Ajcm winter 2014 by American Board of Physician Specialties (ABPS)

American Journal of Clinical Medicine® Owned and Published by the American Association of Physician Specialists, Inc.

Winter 2014 • Volume Ten, Number One

FEATURED IN THIS ISSUE 5

Predictability of Negative Group B Streptococcus at Time of Delivery in Pregnant Women Who Were Negative at 35-37 Weeks

Positive Predictive Value of D-dimer in Diagnosing Pulmonary Embolism in Patients With No Risk Factors

Comparison of Delivery Procedure Rates Among Obstetrician-Gynecologists and Family Physicians Practicing Obstetrics

Older Patients’ Perception and Experience with Lifestyle Changes Following Cardiac Revascularization

Ocular Manifestations of Domestic Violence: A Case Review

AJCM

Comparison of Delivery Procedure Rates Among Obstetrician-Gynecologists and Family Physicians Practicing Obstetrics Daniel M. Avery, Jr, MD Kristine R. Graettinger, MD Shelley Waits, MD Jason M. Parton, PhD

In This Issue EDITORIAL Family Medicine Obstetrics: A Wide Spectrum of Training and Practice

Predictability of Negative Group B Streptococcus at Time of Delivery in Pregnant Women Who Were Negative at 35-37 Weeks

26 5

Dwight E. Hooper, MD, MBA Caneita Creighton, MD Salah Al-Abbadi, MD Thomas W. Broughton, MD Jessica Grayson, BS

Positive Predictive Value of D-dimer in Diagnosing Pulmonary Embolism in Patients With No Risk Factors

Held September 12-14, 2012, Nunziatella Military School, Naples, Italy

Rostislav Kostadinov, MD, PhD

SOUNDING BOARD Minimalism and the Promotion of Substandard Medical Care: A Lawrence, Kansas Perspective Bruce Rothschild, MD

Older Patients’ Perception and Experience with Lifestyle Changes Following Cardiac Revascularization Lufei Young, PhD, RN, APRN-NP Susan Barnason, PhD, RN, APRN-CNS, CCRN, CEN, FAHA

8 40

Kishore Yellumahanthi, MD, MPH John B. Waits, MD Melanie Tucker, PhD Sarah Gilmore

Summary of the International Scientific Conference “Civil Military Cooperation Enhancing Combat Trauma System and Disaster Medical Management Capabilities”

Daniel M. Avery, Jr, MD Shelley Waits, MD Jason M. Parton, PhD

Mark T. Loafman, MD, MPH

Comparison of Delivery-Related Complications Among ObstetricianGynecologists and Family Physicians Practicing Obstetrics

Ocular Manifestations of Domestic Violence: A Case Review Anjulie Kelkar, BS W. Abraham White, MD Omofolasade Kosoko-Lasaki, MD, MSPH, MBA, FAASS

Medical Ethics Without the Rhetoric Mark Pastin, PhD

American Association of Physician Specialists, Inc.® 5550 West Executive Drive Suite 400 Tampa, Florida 33609-1035 Phone: 813-433-2277 Fax: 813-830-6599 www.aapsus.org

AAPS Board of Directors Daniel M. Avery, MD, FAASS Terrance Lee Baker, MD, MS Scott G. Barnes, DO, FAAIM A. Robert Cerrato, DO, JD Kenneth M. Flowe, MD, FAAEP, MBA Jeffrey T. Follansbee, MD Joseph C. Gallagher, DO, FAASOS Joe Ford Jacobs, MD Surinder K. Kad, MD, FAAIM, MPH, MBA Karl David Kelley, MD Douglas L. Marciniak, DO, FAAIM Stephen A. Montes, DO, FAASOS Asaf R. Qadeer, MD Madonna S. Ringswald, DO, FAAIM Roger Rousseau, MD Anthony P. Russo, Jr., DO, FAAA Craig S. Smith, MD Louis W. Sullivan, MD Martin E. Thornton, DO Kenneth A. Wallace, III, MD

elcome to the American Journal of Clinical Medicine® (AJCM®). The Journal is dedicated to improving the practice of clinical medicine by providing up-to-date information for today’s practitioners. The AJCM is the official journal of the American Association of Physician Specialists, Inc. (AAPS), an organization dedicated to promoting the highest intellectual, moral, and ethical standards of its members, and whose diversity incorporates physicians that represent a broad spectrum of specialties including anesthesiology, dermatology, diagnostic radiology, disaster medicine, emergency medicine, family medicine obstetrics, family practice, geriatric medicine, hospital medicine, internal medicine, obstetrics and gynecology, ophthalmology, orthopedic surgery, plastic and reconstructive surgery, psychiatry, radiation oncology, general surgery, and urgent care medicine. Part of the mission of the AAPS is to provide education for its members and to promote study, research, and improvement of its various specialties. In order to further these goals, the AJCM invites submissions of high-quality review articles, clinical reports, case reports, or original research on any topic that has potential to impact the daily practice of medicine. Publication of a peer-reviewed article in the AJCM is one of the criteria needed to qualify for the prestigious Degree of Fellow in the Academies of Medicine of the AAPS. Articles that appear in the AJCM are peer reviewed by members with expertise in their respective specialties. Manuscripts submitted for publication should follow the guidelines in The International Committee of Medical Journal Editors: “Uniform requirements for manuscripts submitted to biomedical journals” (JAMA, 1997; 277:927-934). Studies involving human subjects must adhere to the ethical principals of the Declaration of Helsinki, developed by the World Medical Association. By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of their article that might create any potential conflict of interest. More detailed information is included in the AJCM Manuscript Criteria and Information on pages 50 and 51. All articles published, including editorials, letters, and book reviews, represent the opinions of the authors and do not reflect the official policy of the American Association of Physician Specialists, Inc., or the institution with which the author is affiliated, unless this is clearly specified. ©2014 American Journal of Clinical Medicine® is published by the American Association of Physician Specialists, Inc.

AAPS Staff

All rights reserved. Reproduction without permission is prohibited. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by the American Journal of Clinical Medicine® and the American Association of Physician Specialists, Inc.

William J. Carbone Chief Executive Officer Andrea Balboa Cook Assistant Director of Certification Christina B. Stebbins Manager of Test Development Karen B. Duchane Certification Coordinator Jillian C. Nelson Certification Coordinator Marilyn D. Whitfield Certification Coordinator Anthony J. Durante Director of Finance & Operations Jackie R. Parker Finance Coordinator Keely M. Clarke Director of CME, Meetings & Membership Debi S. Colmorgen CME, Meetings & Membership Coordinator Jeffery L. Morris, Jr., JD Director of Communications & External Affairs Lauren E. Withrow External Affairs & Public Relations Communications Specialist James G. Marzano Director of Public Relations & Marketing

Editor-In-Chief

Wm. MacMillan Rodney, MD, FAAFP, FACEP

Senior Editor

Kenneth M. Flowe, MD, FAAEP, MBA

Managing Editor Keely M. Clarke

Editorial Board

Harold M. Bacchus, Jr., MD, FAASFP Robert Jean Ferry, Jr., MD Michael K. Garey, MD Surinder K. Kad, MD, FAAIM, MPH, MBA Leslie Mukau, MD, FAAEP, FACEP Thomas G. Pelz, DO, FAAIM

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Moonstruck Marketing Group, Inc.- Kim Patterson www.moonstruckmarketing.com

Cover Imagery

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AJCM is peer reviewed

AJCM

Welcome to the first digital-only issue of theAmerican Journal of Clinical Medicine® (AJCM®)The transition to digital-only publication allows for full-color pages throughout the Journal, searchable text, clickable web links, and ease of access to content. Readers will notice more easily readable tables, charts, graphs, and diagrams. Since 1975, my goals have been to provide exemplary continuing health care for my patients and outstanding educational experiences for my students, residents, and colleagues. It has been an honor to serve as editor of the American Journal of Clinical Medicine (AJCM) since 2009. As an author and/or editor for over 200 publications from 1977 to the present, my compliments to previous editors, authors, and staff for establishing and maintaining the AJCM. Thank you. Authors who produce quality manuscripts must be solicited, encouraged, nurtured, and published. Writing is a labor of love. The only thing more difficult than writing is rewriting. Welcome to the world of publication. All will benefit through the prosperity of the AJCM enterprise. In 2009, I proposed a circular hierarchy of seven activities. These activities are patient care, education, scholarship, administration, ambassadorship, leadership, and legacy. WE must fund our efforts and make the transition to multimedia via the internet and explore a global outreach. Spanish translation should be explored, and, if reasonable, posted. This will strengthen AAPS and ABPS recognition. The AJCM is now being cited as part of the international community of scholars. Beginning in 2009, AJCM issues have been indexed on Google Scholar and BioMedLib. These internet search engines are more extensive than PubMed. This gives published authors international recognition as achieving a universal academic standard of excellence. With this membership, the AJCM joins the major leagues of science, and published work will last as long as our civilization does. The AJCM was cited by the AAFP in 2012 and 2013. There are so many worthy causes, but the AJCM should be a journal which emphasizes the issues which make the AAPS important for physicians who have been challenged by training cartels and economic credentialing monopolies. Our research should demonstrate the role of privilege based on MERIT. The AAPS and the AJCM will develop a nationally recognized leadership position through recognition of its authors and their published research. Without grants or charity, these physicians fund teaching programs and clinical research encompassing almost all of the established specialties. The AJCM will ask for support in developing the AJCM as a medical journal offering useful information for the practicing physician.

To do in 2014 and beyond:

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Continue application for membership in PubMed

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Propose standing features as a strategy for author recruitment

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Mission/Rural Medicine

a. Fractures to Manage

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Point-of-Care Ultrasonography Ecografia/Obstetricia/Trauma/Cirugia

b. Chest Radiograph Interpretation

c. ECG Interpretation

d. Competency Drills in Fetal Monitoring

e. Office Surgery

f. Anesthesia

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Dermatology Quiz

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Patient Centered Medical Home (Spanish - Centro Diagnostico)

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iPad/iPhone Tips and Tricks

On a final note, I would like to join AAPS in welcoming the founding members of the recently developed American Board of Integrative Medicine (ABOIM). The founding board members of ABOIM are all recognized authorities in diverse specialties from both academia and the private sector. The ABOIM offers qualified physicians an accepted way to demonstrate their mastery of knowledge, competencies, experience, and commitment to the field of integrative medicine. The first ABOIM certification examination will be held in May. I look forward to this Board’s contributions to the AJCM and the entire AAPS organization.

Wm. MacMillan Rodney MD, FAAFP, FACEP Editor, American Journal of Clinical Medicine® Vice-Chair, Board of Certification in Family Medicine Obstetrics CEO, Medicos para la Familia

“Medicos - where 10 percent of the information makes over 90 percent of the difference and where, through Grace, twice the service is provided at less than half of the cost.”

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

EDITORIAL Family Medicine Obstetrics: A Wide Spectrum of Training and Practice Optimal maternal child health outcomes depend in part on access to providers who are prepared to manage complications that not uncommonly arise during pregnancy and childbirth, including surgical delivery when indicated. While there is room to improve our knowledge about the indications for cesarean section, there is no doubt that this procedure is at times a necessary and even life-saving procedure for some women and infants. A physician with the skill, training, and experience needed to care for the majority of perinatal clinical needs, including surgical intervention, is a vital resource for any community. In some practice settings, family physicians manage the full scope of perinatal care including operative delivery. Family physicians with advanced skill and training provide full-scope maternity care in settings where obstetricians act either as peers or as supervising physicians and also in settings where there are no obstetricians. In fact, a recent survey revealed that roughly half the counties in America lack even a single obstetrician. Family physicians have long been and continue to be a critical part of the maternity care workforce, often locating in areas where others do not. Advance practice providers and midwives, in particular, are known for providing much needed maternity care services and are well-established members of the health workforce. However, the scope of practice for midwives does not include surgical or advanced medical complications. In almost every setting, pregnancy and childbirth includes ready access to a safe and timely surgical intervention. Two papers in this issue of the Journal look critically at the care provided by family physicians in comparison to obstetricians practicing in the same institution. The authors report on several commonly observed quality and outcome indicators for maternity care in a setting where obstetricians and family physicians with advanced training in maternity care practice alongside one another as peers. Surveillance of standard quality measures is the usual and customary method of assessing provider performance and is considered a proxy for assessing the competency of practicing clinicians. The authors’ conclusions from the data presented both support and help to replicate several other studies, which have looked at similar measures in other practice settings. These two papers are timely amidst the current debate on the role of maternity care as a core family medicine competency. This is of particular concern in the context of three converging physician workforce trends among obstetricians: 1) increasing movement among residency graduates to non-delivering subspecialties, 2) an exodus from maternity care among senior physicians, and 3) a tendency for practicing obstetricians to choose practice locations in populated, already-served locales. From a population health perspective, there is simply no question that we need some family physicians with the skill and

training needed to provide full-scope maternity care. Preparing physicians to provide family medicine obstetrics, however, has proven to be easier said than done. An array of barriers and competing interests have coalesced to make maternity care among the most challenging issues for many family medicine training programs, where experiences are not uncommonly described as hostile or toxic. At the heart of this debate is an unsustainably wide range of maternity care practice and experience among family medicine training programs. On one end of this spectrum, we have family physicians whose maternity care ended after satisfying the minimum exposure provided during residency. On the other end of the spectrum, we have fellowship or equivalently trained family physicians practicing full-scope family medicine obstetrics with skill and privileging equivalent to that of obstetricians. Regardless of the eventual outcome in terms of national training standards, it is likely that the ongoing needs in the maternity care workforce will generate an increased emphasis on programs and institutions offering advanced training in family medicine obstetrics. Considering the realities in both health profession training and the distribution and supply of our physician workforce, it seems clear that we will continue to see a scope of family medicine maternity care ranging from inconsequential on one end to essential on the other. Simply put, a one-size-fits-all approach to maternity care training, practice, certification, and privileging does not meet the need and is no longer applicable. Family medicine is a comprehensive, family-centered specialty. Family physicians are uniquely prepared to care for women and infants and are far more likely than obstetricians and pediatricians to make underserved settings a vocationally desired destination. As a result, family physicians are not only uniquely prepared to provide an essential and much needed scope of care, but in many communities they are the only providers available to do so. It is difficult to imagine a more readily attainable and clinically effective solution to the workforce aspects of disparate outcomes than increasing the number of family physicians who provide full-spectrum maternal child health care. The need for rigorous training and evidence-based assessment of quality and performance has never been greater. All the more reason to study the descriptive and observational data from family medicine obstetrics as reported in this issue of the Journal. Mark T. Loafman, MD, MPH Chair, Board of Certification in Family Medicine Obstetrics

Editorial

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Predictability of Negative Group B Streptococcus at Time of Delivery in Pregnant Women Who Were Negative at 35-37 Weeks Dwight E. Hooper, MD, MBA Caneita Creighton, MD Salah Al-Abbadi, MD Thomas W. Broughton, MD Jessica Grayson, BS

Introduction Group B streptococcus (GBS), also known as Streptococcus agalactiae, is the leading cause of neonatal morbidity and mortality in the United States. Early-onset GBS disease (EOGBS) in newborns occurs within the first week of life. Clinical syndromes associated with EOGBS include meningitis, pneumonia, and sepsis, which can ultimately lead to death. Neonates acquire GBS colonization or infection from the mother, whose primary sources of GBS vaginal and rectal colonization are the gastrointestinal and genitourinary tracts, respectively.7,32,33 Although asymptomatic, 6-45% of pregnant women have GBS rectal and/or vaginal colonization.4,8-13 The pathogen GBS is transmitted vertically from GBS-positive mothers to their babies. Only 1-3% of colonized infants develop severe syndromes; however, approximately 30-70% of infants born to GBS positive mothers become transiently colonized by the pathogen.6,23,26,28,30,35,36 In 2002, the Centers for Disease Control and Prevention (CDC) published updated guidelines advising all pregnant women be screened at 35-37 weeks’ gestation for vaginal and rectal GBS colonization. The gold standard for GBS identification is enrichment followed by subculture. Women with positive cultures, in addition to women with GBS bacteriuria anytime during pregnancy or who had a previous infant affected by GBS, receive intrapartum antibiotic prophylaxis (IAP). Although the incidence of EOGBS disease has declined 27% since the implementation of the current guidelines for IAP administration, EOGBS cases

continue to occur.6,7,28 This culture-based screening during the third trimester was found to be 50% more effective than other possible screening options for identifying maternal GBS colonization. However, GBS colonization is transient during pregnancy, and increased intervals between screening and delivery decreases the positive predictive value (PPV) for GBS cultures, especially when the interval exceeds six weeks; negative predictive value (NPV) remains unchanged.4,5,7,17-21 Many of the reported cases of EOGBS occur in infants whose mothers had negative cultures at 35-37 weeks’ gestation or in preterm infants born before their mothers could receive the recommended universal screening.1,5 To address these missed cases, in 2010 the CDC revised the guidelines to include separate algorithms for threatened preterm delivery and true preterm labor. The need for improved laboratory screening methods was also addressed in this revision with a detailed procedure for specimen collection and processing. These revisions are hoped to decrease the incidence of EOGBS in preterm infants who have an increased risk of morbidity and mortality from the disease7 and to improve the accuracy of the current recommended prenatal screening.6,26,27,31 With knowledge of the transiency of GBS colonization, the revision does not address the pregnant women that become positive after the culture-based screening at 35-37 weeks’ gestation. The objective of this study is to evaluate the reproducibility of a negative GBS culture at the initiation of labor in a single, small maternity service in West Alabama.

Predictability of Negative Group B Streptococcus at Time of Delivery . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Materials Liquid Stuart media Todd-Hewitt CNA (Lim) broths Columbia CNA Agar with 5% sheep blood plate

Methods Study Population This study enrolled 30 pregnant women who presented to DCH Regional Hospital (Tuscaloosa, Alabama) at term with expected delivery of their pregnancy during that presentation. Approval of the study as designed was obtained from the Institutional Review Board of DCH Regional Hospital prior to enrolling subjects. Each enrolled patient had received her prenatal care with our group at the University of Alabama School of Medicine-Tuscaloosa. Each enrolled patient had had an ultrasound no later than the second trimester of her pregnancy, and gestational age was determined using a combination of last menstrual period and the earliest ultrasound examination. Per our clinic’s prenatal care protocol, each patient had had a lower genital tract culture for screening of group B streptococcus (GBS) colonization. This culture was obtained between 35 and 37 completed weeks’ gestation. Patients that failed to keep scheduled appointments between 35 and 37 weeks’ gestation were excluded from this study. Each of the enrolled patients had a negative GBS culture between 35 and 37 weeks. These prenatal cultures were variously obtained by a medical student, a resident physician, or an attending physician. The enrolled patients that presented for delivery had the GBS culture repeated upon their hospitalization. The repeat culture was obtained during one of their cervical examinations or at the time of delivery. In many instances the culture was obtained following the patient having received epidural anesthesia. The intrapartum culture was obtained by either a post-graduate fellow physician or attending physician. Written consent was obtained for intrapartum GBS testing in English and in Spanish. Patients who did not speak English or Spanish were excluded from the study.

Study Protocol After obtaining informed consent, GBS swabs were collected from the lower vagina and anus of pregnant women at 3537 weeks by the attending physician, resident physician, or medical student that had been taught how to collect GBS specimens. Each culturette was placed in liquid Stuart media made of calcium chloride, mercaptoacetic acid, and sodium glycerophosphate. The samples were brought to the lab within 24 hours and were inoculated into Todd-Hewitt CNA (Lim) broths. The broths were then placed in an incubator at 3537°C for 24 hours. Standard protocol was then followed for GBS screening via Columbia CNA agar. The plates were then assessed for hemolysis. The patients who tested negative for group B streptococcus colonization were re-tested at the time of delivery irrespective of rupture of membranes via the same

method to determine current group B streptococcus status by the attending physician or post-graduate fellow physician. The intrapartum cultures were delivered to the laboratory as soon as possible following collection. However, this could be as many as 60 hours in instances where the culture was obtained on a Friday afternoon then delivered to the laboratory on a Monday morning. The swabs were stored in a safe area from Friday afternoon till Monday morning. This delay could have possibly changed the outcome of the study. Such delay could potentially make even more negative GBS culture results that, if handled more expeditiously, might have been, in fact, positive.

Results Based on the study criteria of having received prenatal care at our center, having a negative group B streptococcus culture obtained between 35 and 37 weeks gestational age, and consenting to have a repeat group B streptococcus culture when in active labor, a total of 30 patients were enrolled in this study. The consent was obtained following admission to the hospital as the patient was either in labor or scheduled for induction of labor. Of these 30 patients, 9 had positive Group B streptococcus cultures when the culture was repeated as the patient was in labor. Nine of thirty or 30% of the patients with negative cultures at gestational age 35-37 were found to be Group B streptococcus positive at the time of labor.

Discussion We do have an understanding of the transience of the discoverability of the presence of GBS in the female lower genital tract; however, we have come to rely upon a negative culture when obtained between 35 and 37 completed weeks. This current study reveals that that reliance was misplaced as often as 30% of the time. Thus, 30% of the women included in this study did not receive prophylactic antibiotics against GBS to protect their newborn infants from EOGBS. Although this study was performed in a small maternity service, if the current guidelines are unreliable 30% of the time, we need more effective screening measures to decrease the risk to neonates at the time of delivery. One way to help ensure that a pregnant woman’s GBS status is reliable is to screen for colonization at the onset of labor. We need a cost effective, rapid screening method in order to properly care for our patients. With a rapid screening method in place, we will be able to provide antibiotic prophylaxis only to women that are GBS positive. This measure will reduce unnecessary exposure to antibiotics that can result in antibiotic tolerance. Thus, in order to better predict a woman’s GBS status at the time of delivery we need better screening methods in place. The development of a cost effective, rapid screening method will decrease the risk of EOGBS in preterm and term neonates; decrease the risk of antibiotic resistance; and, in the long term, decrease costs. This study did not compare rapid testing verses traditional testing. This study was to see if mothers who tested negative at 35-37 weeks were GBS positive at delivery. Through the before mentioned results, it was found that 30% of negative mothers were later found to be positive.

Predictability of Negative Group B Streptococcus at Time of Delivery . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Potential Financial Conflicts of Interest: By AJCM® policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist.

Dwight E. Hooper, MD, MBA, is Professor of Obstetrics and Gynecology at the University of Alabama School of Medicine. Caneita Creighton, MD, is Pediatrics Resident Physician at Baylor College of Medicine. Salah Al-Abbadi, MD, is a Family Medicine and Obstetrics Physician in Grove Hill, Alabama. Thomas W. Broughton, MD, is Family Medicine Obstetrics Fellow at the University of Alabama School of Medicine. Jessica Grayson, BS, is a fourth-year medical student at the University of Alabama at Birmingham School of Medicine.

References 1.

Pupolo KM, Madoff LC, Eichenwald EC. Early-Onset Group B Streptococcal Disease in the Era of Maternal Screening. Pediatrics. 2005;115:1240-46.

Boyer KM, Gadzala CA, Kelly PC, et al. Rapid Identification of Material Colonization with Group B Streptococci by Use of Fluorescent Antibody. J Clin Microbiol. 1981;14:550-56.

Kaanbwa B, Bryan S, Gray J, et al. Cost-effectiveness of rapid tests and other existing strategies for screening and management of early-onset group B streptococcal during labour. BJOG. 2010;117:1616-1627.

Valkenburg-van den Berg AW, Houtman-Roelofson RL, Oostvogel PM, et al. Timing of Group B Streptococcus Screening in Pregnancy: A Systematic Review. Gynecol Obstet Invest. 2010;69:174-183.

Helalil NE, Nguyen JC, Ly A, et al. Diagnostic Accuracy of a Rapid RealTime Polymerase Chain Reaction Assay for Universal Intrapartum Group B Streptococcus Screening. Clin Infect Dis. 2009;49:417-23.

14. Boyer KM, Gadzala CA, Kelly PD, Burd LI, Gotoff SP. Selective intrapartum chemoprophylaxis of neonatal group B streptococcal earlyonset disease. II. Predicative value of prenatal cultures. J Infect Dis. 1983;148:802-809. 15. Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep. 2002;51:1-22. 16. Easmon CS, Hastings MJ, Neill J, Bloxham B, et al. Is group B streptococcal screening during pregnancy justified? Br J Obstet Gynaecol. 1985;92:197-201. 17. Yancey MK, Schuchat A, Brown LK, Ventura VL, Markenson GR. The accuracy of late antenatal screening cultures in predicting genital group B streptococcal colonization at delivery. Obstet Gynecol. 1996;88:811-815. 18. Goodman JR, Berg RL, Gribble RK, et al. Longitudinal study of group B streptococcus carriage in pregnancy. Infect Dis Obstet Gynecol. 1997;5:237-243. 19. Anthony BF, Okada DM, Hobel CJ, et al. Epidemiology of group B Streptococcus: longitudinal observation during pregnancy. J Infect Dis. 1978;137:524-530. 20. Yow MD, Leeds LJ, Thomspon PK, et al. The natural history of group B streptococcal colonization in the pregnant woman and her offspring. I. Colonization studies. Am J Obstet Gynecol. 1980;137:34-38. 21. Centers of Disease Control and Prevention. Prevention of perinatal group B streptococcal disease: revised guidelines from CDC. MMWR Recomm Rep.. 2002;51(RR-11)1-22. 22. Goodman JR, Berg RL, Gribble RK, et al. Longitudinal study of group B streptococcus carriage in pregnancy. Infect Dis Obstet Gynecol. 1997;5:237-43. 23. Baker C, Stevens DL, Kaplan EL, et al. Group B streptococcal infections. In Streptococcal infections. New York, NY: Oxford University press, 2000; 222-237. 24. Centers for Disease Control and Prevention. Perinatal group B streptococcal disease: a public health perspective. MMWR Recomm Rep. 1996;45(RR-7):1-24. 25. Schrag SJ, Zell ER, Lynfield R, et al. A population-based comparison of strategies to prevent early-onset group B streptococcal disease in neonates. N Engl J Med. 2002;347:233-9.

Melin P. Neonatal group B streptococcal disease from pathogenesis to preventive strategies. Clin Microbiol Infect. 2011;17:1924-303.

26. Centers for Disease Control and Prevention. Perinatal group B streptococcal disease after universal screening recommendations-United States, 2003-2005. MMWR Morb Mortal Wkly Rep. 2007;56:701-705.

Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease - revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010;59(RR-10):32.

28. Verani JR, Schrag SJ. Group B streptococcal disease in infants: progress in prevention and continued challenges. Clin Perinatol. 2010; 37:375-392.

27. Van Dyke MK, Phares CR, Lynfield R, et al. Evaluation of universal antenatal screening for group B streptococcus. N Engl J Med. 2009;260:2626-2636.

Valkenburg-van den Berg AW, Sprij AJ, Oostvogel PM, et al. Prevalence of colonisation with group B Streptococci in pregnant women of a multiethnic population in The Netherlands. Eur J Obstet Gynecol Reprod Biol. 2006;124:178-183.

29. Bergeron MG, Menard C, et al. Rapid detection of group B streptococci in pregnant women at delivery. N Engl J Med. 2000;343:175-9.

Ferrieri P, Cleary PP, Seeds AE. Epidemiology of group B streptococcal carriage in pregnant women and newborn infants. J Med Microbiol. 1977;10:103-114.

31. Poyart C, Reglier-Poupet H, Tazi A, et al. Invasive Group B streptococcal infections in infants, France. Emerg Infect Dis. 2008;14:1647-1649.

10. Dillon HC Jr, Gray E, Pass MA, Gray BM. Anorectal and vaginal carriage of group B streptococci during pregnancy. J Infect Dis. 1982;145:794-799. 11. Bergseng H, Bevanger L, Rygg M, Bergh K. Real time PCR targeting the sip gene for detection of group B Streptococcus colonization in pregnant women at delivery. J Med Microbiol. 2007;56:223-228. 12. Gavino M, Wang E. A comparison of a new rapid real-time polymerase chain reaction system to traditional culture in determining group B streptococcus colonization. Am J Obstet Gynecol. 2007; 197:388.el-4. 13. Barcaite E, Bartusevicius A, Tameliene R, et al. Prevalence of maternal group B streptococcal colonization in European countries. Acta Obstet Gynecol Scand. 2008;87:260-271.

30. Heath PT, Schuchat A. Perinatal group B streptococcal disease. Best Pract Res Clin Obstet Gynecol 2007;21:411-24. Epub 2007 Mar 2.

32. Phares CR, Lynfield R, Farley MM, et al. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA. 2008;299:2056-65. 33. Schrag SJ, Zywicki S, Farley MM, et al. Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis. N Engl J Med. 2000;342:15-20. 34. Yancey MK, Schuchat A, Brown LK, et al. The accuracy of late antenatal screening cultures in predicting genital group N streptococcal colonization at delivery. Obstet Gynecol. 1996;88:811-5. 35. Boyer KM, Gotoff SP. Prevention of early-onset neonatal disease with selective intrapartum chemoprophylaxis. N Engl J Med. 1986;314:16651669. 36. Schuchat A. Group B streptococcus. Lancet. 1999;353:51-6.

Predictability of Negative Group B Streptococcus at Time of Delivery . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Positive Predictive Value of D-dimer in Diagnosing Pulmonary Embolism in Patients With No Risk Factors Kishore Yellumahanthi, MD, MPH John B. Waits, MD Melanie Tucker, PhD Sarah Gilmore

Abstract Serum D-dimer measurement is the most common screening test used to diagnose venothromboembolic disorders that constitute pulmonary embolism (PE) and deep venous thrombosis (DVT). D-dimer testing has high sensitivity but poor specificity to detect venous thromboembolism (VTE). Therefore, D-dimer testing for VTE is associated with high false positives. Based on an elevated D-dimer, vast numbers of patients who have no risk factors are routinely worked up for PE with a battery of tests, including computed tomographic angiography (CTA) of the chest which exposes patients to significant radiation. We are not certain whether this elaborate workup is warranted in this subset of population with no risk factors. To address this concern, it was felt that knowing positive predictive value (PPV) of D-dimer in predicting PE in patients with no risk factors would be helpful. However, to our knowledge, no studies were documented in the literature assessing PPV in those with no risk factors for PE. Hence this study was designed.

Objective:

To assess the PPV of Liatest D-dimer assay used at Druid City Hospital (DCH), Tuscaloosa, Alabama, in diagnosing PE among patients who have no risk factors based on revised Geneva score.

Methods:

A retrospective chart review of family medicine patients with an elevated D-dimer seen from January 1, 2010, to December 31, 2010, at DCH, Tuscaloosa, Alabama, was per-

formed. Based on revised Geneva score, patients without any risk factors were identified. Prevalence of PE in this subset of the population was calculated.

Results: There were 170 patient encounters with elevated D-

dimer during the study period. Among those, based on revised Geneva score, 19 patients had zero risk factors and none of them had PE. We recommend future studies to explore this more in depth. If future studies confirm this study’s findings, new strategies may have to be implemented regarding the approach of PE workup in this subset of population with no risk factors.

Introduction Serum D-dimer measurement is the most common screening test used to diagnose venothromboembolic disorders that constitute pulmonary embolism (PE) and deep venous thrombosis (DVT). Plasma D-dimers are cross-linked fibrin derivatives produced when fibrin is degraded by plasmin. In general, Ddimer testing has high sensitivity but poor specificity to detect venous thromboembolism (VTE) as D-dimer can be elevated in any condition that causes activation of coagulation pathways, such as pregnancy, severe infection, liver disease, surgery, trauma, malignancy, ischemic heart disease, stroke, peripheral arterial disease, and advanced age.1 As a result, D-dimer testing for VTE is associated with high false positives.

Positive Predictive Value of D-dimer in Diagnosing Pulmonary Embolism . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

It is not uncommon for physicians to encounter patients with virtually no risk factors for PE and who may not have needed to have a D-dimer test done in the first place but ended up having one and it is elevated. In such scenarios, although it is known that D-dimer is associated with high false positives, physicians often find themselves obligated to perform an extensive work up to rule out PE because of concerns of medico-legal issues. Given the high occurrences of such situations, routinely based on an elevated D-dimer, vast numbers of patients with no risk factors are being worked up for PE. The work up often involves a battery of investigations including computed tomographic angiography (CTA) of the chest, an invasive test that exposes the patients to a significant amount of radiation. We are not certain whether this elaborate workup is warranted in this subset of population with no risk factors. With this background, it was felt that knowing positive predictive value (PPV) of D-dimer in predicting PE in patients with no risk factors would be helpful. However, to our knowledge, no studies were documented in the literature assessing PPV in those with no risk factors for PE. Hence this study was designed.

Objective The objective of this study was to assess the positive predictive value of Liatest D-dimer assay used at Druid City Hospital (DCH), Tuscaloosa, AL, in diagnosing PE among patients who have no risk factors based on revised Geneva score.

Table 1: Revised Geneva score

Age 65 years or over Previous DVT or PE Surgery or fracture within one month Active malignant condition Unilateral lower limb pain Haemoptysis Heart rate 75 to 94 beats per minute Heart rate 95 or more beats per minute Pain on deep palpation of lower limb and unilateral edema

D-dimer Assay D-dimer levels are determined by Liatest assay at DCH, Tuscaloosa. It is an automated quantitative immunoturbidimetric assay. The assay is performed with the use of Diagnostica Stago kits. Based on normal-range studies performed across our health system, the Department of Pathology at our institution established a value of 420 ng/mL as the cutoff for venous thromboembolism. This standard cutoff value for the D-dimer assay is lower than that suggested by the manufacturer (500 ng/mL). Results were reported from the laboratory within approximately 20 minutes. The study was approved by the Institutional Review Boards of both University of Alabama and DCH, Tuscaloosa.

Methods A retrospective chart review of family medicine patients with an elevated D-dimer seen from January 1, 2010, to December 31, 2010, at DCH, Tuscaloosa, AL, was performed. Exclusion criteria included patients younger than 18 years old and pregnant women. Of the patients who had an elevated D-dimer using revised Geneva score, patients with no risk factors for PE were identified. While both Wells criteria and revised Geneva Score are commonly used to employ the pre-test probability, we found it is more practical to use revised Geneva score since one of the criteria of Wells criteria is “alternative diagnosis is less likely than PE” which we feel is very subjective. Therefore, we preferred revised Geneva score. The risk factors used in revised Geneva score are age 65 years or over, previous DVT or PE, surgery or fracture within one month, active malignant condition, unilateral lower limb pain, haemoptysis, heart rate 75 or more beats per minute, pain on deep palpation of lower limb, and unilateral edema.2 Prevalence of PE was calculated among these patients without any risk factors. PE was ruled out with CTA of the chest or ventilation-perfusion (V/Q) scan. In patients who did not have either of them, we ruled out PE based on three-month follow up. Table 1 shows the parameters used in revised Geneva score. SAS version 9.2 was used for data analysis.

Results There were a total of 170 patient encounters with elevated D-dimer during the study period. The mean age was 58.5 years. Females composed 76.4% of patient encounters. Of these patients, 55.3% were African American and the rest were Caucasian. Of these patients, 19 qualified to have zero risk factors based on revised Geneva score. Of the patients with zero risk factors, 63.2% were female, 89.5% were African-American, and 10.5% were Caucasian. The median heart rate was 72 beats per minute. The median age was 53 years (range: 23-62 years) and none had PE. Table 2 shows the description of these patients. Table 2: Description of patients without any risk factors based on revised Geneva score

Gender

Females: 12 (63.2%)

Median Age

53 (Range: 23-62)

Race

African American: 17 (89.5%) Caucasians: 2 (10.5%)

Median Heart Rate 72 beats per minute D-dimer

0.83 (0.43-2.29)

Positive Predictive Value of D-dimer in Diagnosing Pulmonary Embolism . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Discussion Since D-dimer was introduced as a screening test for VTE, it has been widely used because of its high negative predictive value, ease of administration, and short time for reporting results. These advantages have masked the fact that it has a very low positive predictive value. Because of its very low PPV and its wide usage, large numbers of false positives occur. The increased number of false positives has resulted in excessive workup of PE with a battery of investigations including chest CTA. Although pulmonary angiography is currently the gold standard to diagnose PE, chest CTA is commonly used to diagnose PE. The current literature shows that chest CTA involves an effective radiation dose of 3 - 5 mSv, which is equivalent to one to two years of background radiation exposure. The lifetime attributable risk of lung cancer from this exposure can be anywhere from 38 to 118 cases per 100,000 patients depending on age and gender. The risk of breast cancer is also not negligible, especially in young women who have a risk as high as 503 per 100,000 excess cases.3 In addition to radiation hazards, contrast-induced nephropathy occurs in 6.5% to 19% of patients who undergo chest CTA.4 The fact that most of those who were subjected to CTA based merely on an elevated D-dimer were not having PE prompted some authors to recommend usage of CTA based on clinical risk stratification and not solely based on an elevated D-dimer.5,6 Chopra et al6 have assessed the diagnostic and financial yield of D-dimer in diagnosing PE. It is noteworthy that the PPV of 4.2% reported by Chopra et al is for all patients who had an elevated D-dimer and no value was mentioned based on clinical stratification. The authors also mentioned that “tests ordered based on elevated D-dimer values were billed for more than $200,000.” Based on this, the authors concluded that “the current diagnostic approach has been medically and financially inefficient. Patients should not be worked-up for a PE based primarily on an elevated D-dimer value. Two prominent factors, independent of PE, that result in elevated D-dimer values and were pertinent to the studied population, are age and African-American origin. Implementing a scoring system, like the revised-Geneva scale, will establish a better index of suspicion to improve both the physician’s diagnostic approach and the yield of the work-up.” Along the same lines, Deonarine et al5 recommended that a “clinical probability assessment and d-dimer value should be combined and used to quantify the patient’s risk of PE as low, moderate, or high. CTPAs are only indicated for those patients judged to be at moderate or high risk.” The authors explain, however, that “this approach is seldom used in practice, resulting in unnecessary CTPAs being performed. This is an inefficient use of limited time and resources and exposes patients to avoidable irradiation and potential complications of iodinated contrast. Further research is required to better understand the challenges in promoting and implementing the routine use of clinical risk stratification for ambulatory patients with suspected PE.”

Despite these recommendations, in reality it has become difficult to stratify elevated D-dimer patients on the basis of risk factors and use CTA accordingly, the most common reason for this being liability. Often, physicians feel that they are obligated to workup for PE in those who had an elevated D-dimer, regardless of patient’s risk factors. We wonder if such a workup for PE, based merely on an elevated D-dimer is warranted; especially knowing that D-dimer can be elevated in several other conditions. It was felt that knowing the PPV of D-dimer in predicting PE in patients with no risk factors could help us answer this question. Although there were few studies which assessed the overall PPV of D-dimer across all risk groups and also in low risk groups,1,6 there were no studies documented in the literature studying PPV of D-dimer in those with no risk factors for PE. Our study suggested that positive predictive value of D-dimer in patients without any risk factors for PE was zero based on revised Geneva score. Our study has two main limitations: the sample size was small and our study population may not represent the patient population generally seen in the emergency room (ER). Given the suggested low PPV of D-dimer in patients who do not have any risk factors, we recommend that adequately powered studies that represent the actual population of the ER are carried out. The advantages of such studies are twofold: 1) If the value is found to be zero as evidenced by our study based on revised Geneva score, then we could defer doing any PE workup in those who have no risk factors, even if the D-dimer is elevated. This would be very appropriate if liability was the only reason for further workup. 2) We also believe it would be helpful to know the PPV of D-dimer in that subset of the population with no risk factors as it would help us in involving the patient in decisionmaking. In other words, if we come across a patient with no risk factors and an elevated D-dimer test, we can discuss with our patient the probability of having a positive CTA and the potential hazards of having a CTA. Based on this, our patients would be able to guide us in making a decision; some of them could choose to opt out of further workup if PPV is very low. This approach could again be beneficial in those scenarios where physicians think liability could be an issue. In conclusion, we reiterate that our study suggested that the PPV of D-dimer in predicting PE in patients without any risk factors could be as low as zero. We recommend future studies to explore this more in depth. If future studies confirm this study’s findings, new strategies may have to be implemented regarding the approach of PE workup in this subset of population with no risk factors in order to avoid the wasteful usage of resources and to prevent patients from getting unnecessary radiation exposure with CTA and putting them at risk of developing cancer. Potential Financial Conflicts of Interest: By AJCM® policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist.

Positive Predictive Value of D-dimer in Diagnosing Pulmonary Embolism . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Kishore Yellumahanthi, MD, MPH, is a Family Physician at Maude Whatley Health Center in Tuscaloosa, AL. John B. Waits, MD, is Associate Professor of Family Medicine and Obstetrics and Gynecology at the University Of Alabama School Of Medicine in Tuscaloosa, AL. Melanie Tucker, PhD, is Assistant Professor, Department of Community and Rural Medicine at the University of Alabama in Tuscaloosa, AL Sarah Gilmore is a medical student at the University of Alabama School of Medicine in Birmingham, AL.

References 1.

Yin F, Wilson T, Della Fave A, et al. Inappropriate use of D-dimer assay and pulmonary CT angiography in the evaluation of suspected acute pulmonary embolism. Am J Med Qual. 2012;27(1):74-79.

Wikipedia contributors. Geneva score. Wikipedia, The Free Encyclopedia. http://en.wikipedia.org/wiki/Geneva_score.

Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest. 2011;140(2):509-1t8.

Kooiman J, Klok FA, Mos IC, et al. Incidence and predictors of contrastinduced nephropathy following CT-angiography for clinically suspected acute pulmonary embolism. J Thromb Haemost. 2010;8:409-411.

Deonarine P, de Wet C, McGhee A. Computed tomographic pulmonary angiography and pulmonary embolism: predictive value of a D-dimer assay. BMC Res Notes. 2012;5:104.

Chopra N, Doddamreddy P, Grewal H, et al. An elevated D-dimer value: a burden on our patients and hospitals. Int J Gen Med. 2012;5:87–92.

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BCUCM is a Member Board of the American Board of Physician Specialties® Positive Predictive Value of D-dimer in Diagnosing Pulmonary Embolism . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

A September 2012 conference in Naples, Italy, brought together physicians and other medical care providers to discuss the newly emerging specialty of disaster medicine. The focus was on civil-military cooperation in disasters and especially NATO operations in the last few years. Participants and speakers included many from former Eastern Bloc countries. This conference was significant for sharing information about existing training programs and institutions which have already focused on disaster medicine, in some cases, for decades. The summary below was compiled by Col. Rostislav Kostadinov, MD, PhD, Colonel, Bulgarian Armed Forces, JFC HQ Naples, NATO Joint Medical Coordinator. - J.W. Terbush, MD, MPH, CAPT MC USN

Summary of the International Scientific Conference

“Civil Military Cooperation Enhancing Combat Trauma System and Disaster Medical Management Capabilities” Held September 12-14, 2012, Nunziatella Military School, Naples, Italy Col. Rostislav Kostadinov, MD, PhD

The last several decades have recorded a dramatic increase in the frequency and severity of man-made and natural disasters. Climate change and technological developments create new sources of disaster. Population growth contributes to the severity of disasters’ impact, and emerging infectious diseases present new challenges to crisis managers. With globalization, society is becoming more complex and interdependent. Medical science and technological development have significantly increased the capabilities and capacities of the disaster response community over the last 20 years.

Proactive and timely civil-military medical cooperation and coordination of activities is an example of measures aimed to reduce disasters’ impact. In convening the international scientific conference, “Civil Military Cooperation Enhancing Combat Trauma System and Disaster Medical Management Capabilities” (CMCECTSDMMC-2012), the Italian Military Medical Service understands the need for scientific discussion on medical coordination and cooperation issues, international exchange of information and best practices, disaster medical support plans, and standard operating procedures.

Despite the fact that rescue and medical teams are becoming more professional and better skilled, the modern world is seeing an inexorable rise in the impact of disasters. Faced with more intense, frequent, and complex impacts, there is a pressing need to conduct research into sources of hazards, vulnerability and risks, planning and organization of disaster medical support, and required cooperation/coordination between rescue teams and organizations during disaster medical response execution. There is also a need to better disseminate the results of this research and use them for the purposes of reducing or coping better with the threats and risks. There is clearly a growing interest among scientists in many countries for new approaches to disaster medical support management. Consequently, the international community is paying increasing attention to enhancing national capabilities for disaster response and reducing population vulnerability in case of calamities.

The CMCECTSDMMC-2012 international organizing committee defined the key topic areas for the conference, namely: national civilian and military medical services in disaster management; international coordination in disaster medical management; multinational experience in disaster relief operation; and civil-military cooperation in training, planning and execution of disaster medical support. A total of 100 members of national and international military medical services, military logistic commands, civilian medical entities, academia, and other experts attended the conference, representing eight countries of Europe and America, non-governmental organizations (NGOs), businesses, and international organizations. In accordance with the CMCECTSDMMC-2012 agenda, six scientific sessions ending with panel discussions, a poster session, and three round tables were organized. There were 54 oral presentations and 15 poster presentations made

Summary of the International Scientific Conference

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

on the four key topic areas of the conference. Forty-five interventions were made at the roundtables and panel discussions. The scientific sessions were organized in the following panels: “Italian Military Medical Experience in Disaster Medical Management and Support”; “Italian Civilian Medical Experience in Disaster Medical Management and Support”; “National Medical Experience in Disaster Medical Management and Support”; “Multinational Military Medical Experience in Disaster Medical Management And Support”; “Clinical and Organizational Aspects of Disaster Medical Support”; and “Disaster Medical Management and Support – Education and Training.” During the last panel, “Civil Military Medical Cooperation in Disaster Medical Management and Support – Way Ahead,” a summary of the key conclusions, assessments, and proposals made was presented for final discussions. The conference presentations on “Italian Civilian and Military Medical Experience in Disaster Medical Management and Support” represented experience gained by the Italian Armed Forces and Italian healthcare system during medical support to the disaster relief and humanitarian operations in Italy and abroad. Moderators and delegates of the conference noted that: • Civil-military cooperation in medical support to an Italian army-led disaster relief operation was executed in various calamities and proved to be efficient and effective. • Italian military medical entities have capabilities and are ready to provide support to civilian healthcare providers when requested and where required. • The capabilities required for disaster medical support differ from those for medical support to military operations. • The established civilian and military medical standard operating procedures (SOPs) in case of disaster medical support coincide in their majority. When discussing the issues of Italian civilian and military medical support in disaster relief and humanitarian operation, the moderators of the panels concluded that achieving better preparedness and more efficient medical support requires several challenges to be addressed: • Better coordination and information exchange between civil and military medical services is required. • The radiological health risk management and mitigation needs further study and protocols clarification. • The differences between trauma system and combat trauma system could form the basis for development of both systems. The discussion at the conference indicated that in Italy, at least, civil-military medical cooperation during disaster relief operations is not a top national priority. The significance of the problem is also underestimated by healthcare authorities in many other countries. During the panels “National Medical Experience” and “Multinational Military Medical Experience in Di-

saster Medical Management and Support,” several speakers noted that civil-military medical cooperation issues should be incorporated in national development plans and into the planning of the international organizations as well. Delegates of the conference also noted that international organizations and individual countries have already accumulated a large amount of data and experience and highlighted the following: • The majority of nations have a similar national approach to disaster medical support: - Disaster medical support is under the lead of civilian healthcare authorities. - There is a need for specific training, specialties, and equipment for disaster medical support provision. - National coordinating systems are complicated and relatively slow, and coordination and cooperation between the actors have to be improved. - A shortened response timeline for capabilities and resources allocation and transportation will increase the efficiency of the medical support. • During medical support to disasters and humanitarian operations, cooperation with governmental organizations (GOs), non-governmental organizations (NGOs), and international organizations (IOs) is required and has to be broadened. - National and international medical communities’ level of ambition in this regard is high, but there are several obstacles and challenges to be addressed and differences to be overcome. - Despite different cultures, environments, and experience, all the rescue and humanitarian actors have a common goal and similar tasks. - The best way for convergence is sharing of the capabilities and information. - Medical information exchange is an achievable and realistic bridge. • NATO possesses civilian and military capabilities that could be utilized after approval and in a supporting role. The experience and organization of the medical support team in the NATO environment could become a basis for international medical support solutions development. • Multi-nationality and close cooperation between players in medical support to devastating disasters will reduce the overall financial burden and enhance national capabilities. • Elements of military medicine could enhance the disaster medicine capabilities – C4I (command, control, coordination, cooperation, and information), SOPs, triage, treatment, and evacuation principles, to mention just a few.

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

• Focused education and training could reduce population vulnerability and increase the possibilities for better medical preparedness and responsiveness. During the panel “Clinical and Organizational Aspects of Disaster Medical Support,” conference delegates agreed that every effort should be made to bridge the gap between the patients’ need for emergency life, limb, and eyesight-saving medical assistance and the populations’ expectation of medical best practices, recognizing the relative paucity of medical means and capabilities available. In concert with reducing the populations’ vulnerabilities and enhancing the rescue teams’ preparedness, the conference stressed that education and training are key to reducing disaster risks. The presentations and discussions in the panel “Disaster Medical Management and Support – Education and Training” emphasized: • The requirement for medical students to be better prepared for the challenges of medical support to military operations. • Make transparent the objectives and tasks of the proposed master-level program in military medicine. • Describe the different approaches for students to be better prepared for disaster relief and humanitarian operations medical support: - Disaster medicine courses in the medical universities’ programs and postgraduate specializations. - Trauma care courses for surgical specialties. - Major Incident Medical Management and Support advanced course. - Forward medevac course for military medical officers. • The requirement for common standard operating procedures for civilian and military field hospital organization and management in case of disaster relief operations.

ment by sharing its experience in multinational medical support provision in austere and hostile environments. • The utilization of all available databases and trauma registries in disaster response planning and execution. • The healthcare system needs to be more resilient in case of disaster which is an objective of the preparedness process. • The importance of the fitness and training of the emergency care providers. • Familiarization of all healthcare providers with their own community plan for disaster response and their training to fulfill their specific duties according the planned activities. • The exploration of all possible means of education, from online courses to postgraduate master programs and specializations. • The recommendation that disaster medicine concepts and principles be included in all medical residencies. • That to be educated means to be ready. • A base of knowledge for disaster medical support has to be included in the theoretical and practical surgical courses. During the final panel, all these issues were discussed, and the delegates reached consensus and provided, in return, some proposals for achieving better civil-military medical cooperation in the provision of medical support to disaster relief and humanitarian operations: 1. With regard to civilian trauma systems and combat trauma systems, the similarities between the two systems as their common objective could form the basis for common education and training of civilian and military healthcare providers. 2. It is highly desirable that the specialty of disaster medicine enter into the Italian civilian and military medicine educational programs.

• The requirement for advanced technologies implication in the training process.

3. Disaster medicine education should be continuous over a person’s career.

• The essential need for preventive measures in disaster response planning and execution.

4. Specific medical training in assuring rescue teams’ safety has to be planned and executed.

• The significance of rescue teams’ safety training and research.

5. The integration between civilian and military medical systems’ disaster response planning and execution is required.

• The need for disaster medicine national systems to be focused on research and education not only of medical professionals but also trainers and therefore the continuity of disaster medicine education. • The requirement for acquired knowledge to be shared between countries for the benefit of their training and educational programs. • The option for NATO to play a greater role in prevention and preparedness for disaster medical support manage-

6. The requirement for realism in disaster medicine education and training processes’ length and content was noted. 7. The role of international organizations such as NATO in supporting educational, training, planning, and execution of disaster medical support management was highlighted. 8. The interoperability between civilian and military medical equipment and standard operating procedures has to be addressed.

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9. As a final conclusion, there is a requirement for better information exchange in health risk evaluation and common disaster medical response planning with clear and transparent command, control, communication, and coordination between military and civilian medical entities.

10. The delegates proposed establishment of International Civil-Military Medical Board in order to prepare proposals to the civil and military medical authorities for educational, training, and planning measures to be implemented for assuring better disaster medical support management preparedness

Col. Rostislav Kostadinov, MD, PhD, Colonel, Bulgarian Armed Forces, JFC HQ Naples, NATO Joint Medical Coordinator.

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Summary of the International Scientific Conference

American Journal of Clinical MedicineÂŽ â&#x20AC;˘ Winter 2014 â&#x20AC;˘ Volume Ten Number One

Abstract

Results:

Background: Delivery rates and maternal postpartum out-

comes comparing obstetrician-gynecologists (OB/GYNs) and family physicians practicing obstetrics have been studied for the last four decades. Family physicians who practice obstetrics and perform cesarean sections have lower rates of cesarean section, use of forceps, and labor inductions in low risk pregnancies. Family physicians have higher rates of spontaneous vaginal delivery, vaginal birth after cesarean section (VBAC), and vacuum-assisted delivery. There is very little information in the literature regarding maternal outcomes and mode of delivery of patients under the care of family physicians when high-risk pregnancies are included.

Methods:

Data were gathered from medical records of 14,576 deliveries at a regional community medical center regarding total numbers of overall, primary and repeat cesarean sections, VBAC, instrumental delivery, induction of labor, postoperative cesarean section length of stay, transfusion, evacuation of perineal hematomas, and peripartal hysterectomy following cesarean section including high-risk pregnancies. The number of deliveries included all that were performed between January 1, 2003, through December 31, 2011, regardless of provider.

The overall, primary and repeat cesarean section rates of family physicians practicing high-risk obstetrics compared to obstetrician-gynecologists were lower. The VBAC, instrumental delivery, and transfusion rates were higher for family physicians. Postoperative cesarean section length of stay, evacuation of perineal hematomas, and peripartal hysterectomies were similar for both groups.

Conclusions:

Family physicians and obstetrician-gynecologists deliver comparable maternity care and both can practice obstetrics including high-risk pregnancies.

Introduction Postgraduate education in obstetrics and gynecology, family medicine, and family medicine obstetrics includes training in cesarean section, forceps delivery, and vacuum extraction. Delivery procedure rates and resulting maternal outcomes comparing obstetrician-gynecologists and family medicine physicians practicing obstetrics have been studied for the last 4 decades.1-18 Differences in the management of obstetrical patients between obstetricians and family physicians have been noted in at least 2 studies.2,5 Family physicians who practice obstetrics and perform cesarean sections have lower rates of cesarean section, use of forceps, use of epidurals, episiotomies, inductions, pitocin use, diagnosis of cephalopelvic disproportion (labor dystocia),

Comparison of Delivery Procedure Rates . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

and low birth weight babies compared to obstetrician-gynecologists.1-4,6-8,14,17,18 Family physicians have a higher rate of spontaneous vaginal delivery, vaginal birth after cesarean section (VBAC), and vacuum-assisted delivery.6,7 Family physicians have a 34% lower cesarean section rate than obstetriciangynecologists according to one study.4 Family physicians and obstetrician-gynecologists both deliver high-quality maternity care, although they have different styles of care.14 Family physicians are capable of performing cesarean sections and practicing obstetrics with comparable outcomes.6,19 There is no difference in neonatal outcomes between the two specialties.14,17 Family physicians use less interventions and more “expectant care” than obstetrician-gynecologists who typically use more invasive interventions; this difference has not been shown to improve obstetrical care.6-8 Applegate and Walhout reported that obstetricians had higher cesarean section rates than family physicians.14 Some family physicians may attempt vaginal delivery longer because they do not have cesarean section privileges.14 Both groups had equal rates for forceps deliveries, and neonatal outcomes were similar.14,17 Table 1: High-Risk Obstetric Categories Often Managed by Family Medicine Obstetricians • Hypertensive Disorders

• Fetal Demise (Stillbirth)

• Gestational Diabetes

• Previous Cesarean Section

• Preterm Labor and Delivery

• Vaginal Birth After Cesarean Section (VBAC)

• Intrauterine Growth Abnormalities

• Multiple Gestation

• Fetal Heart Rate Abnormalities

• Hydatidiform Mole

• Premature Rupture of Membranes

• Fourth-Degree Extension of Episiotomies

• Malpresentations

• Vulvar and Vaginal Hematomas

• Dystocia

• Asthma

• Sterilization

• Rupture of the Uterus

• Abnormalities of Placentation

• Inversion of the Uterus

• Placental Abruption

• Pelvic Hematomas

• Chorioamnionitis

• Low Apgar Scores

• Obstetrical Hemorrhage

• Lacerations of the Cervix

• Endometritis

• Pulmonary Embolus

• Postdates

• Puerperal Sepsis

• Disorders of Amniotic Fluid Volume

• Wound Dehiscence

• Thyroid Disease

• Deep Venous Thrombosis

• Sexually Transmitted Diseases

There are only a few studies comparing high-risk obstetrics between the two specialties.20 Most studies comparing cesarean section rates in family physicians practicing obstetrics versus obstetrician-gynecologists have examined either low-risk pregnancies or risk-adjusted patient populations.1 Family physicians may have lower cesarean section rates due to lower-risk patients in some studies; other studies have shown that patient risks are similar.1 Family physicians are often required to care for high-risk patients and subsequently deliver them by cesarean section especially in rural, underserved areas.21-24 In our experience, many patients that are high risk either do not want to be transferred to a higher level or do not have the means to travel. In our regional medical center, family medicine physicians are granted obstetric privileges carrying the same responsibilities given to obstetrician-gynecologists by the credentialing committee or professional activity committee. They are expected to care for whatever patients present for care, including unattached call, without backup by an obstetrician-gynecologist. Despite the deficit of obstetrician-gynecologists, less than 50% of OB/ GYNs believe that family physicians should practice obstetrics; however, those that do, feel that family physicians can handle most complications of pregnancy.20, 25 This study sought to compare the delivery-related procedures among family physicians and obstetrician-gynecologists when high-risk patients were included and there was no risk adjustment. High-risk pregnancy categories managed by family physicians are listed in Table 1. Table 2: Characteristics of Obstetrician-Gynecologists in Study • Graduates of four-year accredited OB/GYN Residencies • All certified by the American Board of Obstetrics and Gynecology • Experience ranged from 1 to 30 years • Privileges from the Department of Obstetrics and Gynecology

Materials and Methods The study is approved by the Institutional Review Boards of The University of Alabama and DCH Regional Medical Center. This study is a retrospective investigation of de-identified delivery and birth-related information at DCH Regional Medical Center from January 1, 2003, through December 31, 2011, regardless of provider. The hospital is a 583-bed teaching hospital and tertiary referral center for West Alabama. Family physicians practicing obstetrics are required to have completed a one-year family medicine obstetrics fellowship in order to obtain obstetrics privileges which are the same obstetrics privileges granted to obstetrician-gynecologists. There is no restriction on their privileges nor are they required to have an OB/GYN backup for obstetrical care. The family physician is expected to care for all maternity cases that present for care, regardless of patient acuity, diagnosis, or risk. Physicians were grouped into two groups: obstetrician-gynecologists and family physicians practicing obstetrics. Characteristics of each physician group are found in Tables 2 and 3. High-risk pregnancy categories managed by family physicians are listed in Table 1.

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Table 3: Characteristics of Family Medicine Obstetricians in Study • Graduates of three-year accredited Family Medicine Residencies • All certified by the American Board of Family Medicine • Three completed Family Medicine/Obstetrics Fellowships • Experience ranged from 1 to 22 years • Privileges from the Department of Family Medicine

The medical records department at DCH Regional Medical Center agreed and was authorized to access their medical records and provide the investigators with de-identified data from delivery of infants by family physicians practicing obstetrics and obstetrician-gynecologists from the period of January 1, 2003, to December 31, 2011. The patients, newborns, delivering physicians, types and dates of delivery are unknown to the investigators. There are sufficient numbers of each type of physician so that no single physician could be identified. The procedure descriptions, totals, rates and statistics are listed in Table 4. Once the de-identified data was supplied by DCH personnel, it was stored on an encrypted desktop computer that is password protected and located in a locked office with limited access. The data were then analyzed using SAS version 9.3 statistical software. All measurements utilized contingency tables with either a Pearson’s chi-square statistic or a Fisher’s exact test for cells with less than 5 observations.

Results This study included 14,576 deliveries at DCH Regional Medical Center between January 1, 2003, and December 31, 2011. The

delivery procedure rates are listed in Table 4. Obstetrician-gynecologists (OB/GYNs) delivered 12,033 (82%) of the babies and family medicine obstetricians (FM/OBs) delivered 2,543 (18%). Family physicians had lower overall rates of cesarean section compared to obstetrician-gynecologists (30.80% vs. 39.00%) (p<0.001). Family physicians had lower rates of primary cesarean section compared to obstetrician-gynecologists (19.85% vs. 22.50%) (p=0.003). Family physicians also had lower rates of repeat cesarean section compared to obstetriciangynecologists (11.00% vs. 16.60%) (p<0.001). Family physicians had significantly higher rates of vaginal birth after cesarean section (VBAC) than obstetrician-gynecologists (18.31% vs. 4.30%) (p<0.001). The VBAC rate was determined by the CDC formula of number of VBACs divided by the number of VBACs plus the number of repeat cesarean sections. Family physicians had a higher instrumental delivery rate than obstetrician-gynecologists (15.69% vs. 8.76%) (p<0.001). Instrumental deliveries included both forceps deliveries and vacuum-assisted vaginal deliveries. Both rates are higher than the published rate of 12.90%.26 Both physician groups had similar rates of inductions of labor (16.59% vs. 16.27%) (p=0.697). Both groups had rates lower than the 18.4% reported by ACOG.27 The average postoperative cesarean section length of stay was the same at 3.17 days for OB/GYNs and 3.24 for FM/OBs. Family physicians had a higher rate of blood transfusion than obstetrician-gynecologists (2.32% vs. 1.38%) (p<0.001). Both groups had similar rates of evacuation of perineal hematomas (0.07% vs. 0) (p=0.337). Obstetrician-gynecologists and family physicians had similar rates of peripartal hysterectomy (0.11% vs. 0)(p=0.595). Glaze reported a rate of 0.08% of re-exploration after cesarean section for peripartal hysterectomy.28

Table 4: Delivery Procedure Descriptions, Totals, Rates, Statistics PROCEDURE

OB/GYN

FM/OB

p Value

Total Deliveries

12.033

2,543

Total Vaginal Deliveries

7,338

1,759

Total Cesarean Sections

4,695

39.00%

784

30.80%

p<0.001

Primary Cesarean Section

2,710

22.50%

505

19.85%

p=0.003

Repeat Cesarean Section

2002

16.60%

281

11.00%

p<0.001

Vaginal Birth After Cesarean

4.30%

18.31%

p<0.001

Instrumental Delivery

643

8.76%

276

15.69%

p<0.001

1,997

16.59%

414

16.27%

p=0.697

2.32%

p<0.001

Induction of Labor Postop Cesarean LOS

3.17 days

Transfusion of Blood Products

3.24 days

167

1.38%

Postop Cesarean Peripartal Hysterectomy

0.11%

P=0.595

Evacuation of Perineal Hematoma

0.07%

P=0.337

Comparison of Delivery Procedure Rates . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Discussion The overall total cesarean section rate, primary cesarean section rate and repeat cesarean section rate of family medicine obstetricians was lower than the rates for obstetrician-gynecologists including high-risk deliveries. The VBAC rate of FM/OBs was considerably higher than OB/GYNs. The higher VBAC rate is probably associated with the lower repeat cesarean section rate. The instrumental delivery rate for FM/OBs was higher than for OB/GYNs. The postoperative cesarean section length of stay was the same for both groups. The transfusion rate for FM/OBs was higher than for OB/GYNs. Rates for evacuation of perineal hematomas were the same for both groups. In this institution, family physicians do not transfer their high-risk patients so the data includes a range of low and high-risk patients. This study has implications for obstetrics fellowship training programs. If the rates are comparable, training programs are fulfilling the requirements to practice obstetrics; if not, fellowship training programs need to re-evaluate and improve their training. Decreases in family physicians practicing obstetrics in rural, underserved communities could increase cesarean section rate.16 This data suggests that family medicine obstetricians provide adequate, full service obstetrical care including instrumental and cesarean section deliveries.1-4,6-8,14,17,18 These physicians can work independently without OB/GYN backup and often provide prenatal care in rural, underserved areas.21-24 They are able to provide high-risk obstetrical care as listed in the highrisk categories in this paper.20 In response to the paper by Rayburn,25 family medicine obstetricians can help meet the current deficit of obstetric providers in this country with good outcomes. Family medicine physicians practicing obstetrics help the maldistribution of obstetric providers as they often practice in rural, underserved areas of the country, where obstetriciangynecologists seldom practice. Potential Financial Conflicts of Interest: By AJCM® policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist.

Daniel M. Avery, Jr, MD, is Professor and Chair of OB/GYN and Professor and Division Chief of Pathology at the University of Alabama School of Medicine in Tuscaloosa, AL. Kristine R. Graettinger, MD, is an Assistant Professor of OB/ GYN and Assistant Clerkship Director for OB/GYN at the University of Alabama School of Medicine in Tuscaloosa, AL. Shelley Waits, MD, is a Fellow of University of Alabama Family Medicine Obstetrics Fellowship Program in Tuscaloosa, AL. Jason M. Parton, PhD, is a statistician for the University of Alabama in Tuscaloosa, AL.

References 1.

Nicholson JM. Risk Adjustment in Maternity Care: The Use of Indirect Standardization. Int J Womens Health. 2010;2:255-262.

Rosenblatt RA, Dobie SA, Hart LG, Schneeweiss R, Gould D, Raine TR, Benedetti TJ, Pirani MJ, Perrin EB. Interspecialty Differences in the Obstetric Care of Low-Risk Women. Am J Pub Health. 1997;87:344-351.

Franke L, Jackson EA, Vsilenko P. Management of Gestational Diabetes by Family Physicians and Obstetricians. J Fam Pract. 1996 Oct;43(4):383-8.

Coco AS, Gates TJ, Gallagher ME, Horst MA. Association of Attending Physician Specialty With the Cesarean Delivery Rate in the Same Patient Population. Fam Med. 2000;32(9):639-44.

Hueston WJ. Variations Between Family Physicians and Obstetricians in the Evaluation and Treatment of Preterm Labor. J Fam Pract. 1997;45:336-340.

Deutchman ME, Sills D, Connor PD. Perinatal Outcomes: A Comparison Between Family Physicians and Obstetricians. J Am Bd Fam Pract. 1995;8(6):440-7.

Reid AJ, Carroll JC, Ruderman J, Murray MA. Differences in Intrapartum Obstetric Care Provided to Women at Low Risk by Family Physicians and Obstetricians. CMAJ. 1989;140:625-633.

Hueston WJ. Specialty Differences in Primary Cesarean Section Rates in a Rural Hospital Fam Pract Res J. 1992;12(3):245-253.

Elliot JP, Russell MM, Dickason LA. The Labor-Adjusted Cesarean Section Rate—A More Informative Method Than The Cesarean Section “Rate” for Assessing A Practitioner’s Labor and Delivery Skills. Am J Obstet Gynecol. 1997;177:139-43.

10. Hueston WJ, Lewis-Stevenson S. Provider Distribution and Variations in Statewide Cesarean Section Rates. J Community Health. 2001;26(1):1-10. 11. Beal JR, Burd L, Dahl S, Klug MG, McCulloch KD. Family Physicians vs. Obstetricians….Differences in Cesarean Section Rates and Indications in Rural Dakota. North Dakota J Hum Serv. 1999;2(4):1-8. 12. Clark SL, Xu, W, Porter TF, Love D. Institutional Influences on the Primary Cesarean Section Rate in Utah, 1992-1995. Am J Obstet Gynecol. 1998;179:841-5. 13. Caetano DF. The Relationship of Medical Specialization (Obstetricians and General Practitioners) to Complications in Pregnancy and Delivery, Birth Injury, and Malformation. Am J Obstet Gynecol. 1975;123(3):221-27. 14. Applegate JA, Walhout MF. Cesarean Section Rate: A Comparison Between Family Physicians and Obstetricians. Fam Pract Res J. 1992;12(3):255-262. 15. Hueston WJ. Site-to-Site Variation in the Factors Affecting Cesarean Section Rates. Arch Fam Med. 1995;4:346-51. 16. Taylor GW, Edgar W, Taylor BA, Neal DG. How Safe is General Practitioner Obstetrics? Lancet. 1980 Dec 13;(8207):1287-89. 17. Beal JR, Burd L, Dahl S, Klug MG, McCulloch KD. Family Physicians vs. Obstetricians…Differences in Cesarean Section Rates and Indications in Rural North Dakota. North Dakota J Hum Serv. 1999;2(4):1-8. 18. Applegate JA, Hueston WJ, King DE, Mansfield CJ, McClafin RR. Practice Variations Between Family Physicians and Obstetricians in the Management of Low Risk Pregnancies. J Fam Pract. 1995;40:345-51. 19. Deutchman M, Connor P, Gobbo R. Outcomes of Cesarean Sections Performed by Family Physicians and The Training They Received: A 15Year Study. J Am Bd Fam Pract. 1995;8:81-90. 20. Topping DB, Hueston WJ, MacGilvray P. Family Physicians Delivering Babies: What Do Obstetricians Think? Fam Med. 2003;35(10):737-41. 21. Rodney WM, Martinez C, Collins M, Laurence G, Pean C, Stallings J. OB Fellowship Outcomes 1992-2010: Where Do They Go, Who Stops Delivering and Why? Fam Med. 2010;42(100):712-6. 22. Loafman M, Nanda S. Who Will Deliver Our Babies? Crisis in the Physician Workplace. Am J Clin Med. 2009;6(2):11-16. 23. Cohen D, Coco A. Declining Trends in the Provision of Prenatal Care Visits by Family Physicians. Ann Fam Med. 2009;7(2):128-33.

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

24. Tong STC, Makaroff LA, Xierali IM, Parhat P, Puffer JC, Newton WP, Bazemore AW. Proportion of Family Physicians Providing Maternity Care Continues to Decline. J Am Bd Fam Med. 2012;25(3):270-71. 25. Rayburn WF, Klagholz JC, Murray-Kregan C, Dowell LE, Strunk AL. Distribution of American Congress of Obstetricians and Gynecologists Fellows and Junior Fellows in Practice in the United States. Obstet Gynecol. 2012;119:1017-22.

26. Cunningham FG, Gant NF, Leveno KT, Gilstrap LC, Hauth JC, Wenstrom KD, eds. Williams Obstetrics. 21st Edition. New York: McGraw-Hill. 2001. 27. ACOG American College of Obstetricians and Gynecologists. ACOG Compendium of Selected Publications 2010. Washington, DC. 2010. 28. Glaze S, Ekwalanga P, Roberst G, Lange I, Birch C, Rosengarten A, Jarrell J, Ross S. Peripartum Hysterectomy. Obstet Gynecol. 2008;111(3):732-38.

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Comparison of Delivery Procedure Rates . . .

American Journal of Clinical MedicineÂŽ â&#x20AC;˘ Winter 2014 â&#x20AC;˘ Volume Ten Number One

Comparison of Delivery-Related Complications Among Obstetrician-Gynecologists and Family Physicians Practicing Obstetrics Daniel M. Avery, Jr, MD Shelley Waits, MD Jason M. Parton, PhD

Abstract Background:

Delivery-related complications and maternal postpartum outcomes of family physicians practicing obstetrics and obstetrician-gynecologists have been studied for four decades. Previous studies have shown no difference in the outcomes of family physicians practicing obstetrics compared to obstetrician-gynecologists in low-risk pregnancies. However, there is very little information in the literature regarding maternal outcomes under the care of family physicians when high-risk pregnancies are considered. This study compares the delivery-related complications among family physicians practicing obstetrics and obstetrician-gynecologists when high-risk pregnancies are included without any risk adjustment.

Methods:

Nineteen common delivery complications were selected and assessed from medical records of 14,586 patients at a regional community medical center with totals for family physicians practicing obstetrics and obstetrician-gynecologists.

Results: Family physicians practicing obstetrics and obstetri-

cian-gynecologists have similar rates of uterine rupture during labor, uterine inversion, pelvic hematomas, stillbirths, neonatal deaths, babies with Apgar scores less than 6 at 5 minutes, pulmonary emboli, placenta accreta, maternal deaths, perineal hematomas, urinary bladder and urethral injuries, and birth trauma. Family physicians had more fourth-degree extensions of episiotomies, lacerations of the cervix and postpartum hemorrhage.

Conclusions: Family physicians practicing obstetrics have comparable delivery-related complications as obstetrician-gynecologists with the same outcomes.

Introduction Delivery-related complications and maternal outcomes of obstetrician-gynecologists and family physicians providing obstetric care have been studied for four decades.1,2 There is no difference in the outcomes of low-risk pregnancies when obstetrician-gynecologists are compared to family physicians practicing obstetrics.1-13 Family physicians had the same perinatal outcomes with a considerably lower cesarean section rate than obstetrician-gynecologists.7,13 Outcomes of family medicine physicians providing obstetric care are equivalent to those of obstetricians.7 Family physicians had no difference in newborn Apgar scores, neonatal intensive care unit admissions, birth trauma, neurological outcome, neonatal infection, rates of complications, postoperative length of stay, maternal deaths and transfusion when compared to obstetricians.8,11,14,15 Family physicians had a lower rate of low birth weight babies.7 Family physicians provide safe, high-quality maternity care and meet the standard of care when compared to obstetrician-gynecologists.2,4-10,16 Family physicians are able to perform cesarean sections and those with surgical skills have excellent outcomes.7,16 Family physicians often manage pregnancies more expectantly with fewer interventions.9 Management of obstetrical problems by family physicians is often different from

Comparison of Delivery-Related Complications . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

obstetrician-gynecologists; however, the neonatal outcome is often comparable.3,6 Obstetricians had higher rates of intervention and these did not improve neonatal outcome.9,11 Obstetricians that had higher rates of interventions also had higher rates of complications.11

Materials and Methods

• Hypertensive Disorders

• Fetal Demise (Stillbirth)

• Gestational Diabetes

• Previous Cesarean Section

• Preterm Labor and Delivery

• Vaginal Birth After Cesarean Section (VBAC)

• Intrauterine Growth Abnormalities

• Multiple Gestation

• Fetal Heart Rate Abnormalities

• Hydatidiform Mole

• Premature Rupture of Membranes

• Fourth-Degree Extension of Episiotomies

• Malpresentations

• Vulvar and Vaginal Hematomas

This study was approved by the Institutional Review Boards of The University of Alabama and DCH Regional Medical Center. The study is a retrospective investigation of de-identified delivery and birth-related information from January 1, 2003, to December 31, 2011, at DCH Regional Medical Center in Tuscaloosa, Alabama. The hospital is a 583-bed teaching hospital and tertiary referral center for West Alabama. Family physicians practicing obstetrics are required to have completed a oneyear family medicine obstetrics fellowship in order to receive obstetrics privileges, which are the same obstetrics privileges granted to obstetrician-gynecologists. There is no restriction on their privileges nor are they required to have an obstetriciangynecologist backup for obstetrical care. The family physician practicing obstetrics is expected to care for whatever type of obstetric patient that presents for care, regardless of acuity. Physicians were grouped into two groups: obstetrician-gynecologists and family medicine obstetricians. Characteristics of each physician group are found in Tables 2 and 3. High-risk obstetrics was defined by a list of high-risk obstetrics categories found in Table 1.

• Dystocia

• Asthma

Table 2: Characteristics of Obstetrician-Gynecologists in Study

• Sterilization

• Rupture of the Uterus

• Abnormalities of Placentation

• Inversion of the Uterus

• Placental Abruption

• Pelvic Hematomas

• Chorioamnionitis

• Low Apgar Scores

• Experience ranged from 1 to 30 years

• Obstetrical Hemorrhage

• Lacerations of the Cervix

• Endometritis

• Pulmonary Embolus

• Privileges from the Department of Obstetrics and Gynecology

• Postdates

• Puerperal Sepsis

• Disorders of Amniotic Fluid Volume

• Wound Dehiscence

• Thyroid Disease

• Deep Venous Thrombosis

Table 1: High-Risk Obstetric Categories Often Managed by Family Medicine Obstetricians

•Graduates of four-year accredited Obstetrics and Gynecology Residencies •All certified by the American Board of Obstetrics and Gynecology

Table 3: Characteristics of Family Medicine Obstetricians in Study • Graduates of three-year accredited Family Medicine Residencies • All certified by the American Board of Family Medicine

• Sexually Transmitted Diseases

There are only a few studies comparing high-risk obstetrical care between the two specialties.2,7,8,17 Most studies have looked at either low-risk pregnancies or risk-adjusted patient populations.2,5,9,11 Obstetricians in favor of family physicians providing obstetrical care, feel that family physicians can also handle most complications of pregnancy.17 Deutchman reported a 15year study of outcomes of family physicians practicing obstetrics with no difference in care of high-risk patients.7 Family physicians often have to care for high-risk pregnancies because of patients’ difficulty with access to care in higher levels of care such as tertiary care medical centers.2,8,17 This study seeks to compare the delivery-related complications among family physicians practicing obstetrics and obstetrician-gynecologists in high-risk patients. High-risk pregnancies managed by family physicians are defined by 20 categories listed in Table 1.

• Three completed Family Medicine/Obstetrics Fellowships • Experience ranged from 1 to 22 years • Privileges from the Department of Family Medicine

Comparison of Delivery-Related Complications . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Table 4: Delivery Complications, Descriptions, Codes, Totals, Rates, Statistics Delivery Complication

Code

OB/GYN

FM/OB

p Value

Fourth-Degree Episiotomy

664.31

0.39%

1.02%

p<0.001

Perineal Hematoma

664.51

0.04%

0.07%

p=0.352

Rupture of Uterus

665.11

0.11%

Inversion of the Uterus

665.31

0.02%

Pelvic Hematoma

665.71

0.06%

Stillbirth

656.40-656.43

0.53%

0.70%

p=0.281

Neonatal Death

V30.00-V39.01

0.60%

0.83%

p=0.210

665.51

0.66%

0.94%

p=0.129

767.0-767.9

273

2.26%

2.39%

P=0.691

0.75%

0.90%

p=0.441

Bladder or Urethral Injury Birth Trauma Apgar score<6 at 5 Minutes

p=0.170 0.11%

p=0.170 p=0.611

Laceration of the Cervix

665.31

0.23%

1.48%

p<0.001

High Vaginal Laceration

665.41

1.14%

0.79%

p=0.203

Placenta Accreta

667.04

Puerperal Endometritis & Sepsis

670.20 - 670.24

0.53%

0.31%

P=0.156

Pulmonary Embolus

673.21 or 673.24

0.01%

0.04%

P=0.319

Maternal Death

761.6

Postpartum Hemorrhage

666.14

158

1.31%

2.00%

P=0.008

Wound Dehiscence

674.14

0.47%

0.13%

P=0.238

Deep Venous Thrombosis

671.4

0.03%

P=1.000

delivery procedure descriptions and codes are listed in Table 4. Once the de-identified data were supplied by DCH personnel, they were stored on an encrypted desktop computer that was password protected behind a locked door with limited access. The data were then analyzed using SAS version 9.3 statistical software. All proportional measurements utilized contingency tables with a Pearson’s chi-square statistic or a Fisher’s exact test for cells with less than five observations. Some of the complications were compared to standards in Williams Obstetrics,18 Obstetrics: Normal and Problem Pregnancies,19 ACOG Compendium20 and the obstetrical literature.

Results Nineteen common delivery complications were selected and assessed from medical records with totals for family physicians and obstetrician-gynecologists. These data along with inci-

p=1.000

dences and statistics are found in Table 4. This study evaluated 14,576 deliveries at DCH Regional Medical Center between January 1, 2003, and December 31, 2011. Obstetrician-gynecologists (OB/GYNs) delivered 12,033 (82%) of the babies and family medicine obstetricians (FM/OBs) delivered 2,543 (18%). Family physicians had a higher rate of fourth-degree extensions of episiotomy than obstetrician-gynecologists (1.02% vs. 0.39%) (p<0.001). These incidences are consistent with the 0.6% incidence of fourth-degree extension of episiotomies reported by Konnyu.21 Family physicians had similar rates of perineal hematomas compared to obstetrician-gynecologists (0.04% vs. 0.07%) (p=0.352). These incidences were consistent with the 0.1% incidence reported in Williams.18 Family physicians had no uterine ruptures during labor compared to 0.11% by obstetrician-gynecologists (0% vs. 0.11%) (p=0.170). This incidence was consistent with the 0.1% incidence reported in Williams.18

Comparison of Delivery-Related Complications . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Family physicians and obstetrician-gynecologists had similar rates of uterine inversion (0.02% vs. 0.11%) (p=0.170). These incidences were consistent with the 0.05% incidence reported in Gabbe et al.19 The rates of pelvic hematomas in both obstetriciangynecologists and family physicians were similar (0.13% vs. 0%) (p=0.097). The incidences were consistent with the 0.10% incidence reported in Williams.18 Family physicians and obstetrician-gynecologists had similar rates of stillbirth (intrauterine fetal demise) (0.53% vs. 0.70%) (p=0.281). These incidences are consistent with the 0.62% incidence reported in ACOG.20 Obstetrician-gynecologists and family physicians had similar rates of neonatal death (0.60% vs. 0.83%) (p=0.210). These incidences are both higher than the 0.48% incidence reported in Williams.18 Family physicians and obstetrician-gynecologists had similar rates of urinary bladder or urethral injury (0.66% vs. 0.94%) (p=0.129). Both obstetrician-gynecologists and family physicians had similar rates of birth trauma to the baby (2.26% vs. 2.39%) (p=0.691). These incidences are consistent with the 2.59% incidence of birth trauma reported by Moczygemba.22 Family physicians and obstetrician-gynecologists had similar rates of Apgar scores less than 6 at 5 minutes (0.75% vs. 0.90%) (p=0.441). Family physicians had higher rates of lacerations of the cervix than obstetrician-gynecologists (1.48% vs. 0.23%) (p<0.001). The rates of high vaginal lacerations were similar in obstetrician-gynecologists and family physicians (1.14% vs. 0.79%) (p=0.203). Obstetrician-gynecologists and family physicians had similar rates of pulmonary emboli (0.01% vs. 0.04%) (p=0.319). These incidences are consistent with the incidence of 0.02% reported in Williams.18 No cases of placenta accreta were reported in either group. Obstetrician-gynecologists and family physicians had similar rates of puerperal endometritis and sepsis (0.53% vs. 0.31%) (p=0.156). No cases of maternal death were reported in either group (p=1.000). The incidence of maternal death in Williams18 is 0.008%. Obstetrician-gynecologists and family physicians had similar rates of wound dehiscence (0.47% vs. 0.13%) (p=0.238). This is consistent with the incidence of wound dehiscence reported in Williams18 of 0.3%. Family physicians had higher rates of postpartum hemorrhage than obstetrician-gynecologists (2.00% vs. 1.31%) (p=0.008). This is lower than the incidence of postpartum hemorrhage reported by Williams18 of 5%. The incidence of deep venous thrombosis was the same for obstetrician-gynecologists and family physicians (0.03% vs. 0.03%) (p=1.000). The incidence of deep venous thrombosis reported in Williams18 is 0.45%.

Discussion This study demonstrates that obstetrician-gynecologists and family medicine obstetricians have comparable rates of uterine rupture during labor, uterine inversion, pelvic hematomas, stillbirths, neonatal deaths, babies with Apgar scores less than 6 at 5 minutes, pulmonary emboli, placenta accrete, maternal deaths, vulvar and vaginal hematomas, urinary bladder or urethral injuries and birth trauma to the baby. Family medicine obstetricians

had more fourth-degree extensions of episiotomies, lacerations of the cervix and postpartum hemorrhage. Complications in the hospital system may be assigned to other specialties, such as birth trauma to the baby is assigned and coded to the admitting pediatrician or neonatologist. These data suggest that family medicine obstetricians provide adequate obstetrical care. These physicians can work independently without obstetrician-gynecologist backup as they often provide care in rural, underserved areas. They are able to provide high-risk obstetrical care as listed in the high-risk categories in this paper. In response to the paper by Rayburn,23 family medicine obstetricians can help meet the current deficit of obstetric providers in this country with good outcomes. Family medicine physicians practicing obstetrics help the maldistribution of obstetric providers as they often practice in rural, underserved areas of the country, where obstetrician-gynecologists seldom practice. Potential Financial Conflicts of Interest: By AJCM® policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist.

Daniel M. Avery, Jr, MD, is Professor and Chair of OB/GYN and Professor and Division Chief of Pathology at the University of Alabama School of Medicine in Tuscaloosa, AL. Shelley Waits, MD, is a Fellow of University of Alabama Family Medicine Obstetrics Fellowship Program in Tuscaloosa, AL. Jason M. Parton, PhD, is a statistician for the University of Alabama in Tuscaloosa, AL.

References 1.

Caetano DF. The Relationship of Medical Specialization (Obstetricians and General Practitioners) to Complications in Pregnancy and Delivery, Birth Injury, and Malformation. Am J Obstet Gynecol. 1975;123(3):221-27.

Nicholson HM. Risk Adjustment in Maternity Care: The Use of Indirect Standardization. Int J Womens Health. 2010;2:255-262.

Franke L, Jackson EA, Vsilenko P. Management of Gestational Diabetes by Family Physicians and Obstetricians. J Fam Pract. 1996 Oct;43:383-88.

Rosenthal TC, Holden DM, Woodward W. Primary Care Obstetrics in Rural Western New York. A Multi-Center Case Review. N Y State J Med. 1990;90:537-540.

Kirke AB. How Safe is GP Obstetrics? An Assessment of Antenatal Risk Factors and Perinatal Outcomes in One Rural Practice. Rural Remote Health. 2010;10:1545 (Online).

Hueston WJ. Variations Between Family Physicians and Obstetricians in the Evaluation and Treatment of Preterm Labor. J Fam Pract. 1997;45:336-340.

Deutchman ME, Sills D, Connor PD: Perinatal Outcomes. A Comparison Between Family Physicians and Obstetricians. J Am Board Fam Pract 1995;8(6):440-7.l.

Deutchman M, Connor P, Gobbo R. Outcomes of Cesarean Sections Performed by Family Physicians and The Training They Received: A 15Year Study. J Am Board Fam Pract. 1995;8:81-90.

Comparison of Delivery-Related Complications . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Reid AJ, Carroll JC, Ruderman J, Murray MA. Differences in Intrapartum Obstetric Care Provided to Women at Low Risk by Family Physicians and Obstetricians. CMAJ. 1989;140:625-633.

10. Beal JR, Burd L, Dahl S, Klug MG, McCulloch KD. Family Physicians vs. Obstetricians….Differences in Cesarean Section Rates and Indications in Rural Dakota. North Dakota J of Hum Serv. 1999;2(4):1-8. 11. Berghs G, Spanjaards E, Driessen L, Doesburg W, Eskes T. Neonatal Neurological Outcome after Low-Risk Pregnancies. Eur J Obstet Gynecol. 1995;62:167-71. 12. Taylor GW, Edgar W, Taylor BA, Neal DG. How Safe is General Practitioner Obstetrics? Lancet. 1980;2:1287-89. 13. Rosenblatt RA, Dobie SA, Hart LG, Schneeweiss R, Gould D, Raine TR, Benedetti TJ, Pirani MJ, Perrin EB. Interspecialty Differences in the Obstetric Care of Low-Risk Women Am J Public Health. 1997;87:344-351. 14. Applegate JA, Hueston WJ, King DE, Mansfield CJ, McClafin RR. Practice Variations Between Family Physicians and Obstetricians in the Management of Low-Risk Pregnancies. J Fam Pract. 1995;40:345-51. 15. Applegate JA, Halhout MF. Cesarean Section Rate: A Comparison Between Family Physicians and Obstetricians. Fam Pract Res J. 1992;12(30):255-262. 16. Notrris TE, Pirani MJ, Reese JQ, Rosenblatt RA. Are Rural Family Physicians Comfortable Performing Cesarean Sections? J Fam Pract. 1996;43:455-60. 17. Topping DB, Hueston WJ, MacGilvray P. Family Physicians Delivering Babies: What Do Obstetricians Think? Fam Med. 2003;35(10):737-41. 18. Cunningham FG, Gant NF, Leveno KT, Gilstrap LC, Hauth JC, Wenstrom KD, eds. Williams Obstetrics. 21st ed. New York: McGraw-Hill; 2001. 19. Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: Normal and Problem Pregnancies. 4th ed. Philadelphia: Churchill Livingstone; 2002. 20. American College of Obstetricians and Gynecologists. ACOG Compendium of Selected Publications 2010. Washington, DC. 2010.

SETTING RIGOROUS STANDARDS OF CARE IN INTEGRATIVE MEDICINE

Do you incorporate integrative medicine into your practice?

21. Konnyu K, Grimshaw J, Moher D. What is Known About 3rd and 4th Degree Lacerations Occurring During Vaginal Birth? Ottawa Hospital Research Institute. 2010 Dec;9:1-13. 22. Moczygemba CK, Paramsothy P, Meikle S, Kouris AP, Barfield WD, Kuklina E, Posner SF, Whiteman MK, Jamieson DJ. Route of Delivery and Neonatal Birth Trauma. Am J Obstet Gynecol. 2010;202:361.e1-6. 23. Rayburn WF, Klagholz JC, Murray-Kregan C, Dowell LE, Strunk AL. Distribution of American Congress of Obstetrician and Gynecologist Fellows and Junior Fellows in Practice in the United States. Obstet Gynecol. 2012;119:1017-22.

Visit www.ABOIM.org or call (813) 433-2277 to see if you meet the certification eligibility requirements of the American Board of Integrative Medicine®. “Finally there’s a way for qualified physicians to present themselves as experts in offering competent integrative care to patients.” - Andrew Weil, MD

Comparison of Delivery-Related Complications . . .

American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

sounding board

Minimalism and the Promotion of Substandard Medical Care: A Lawrence, Kansas Perspective Bruce Rothschild, MD

Semantics is a major challenge in medicine, as in most other fields. The term “minimalistic medical care approaches” utilized herein reflects how little effort is expended, in contrast to the effort-intensive process of medication minimalism. The latter is exemplified by utilization of the safest medications at the lowest effective doses, mindful of their continuing necessity and vigilance for drug interactions and development of side effects and obtaining consultations in a timely manner. A disconcerting phenomenon seems pervasive in certain areas of the country: Patient statements to their physician that they “never had such a complete examination” might at first glance be perceived as simply complimentary. However, such comments elicit the observation that the examination that they just experienced is no different from that which should routinely be performed by any internist or family physician. When questioned as to how it differs, they frequently indicate that it was the first time they had undressed for an examination – even by subspecialty internists (e.g., rheumatologists). The importance of adhering to a full physical examination was drilled into me early in my career. I discovered advanced breast cancer in a patient who had been under the care of a superb physician. It turned out that they had become friends and he had, therefore, not performed a breast examination in years. That physician was badly shaken by the results of his “consideration,” and we all learned an important lesson: Friends should not receive a lower level of care than what we owe the rest of our patients, and our patients deserve the full measure of our attention.

History and physical examination provide 3/4 of correct diagnosis; physical examination contributes 40%.1 Minimalistic approach was assessed with a very limited, allegedly directed examination2 with a sensitivity of 60% and specificity of 70%.3 While that approach was more extensive than that pursued by most physicians, diagnosis was missed in 40% of patients. Even specialists aware that their examination was being evaluated only performed extensive physical examination in 64% of ankylosing spondylitis, 57% of psoriatic arthritis, 38% of rheumatoid arthritis, and 85% of fibromyalgia.4 Diagnoses were commonly missed: These included 27% of fibromyalgia cases, 46% of ankylosing spondylitis cases, 39% of psoriatic arthritis cases, and 50% of osteoporotic fractures. Ninety-five percent missed cervical instability! Failure to obtain routine cervical spine x-ray studies (with flexion extension views) is inexcusable when one in four individuals with rheumatoid arthritis has cervical instability.5 This is a reminder that the complete history and physical is essential to patient care and return to basics seems in order. Another complication of minimalistic evaluations is simply accepting previous diagnoses, rather than verifying that they were accurate and complete. Protocols have been utilized, without analysis/verification of original diagnosis and assessment of whether it applies to the actual clinical situation.6,7 This blind approach even extends to some post hoc errors as some physicians became aware of an article on new treatment approaches to “COLD” not realizing that the subject was chronic obstructive lung disease, not the common cold.

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American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

sounding board One of the factors leading to such minimalistic approaches may be the medical equivalent of the “no child left behind” approach. “Grading” physicians and facilities on the basis of fulfilling a discharge checklist for specific diagnoses may be a step in establishing standards but also compromises care on several levels. It distracts from the need for cognitive evaluation of the patient and individualization of care, especially related to ancillary problems. It is intriguing that prospective monitoring of hospital care has been essentially limited to such checklists,6,7 an approach that one might expect to eliminate at least related lapses. Requirement for aspirin prescription clearly reveals the fallacy of even standard checklists. Standard doses of aspirin (81 mg/day) inadequately “control” platelet adhesiveness in a large portion of patients,7,8 while higher doses often impair endothelial cell prostaglandin production so important for vascular patency.7 If aspirin is to be prescribed, shouldn’t its efficacy related to the desired effect also be assessed? Thoughtful care, not routine care, seems the appropriate practice model.7 “Standardized approaches” have other effects. Phlebotomists and radiology technicians often disapprove of the number of tests or number of views ordered by physicians who refuse to be minimalistic in the evaluations and care they provide. In some cases, the technicians/technologists even tell patients that studies are unnecessary – without even talking to the physician ordering the test(s). Another aspect of minimalism is compromise of clinical diagnostic skills. Minimalistic approaches remove/reduce the challenges of appropriate individualization of care, resulting in physician’s cognitive atrophy and subsequent medical errors. This has resulted in the tendency and, perhaps, the necessity in those evaluation-compromised physicians to rely upon laboratory test results. Attributing diagnosis on the basis of such tests, however, is fraught with risks. The antinuclear antibody (ANA) test is a classic example. Many other disorders can produce a positive test and 5-30% of individuals with systemic lupus erythematosus have a negative ANA.9 Even dependency on laboratory test results is compromised by minimalism. Cryoglobulinemias are detected by the presence of cold-precipitable protein. If cryoglobulins are categorized according to whether their components are mono-specific or poly-specific varieties, observing serum for three days will identify most individuals with the mono-specific variety. However, that group represents only 10% of individuals with cryoglobulinemia.10 Detectable precipitation of the cryoglobulin takes up to 10 days for 90% of individuals with cryoglobulins, yet most laboratories (both commercial and hospital-based) refuse to run the test for more than three days. “Running the test” means visually examining the tube daily for precipitate, not really a hardship. The minimalistic approach being utilized potentially fails to recognize

90% of individuals with cryoglobulinemia, yet the minimalistic approach has not been abandoned. Another outcome of minimalism is failure to distinguish signs from diagnoses. Giving a name to a physical finding is not the same as attribution. Lichen planus is a classic example. It names a physical alteration of the skin. Unfortunately, minimalistic approaches have led to that being perceived as the patient’s problem, rather than searching for its etiology. Appropriate searches uncover the responsive medication side effect, collagen vascular diseases (e.g., lupus), or paraneoplastic disease. Skin alterations are often an early sign of the latter, permitting intervention when retention or restoration of quality of life and even cure are often feasible. Treatments have anticipated outcomes. When that outcome is not achieved or unexpected events occur, complete reevaluation is required. The minimalistic approach overlooks the need for and value of consultations and second opinions, leading to cessation of intellectual growth, stagnation and loss of skills for the physician, and medical error sequelae (increased morbidity and mortality for the patient). Failure to consult makes primary care physicians less aware of key advances6,7,11 and less responsive to new standards of practice. Medications often are added to a patient’s regimen, few are deleted, and monitoring safety “falls through the cracks.” Medication side effects can occur at any time during the course of their utilization. Periodic monitoring (including laboratory testing) is critical. If the physician is not assiduous in assuring this important process, can patients be expected to perceive its importance? A great deal of effective medical intervention is determined by patient motivation. If the physician is perceived as cavalier about patient care and monitoring for medication side effects, what can be expected of patients? The result is often failure to appreciate the importance of monitoring. It is problematic when a subspecialist’s assiduous approach conflicts with the minimalistic approach of the patient’s primary physician. Contributing to the problem of minimalism is the primary physician’s perceived time constraints. When a patient requests a certain medication or long intervals between visits, it takes less time to accede to that request than it does to educate the patient as to what is appropriate or safe. Combine that approach with scheduling limitations (e.g., when a patient reschedules a missed appointment, an idiosyncrasy of this area is that they may have to wait several months “to be fit in” for a “replacement” appointment), is it surprising that patients do not perceive the appointments and their timing as important? Reinforcing the significance and importance of interactions is as important to patient care as the actual advice and medications we dispense.

Minimalism and the Promotion of Substandard Medical Care . . .

American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

sounding board Part of minimalism may relate to automation of laboratory testing. The test is performed, and the results are entered into a system. The recording system is typically organized according to the convenience of the laboratory and not necessarily amenable to the physician ordering the test. Between the time the patient is given the order, the time the laboratory receives the material for testing, and the time requirements/scheduling of those tests, the physician has very limited insight as to when the results will be available. The electronic records utilized by the laboratories require that the physician examine each individual “chart” of all their patients every single day – if they were to learn of results in a timely manner. That impediment typically seems to lead to the minimalistic approach of only examining results when the patient has their next scheduled visit. A simple alternative solution would appear to be acquiescence (by the performing laboratory or hospital) to physician requests that the results be directly faxed to the requesting physician, rather than simply entered into an electronic database. That alternative, however, exceeded the minimalistic approach in vogue in this area, and it took two years for that request to be routinely honored. While the phenomena described above may be simply a local phenomenon, its exposure serves as a sign. Impediments to provision of quality medical care must be removed. Minimalism may be convenient, but I suggest that the price is too high. Patients deserve the full measure of our attention and skills. It is time not simply to fulfill checklists, but to extirpate associated minimalism. While minimalistic approaches may be time-effective for the practitioner, at least in the short term, it must be acknowledged that they have no role in the following circumstances and are more expensive (both fiscally and physically) over time: 1. First contact with the patient. This includes assurance that previous diagnoses are correct and that no pertinent diagnosis has been missed. 2. Occurrence of new symptoms. This is contradistinctive to appropriateness of minimalistic evaluations when the purpose of a given patient visit is to assure the safety and appropriateness of their ongoing therapeutic regimen. 3. Acute change in chronic symptoms. 4. Occurrence of falls and/or injuries – to assure no underlying health contribution. 5. Evaluation of safety of anesthesia or surgery.

Guidelines are not without merit and should be disease-responsive but not limit evaluation or treatment. This would obviate the minimalism-related morbidity/mortality related to anesthesia and/or surgery for patients with inflammatory arthritis. It is critical to assure that cervical spine x-rays (including flexion and extension views) have been obtained within the six months prior to any considered procedure. Further, given the frequency with which cervical subluxations and cranial settling are overlooked in standard reports, it is critical that the films be examined specifically for those problems by an individual skilled in skeletal radiology (e.g., rheumatologist). Medicine has changed. Many hospitals have become businesses with clients, rather than health care providers with patients. As patient satisfaction surveys have become a major component of hospital evaluations and with movements towards diseasebased, rather than care-based, reimbursement as a function of payment schedules, there are market forces motivating economic shortcuts, propaganda-related efforts, and the mind-set that change suggests that current approaches have been deficient or negligent. When a physician reports behaviors that compromise patient care or put patients at risk, the concern is not reviewed by physicians but by managers. All of this impedes provision of quality patient care. What solutions can be offered to “reorient” this behavior and correct the problems? These problems have persisted because people of good will have not been successful in motivating their resolution. Part of the problem relates to what might be considered inertia (e.g., hospital, laboratory, and insurance company demands for adherence to their status quo) and the other part involves the risk of being penalized and labeled disruptive if modifications are requested. First and foremost, there is a need for patient education as to what constitutes appropriate medical care and the risks associated with minimalistic approaches to that care. Avenues for such communication must be developed. This requires a free and open press, unfettered by the economic pressures applied by major advertisers (e.g., hospitals and insurance companies). Thus, those parties would not be able to control the flow of information and their misleading claims would be exposed. It is critical that regulations be in place and enforced to assure that reports of deficiencies and other insurance company activities that compromise patient care are resolved in a timely manner. Their medical directors must not have immunity to state medical board actions (as appears to be the case in Kansas) and must have the authority that should accompany such responsibility. That obviously requires “whistleblower” protection to make it illegal to disadvantage physicians who report concerns, and “gag” rules must be removed from hospital and insurance

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American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

sounding board company bylaws/contracts. Physicians must take back the helm. It is most appropriate for pharmacists and laboratory/ radiology technicians to question the physician directly regarding their requests. Medical care is compromised when such communication occurs only with the patient. Insurance companies have “convinced” some pharmacists to suggest alternative medications to the patient, medications which, in some instances, they (both the insurance company and the pharmacist) should know are less safe. Such communications should be professionally conducted, and that means between professionals. They should not be touting alternatives to less medicallyknowledgeable individuals – our patients. Insurance companies claim they are not directing medical care; they say they just won’t pay for it. However, when they suggest alternatives, they are actually promoting specific approaches to medical care. Thus, they appear to be practicing or enlisting others to practice without a license. State medical boards need to vigorously police such practices. State insurance commissions need to actually regulate insurance company behavior and hold them to the standards of due diligence, ethical behavior, non-compromise of patient care, and routine billing practices. The Kansas State Insurance Commission refused to take action when an area insurance company stated that acceptance of those standards would change its contracts. Perhaps it is time for another czar? It needs to be assured that regulatory agencies are charged with clearly defined duties and that they pursue them vigorously in an unbiased manner. It is only a matter of time before the effects of minimalism become common legal fodder and physicians will likely be the target, however inappropriate. It was once said that a physician was at risk for malpractice if he or she did not fight hard enough against an insurance company patient-compromising rule, so as to get him or herself deselected from that insurance company’s panel of preferred physicians - with the associated economic losses. Our responsibility is to our patients. Our only options are to reject minimalism and to continue to fight for the ability to provide the care that our patients deserve and to resist becoming victims of the Stockholm syndrome.

References 1.

Cheitlin M. Medical technology - Still an adjunct to clinical skills in making a diagnosis. Arch Intern Med. 2011;171:1396-1397.

Doherty M, Abawi J, Patrick M. Audit of medical inpatient examination: A cry from the joint. J R Coll Physians Lond. 1990;24:115-118.

Beattie KA, MacIntire NJ, Cividino A. Screening for signs and symptoms of rheumatoid arthritis by family physicians and nurse practitioners using the Gait, Arms, Legs, and Spine musculoskeletal examination. Arthritis Care Res. 2012;64:1923-1927.

Gorter S, van der Linden S, Brauer J, et al. Rheumatologist’s performance in daily practice. Arthritis Care Res. 2001;45:16-27.

Mathews JA. Atlanto-axial subluxation in rheumatoid arthritis: A 5-year follow-up study. Ann Rheum Dis. 1974;33:526-531.

Chassin MR, Kosecoff J, Winslow CM, et al. Does inappropriate use explain variations in the use of health care services? JAMA. 1987;258:2533-2537.

Mitchell JR. “But will it help my patients with myocardial infarction?” The implications of recent trials for everyday country folk. Br Med J. 1982;285:1140-1148.

Rothschild BM. Comparative anti-platelet activity of COX-1 NSAIDS versus aspirin, encompassing regimen simplification and gastroprotection: A call for a controlled study. Reumatismo. 2004;56:89-93.

Rothschild BM, Jones JV, Chesney C, et al. Relationship of clinical findings in systemic lupus erythematosus to seroreactivity. Arthritis Rheum. 1983;26:45-51.

10. Vermeersch, Gijbels K, Marien G, et al. A critical appraisal of current practice in the detection, analysis, and reporting of cryoglobulins. Clin Chem. 2008;54:39-43. 11. Ayanian JZ, Hauptman PJ, Guadagnoli E, et al. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994;331:1136-1142.

Bruce Rothschild, M.D., is Professor of Medicine at Northeast Ohio Medical University and Professor of Anthropology and Geology and Research Associate in the Biodiversity Institute at the University of Kansas.

Minimalism and the Promotion of Substandard Medical Care . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Older Patients’ Perception and Experience with Lifestyle Changes Following Cardiac Revascularization Lufei Young, PhD, RN, APRN-NP Susan Barnason, PhD, RN, APRN-CNS, CCRN, CEN, FAHA

Abstract Objective: To describe patients’ perception and experience related to lifestyle change after coronary revascularization.

Background: Engaging in lifestyle change is crucial to re-

alizing the benefits of cardiac revascularization. However, patients often fail to adhere to lifestyle change recommendations after cardiac revascularization.

Method:

A qualitative study of 30 patients following cardiac revascularization was conducted. Data were collected by telephone using a semi-structured interview questionnaire.

Results:

The average age of the patients was 73.9 (± 6.0) years. The majority of patients denied that they had a chronic heart condition, even though some had repeated coronary revascularization. Given the false assumption that coronary revascularization had “fixed” their heart problems, patients failed to perceive the critical need to make lifestyle changes. In addition, the relationship with healthcare providers was perceived as an important factor to help patients recognize the need for lifestyle change.

Introduction Coronary revascularization procedures (e.g., coronary artery bypass surgery [CABS], percutaneous coronary intervention [PCI]) result in temporary improvements in symptoms and quality of life of cardiac patients.1-3 To maximize and achieve full, long-term health benefits after the procedures, it is critical for patients to make lifestyle changes and follow secondary prevention recommendations (e.g., participating in cardiac rehabilitation, taking prescribed medications, and making lifestyle modifications regarding dietary changes, smoking, and exercise).4-14 Studies have shown that long-term lifestyle changes can reduce cardiac risk factors, improve postoperative recovery and prognosis,6 and reduce symptoms and recurrence rates.13 Despite the importance of secondary prevention, the adherence to behavioral modification guidelines in cardiac populations remains suboptimal. It was reported that less than 20% of cardiac patients participate in cardiac rehabilitation,15-18 less than 37% of patients adhere to an exercise regimen, and less than 42% of patients adhere to a recommended diet.10,19 The reasons contributing to low adherence to secondary prevention guidelines after cardiac procedures include age, gender,20 illness and treatment beliefs,21-23 motivation,24,25 self-efficacy,25 knowledge about lifestyle changes,21 psychological distress,20,25,26 type of procedure (PCI vs. CABS),24,27 comorbidity,15,24 current lifestyle,24,26 family members’ lifestyle,15 support systems,24,25 and accessible resources.15

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

In the past three decades, there has been much attention on exploring patients’ post-surgical experiences and the development of interventions to improve the adherence to recommended secondary prevention following cardiac procedures.15,24,28-31 However, the effectiveness of these interventions is often ambiguous.13,32-36 In order to develop effective adherence-enhancing interventions, we need to have a deeper understanding of why patients persistently fail to initiate and sustain recommended behavioral changes following cardiac procedures. Therefore, we conducted a qualitative study to explore cardiac patients’ perception and experience with lifestyle changes following cardiac revascularization. The research questions of this study were: 1. What are the perceived enabling factors to make lifestyle changes following a cardiac procedure? 2. What are the perceived blocking factors to make lifestyle changes following a cardiac procedure? The findings from this study may help to better understand patients’ perceptions about heart problems and cardiac revascularization, as well as the impact of these perceptions on their decisions to adopt a healthier lifestyle. Based on the study findings, strategies can be identified and developed to meet patients’ needs in making lifestyle changes during the early stage of transition from hospital to home after a cardiac procedure.

Methods Research Design and Sample This was an exploratory study using a qualitative design to gain an understanding of participants’ perceptions in making lifestyle changes after having a heart procedure. A convenience sample of 30 individuals undergoing CABS (n = 15) and PCI (n = 15) was recruited from a tertiary hospital in a Midwest region. Participants were included in the study if they: 1) were age 65 years or older, 2) underwent CABS or PCI within 3-7 weeks, 3) were not visually impaired, and 4) were able to hear, speak, and read English. Study procedures were approved by the hospital and the University of Nebraska Medical Center Institutional Review Boards.

Procedures

Data Collection and Analysis Data collection took place over a five-month period. A onetime, semi-structured phone interview was conducted after hospitalization. An interview guide was developed for this study in an attempt to explore participants’ experiences with lifestyle change following a cardiac procedure. Sample questions included in the interview guide are presented in Table 1. All interviews were audio-recorded and transcribed verbatim. Additional field notes were taken by the interviewers. Data collection took approximately 20-30 minutes. To ensure reliability and validity of the data collection and analysis, the same interview guide was used to ensure consistency. In addition, the principal investigator assumed the primary role in data analysis to ensure internal consistency with data coding. Finally, two researchers (SB and LY) independently reviewed the interview data and grouped the transcripts into themes. After repeated reviews, they reached a consensus and identified common themes under the five areas that emerged from the interview data. Table 1: Examples of Interview Guide INTRODUCTORY QUESTION: • Can you tell me about your life after the heart surgery or procedure? • Do you think you have a “chronic” disease or health problem? QUESTIONS RELATED TO LIFESTYLE CHANGES: • Were you given the following instructions or recommendations to make any lifestyle changes to reduce your risk of future heart problems? − Follow a healthy diet (portion control, low salt and fat) − Become physically active and exercise − Maintain a healthy weight − Quit smoking and drinking − Manage stress and reduce workload − Take medicines to control chest pain or discomfort, high blood cholesterol, high blood pressure, and your heart’s workload − Attend the cardiac rehabilitation program • If you were given the recommendations on lifestyle changes, − Who gave the recommendations?

Hospital staff with clinical access to patient records identified prospective participants and notified the investigators. Potential participants were then screened by the principal investigator to determine if they met the inclusion criteria for the study. Those who met inclusion criteria were invited to participate in the study, and written informed consent was obtained. Detailed information about the study was provided to the participant, and a phone interview appointment time was set. A postcard was sent one week prior to the phone interview to remind him/her of the scheduled appointment. The participants’ background and clinical information were collected using a demographic and clinical data tool prior to hospital discharge.

− What recommendation(s)? − When were the recommendations given? − How did you follow the recommendations? Are there any changes you have made in response to these recommendations? • If you made lifestyle changes since you returned home after your heart event, what were your short- or longterm plans for changing your daily lifestyle? • Has anyone (e.g., spouse, children, other family members, close friends, coworkers, health care providers, etc.) been helpful when you were making lifestyle change?

Older Patients’ Perception and Experience with Lifestyle Changes . . .

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Table 2: Characteristics of participants Sample

N = 30

N (%)

Age

73.9±6

Gender

Male Female

15 (50%) 15 (50%)

Procedures

PCI CABS

15 (50%) 15 (50%)

Married

20 (67%) Hypertension Hypercholesterolemia Diabetes Mellitus Current Smoker

23 (77%) 23 (77%) 7 (23%) 2 (7%)

Healthy eating and portion control Attending cardiac rehabilitation Self-directed exercise Lifestyle Stress management Changes Reducing workload Smoking cessation Multiple lifestyle changes

15 (50%) 10 (33%) 5 (17%) 3 (10%) 1 (3%) 1 (3%) 3 (10%)

Risk Factors

CABS, Coronary artery bypass surgery; PCI, Percutaneous coronary intervention

Results Sample Characteristics The interviewed participants (N = 30) were recruited from a Midwest regional hospital during the spring and summer of 2009. Table 2 provides the characteristics of participants. The sample consisted of 15 males and 15 females. Subjects ranged in age from 65 to 88, with a mean age of 73.9 ± 6.0 years. Data were collected during the first month after surgery or PCI (34.3 ± 12.6 days). Participants’ cardiac procedures included PCI (n = 15) and CABS (n = 15). The sample shared similar sociodemographic characteristics. The majority of participants were married (67%), had at least one risk factor of heart disease, including hypertension (77%), hypercholesterolemia (77%), diabetes (23%), and 7% were current smokers. When participants were asked what lifestyle changes they made, healthy eating and portion control were most frequently reported as secondary prevention practices (50%), followed by attending cardiac rehabilitation (33%) and self-directed exercise (17%). Other risk behavior modification practices addressed were stress self-management (10%), the reduction of workload (3%), and smoking cessation (3%). Only three of the thirty participants (10%) reported multiple lifestyle changes (exercise, diet control, and/or managing stress). As participants discussed their decisions to follow a secondary prevention regimen (e.g., lifestyle change and risk behavioral modification), the shared themes reflected both enabling and

blocking factors to their engagement in healthy behavioral changes. These themes were grouped into five sections: 1) personal characteristics, 2) clinical characteristics, 3) transitional care, 4) social and environmental aspects, and 5) treatment outcomes.

RESEARCH QUESTION 1:

What are the perceived enabling factors to make lifestyle changes following a cardiac procedure?

Personal Characteristics The decision to engage in a secondary prevention practice was affected by the following themes: 1) positive illness and treatment beliefs, 2) sense of control, and 3) positive previous experience. Personal beliefs about the illness causality played an important role in participants’ decision to make lifestyle changes. • “If I keep my cholesterol down, I don’t think I should have any problems.” • “I have the same symptoms that my father had, I am convinced that a lot of this is hereditary, yes, I have chronic heart disease, and I have to make and stick with life changes.” • “I had a stent four years ago. I suppose exercise and watch my diet more, so maybe it won’t happen again.” • “I’d say it in my mind, you can’t just lay around, you have to get up and you have to move and work. You are going to have pain because of surgery, but you have to go ahead and work to keep that pain down. You exercise and do things like that, don’t lay around because it hurts. You go on with life. I changed my lifestyle, it is a whole new life. I mean you come out from dying, and you have to start all over again, it is a new life.” • “Well, my grandmother on my father’s side died at a young age from heart disease, my father had heart disease, and now I’m having the same symptoms that my father had . . . So I am pretty much convinced that I have chronic heart disease, a lot of it is probably hereditary, I am realizing that (hereditary is a nonmodifiable factor), so I am going to have to be more strict on changing my lifestyle, or I’m going to continue to have problems.” • “My mother had heart disease. Just because your family has it (heart disease), that doesn’t mean you are going to have it. Yes, you are more likely to have it (heart disease), but just go on with life, watch the things you can and can’t. Don’t overlook everything, and think well that I am in good health and I don’t want to ruin it again.” • “I pay attention and do what the doctor says, do it right, and it’s going to help my recovery and it’s going to help my well-being and give me a better outlook on everything.”

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

The decision to engage in lifestyle changes and risk modification was also influenced by personal belief regarding the benefits of a secondary prevention regimen. • “Cardiac rehab has been very helpful, beneficial, and safe.” • “You know I just have that comfort of (going to cardiac rehabilitation) when I go there to exercise. They have the monitor on me and things like that…” • “I’m going to rehab three times a week, and I can see where my strength is gaining all the time. I can really tell a difference from when I first started (cardiac rehabilitation).” • “I walk every day, and I am going to rehab now, and I think that is making me stronger.” • “I think having cardiac rehab is just an absolute plus because the two ladies – the physiologist and the nutritionist – are monitoring us all the time and checking, you know, our blood pressure three times during the hour, I just think that’s bringing me around really fast. It’s getting me back on top of my schedule again, and I just – and peace of mind – I just feel they’re monitoring me, they put the electrodes on me when we’re working out so if there’s anything going wrong, they’re going to know right away because they’re monitoring that computer all the time so …so I’m pleased. I think that’s probably one of the best things that they have done for us or for me, so – yeah, that’s a good follow-up. I’ll be on that for 18 weeks or so.” • “…Yeah, I think rehab has done a lot to educate me. They’ve been tremendous.” Some participants expressed a strong desire to have control over their health. • “The home health nurse is very good about letting me do my own thing. If people (providers) want to do it (change my lifestyle) by force, I’d say no. It is not always doing things by the rules. I don’t mean disobeying the doctors’ rules. I have to kind of adjust them for what works for me and how I am feeling.” Participants who had previous experience with cardiac revascularization expressed willingness to change lifestyle and modify cardiac risk factors more readily. • “My husband had heart surgery six years ago so we pretty much watch (our diet).” • “I had four stents put in years ago, but it plugged up again, so I’m going to be aware of it and carrying my nitro in case things plug up again, you know, and have more (doctor) check-ups than what I had been doing.” • “I had bypass surgery six years ago so I have been on a special diet, staying away from salt, less caffeine, low or non-fat diet….”

• “I had five stents and one bypass; we have been trying to eat low-fat foods, drinking skim milk since 1990.”

Social and Environmental Aspects Many participants reported that their support system helped them initiate and maintain lifestyle changes. • “Well, well I have a wonderful wife that used to be a wonderful nurse … And I can see if I did not have a spouse, I would not want to have to come home alone and I would hope that somebody would tell me to go to the assisted living complex for a while, you know, because I can see where you would get yourself in trouble by not eating properly and bathing properly and things like that so… My wife monitors me here at home. We have our own blood pressure machine too, and then she makes sure I take all my pills when I’m supposed to and things like that. . . The diet is working really well, my wife is careful that we’re eating lots of veggies and fruit, ahh, we’re trying to follow the program. I think it’s helping a lot.”

Outcomes Positive outcomes reinforced behavioral change adherence, as these participants noted: • “Now I pay attention to how much sodium is in things I buy, and you wouldn’t realize how much sodium is in everything. I have been cutting down on my eating, and you know watching for the fat and everything, sodium, and I have lost 12 pounds.” • “I’m starting rehab now, and I think that made a difference. I started to get a little more exercise and, when I started that, I started to change.” • “I’m in rehab right now, and boy, my blood-pressure is the best that it’s been in 15 years and things are going great!! I mean I just feel really good. Of course, we’re working on nutrition too, we’re working on our diet so I think things are going along really pretty good. I went back to see my doctor the first two weeks afterwards, he gave me a good evaluation and checked it all out.” In addition, those who made a connection between his/her expected outcomes and behavioral change were more likely to follow a secondary prevention practice. • “I am 81 years old; if I take care of myself, I might be around three or four more years.” • “If we got on top of it pretty quickly and control it, I behave myself and do what I should; I can get another 10 or 20 years out of my life anyway.” • “I really watch what I eat because I want to get back to doing what I was doing before.”

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RESEARCH QUESTION 2:

What are the perceived blocking factors to make lifestyle changes following a cardiac procedure?

Personal Characteristics The following themes indicated that participants could have difficulty in adopting a secondary prevention practice: 1) believing their heart problems have been “fixed”, not perceiving as a chronic disease; 2) perceiving chronicity as “loss of control”; 3) attributing heart disease to genetic factors (nonmodifiable factor); 4) negative attitude toward behavioral change; 5) financial burden associated to a secondary prevention practice; 6) failing to establish goals to change behaviors, and 7) lack of knowledge and information regarding heart disease and secondary prevention. Participants perceived the heart surgery as a “permanent cure,” and they were “fixed” by the procedure. As a result, most participants (67%) denied having chronic heart disease. Participants’ responses typified this perception. A participant who had valve disease and atrial fibrillation claimed: • “No, they (healthcare providers) say this is pretty well taken care of, I don’t have chronic heart disease.” Another participant who had CABS six years ago denied he had chronic heart disease. Other participants stated: • “I thought they fixed it, so it is just a health problem.” • “Well, I think to some extent it may, I mean, yeah, it has slowed me down and … but I don’t think it will take that big of a toll, no, I don’t have chronic disease.” • “I don’t think I have chronic heart disease, I feel like it is fixed, no.” • “I think I am cured for now, for quite a while.” Only four of the 30 participants (13%) believed they had chronic heart disease, and six of the 30 participants (20%) had ambiguous feelings about the chronic nature of their heart conditions. One participant described: • “I feel like it is fixed, and that’s something I was kind of wondering about, what would determine my problems and do I really have heart disease? I don’t think I do. I think I just have something that wore out. I mean that is the way I look at it.” Some participants started to make adjustments and accepted the fact of having a chronic heart problem. • “They (healthcare providers) warned me, don’t get fooled into thinking you’re better off than you were, and I realized that’s why I feel now, it’s coming back….”

The participants who attributed their heart condition to a sole genetic factor did not believe the benefits of a secondary prevention. A couple of participants stated: • “I wish it is something that I can do something about it, but each time the doctors have told me it is pretty much an inherited factor that I am going to have to live with it. You can only control about so much of this in your lifestyle and that is about all you can do.” • “I don’t know, it is all in God’s hands, whatever he decides, no matter what I do, it’s up to him.” Some participants expressed a negative attitude towards risk behavioral modification. Others did not think making a behavioral change would make a difference. • “I have gone to 1% milk instead of 2% but I refuse to go to skim milk. If I have to drink skim milk, I am going to drink water.” • “I am lazy, don’t want to do too much on exercise.” • “They got me on this diet deal, I am not too crazy about the diet but I am following it.” • “Well, at my age, I don’t really think that there is too much room to change. I will be 80 my next birthday.” • “I haven’t really found anything that has improved my recovery that much.” For some participants, cost was a barrier to engaging in recommended cardiac rehabiliation. One reported: • “I don’t know for sure if I am going to cardiac rehabiliation. If I get along here with my own exercise, I will stick with that. It is cheaper.” Many participants struggled with personal goals for behavioral change. Twenty-four of the 30 participants (80%) did not have either short- or long-term goals for lifestyle changes. • “Cutting out salt and eating better, I was not too good at that. I don’t have goals yet to change my lifestyle. Plus, it is hard to get them implemented. We get them started, we don’t follow through usually.” Participants’ responses revealed many of them lacked knowledge and had a misunderstanding in terms of heart disease risk factors and their association with secondary preventions. • “If I keep my cholesterol down, I don’t think I should have any problems.” • “I am like 5’6” but I weigh 180-some pounds but I don’t consider myself fat, maybe just a freckle being overweight.” • “I am diabetic, but I am not at risk for heart disease because I have more trouble with low blood sugar than high.” • “I am overweight and I don’t know what I should weigh.”

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• “I don’t know how much, how hard to push myself (on increasing physical activity).”

Clinical Characteristics Clinical factors, such as comorbidity, symptom burden, impaired functioning were perceived as blocking factors that prevented participation in cardiac rehabilitation. One participant reported: • “I’ve been doing some exercise in between rehab at home, but sometimes I wonder if, on account of my bad knee that maybe I should have rested that day but I don’t know.” Several participants were unable to walk due to musculoskeletal problems and surgeries (e.g., open reduction internal fixation [ORIF] of foot, chronic back pain). One participant had chronic leukemia, so he was concerned about getting the flu from other people who attended cardiac rehabilitation. Another participant was reluctant to go to cardiac rehab due to a gastrointestinal problem. In addition, the disease-specific, self-management instructions created confusion to participants when they tried to manage their multiple problems. • “I got some pamphlets from the hospital (when I was discharged). I was on a special diet for my colitis, and I was trying to figure out how I could work both diets together (heart and colitis diets), they don’t always agree.”

Transitional Care Many participants expressed feelings of frustration and disappointment with the care provided during transition from hospital to home. Their negative experience influenced their decision to make lifestyle changes and included: 1) inadequate coordination during care transition after hospitalization, 2) perceived poor discharge teaching, 3) inconsistent information given by different healthcare professionals, and 4) lack of recommendation of a secondary prevention program from providers (especially the physicians). Some participants were unable to attend cardiac rehabilitation programs due to poor coordination between care settings and providers. • “I was supposed to start rehab at the community hospital, but they don’t want to do that until after I see the doctor (the cardiologist).” One participant had difficulty in making follow-up appointments. • “I was quite disappointed in the scheduling of doctors. They (the scheduler at the physician’s office) had scheduled me to see the cardiologist, but they didn’t have me scheduled with the right doctor at all. I was, I was very upset with that. So then I couldn’t get in to see him until the next Thursday. I had pain at my whole chest and was really afraid of angina again. That was totally uncalled for, and they should have gotten me by at least the next day. I haven’t seen any (doctors), and the appointment I had with the cardiologist was with the wrong doctor. Had

I not called, I would have really been upset.” The discharge teaching content was perceived as inadequate and the timing of the teaching was inappropriate. Twenty-one out of 30 participants (70%) could not remember who provided the discharge instruction regarding secondary prevention. • “I don’t remember, well it was the people from the hospital where I had my heart surgery.” • “Well I don’t remember, I’m sure somebody – they told me so much stuff that …” • “I don’t remember who gave the instruction. They gave me a book and told me to read that and do what is said.” • “They kicked you out there in a hurry, and they did not have enough time to tell you anything.” Some participants reported they received contradictory advice regarding secondary prevention practices from different providers. • “… I know you are not supposed to eat so many eggs, but there is kind of a different story about eggs from different people (providers).” Some participants reported physicians failed to recommend cardiac rehabilitation. • “I had five stents and one bypass, my doctor said that if I can use my treadmill for 25-30 minutes a day, that would be sufficient, no need to go to cardiac rehab.” • “I did not go to heart rehab. My doctor did not think it was necessary for me to do that because I was active enough. I walked to my mailbox every day…” • “I did not go to cardiac rehab, my doctor said once the weather straightens out and I can get outside, everything will come back to you in good shape.” • “They (healthcare professionals) have not yet talked to me about lifestyle changes.” • “Nobody has said anything about cardiac rehab to me yet, I don’t know, usually they do cardiac rehab, don’t they?”

Social and Environmental Aspects Participants living in rural communities found it difficult to make lifestyle changes because of inability in obtaining the resources needed. • “We live in a small town, less than 1000 people, and the grocery store here didn’t have anything healthy. . .” • “I can’t see driving long distance for cardiac rehab unless the doctor insists upon it. I don’t feel like I am safe on the road, then my husband would have to take me and wait for me.” • “It is about 26 miles of driving to cardiac rehabilitation. That’s why I only did two weeks…”

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Outcomes The negative experience from a secondary prevention practice became a barrier for some participants to follow the behavioral change regimen. • “I think the hardest thing is the salt. I am finding it is tough to stay under 2000 mg of salt a day. I like salt, food does not taste right without salt. Pretty tough when you work on gardening, salt gives you the energy.” • “I did not take any medicine because I know from experience, medicine does not agree with me when I get sick. I did not ask a doctor for permission. To tell you the truth, I am not taking any of my medicines except TUMS right now because I have gotten better in the last few days after quitting the medicine.” • “I put in a lot of long hours during harvest but I get so hungry that vegetables don’t quite give me enough energy to run our days.”

Discussion This study revealed insight into participants’ experiences regarding their recovery and care received during the transition to home following hospitalization for a cardiac procedure. The findings further improved our understanding of the impact of participants’ perceptions and recovery progress on their adherence to secondary preventive regimens. Overall, participants adopted some behavioral lifestyle changes after their cardiac procedure. Similar to the findings from other studies,25,37 we found the most frequently reported modified behaviors were diet and physical activity. Generally, participants often only engaged in a single lifestyle behavioral change (e.g., diet, exercise, stress management), as reported by 3-50% of the participants. Only 10% of participants reported multiple lifestyle changes. Sustained lifestyle modifications are of paramount importance for patients after cardiac revascularization to delay the progression of heart disease. However, the rate of adherence to recommended secondary prevention in our study group was low, similar to those reported in previous research. Comparable to previous studies, our study found participants had misperceptions of being “cured” or “fixed” following cardiac revascularization. Therefore, they were less likely to engage in risk behavioral modifications compared to non-surgical cardiac patients and experienced significant levels of psychological distress over time if these misconceptions were not corrected during early recovery.15,24,29,37-41 Perioperative and discharge teaching is implemented to modify patients’ misconceptions and emphasize the importance of adopting long-term lifestyle changes to prevent further cardiac disease.15,42 However, similar to other studies,25,43-45 the participants enrolled in our study perceived discharge teaching was insufficient in meeting their informational needs. Timing of the delivery of teaching was thought inappropriate. Most participants could not recall what was taught at discharge. In addition,

participants reported that inconsistent, contradictory, and incorrect information was provided by different providers. Adequate discharge teaching and planning is critical in providing accurate information to assist patients’ transitioning from hospital to home.43,46 With shortened hospital stays, healthcare professionals often have little or no time to correct these aforementioned misperceptions, which may result in non-adherence to secondary prevention.39 In addition, the quality of discharge education may be suboptimal. Literature suggests that healthcare professionals have limited knowledge and skills to teach patients how to manage their chronic problems and make lifestyle changes.47,48 Furthermore, standardized discharge information fails to tailor to each individual’s unique needs.45 Due to poor discharge teaching and insufficient post-discharge follow-up programs,28 patients and their families often feel uncertain about their disease prognosis and treatment outcomes. In addition, patients struggle for sense of control, feel unprepared to perform self-management,38 and have difficulty in making lifestyle changes during the early stage of transition from hospital to home after a cardiac procedure.25,28 Studies have shown that positive recovery experiences during the early stage of transition after a cardiac event promote adherence to recommended lifestyle changes.38 Therefore, home-based, tailored transitional care programs are increasingly needed to provide post-acute care services to prematurely discharged patients who still have complex, intensive care needs that family members cannot accommodate. In addition, these transitional programs play a vital role in helping patients engage in and sustain their behavioral change. Nurses, in conjunction with multidisciplinary teams, have the opportunity to make a significant impact on helping patients adopt life-long secondary prevention practices following cardiac surgery.

Clinical Implication Healthcare professionals need to identify patients’ misperceptions about cardiac revascularization and send a clear message that coronary revascularization does not cure heart disease but only relieves symptoms. Lifelong secondary prevention is required to improve the outcomes of the procedure, prolong life, further reduce symptoms, and enhance the functioning level. To avoid conflicting information provided by different healthcare professionals, guidelines are needed to develop consistent and accurate transitional care for these patients.

Research Implication Current adherence-enhancing interventions often target only singular psychosocial and cognitive factors (e.g., self-efficacy, motivation, knowledge) influencing the decision-making process related to behavioral change.32,34,35,39,49-53 These interventions may overlook the contextual factors, such as care transition processes, patient-provider interactions, household health belief and practice, and community resources.15 There is a need to develop a comprehensive transitional care model to address both patient factors (e.g., knowledge, self-efficacy, and moti-

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

vation) and contextual factors that impact patients’ behavioral change to guide development of effective interventions.

Education Implication Considering the progressively increasing aged population with multiple chronic conditions, school curricula need to be redesigned to produce future healthcare professionals who are knowledgeable and capable in caring for patients with multiple chronic diseases, as well as meeting their complex care needs. In addition, adequate information and practice opportunities need to be provided to augment healthcare professionals’ teaching skills in conducting effective patient education.

Limitations This study used a small, homogenous group, which limits the generalizability. Although this study was small, it provided a deeper understanding of participants’ experiences as the postdischarge interview allowed the authors to identify factors that influenced lifestyle behavioral change in the home setting.

Conclusion Sustained lifestyle change reduces coronary artery disease risks and improves coronary revascularization outcomes. This study reinforced the variety of complex barriers in adopting health behaviors experienced by cardiac patients, including misperception about heart disease and treatment outcomes, perceptions of inadequate discharge teaching, limited community resources, and lack of transitional care after hospitalization. Potential Financial Conflicts of Interest: By AJCM® policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist.

Lufei Young, PhD, RN, APRN-NP, is Assistant Professor at the University of Nebraska Medical Center, College of Nursing. Susan Barnason, PhD, RN, APRN-CNS, CCRN, CEN, FAHA, is Professor at the University of Nebraska Medical Center, College of Nursing.

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39. Astin F, Jones K. Changes in patients’ illness representations before and after elective percutaneous transluminal coronary angioplasty. Heart Lung. 2006;35(5):293-300. 40. Hajek P, Taylor TZ, Mills P. Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and bypass surgery: Randomised controlled trial. BMJ. 2002;324(7329):87-89. 41. Oldenburg B, Martin A, Greenwood J, Bernstein L, Allan R. A controlled trial of a behavioral and educational intervention following coronary artery bypass surgery. J Cardiopulm Rehabil. 1995;15(1):39-46. 42. Lau-Walker M. Importance of illness beliefs and self-efficacy for patients with coronary heart disease. J Adv Nurs. 2007;60(2):187-198. 43. Fredericks S. Timing for delivering individualized patient education intervention to coronary artery bypass graft patients: An RCT. Eur J Cardiovasc Nurs. 2009;8(2):144-150. 44. Fredericks S, Sidani S, Shugurensky D. The effect of anxiety on learning outcomes post-CABG. Can J Nurs Res. 2008;40(1):127-140. 45. Hanssen TA, Nordrehaug JE, Hanestad BR. A qualitative study of the information needs of acute myocardial infarction patients, and their preferences for follow-up contact after discharge. Eur J Cardiovasc Nurs. 2005;4(1):37-44. 46. Maloney LR, Weiss ME. Patients’ perceptions of hospital discharge informational content. Clin Nurs Res. 2008;17(3):200-219. 47. Washburn SC. Nurses knowledge of heart failure education topics as reported in a small midwestern community hospital. J Cardiovasc Nurs. 2005;20(3):215. 48. Washburn SC, Hornberger CA. Nurse educator guidelines for the management of heart failure. J Contin Educ Nurs. 2008;39(6):263-267. 49. Phillips LA, Leventhal H, Leventhal EA. Physicians’ communication of the common-sense self-regulation model results in greater reported adherence than physicians’ use of interpersonal skills. Br J Health Psychol. 2012;17(2):244-257. 50. Krannich JH, Weyers P, Lueger S, et al. The short- and long-term motivational effects of a patient education programme for patients with coronary artery bypass grafting. Rehabilitation (Stuttg). 2008;47(4):219225. 51. Jiang X, Sit JW, Wong TK. A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: Evidence from Chengdu, China. J Clin Nurs. 2007;16(10):1886-1897.

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American Journal of Clinical MedicineÂŽ â&#x20AC;˘ Winter 2014 â&#x20AC;˘ Volume Ten Number One

Ocular Manifestations of Domestic Violence: A Case Review Anjulie Kelkar, BS W. Abraham White, MD Omofolasade Kosoko-Lasaki, MD, MSPH, MBA, FAASS

Presented by Dr. Kosoko-Lasaki at the AAPS Annual Scientific Meeting in San Juan, Puerto Rico, June 2013

Domestic violence is a serious and preventable worldwide problem that may be unrecognized by health care providers as the primary cause of ocular trauma. Proper management and counseling in these cases is crucial in limiting adverse effects from injury and preventing future cases of violence. We discuss a case of an adult female who presented to the emergency department following an assault by her husband. The diagnosis and management will be discussed, and a logical model will be provided for treatment using a multidisciplinary and social team approach. Preventive modalities will also be discussed. This case highlights the need for healthcare workers to recognize and advocate for the early recognition and management of ocular manifestations of injury from domestic violence.

Introduction Domestic violence (also known as domestic abuse, spousal abuse, battering, family violence, and intimate partner violence) is defined as a pattern of abusive behavior by one partner against another in an intimate relationship such as marriage, dating, family or cohabitation.1 Domestic violence can be divided into different types: sexual, physical, verbal, and psychological. There are many forms of physical abuse that include hitting, kicking, biting, shoving, restraining, slapping, and throwing objects. One in four American families is affected by battering.2 Domestic violence is primarily a crime affecting women; it is estimated that 1.5 million women are physically abused in the United States each year.3 Men may also be abused in some cases. However, worldwide, domestic violence is a serious problem with women being four times as likely to be victims of abuse.4

The most frequent location of injury for victims of all types of violence is the head and neck region with ocular injuries often being an identifiable manifestation of physical violence.5 Ocular injuries can range from a small laceration on the eyelid to an orbital fracture and may be the result of a penetrating, perforating, or blunt trauma. The majority of orbital fractures in females result from domestic violence.6 The injury may result from an acute attack or chronic, continuous battering. In most cases, health care workers are often the first people the victim approaches for help. In this paper, we discuss the case of a patient that presented to the emergency department after a domestic assault with a closed fist, resulting in injury to the face and eyes.

Case Report R.H. is a 42-year-old female patient who presented to the ophthalmology clinic upon referral from an outside emergency department. The patient was seen in the emergency department a few hours after her husband struck her in the right eye with a closed fist, sustaining a laceration to her face involving the medial canthus. The patient complained of mild blurred vision and pain in the right eye and denied concurrent injuries elsewhere. Binocular visual acuity was assessed as 20/20 by Snellen Distance Acuity Chart. She did not receive a full ocular examination or imaging studies while in the emergency department. Patient was given analgesic for her eye pain. Her immunization status was assessed and she was administered intramuscular tetanus, diphtheria, and acellular pertussis toxoid vaccine (Boostrix).

Ocular Manifestations of Domestic Violence: A Case Review

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Her wound was cleaned, and a wet-to-dry was applied over the right eye. Because of the circumstances surrounding her trauma, R.H. was given a pamphlet for a women’s shelter and referred to the ophthalmology clinic for a complete eye exam. Attempts were made to refer the patient to the police; however, the patient declined to pursue charges. Her past medical history was unremarkable for any medical problems. She had an allergy to codeine, which caused a rash, itching, and edema. She was not taking any prescription medication, over-the-counter, or herbal medications. Her past ocular history and family history were non-contributory. R.H. lived at home with her husband and two children and was unemployed. She denied any previous domestic violence incidents. She admitted to smoking cigarettes (one pack per week for several years) but denied any alcohol or illicit drug use. Review of systems was positive for right eye pain and redness but negative for diplopia and excessive tearing. Systemic review was negative for easy bruising, heavy menstrual periods and nosebleeds to rule out hypercoagulation disorders.

Image 1: Right eye of patient R.H. with significant ecchymosis and 5 cm laceration. The dilated pupil is secondary to the use of mydriatic drops. The pupil is round and symmetrical demonstrating the absence of anterior globe laceration.

On examination, R.H. was in acute pain. Inspection of her face (see Image 1) revealed a 5 cm laceration extending in a linear fashion along the lateral edge of the nose up to the medial canthus on the right side along the tear trough. The superior edge of the laceration extended to the medial canthus tendon, but the tendon appeared to be intact. There was significant ecchymosis surrounding the right eye but no hypertelorism, lid lash malposition or epiphora. Her best visual acuity was 20/20 without correction in both eyes using the Snellen visual acuity chart at distance. Both pupils were 4 mm in size and were equal, round, and reactive to light and accommodation. There was no asymmetry of the pupils and no afferent pupillary defect (APD) in either eye. Confrontation visual field was full in both eyes. Eye motility was full in the left eye but limited on the right eye when looking upward. She did not report diplopia in

any direction of gaze. Intraocular pressure (IOP) by applanation tonometry was 16mmHg in both eyes. The facial exam is illustrated in Image 1. Slit-lamp examination was significant for inferior conjunctiva injection in the right eye and early nuclear sclerotic cataract in both eyes. There was no corneal abrasion, no anterior chamber hyphema or lenticular displacement. The patient’s eyes were dilated with phenylephrine hydrochloride, 2.5% (EyePhrine, Eye Supply, USA) and tropicamide, 1% (Akorn, Inc., USA). Dilated pupils were round and symmetrical demonstrating the absence of anterior segment laceration. The dilated fundus examination revealed normal vitreous and normal-appearing optic nerves with no retinal hemorrhages, holes, or tears in both eyes. Given the location of the patient’s laceration, the inferior punctum was irrigated with passage of fluorescein into the nose using a cannula. The result confirmed that the canalicular system on the right side was intact. R.H. was taken to a minor procedure room for repair of the laceration. After informed consent, the patient was prepped in the usual sterile fashion for primary surgical repair of the wound. Six mL of 2% lidocaine with epinephrine (Hospira, Inc., USA) was injected around the skin in a superficial manner surrounding the laceration. The wound was explored and cleaned, with no foreign bodies found. The laceration was closed in a layered fashion with six interrupted 6-0 vicryl sutures deep and 13 interrupted 6-0 plain gut sutures to the skin. There were no complications. The patient was prescribed erythromycin ophthalmic ointment (Romycin) to be applied three times a day until follow-up appointment in one week. Because of the possibility of an orbital fracture, R.H. was sent for a computed tomography (CT) scan of the orbit and maxillofacial area with coronal reconstruction. Result is shown in Image 2. At the one week follow-up, R.H. reported continuing discomfort and tearing in the right eye. She also complained of sleep disturbance and anxiety. On external examination, the incision was clean, dry, intact, and lid position was good. Motility testing revealed diplopia in primary and up gaze. Hertel exophthalmometry revealed 2mm of enophthalmos in the right eye (13 right eye, 15 left eye with a base of 100). Slit-lamp examination was significant for mild conjunctiva injection. The CT results showed a right orbital floor blowout fracture and medial wall fracture without evidence of muscle entrapment (Image 2). The patient was instructed to continue with erythromycin ointment application three times a day to the right eye and to follow up with an oculoplastics specialist for evaluation and possible repair of the orbital fractures. One week later, the patient met with the oculoplastics specialist. She had severe sinus pain that worsened when she sneezed or coughed. Her initial symptoms and signs were unchanged. In addition, she had numbness in the distribution of the infraorbital nerve. The risks, benefits, and alternatives of orbital floor repair were discussed with the patient, and she elected to proceed. The repair was done one week later with no complications.

Ocular Manifestations of Domestic Violence: A Case Review

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

CT when patient presents with a blunt trauma to the orbital region.9 A CT scan can assess for globe injuries, retro-orbital hematomas, and existence of free air in the adjacent soft tissues or orbit. It also provides visualization for a zygomaticomaxillary complex (ZMC) fracture and thus future planning for operations. Indications for surgery include large orbital floor defect (>1 cm2), early enophthalmos, significant hypoglobus, or persistent diplopia in the primary field of gaze.10 Studies have shown that orbital fractures should be fixed in a timely manner to avoid permanent diplopia and loss of binocular vision.11

Epidemiology of Domestic Violence

Image 2: CT image of patient R.H. showing: 1) maxillary fluid (blood presumed within the context of trauma); (2) inferior orbital wall fracture; (3) medial orbital wall fracture; (4) ethmoidal air cell fluid (blood); (5) nasal septal deviation; (6) absence of intra orbital free air.

Discussion Ocular injuries due to domestic violence can include ecchymosis of the eye (black eye), lenticular dislocation, globe rupture, traumatic hyphema, or orbital wall fractures. The treatment depends on the severity and duration of the injury. In the case presented, the patient sustained a laceration from the cheek to the medial canthus and an orbital fracture caused by a domestic assault by the patient’s husband. With any ocular injury due to trauma, an evaluation should be made for the need of emergent surgery, such as in an open globe. When a vision-threatening emergency is ruled out, a full medical history and ocular examination should be conducted by a physician. A medial canthus injury, such as in this case, should be evaluated by an ophthalmologist to rule out a canalicular laceration in order to minimize the incidence of posttraumatic epiphora. The method used to detect a canalicular obstruction varies among practitioners. The preferred method is to inject fluid, such as fluorescein, through the canaliculus in the area of the injury while observing for signs of reflux into the wound, indicating damage to the canalicular system.7-8 An intact system is confirmed when the irrigant enters the patient’s nasopharynx, which is confirmed by the patient reporting a salty taste. In this case, a CT scan was not ordered in the emergency department. However, it is encouraged to order an immediate

Domestic violence is a public health problem that affects over two million men and women in the United States.12 In the most recent report by the Centers for Disease Control, it was found that 35.6% of women in the United States are raped, assaulted, or stalked by intimate partners at some point during their lives, and approximately 6% experience these events in any given year. Men are also at risk for domestic violence with 28.5% reporting victimization at some time during their lifetime and 5% reporting victimization within the past year. Worldwide, between 15–71% of women report experiencing physical and/or sexual violence by an intimate partner at some point in their lives.13 Domestic violence can have physical, economic, social, and psychological impacts. Women affected by sexual and physical abuse are more likely to contract sexually transmitted diseases,14,15 abuse alcohol and tobacco,16 and commit suicide.17 Intimate partner victimization of women increases the risks of injury, gastrointestinal disorders, chronic pain, central nervous symptoms (including fainting and seizures), hypertension, and gynecologic problems.18 Over eight million workdays are lost as a result of intimate partner violence each year and costs exceed $8.3 billion due to rape, physical assault, stalking, and in the value of lost lives.19 Many studies show that domestic violence is a cause of homelessness for women and their families.20-22 Domestic violence may represent up to 20% of ocular traumas presenting to emergency departments.23 The most frequent location of injury for victims of all types of violence is the head and neck region, where 93% of fractures involved facial bones.24 One study found that domestic violence was the cause of injury in 7.3% of adult female orbital fracture patients. However, only 30% of injured females and 20% of males who are rape and physical assault victims receive medical treatment.25

History A thorough history will help in identifying the cause of the ocular damage and detail the circumstances surrounding the injury. The patient may directly say he or she has been a victim of domestic abuse. If not, other clues may lead the physician to suspect domestic abuse, such as reported mechanism inconsistent with injury, vague complaints, and delay in seeking care for injury. It is ideal for the physician to interview the patient in a safe, private environment, especially if the suspected abuser is

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

present. The physician should ask simple, direct questions to validate patient’s concerns and assess their safety (Table 1).26 It is important to take note of any behavioral clues, such as reluctance to speak in front of the partner, evasiveness, and an overly controlling or protective partner. Table 1: Statements that can be made by the healthcare provider.26 Validation statements • You are not alone. • There is help available. • You are not to blame. • There are places where you can go. Assess safety • Are you afraid to go home? • Do you have a safe place to go? • Do you need access to a refuge? • Are there weapons present? • Do you want police intervention?

With a suspected domestic violence case, it is imperative to document the details of the incident to prepare for any legal action that will be taken. Particular attention should be paid to the eye if a foreign object, such as glass, was involved because it has the potential to perforate the globe. Double vision can be a sign of muscle entrapment after an orbital wall fracture. This is an indication for imaging studies to assess for fractures. The patient should be asked about any previous domestic violence injuries. The physician should inquire into the patient’s ocular history including any previous ocular injuries, ocular surgeries, contact lens use, or history of strabismus/amblyopia. The list of current medications, allergies, family history, social history, and date of last tetanus vaccination will complete the highlights of the patient’s medical history. Particular attention should be paid to the social history (i.e., where they live, the number of children, number of partners, alcohol and drug use). Review of systems is important to assess for any other injuries related to domestic violence and to assess for a hypercoagulability disorder. A checklist of important factors for health care workers to consider is shown in Table 2.27 Table 2: Checklist for assessing domestic violence cases.27 • Perform full history and physical • Clear documentation of history • Write legibly • Avoid abbreviations • Put patient’s words in quotations • Describe patient’s demeanor • Record time of day patient is examined • Take photographs of injuries • Create “body map” documenting injuries • Obtain basic labs and hypercoagulation studies • Contact police depending on state laws • Contact social worker to assess living situation or other requirements.

Ophthalmic Examination With any ocular injury due to trauma, initial evaluation should ensure the integrity of the globe. In suspected cases of an open globe, there should be an immediate evaluation by an ophthalmologist. A comprehensive ocular examination may not be possible in the emergency room setting and may have to be done in the operating room. Ocular signs suggestive of a ruptured globe include a pupil that is not round, 360 degrees of hemorrhagic chemosis, and a loss of the normal spherical contour of the cornea or sclera on exam. The eye should be protected with a Fox shield and the patient prepared for the operating room where a thorough exam and repair will be performed under anesthesia. In the absence of signs suggestive of a ruptured globe, the patient should have a complete eye exam, which includes visual acuity, pupil exam, motility exam, confrontation visual fields, slit lamp exam, tonometry, and a dilated eye exam (Figure 1).28 Both eyes should be examined thoroughly, even if it is obvious that the other eye is not affected, as intraocular trauma may be present in eyes that lack external evidence of injury.29,30 The ocular exam should focus on extraocular motility, as well as the pupil exam and a dilated fundus exam to search for any evidence of optic nerve compression in these cases. The complete absence of elevation suggests the possibility of entrapment; this can be differentiated from a traumatic third nerve palsy by forced duction testing. In cases of suspected orbital wall fracture, imaging should be ordered to complement a complete eye examination.31 A CT of the head is not sufficient to rule out facial and orbital fractures; a dedicated scan of the facial bones with coronal reconstruction is warranted, allowing for assessment of the globe and facial bones to assist in diagnosis and surgical planning in cases of fracture. Magnetic resonance imaging may be utilized in selected cases, but it is generally unnecessary and is contraindicated if a metallic foreign body is suspected. In a domestic violence case, it is necessary to document ocular injuries, as well as other parts of the body that are injured due to abuse, with photographs.

Medical and Surgical Management As stated previously, the most important component of management is to rule out an ocular emergency, such as an open globe. After thorough ocular examination has been made, it is important to know when it is appropriate to consult an ophthalmologist. In general, family medicine and emergency medicine physicians can manage corneal abrasions, some superficial foreign bodies, and small eyelid lacerations not involving the lid margins. Injuries such as deep corneal foreign bodies and any signs of hyphema should be managed by an ophthalmologist in centers where slit lamp examinations can be performed and intraocular pressure can be measured. In addition, open globe injuries, lid lacerations involving the lid margin or canalicular system, orbit fractures, and any potential intraocular foreign body should be referred to an ophthalmologist.32

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American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Figure 1: Management Guide for Ocular Trauma Due to Domestic Violence

Obtain a medical history Classify injury as blunt or penetrating

Blunt trauma

Penetrating injury

Check visual acuity, pupils, and EOM

Baseline visual acuity and presence of APD

Examine eyelids, adnexa, and lacrimal system

Orbital CT or radiographs

Palpate orbital rim for fractures or crepitus

Limit exam until operating room is available

Patch both eyes

Prompt ophthalmology referral for repair

Examine globe for conjunctiva or corneal lacerations, presence of foreign bodies, or media opacities

Measure the IOP

Dilated exam of the fundus for signs of posterior injuries

Targeted management of elevated IOP with short interval rechecks

Appropriate imaging to determine extent of injury

Referral to social services

Referral if IOP severely elevated or refractory Referral to case worker

Social Management After medical evaluation and management, it is important to address the patient’s needs concerning his or her safety. A social worker should be contacted who can provide resources for the domestic violence shelters, social services, legal assistance, and support groups. If the patient has no safe place to go, the physician should contact social services for intervention. Child Protective Services should be consulted for children.33

Involve law enforcement services

Referral to mental health services

In jurisdictions where reporting of domestic violence is mandated, the legal obligation to report abuse should be discussed with the patient. The laws vary from state to state but generally fall into four categories: states that require reporting of injuries caused by weapons, states that mandate reporting for injuries caused in violation of criminal laws, as a result of violence or through non-accidental means; states that specifically address reporting in domestic violence cases; and states that have no general mandatory reporting laws.34

Ocular Manifestations of Domestic Violence: A Case Review

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

It is important for health care providers to check their state’s laws regarding reporting domestic violence. Without appropriate intervention, the violence can become cyclic, resulting in repeat visits to the emergency room and primary care offices. The patient’s life may also be threatened if the abuse is not terminated.

Prevention of Domestic Violence Injuries Although health care professionals need to be prepared to treat ocular injuries related to domestic violence, the goal for domestic violence is prevention. There are numerous professional and health care organizations,30, 35-367including the Institute of Medicine,38 that recommend screening or assessment of patients for partner violence in primary care settings. New guidelines under the Affordable Care Act require insurance coverage to include intimate partner violence screening and counseling as part of eight essential health services for women at no additional cost to the patient.39 However, physicians may be afraid to ask such questions because of a lack of time, training, and easy access to services that help these patients.40 Recent evidence encourages shifting the focus away from universal screening to case finding-identifying and providing appropriate clinical and social services to women who show signs of abuse.41,42 With this evidence, it is imperative to inquire about domestic violence when a suspected patient presents.

Conclusion Ocular injuries due to domestic violence are a common occurrence worldwide. With the proper medical and surgical care and social management, patients can have successful outcomes both physically and emotionally. Primary prevention modalities, including screening in the primary care setting, may help avoid increasing health costs and injury to patients. Physicians should always consider and recognize that domestic violence may be the cause of the injury for patients presenting with ocular injuries.

Acknowledgement The authors would like to thank Justin Daugherty, MFA, and Elaine Ickes for their editorial assistance. Potential Financial Conflicts of Interest: By AJCM® policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist.

Anjulie Kelkar, MD, is an intern at the University of Kansas Medical Center. W. Abraham White, MD, is a Clinical Instructor, University of Kansas Medical Center Department of Ophthalmology, Kansas City. Omofolasade Kosoko-Lasaki, MD, MSPH, MBA, FAASS, is Professor of Surgery (Ophthalmology), Creighton University School of Medicine, Omaha.

References 1.

Saltzman L, Fanslow J, McMahon P, et al. Intimate partner violence surveillance: Uniform definitions and recommended data elements, version 1.0. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 2002.

Novello AL, Rosenberg M, Saltzman L, et al. From the Surgeon General, U.S. Public Health Service. JAMA. 1992;267:3132.

Goldberg SH, McRill CM, Bruno CR, et al. Orbital fractures due to domestic violence: An epidemiologic study. Orbit. 2000 Sep;19(3):143-54.

Greene D, Raven R, Carvalho G, et al. Epidemiology of facial injury in blunt assault. determinants of incidence and outcome in 802 patients. Arch Otolaryngol Head Neck Surg. 1997 Sep;123(9):923-8.

Shepherd JP, Shapland M, Pearce NX, et al. Pattern, severity and aetiology of injuries in victims of assault. J R Soc Med. 1990 Feb;83(2):75-8.

Arosarena OA, Fritsch TA, Hsueh Y, et al. Maxillofacial injuries and violence against women. Arch Facial Plast Surg. 2009 JanFeb;11(1):48-52.

Ho T, Lee V. National survey on the management of lacrimal canalicular injury in the United Kingdom. Clin Experiment Ophthalmol. 2006 JanFeb;34(1):39-43.

Jones LT, Marquis MM, Vincent NJ. Lacrimal function. Am J Ophthalmol. 1972 May;73(5):658-9.

Tanaka T, Morimoto Y, Kito S, et al. Evaluation of coronal CT findings of rare cases of isolated medial orbital wall blow-out fractures. Dentomaxillofac Radiol. 2003 Sep;32(5):300-303.

10. Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital fractures. Plast Reconstr Surg. 2007 Dec;120(7 Suppl 2):57S-63. 11. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol. 2003 Oct;14(5):236-40. 12. Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence among women: Findings from the national violence against women survey. 2000;U.S. Dept of Just, NCJ 183781. 13. Garcia-Moreno C, Jansen HA, Ellsberg M, et al. WHO multi-country study on women’s health and domestic violence against women. World Health Organization (WHO). 2005. 14. Zand L, Hoffman SJ, Nyman MA. 74-year-old woman with new-onset myoclonus. Mayo Clin Proc. 2010 Oct;85(10):955-8. 15. Plichta SB. Intimate partner violence and physical health consequences: Policy and practice implications. J Interpers Violence. 2004 Nov;19(11):1296-323. 16. Silverman J, Raj A, Mucci L, et al. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA. 2001;286(5):572-9. 17. Roberts TA, Klein JD, Fisher S. Longitudinal effect of intimate partner abuse on high-risk behavior among adolescents. Arch Pediatr Adolesc Med. 2003 Sep;157(9):875-81. 18. Campbell JC. Health consequences of intimate partner violence. Lancet. 2002 Apr 13;359(9314):1331-6. 19. Max W, Rice DP, Finkelstein E,et al. The economic toll of intimate partner violence against women in the United States. Violence Vict. 2004 Jun;19(3):259-72. 20. American Civil Liberties Union, Women’s Rights Project. Domestic violence and homelessness. 2004. 21. Owen G. Minnesota statewide survey of persons without permanent shelter; volume I: Adults and their children. Wilder Research Center. 1998. 22. Douglass R. The state of homelessness in Michigan: A research study. Michigan Interagency Committee on Homelessness. 1995. 23. Babar TF, Khan MT, Marwat MZ, et al. Patterns of ocular trauma. J Coll Physicians Surg Pak. 2007 Mar;17(3):148-53.

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24. Kjaerulff H, Jacobsen J, Aalund O, et al. Injuries due to deliberate violence in areas of Denmark. III. lesions. The Copenhagen study group. Forensic Sci Int. 1989 Apr-May;41(1-2):169-80. 25. Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner violence: Findings from the national violence against women survey. U S Dept of Just, NCJ 181867. 2000. 26. Barking, Dagenham. Domestic violence: Assessment guide for health care professionals. Family Violence Prevention Fund. February 2008. 27. Issac N, Enos V. Documenting Domestic Violence: How Health Care Providers Can Help Victims. National Institute of Justice: Research in Brief. September 2001. NCJ 188564. 28. Rowe JA, Kosoko-Lasaki O. Review of ocular trauma. Archives of Ibadan Medicine. 7:47-50.

29. Friedman NJ, Kaiser PK, eds. The Massachusetts eye and ear infirmary: Illustrated manual of ophthalmology. 3rd ed. Saunders Elsevier; 2009. 30. Rhee DJ, Pyfer MF, eds. The Wills eye manual: Office and emergency room diagnosis and treatment of eye disease. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:452-7. 31. ACOG committee opinion no. 518: Intimate partner violence. Obstet Gynecol. 2012 Feb;119(2 Pt 1):412-7. 32. Assessing and managing eye injuries. Community Eye Health. 2005 Oct;18(55):101-4. 33. Liebschutz JM, Rothman EF. Intimate-partner violence--what physicians can do. N Engl J Med. 2012 Nov 29;367(22):2071-3.

34. Hyman A. Mandatory reporting of domestic violence by health care providers: A policy paper. Family Violence Prevention Fund. 1997. 35. American College of Emergency Physicians. Emergency medicine and domestic violence. Ann Emerg Med. 1995;25(3):442-3. 36. American Medical Association. H-515.965. Family and intimate partner violence. American Medical Association. 37. Family violence: An AAFP white paper. The AAFP commission on special issues and clinical interests. Am Fam Physician. 1994 Dec;50(8):1636,40, 1644-6. 38. Committee on Preventive Services for Women, Institute of Medicine. Clinical preventive services for women: Closing the gaps. 2011. 39. Interpersonal and domestic violence screening and counseling: Understanding new federal rules and providing resources for health providers. [Internet]. Available from: http:// www.futureswithoutviolence. org/userfiles/ file/HealthCare/FWV-screening_memo_Final.pdf. 40. Marcus EN. Screening for abuse may be the key to ending it. The New York Times. 2008 May 8th. 41. Klevens J, Kee R, Trick W, et al. Effect of screening for partner violence on women’s quality of life: A randomized controlled trial. JAMA. 2012;308(7):681-689. 42. MacMillan HL, Wathen CN, Jamieson E, et al. Screening for intimate partner violence in health care settings: A randomized trial. JAMA. 2009 Aug 5;302(5):493-501.

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MEDICAL ETHICS WITHOUT THE RHETORIC

Cases presented here involve real physicians and patients. Unlike the cases in medical ethics textbooks, these cases seldom involve human cloning, bizarre treatments, or stem cell research. We emphasize cases more common to the practice of medicine. Most cases are circumstantially unique and require the viewpoints of the practitioners and patients involved. For this reason, I solicit your input on the cases discussed here at councile@aol.com. Reader perspectives along with my own viewpoint are published in the issue following each case presentation. We are also interested in cases submitted by readers. The following case addresses an ethical issue that arises when a physician is dealing with a patient who has a tendency towards hypochondria. Mark Pastin, PhD Mark Pastin, PhD, is president and CEO of the Council of Ethical Organizations, Alexandria, VA. The Council, a non-profit, non-partisan organization, is dedicated to promoting ethical and legal conduct in business, government, and the professions.

CASE FOURTEEN

- FREQUENT FLYER

You are meeting with a patient who is a “frequent flyer.” You and several other physicians in the area see this patient regularly to deal with the patient’s real and, in most cases, imaginary ailments. In this case, the patient complains of anxiety attacks, a complaint that he has presented before. He tells you that he already visited a specialist, a psychiatrist, but the medicine he prescribed is not working. The psychiatrist told him to take the medicine as prescribed and check back in a week. The prescription was written yesterday and is for a multivitamin. Your inclination is to tell the patient to follow the psychiatrist’s advice, but you wonder if you should tell him that he is taking a placebo. You can understand the psychiatrist’s viewpoint but worry that something might happen if the patient really does need anti-anxiety medication. Would you tell the patient what he is taking? This is an actual case. Of course, there are any number of complicating circumstances and additional details; but please address the case on the basis of the information provided. There will be an analysis of this case and a new case in the next issue.

Medical Ethics Without the Rhetoric

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

MEDICAL ETHICS WITHOUT THE RHETORIC

CASE THIRTEEN ANALYSIS -JAIL TIME

The case from the last issue involves a physician on contract to provide medical services at a correctional facility. The physician is asked by the warden to insert a feeding tube into a patient who is on a hunger strike. The patient is seriously undernourished but not in imminent danger. The question is whether the physician should follow the warden’s instructions, contrary to the prisoner’s stated wishes. It was a consensus view of our readers that the physician should not insert the feeding tube. The reasoning is that the relationship between physician and patient takes priority over the relationship between the prisoner and the justice system. Since you would not insert a feeding tube in a non-incarcerated patient against their will, you cannot override the patient’s wishes in this case. Opinions were more diverse when it came to the issue of whether the patient should be intubated against his will if the hunger strike proceeds to the point where the patient is in imminent danger and the patient does not change his mind. Some readers felt that the case became analogous to an emergency room situation in which you act to save the patient’s life. Others felt that if the patient has clearly expressed his wishes, it would be wrong to intervene even if the patient’s life is in danger. I agree with the latter viewpoint because respecting the patient’s autonomy is, in my opinion, an overriding value in all cases involving adult patients.

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in America

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american Peer reviewed assOciat iOn Of . listed Physicia in GOOGle ns schOlar Pecialists, inc. Summer and b iOmed 2012 lib

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Curriculum Predicting Factors Specialty Family Medic ine An Explo Choice: ratory Rural Medic Study al Schol Among ars

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ISSUE

Malignant and Benign Eyelid Lesions in San Francisco: Study of a Diverse Urban Population

Invasive Squamous Cell Carcinoma of the Cervix Following HPV Immunization in a Nineteen-Year-Old Woman

Medical Ethics Without the Rhetoric

Impact of a Multi-Modality Intervention on Physician Knowledge and Practice in Managing Hepatitis C

Primary Mature Cystic Teratoma of the Liver: Report of a Rare Case

The Role of Physician Experience in Pelvic Examination Accuracy

Anaphylaxis: Diagnosis and Manageme nt in the Rural Emergency Departmen

22 49

Medical Education Cost & Debt Impacting Future Rural Physicians

Investigating a Rural Rotation in the Mississippi Delta: A Qualitative Study Medical Education in

102

104 30

Preconception Counseling to Prevent the Complications of Obesity during Pregnancy

Urgent Care Cente An Overv rs: iew Acute Infect Mononucle ious for Urgen osis: A Revie w t Care Physicians

Review of ECG FindinImportant gs in Patients with Synco pe Wellens’ A Case Syndrome: Report

Medical Ethics Without the Rheto

ric

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

Manuscript Criteria and Information The American Journal of Clinical Medicine® (AJCM®), the official journal of the American Association of Physician Specialists, Inc. (AAPS), is a peer-reviewed journal dedicated to improving the clinical practice of medicine by publishing educational and informational articles. AJCM® is the official journal of the American Association of Physician Specialists, Inc. Send all manuscripts via email to editor@aapsus.org in Microsoft Word format. No other file formats will be accepted. Manuscripts submitted by fax or mail to the Journal WILL NOT BE ACCEPTED AND WILL NOT BE RETURNED. Manuscripts received are not to be under simultaneous consideration by another publication. Accepted manuscripts become the permanent property of the American Journal of Clinical Medicine® and may not be published elsewhere without permission from the publisher. Authorship Responsibility, Financial Disclosure, Assignment of Copyright, and Acknowledgment Forms: Authorship responsibility forms must be completed and signed by each author and accompany submitted manuscripts. Each author must submit a statement that specifies whether he or she has financial or proprietary interest in the subject matter or materials discussed in the manuscript. These forms may be downloaded from the AAPS website www.aapsus.org or may be obtained by request to the AAPS office at 813-433-2277 ext 18 or 30.

Manuscript Preparation: Manuscript preparation should generally follow the guidelines outlined in The International Committee of Medical Journal Editors: “Uniform requirements for manuscripts submitted to biomedical journals,” The Journal of the American Medical Association, March 19, 1997;277:927934. An abstract of 100-150 words is required. The main text should be narrative in form and should be broken up into appropriate headings and/or subheadings. Any abbreviations used should be completely defined upon the first usage. The style of writing should conform to acceptable English usage and syntax. Please avoid slang, medical jargon, obscure abbreviations, and abbreviated phrasing. Manuscripts should be submitted electronically online to the email address above as a Microsoft Word document. Authors’ names should be on the title page ONLY. Revisions, editorials, and editorial correspondence follow the same procedures outlined, including a word count.

Authorship Responsibility: All accepted manuscripts are copyedited; an edited typescript is sent for the author’s approval. The author is responsible for all statements in the work, including the copy editor’s changes.

Title Page: All submissions must include a title page. Titles should be concise, specific, informative, and should contain the key points of the work. Authors’ names should be on the title page only. Include the full names, degrees, and academic affiliations of all authors, indication of the corresponding author, his/her address, phone, fax, e-mail, address for reprint requests, and, if the abstract or any portion of the manuscript was presented at a meeting, the name of the organization, place, and date on which it was read. Include a word count for text only, exclusive of title, abstract, references, figure legends, and tables. Include brief biographical information including current position. Financial disclosure information should be included as a footnote.

Data Access and Responsibility: For reports containing original data, at least one author (e.g., the principal investigator) should indicate that he or she “had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis” (DeAngelis CD, Fontanarosa PB, Flanagin A. Reporting financial conflicts of interest and relationships between investigators and research sponsors. JAMA. 2001;286:89-91).

Acknowledgment Section: List all persons who have made substantial contributions to the work reported in the manuscript (including writing and editing assistance), but who are not authors; any financial interest in the subject matter or materials discussed in the manuscript; any research or project support/funding; any grant support. Manuscripts with statistical evaluations should include the name and affiliation of statistical reviewer(s).

Units of Measure: Conventional units of measure are preferred, with Système International (SI) units expressed secondarily (in parentheses). In tables and figures, a conversion factor to SI may be presented in the footnote or legend to economize space. Exceptions to this policy include calories, hematocrit, glycosylated hemoglobin, blood cell counts, and ejection fraction, for which conventional units alone should be expressed. The metric system is preferred for length, area, mass, and volume.

Original Research: For authors who wish to submit original research, including reports of randomized controlled trials, please contact the editor-in-chief for instructions and criteria for publication. Format: Articles should be submitted in Times New Roman 12 point font, single spaced with no additional or unnecessary styles applied to text.

American Journal of Clinical Medicine® • Winter 2014 • Volume Ten Number One

References: List references numerically (not alphabetically). All subsequent reference citations should be to the original number. Cite all references in the text or tables. Unpublished data and personal communications should not be listed as references. References to journal articles should include (1) author(s) (list all authors and/or editors up to three; if more than three, list first three and “et al.”), (2) title, (3) journal name (as abbreviated in PubMed), (4) year, (5) volume number, and (6) inclusive page numbers. References to books should include (1) author(s) (list all authors and/or editors up to six; if more than six, list first three and “et al.”), (2) chapter title (if any), (3) editor (if any), (4) title of book, (5) city of publication, (6) publisher, and (7) year. Volume and edition numbers, specific pages, and name of translator should be included when appropriate. The reference numbers in the reference list (if any) should be keystroked. Do not let the word processing program generate the reference numbers, using such features as automatic footnotes or endnotes. The author is responsible for the accuracy and completeness of the references and for their correct text citation. Please note how reference is set in text in example below. Set yours to match. References in Text: The following is an example of how to list references within the text: “The Hawaii outbreak included at least one autochthonous case.”7 Do not include “personal communications” in the list of references. Authors who name an individual as a source for information in a personal communication, be it through conversation, a letter, e-mail message, or telephone call, should obtain written permission from the named individual. Tables, Illustrations, Legends: Number all tables and illustrations in the order of their citation in the text. Include a title for each table and figure – a brief, succinct phrase, preferably no longer than 10 to 15 words. Tables: Title all tables and number them in order of their citation in the text. Double-space each table on separate sheets of standard size white paper. If a table must be continued, repeat the title on a second sheet, followed by “cont.” Illustrations: Illustrations should be submitted online as a separate document. Most standard programs will be accepted. Please refer to the next section for details. Digital Art Submissions: Digital images must be submitted electronically online as a separate file from the manuscript. The canvas size of continuous-tone images should be at least five inches wide (depth not important) with an image resolution of at least 300 dpi. Line art images should have a minimum resolution of 1270 ppi. Formats accepted are EPS, TIFF, and JPG. Legends: Include double-spaced legends (maximum length 40 words) on separate pages. Indicate magnification and stain used for photomicrographs and method of enhancement for digitally enhanced images. Photographic Consent: A letter of consent must accompany all photographs of patients in which a possibility of identification exists. Remove identifying information from photos, x-rays, scans, etc. It is not sufficient to cover the eyes to mask identity.

Acknowledgments: Acknowledge illustrations from other publications and, when applicable, include author(s), title of article, title of journal or book, volume number, page(s), month, and year. The publisher’s permission to reproduce in print and online and in AJCM® licensed versions should be submitted to the AJCM® when the manuscript is submitted. Disclaimer: Publication of any article or statement in the AJCM® does not constitute an endorsement by the AJCM® or its editors. Publication of any advertisement in the AJCM® does not constitute an endorsement by the AJCM® or its editors.

Manuscript Submission Checklist  Submit manuscript electronically online as a Microsoft Word document to editor@aapsus.org. Use Times New Roman 12 point font. Leave right margins unjustified (ragged).  On the title page, designate corresponding author with complete address, telephone, fax numbers, and e-mail address. Authors’ names should be on the title page ONLY. This allows reviews to be anonymous. Each author must also include current employment/position information and any other biographical information that author wishes to be included at the end of the article.  On the title page, include word count for text only, exclusive of title, abstract, references, tables, and figure legends.  Complete Authorship Responsibility Form, which includes Financial Disclosure, Assignment of Copyright and Acknowledgement. Include signed form with your submission.  Include statement signed by corresponding author that written permission has been obtained from all persons named in the acknowledgment (if applicable).  Include research or project support/funding in an acknowledgment (if applicable).  Check all references for accuracy and completeness. Put references in proper format in numerical order, making sure each is cited in sequence in the text. Please see In-Text Example above and make sure your references are set the same way.  Include a title for each table and figure – a brief, succinct phrase, preferably no longer than 10 to 15 words.  Submit illustrations electronically online in a file separate from the manuscript.  For digitally enhanced images, indicate method of enhancement in legend and submit electronically online.  Include informed consent forms for identifiable patient descriptions, photographs, and pedigrees (if applicable).  Include written permission from publishers (or other copyright owner) to reproduce or adapt previously published illustrations and tables (if applicable). Rev. 12/13

CALL FOR PAPERS American Journal of Clinical Medicine

Owned and Published by the American Association of Physician Specialists, Inc.

American American Journal of Jo A urn cao Clinic® al M merial n® fJou Clinical Medicine ed C liic niin cael M rnal of edici ® ne FEATURED Owned and Publishe d by the a merican assOciat Owned and Published by the american assOciatiOn Of Physician sPecialists, inc. iOn Of Physician Peer reviewed. sPecialists, inc listed in GOOGle . schOlar and b Owned iOmedlib and P Winter 2012 • Winter 2011 • Volume eight, number one ublished Volume

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FEATURED IN THIS ISSUE

IN THIS ISSU

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Review of Medical and Surgical Management of Postpartum Hemorrhage

10 A Critical Appraisal of the Evolution of ST Elevation Myocardial Infarction (STEMI) Therapy and the Evidence Behind the Current Treatment Guidelines

Malignant and Benign Eyelid Lesions in San Francisco: Study of a Diverse Urban Population

Invasive Squamous Cell Carcinoma of the Cervix Following HPV Immunization in a Nineteen-Year-Old Woman

22 49

Impact of a Multi-Modality Intervention on Physician Knowledge and Practice in Managing Hepatitis C

Primary Mature Cystic Teratoma of the Liver: Report of a Rare Case

The Role of Physician Experience in Pelvic Examination Accuracy

ED IN

The Rural Health Landscape in Jeopar

Transfuse or Not to Transfuse: For Post-op Anemia

FEATUR

About Rural Health

in America

Medical Educa tion Cost & Debt Impacting Future Rural Physicians

Anaphylaxis: Diagn and Management osis in the Rural Emergency Department

Investigating a Rural Rotati on in the Mississippi Delta: A Qualitative Study in Medical Educa tion

102 104

Preconception Counseling to Prevent the Complications of Obesity during Pregnancy

THIS ISS

UE -

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by the

amer Peer revie ican assOciatiO wed. listed in n Of Physician GOOGle s schOlar Pecialists, inc. Summer and b iOmed 2012 lib

• Volu

NiNe, N

umber

Two

Curricu lum Predicting Factors Specialty Family Medic ine An Exp Choice: lora Rural Me tory Study Am dical Sch ong olars

Urgent Car An Overv e Centers: iew Acute Infe ctious Monon ucl for Urg eosis: A Review ent Car e Physici ans

Review of ECG Fin Important dings in Patients with Syn cope Wellen s’ A Case Syndrome: Report

Medical Ethics Without the Rhe tor

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The American Journal of Clinical Medicine® (AJCM®) is the official, peer-reviewed journal of the American Association of Physician Specialists, Inc. (AAPS), an organization dedicated to promoting the highest intellectual, moral, and ethical standards of its members. Its diversity incorporates physicians that represent a broad spectrum of specialties including anesthesiology, dermatology, diagnostic radiology, disaster medicine, emergency medicine, family medicine/OB, family practice, geriatric medicine, hospital medicine, integrative medicine, internal medicine, obstetrics and gynecology, ophthalmology, orthopedic surgery, plastic and reconstructive surgery, psychiatry, radiation oncology, general surgery, and urgent care medicine. To further the goals of AAPS, which include providing education for its members and promoting the study, research, and improvement of its various specialties, the AJCM® invites submissions of high-quality review articles, clinical reports, case reports, or original research on any topic which has potential to impact the daily practice of medicine. Publication in the AJCM® is one of the criteria to qualify for the prestigious Degree of Fellow within the Academies of Medicine of the AAPS.

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