-346.
3.FolkJ,Leslie-BrownH,NosovitchJ,SilvermanR,AubryR.Hyperemesis Gravidarum: Outcomes and ComplicationsWithandWithoutTotalParenteralNutritionJ Reprod Med 2004;49:497-502.
4.HolmgrenC,Aagaard-TilleryKM,SilverRM.Hyperemesisinpregnancy:Anevaluationoftreatmentstrategieswithmaternalandneonataloutcomes.Am J Obstet Gynecol2008(198):56.
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 45
Update on Haiti Relief Efforts
Baptist Health Affiliated Physicians Provide Assistance to Haitians
IntheweeksandmonthsfollowingtheJanuary12,2010earthquakeinHaiti,anumberofphysiciansandstaffaffili-atedwithBaptistHealthinJacksonville,FLtraveledtoHaititoprovidemuchneededmedicalassistance.ThosefeaturedbelowarealsoDCMSmembers.
Doug Johnson, MD, a radiation oncologist at BaptistCancerInstitute,isamemberoftheFlyingPhysiciansAs-sociation.ThisgroupworkedwiththeU.S.StateDepart-mentandtheUnitedNationstogetneededsuppliestotheFondParisianFieldHospitalinHaiti.OnFebruary8,Dr.Johnsonandotherphysicianpilotsflew24privateaircraftloadedwith95boxesweighingnearly1,500poundstotheDominicanRepublicwhereaUNhelicopterthentransportedthesesuppliestothehospitalinHaiti.Dr.Johnsonsaid,“Oursuppliesgotwheretheyneededtobeandwereexactlywhattheclinicneeded.”
Richard Picerno, MD, anorthopaedicsurgeonwithJack-sonvilleOrthopaedicInstituteandMeridith Farrow, MD, anobstetricianwhopracticesatBaptistBeaches,werepartofa12-personteamthatwenttoHaitiFebruary2-11undertheauspicesoftheSouthernBaptistConvention.TheyworkedattheNationalHospital,amedicaltentcompoundcreatedafter the earthquake. They triaged and treated up to 400patientsadaywhohadmultipletypesofmedicalproblems.Dr.Picernosaid,“Itwaslife-changingforusjustseeingthepeopleandhearingtheirstories.”
John Von Thron, MD, anorthopaedicsurgeonwithJack-sonvilleOrthopaedicInstitute,wenttoHaitiattheendofJanuarywithaPresbyterianMinistriesteamtohelppatientsatageneralhospitalinPort-Au-Prince.Dr.VonThronprovidednon-surgicalorthopaediccareanddressingchanges.Hesaid,“Itwasquiteanamazingsighttoseepeoplefromallovertheworldhelpingout.”
Brooks Donates to Doctors Without Borders and its Haiti Recovery Efforts
BrooksRehabilitationinJacksonville,FLdonated$50,000toDoctorswithoutBorders/MedecinsSansFrontieres(MSF)tohelpfunditseffortsforHaitiduringthatcountry’sreha-bilitationandrecoverystages.
DougBaer,PresidentandCEOofBrookssaid,“WewantedtofindawaytohelpthepeopleofHaitithatwouldbetruetoourmissionof advancing thehealth andwell-beingofpersonsrequiringrehabilitation.WefeelDoctorsWithoutBorders/MSFsharethesamevaluesandwewantedtosupportthemintheiron-goingefforts.”
In emergencies, MSF provides essential health care, re-habilitatesandrunshospitalsandclinics,performssurgery,responds to epidemics, carriesoutvaccinationcampaigns,operatesfeedingprogramsformalnourishedchildren,andoffersmentalhealthcare.
Onitswebsite(www.doctorswithoutborders.org),DoctorsWithoutBordersdescribesitselfas“amedicalhumanitarianorganization” and states, “MSF is continuing to developstrategiestorespondtotheevolvingrealitiesonthegroundandserveboththeimmediateandthelonger-termneedsoftheHaitianpeople.”
Continued, page 48
How’s Haiti?Joan Huffman, MD, FACS,
Editor-in-Chief,NortheastFloridaMedicine
NinetydaysafterthehorridJanuary12earthquakethatrockedandflattenedPort-au-Prince,progressispalpabletothereturnvisitor,butinvisibletoanewinitiate.(ObservationsbasedonmyApril9-17returntriptoHospiceSt.JosephinHaiti)
Food: Thete marchant(smallmerchants)havereturned,lin-ingthestreets,eachprofferingtheirsmallquantityofgoods–mangoes,charcoal,orfly-coveredchicken.Worldaidpestersthetentcities–womenmustlineupat12midnighttoacquiretheirdailyfoodcouponandthenreturntoqueueat6AMforaday’srationofriceandbeansthattheymightreceiveby12noon.90%ofmypatientscomplainoftet fe mal, verti, vant doule(headache,dizzinessandstomachpain);inotherwords,HUNGER.AfterawhileIstopaskinghowmanymealstheyeataday–atmostoneortwo,formothers,less.Theyfeedtheirsmallportionstotheirchildren.TheHospicestaffteachesustosingtheblessingforourrice,beans,andplantaindinner,“Merci a Papa, Merci a Mama…”Wearetrulythankful.
Shelter: Thecityhasinspectedandmarkedthebuildings.Aredstampdemandsdemolition;yellowallowsrenovation;onlygreenpermitshabitation.Iseemanyredstamps.Menarmedwithpickaxes,sledgehammersandshovels,laborfromdawn
(L, top) Dr. Richard Picerno attends a Haitian patient while working at the National Hospital under the auspices of the Southern Baptist Convention. (R) Dr. John Von Thron with two Haitians he met and assisted while at a general hospital in Port-Au-Prince with a Presbyterian Ministries team. (L, bottom) Dr. Doug Johnson unloads supplies he helped fly to Haiti.
46 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
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www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 47
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AMA Leadership Dinner Reunites Friends
AttheAMALeadershipDinner,April26hostedbytheDCMS,Dr.YankD.Coble, Jr. (left, above) andDr.CecilB.Wilson(right,above)enjoyedsharingstoriesandmemoriesfromtheirmanyyearsservingorganizedmedicinetogetherthroughtheirlocalmedicalsocieties,FloridaMedicalAssociation(FMA)andtheAmericanMedicalAssociation(AMA).
Dr.Coble.apastDCMS,FMA,AMAandalsoWorldMedi-calAssociationpresident,isnowtheDirectoroftheCenterforGlobalHealthandMedicalDiplomacyattheUniversityofNorthFlorida.Dr.Wilson,apastOrangeCountyMedicalSocietyandFMApresidentisthePresident-ElectoftheAMA.
DinnerguestsheardDr.WilsonspeakabouttheAMA’sresponsetohealthcarereformandenjoyedapatioreceptionandmealatEppingForest.
48 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
todusk,takingdownthecity,concretechunkbychunk.ClustersofstakesshadedwithshowercurtainshavemorphedintoShelter-boxtentsandUSAIDtarps.
Water: InJanuary,thirstanddehydrationdroppedcitizensand volunteers. Now the monsoons have arrived. Eachnight torrential rainfall brings homeless residents to theirfeet,beddingsoakedbyrivuletsofrunoff,patchedsheltersleakinglikecolanders.
Sanitation: TentcitiesdevoidoftoiletsarenowringedwithPorta-Potties.Notbadifyoudon’tmindsharingthefacilitiesatarateof1:100.InSolino,deepinthepoorerheartofthecity,theproportionworsensexponentially.
Healthcare: Ourhosthasreopenedtheirmaternal-childclinicwhichisnowhousedinacorrugatedtinstructureboastingalimitedpharmacy,twocloset-sizedexamroomsandatiny,notyetfunctionallab.Thestaffhasreturned,theirpersonaltragediesallayed–twonurses,apharmacist,ageneralmedi-caldoctorandapediatrician.Theystruggletoprovidecarewithminimaldrugsandsupplies.
Eachmorningbeforedawn,patientslineupoutsidethecom-poundwalls,streaminat6a.m.andwait,quietly,patientlyuntiltheclinicopensat8a.m.By2p.m.theydwindleaway,wilted,weakintheafternoonsun.
HospitalGeneral,theteachinghospitalsoldierson:moreorganized but still makeshift. An admissions desk triagespatients;staffnowidentifiedbyT-shirtsratherthantape&markernametags.Pre-opandpost-opstillsheltersinlargemilitarytents.Wespendamorningatatentcityfullofor-phans,mothers,childrenandoldmen.Thereisnoevidenceofpriorhealthcarehere.
Education: Schoolsarebeginningtoreopen.Childreningingham-check dresses and shirts, reminiscent of colonialtimes,walkthroughrubbletorenovatedclassrooms.HospiceStJosephnowhostssixclassesaday,threeeachmorning,threeeachafternoon.Everystudentgetsameal,theironlyoneoftheday.Therearenobooks,justerasableboardsforteachersandrotelessons.
The People: Haitianspersevere-ChristRoiisexuberanttoseetheirblanfriendsreturn,showeringuswithdouble-cheekkisses.Webringlaughterandmerrimenttochildrenandadultsalike,includingasmallshell-shockedboywhohasn’tsmiledinthreemonths.Theygiggleatourattemptstomakeakite
A Caring Jacksonville Community Reaches Out to Haitian Amputees
John Lovejoy, MD
thatrefusestobecomeairborne;twogrownmenspendhalfadayconstructingaproperHaitiankite,neighborhoodboyssolemnlyinstructDokteEricinthefinerpointsofkiteflying.Weshareournon-perishablefoodswiththecookladies.Theyare ecstatic to receive cannedpeaches and tuna.Childrentreasureeverylittlejellybeanasitifwereagoldnugget.
SohowisHaiti?Port-au-Princemarchesalongfromravagedtoresilient.Ateenmothertriestopassherinfantthroughthebuswindow–hopingforafutureforherchild.Eachmorningat5a.m.hymnsliftoverthedestruction,prayingforstrengthforanotherday.Haitistillbleeds,andwewillreturn.
Dr. Joan Huffman dresses a wound on a patient dur-ing her first trip to Haiti. Both times in Haiti, she has worked at field hos-pitals with only primitive equipment.
Continued from p. 45
Thisisastoryaboutacaringcommunity…Jacksonville,FL.AftermakingtwotripstoHaitifollowingtheJanuary12,2010earthquakeandperformingmanyamputations,Iaskedmyself,“HowaretheHaitianpatientsgoingtodealwithalltheseamputations?”
Frommyprevioustrips,IknewhowdifficultitistogetaprosthesisinHaiti,muchlessonethatfitswell.Uponre-turningtotheU.S.,IcouldnotgetthethoughtsoutofmymindonhowtofitmyHaitianspatientswithaprosthesis.Mike Richard, CPO/LPI, President/Owner of AdvanceProsthetics&Orthotics, (APO)andIhaddealtwiththisproblembefore inGrenada,soIwenttoseehim.Inthatsituation,wehadsuccessfullyturnedashippingcontainerinto aprosthetic lab.Weknewwecoulddo it again,butthistimewedecidedtooutfitthecontainercompletelyasaworkingprostheticshop.
This iswhere the caring community comes intoplay. Imentionedthisprojecttoafewclosefriendsandtheyen-thusiasticallyjumpedonboard.
First,wehadtosecurea40-footshippingcontainer.TheJacksonvillePortAuthorityfoundusanallmetalcontainer,buttheWilliamsScotsmanCompanyofferedusaninsulatedandlightercontainerthatwasonceusedtoshippineapplesandbananasandthatScotsmanhadconvertedintooffices.IthadA/C,windowsandelectricity,soitmademoresensetogowiththisoption.SinceScotsmanreducedthepriceby80%,wecouldaffordit.Next,wecontactedSuddathRelocationServicestomoveit.Theygraciouslyofferedtheirservices.
Next,EdDoherty,retiredCOOofAtlanticMarine(AM),arrangedtotakethecontainertoAMwhereitwascleaned,painted,flooredandfittedwithanelectricpanel,outletsandlights.Icannotexpressthepridetheworkerstookinthisgratisproject.Theyinstalledthecabinets,drains,floor,trim,watersupplyandoutletandA/C.Mr.Dohertywasthereeachdaymakingsureeverythingwasdoneproperlyjustlikeitwasoneofhisownprojects.Heandhisworkerstrulytookasow’searandturneditintoasilkpurse.
www . DCMS online . org Northeast Florida Medicine Vol. 61, No. 2 2010 49
Jon M. Fletcher, a Florida Times-Union (TU) photographer took this photograph which appeared in the April 3, 2010 TU with the caption, “Retired orthopedic surgeon John Lovejoy of Jacksonville has been coordinating and laboring to complete a prosthetics lab to be shipped to Hospital Sacre Coeur in Milot, Haiti. The lab, which was built inside of a freight shipping container, would help victims of the January earthquake. Several local companies and individuals contributed to make the project possible.” Special thanks to the TU for use of this photograph, the caption, and for featuring this project in its publication.
IcalledmyfriendsatExactInc.,WillAllen,CharlieToddandBuzzyAllen, andasked them if they couldmake thestainlesssteelworkbenchesandsink.Theirreplywas,“Ofcourse!”Iofferedtopayforthematerial,buttheirsupplierdonateditasawaytosupporttheproject.Weneededasinktoputintheworkbench,andIaskedthemaintenancemanat the JacksonvilleSpecialtyHospital, andhe saidhe justhappenedtohavepulledoneoutandwasgettingreadytodisposeofit.Someonewassurelywatchingoverus!
ItseemslikeallalongthewaytheJacksonvillecommunitywantedtobeinvolved.Somuchwasdoneonfaith.Whenwepurchasedthecontainer,mychurch,AllSaintsEpiscopal,raisedthemoneytobuyit.Ipersonallyguaranteedthecostoftheequipment,andwebegantoorder,puttingitonmycharge account. Then people, too numerous to mention,cameforwardtoparticipate.Someoftheonesthattouchedmy heart were friends, patients and families whom I hadtreatedandawidowwhogavehermiteoutofloveforoth-ers.Finally,theKnightsofMaltaofferedtobecomeamajorsponsor. My personal guarantee really was not necessarybecausethecommunitysteppedforwardandshowedhowtheycaredaboutothers.
IamsureIhaveforgottensomeonewhodeservesthanks,butIwillneverforgetourcommunity’swillingnesstohelp
others.AssistancecamefromtheretailerswhodiscountedtheirgoodsandcompanieslikeHomeDepot,Sears,AdvancedFurnitureSolutions,andWalMart(whoofferedtwochairandtable sets for$50eachandthengavemea$100giftcardtopayforthem).TheJacksonvilleJaguarsandownerWayneWeaverdonatedamuchneededminiambulanceforthehospital.BoPhillipsatCannonWeldingfabricatedtheawningandDillonSignspaintedallthelogosonthelab.Thecreditlistgoesonandon.
Besidesthefinancialgifts,therewasalsoalotofdonatedtimeandlabor.MostimportanthasbeenthecommitmentofMikeRichardsandhisstaffatAPO.Theyputinlonghoursdesigning,buildingandorderingequipment.DowningNight-ingaleofLambsYachtCentermadeinhisshopthecabinetstoholdtheplasticandpaintedthestepssoitwouldlookgoodtoallwhovisited.Mike’slandlordletusparkthelabbehindhisshopandthelocalsecurityagencywatchedoveritwithcaringeyes.Finallywhenitwasfinished,SuddathmovedittoFt.LauderdaleforshippingtoCapeHaitian,Haiti.TonyMarcelli,aSanteShippingagent,gottheshippingcostwavedandhadthelabtoploadedforsafety.
It isamazingwhatacaringcommunitycandowhenitpullstogether!
50 Vol. 61, No. 2 2010 Northeast Florida Medicine www . DCMS online . org
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Jacksonville, FloridaPermit No. 2981