Fall 2012 - Volume 16 Number 4

Original Research and Contributions

Changing Risk of Perioperative Myocardial Infarction
Kenneth D Larsen, MD, PhD; Ilan S Rubinfeld, MD, MBA
Years ago, patients with recent myocardial infarction (MI) were reported to be at high risk of reinfarction (27%) and death after surgery. Using the National Surgical Quality Improvement Program Participant Use Data File for 2005 to 2009 (971,455 patients) the authors found that, of patients who had recent MI, 2.1% had reinfarction perioperatively and 26% of those died. Frailty and American Society of Anesthesiologist (ASA) class were stronger predictors of perioperative MI than was history of MI.

Predicting Risk of Death in General Surgery Patients on the Basis of Preoperative Variables Using American College of Surgeons National Surgical Quality Improvement Program Data
Sachin Vaid, MD; Ted Bell, MS; Rod Grim, MA; Vanita Ahuja, MD
From the American College of Surgeons National Surgical Quality Improvement Project Participant Use Data File (2005 to 2008), a preoperative mortality predictor (PMP) was developed to determine which preoperative variables significantly were associated with death. Of the 296,801 patients analyzed, statistically significant variables predicting death were inpatient status, sepsis, poor functional status, do-not-resuscitate directive, disseminated cancer, age, comorbidities, steroid use, and weight loss. PMP score is an accurate, simple tool for predicting operative survival or death using only preoperative variables that are readily available at the bedside.

Patient Experience and Physician Productivity: Debunking the Mythical Divide at HealthPartners Clinics
Troy J Boffeli, DPM, FACFAS; Kerri L Thongvanh, MBA; Sarah J Horst Evans, MA; Clay R Ahrens, MHA
It is a common presumption that higher productivity must entail a sacrifice in patient satisfaction or vice versa. For a large multispecialty medical and surgical practice, an observational study found discrete sets of common characteristics for physicians and staff in four quadrants of high/low productivity and high/low satisfaction. There are many physicians who excel in both high areas simultaneously.

The Uncertainty Room: Strategies for Managing Uncertainty in a Surgical Waiting Room
Anne M Stone, PhD; John C Lammers, PhD
The surgical waiting room represents the intersection of several sources of uncertainty that families experience. Staff are responsible for managing family members' uncertainty related to insufficient information. Practically, this study provided some evidence that staff are expected to help manage the uncertainty that is typical in a surgical waiting room.  Findings also illustrate how staff manage the uncertainty of families in the waiting room by communicating support.

How Do Emergency Physicians Interpret Prescription Narcotic History When Assessing Patients Presenting to the Emergency Department with Pain?
Casey A Grover, MD; Gus M Garmel, MD, FACEP, FAAEM
Pain is a common problem for which patients seek care in the Emergency Department (ED). In an anonymous survey of emergency physicians (EPs) using fictitious cases of patients presenting to the ED with back pain, 59 EP respondents most suspected drug seeking in patients with greater than 6 prescriptions per month or greater than 6 prescribing physicians in 2 months. Access to a prescription history would change EPs prescribing practice in all cases, yet interobserver reliability in the assessment of drug seeking was moderate.

Anesthesiology Leadership Rounding: Identifying Opportunities for Improvement
Dietrich Gravenstein, MD; Susan Ford, RN; F Kayser Enneking, MD
Rounding that includes participation of individuals with authority to implement changes is important to the transformation of an institution into a high-quality and safe organization. The Chief of Anesthesiology, a quality coordinator, up to four residents, the ward charge nurse, and patient nurses participated in rounds at bedsides. The introduction of leadership rounding by an anesthesiology service can identify opportunities for improving quality that are not captured by conventional efforts.

Special Report

Navigating Ethics of Physician-Patient Confidentiality: A Communication Privacy Management Analysis
Sandra Petronio, PhD; Mark J DiCorcia, PhD; Ashley Duggan, PhD
Privacy boundaries are not always clear, and patients can leave an interaction with their physicians feeling uncomfortable about the security of their private medical information. A proposed model is presented as a tool for physicians to establish a confidentiality pledge that can address issues in understanding the best way to communicate about privacy management with patients and more likely overcome potential negative outcomes.

Review Article

Evaluation and Management of Vertebral Compression Fractures
Daniela Alexandru, MD; William So, MD
An estimated 1.5 million vertebral compression fractures occur every year in the US. They are common in elderly populations and affect 25% of postmenopausal women during their lifetime. This review provides information on the pathogenesis and pathophysiology of compression fractures. Among the available treatment options, kyphoplasty and percutaneous vertebroplasty are two minimally invasive techniques to alleviate pain and correct the sagittal imbalance of the spine.

Clinical Medicine

Image Diagnosis: Ramsay Hunt Syndrome
Minh Van Le, MD
A 68-year-old woman was diagnosed in the Emergency Department with left-sided Bell's palsy, and treated with steroids. She returned two days later with left ear pain and swelling with an erythematous vesicular rash on the ear (zoster oticus). Earlier administration of steroids along with antivirals within 3 days of symptom onset results in 75% rate of full recovery.

ECG Diagnosis: Flecainide Toxicity
Joel T Levis, MD, PhD, FACEP, FAAEM
Adverse cardiac effects of Flecainide acetate, a sodium-channel blocking, antiarrhythmic agent, include: negative inotropic action and depression of all major conduction pathways—manifested as a 50% increase in QRS duration or 30% prolongation in PR interval.

Case Studies

From Morbid Obesity to a Healthy Weight Using Cognitive-Behavioral Methods: A Woman's Three-Year Process With One and One-Half Years of Weight Maintenances
James J Annesi, PhD, FAAHB; Gisèle A Tennant, MSc
Although reduced-energy (kilocalorie) eating and increased exercise will reliably reduce weight, these behaviors have been highly resistant to sustained change. A woman, age 48 years, with morbid obesity initiated exercise through a 6-month exercise-support protocol based on social-cognitive and self-efficacy theory. During the 4.4 years reported, use of self-regulatory skills, self-efficacy, and overall mood significantly predicted both increased exercise and decreased energy intake. Morbid obesity was reduced to a healthy weight within 3.1 years, and maintained through the present (1.3 years later).

A Rhinitis Primer for Family Medicine
Eric Macy, MD, MS, FAAAAI
There are four, often overlapping, syndromes or conditions that account for most of what patients perceive as "nose problems" or rhinitis: irritant rhinitis, the anterior nasal valve effect, migraine with vasomotor symptoms, and allergic rhinitis. Failure to consider all of the causes for the symptoms will result in poor clinical outcomes. The work-up and management of these common conditions is discussed in this article.


From Medical Records to Clinical Science
Mikel Aickin, PhD; Charles Elder, MD, MPH, FACP
Medical records contain an abundance of information. Increasing the information flow from medical records to clinical practice requires methods of analysis appropriate for large nonintervention studies. This article explains in nontechnical language what these methods are, how they differ from conventional statistical analyses, and why the latter are generally inappropriate: they use incorrect methods or misuse correct methods. A set of guidelines is suggested for use in nonintervention clinical research.

Electronic Medical Records Research

Analysis of Nonintervention Studies: Technical Supplement
Mikel Aickin, PhD
Methods for analyzing data in nonintervention clinical studies are substantially different from those that are appropriate for randomized clinical trials. A systematic approach for dealing with statistical confounding in nonintervention research has been developed over the past 30 to 40 years, and the essence of this theory constitutes the contents of this online only companion article to "From Medical Records to Clinical Science."

Letters to the Editor

Physician-Assisted Suicide and Euthanasia

Financial Implications of Increasing Medical School Class Size

The Health Care Professional as a Modern Abolitionist

Narrative Medicine

A Model for Humanization in Critical Care
Adriano Machado Facioli, PhD; Fábio Ferreira Amorim, MD, PhD; Karlo Jozefo Quadros de Almeida, MD
Implementing narrative medicine to assist a patient with amyotrophic lateral sclerosis, dependent on mechanical ventilation and prolonged hospitalization, led to the development of more effective communication that strengthened the therapeutic relationship, enhanced humane care practices, and resulted in greater physical and psychological comfort for the patient. The patient is viewed, not merely as a case to diagnose, but as a person with a story that evokes emotions in those who assist him or her.

Soul of the Healer

Original Visual Art

"Shere Kahn"
Shannon Sommers, MD

"Finding Mr Peanut"
Carrie Davino-Ramaya, MD

Ahmed Salahudeen

"Yosemite Colors"
Gary Larsen

On the Cover

"Botswana Lebala"
Stuart Hahn, MD


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