In the Los Angeles Times’s (8/10) Consumer Confidential column, David Lazarus wrote that concierge practices are “a small, but growing, trend in medicine as physicians cut themselves free from insurance companies, and enter into direct relationships with patients who can afford more personalized healthcare.” Typically, “a concierge physician chooses to limit his or her practice to only a few hundred patients, rather than the usual 2,000 or 3,000. Patients may pay the physician an annual retainer that can run as high as $15,000, or an hourly fee of hundreds of dollars, on top of whatever costs may accrue as a result of treatment.” At present, “[n]either the American Medical Assn. nor the American College of Physicians” knows how many such practices exist, “but healthcare professionals peg the number at fewer than 1,000 and growing.” Lazarus noted that while this option may appeal to some consumers, they should shop around and verify the credentials of any concierge physician, because some, like Dr. House Call, may be “on probation…for accusations that include gross negligence, incompetence, and insurance fraud.”

Intro:  We posted, in the past, about this new “push” for zero-tolerance with regard to bad behavior in the hospital.  You know that this is directed mainly at the doctors who yell, curse, throw, and generally intimidate staff. 

However, there is some concern within the profession.  One concern is that “disruptive behavior policies, which can cover everything from criminal assaults to condescension, are often too vague, and [can be] used against physicians who may step on toes when advocating for patients, or who own competing specialty hospitals and ambulatory surgical centers,” AMNews (8/18, O’Reilly) adds. Meanwhile, “[s]ome worry that the commission’s actions could make it easier for hospitals to target outspoken medical staff members.”

The Boston Globe (8/10, A1, Kowalczyk) reported that the Joint Commission (JC), the national group that accredits healthcare organizations, “is requiring all hospitals, nursing homes, and other healthcare facilities to adopt ‘zero-tolerance’ policies by Jan. 1, including codes of conduct, ways to encourage staff to report bad behavior, and a process for helping and, if necessary, disciplining offenders.” An increasing amount of “research suggest[s] that swearing, yelling, and throwing objects are not just rude and offensive to co-workers, but hurt patients by increasing the likelihood of medical errors.” Last month, the JC “issued a safety alert to hospitals…, saying outbursts threaten patient safety because they prevent caregivers from working as a team.” According to Peter Angood, M.D., chief patient safety officer for the JC, “most hospitals have tolerated healthcare road rage to the point where it has become an accepted part of the culture.” Moreover, some say “[t]hat can be particularly true…in high-stakes surgery, a field that can attract high-intensity physicians who are used to being in charge.”

AP, 8/8/08 (http://ap.google.com/article/ALeqM5hvYcph1M945lYEiQlvdmnYPRyw-QD92DVM1O0): When a doctor doesn’t look an Asian-American patient in the eye, that might be seen as a sign of respect. But making eye contact is encouraged with black patients, according to the American Academy of Orthopaedic Surgeons, which has published a guidebook for culturally competent care.As the country’s ethnic profile diversifies, some states are trying to assure that health care providers are trained in “cultural competency.”

New Mexico passed a law last year requiring that higher education institutions with health education programs provide such training, though the state still is grappling with how it will be implemented. New Jersey and California are among a handful of states with similar measures already in place.

“We don’t expect that a provider is going to know everything about every nationality,” said William Flores, chairman of New Mexico’s task force charged with developing the curriculum. “The critical thing here is developing sensitivity and the understanding that not every culture responds to medical providers in the same way, sees medicine in the same way.”

Dr. Elizabeth Szalay, an associate professor of pediatric orthopedics and pediatrics at the University of New Mexico’s Carrie Tingley Hospital, said that it’s important for doctors to understand how patients may be different, but patients also need to be open about themselves, by asking questions and revealing their beliefs, concerns or fears.

Navajos often are reluctant to do so, without the coaxing of a social worker, said Linda Henderson, who interprets for Navajo patients. They view Western health care as foreign and won’t question a doctor even if they don’t understand what is being recommended, she said. It’s a matter of respect.

“From our people’s point of view, we’re offending the doctors, because they’re the experts as far as modern contemporary medicine,” said Henderson, from Sanostee in the Navajo Nation.

Cynthia Lin, 55, of Taiwan, says she never has experienced a cultural barrier between herself and doctors, which she attributed to her open attitude.

She felt the need to tell a pediatrician once about something that’s common among Asian babies — that they are born with a sort of bruised look near the buttocks.

“Some doctors may think, ‘Oh my goodness, what happened to the baby’s butt?’” said Lin, who lives in Albuquerque. “(But) the doctor understood that’s just how Asians are. If the physician already knows about it, if they are aware that certain races have certain characteristics, then they don’t have any doubts.”

The New Mexico task force is holding meetings around the state to gather input on what should be included in the training and hopes to have the curriculum in place by 2010, Flores said.

New Jersey’s law is similar to New Mexico’s, requiring that the state’s medical schools provide instruction to their students as a condition of receiving a degree. But the schools also must provide cultural competency training to licensed physicians who did not receive the training while they were in school — something Flores said the New Mexico Legislature might tackle down the road.

Although New Jersey’s law was passed in 2005, the regulations weren’t finalized until April.

California had a voluntary program in place since 2003 but later made it mandatory for the state’s 400 continuing medical education providers.

Under the law, every CME course has to have an element of cultural and linguistic competency, which are accredited by the Institute for Medical Quality.

Alecia Robinson, project administrator for the Cultural and Linguistic Competency Program under IMQ, said how the requirements would be met has largely been left up to the providers.

“Each program is unique,” she said.

Medical providers agree there’s no one resource that can make a person culturally competent, but they say it’s important to be familiar with a culture, drop any stereotypes or bias and treat patients in the appropriate way.

“It’s a mind-set,” Robinson said. “I’ve heard people speak of it as a level of humility about understanding different cultures. That’s quite appropriate.”

Sacramento Business Journal  (8/8, Robertson) reported that “[n]ew regulations will soon prevent doctors and hospitals from billing patients when their health plan doesn’t pay enough to cover their bills for emergency [department] care, a practice that hammers unsuspecting patients but helps providers recover millions.”

The new rules “by the state Department of Managed Health Care that ban the controversial practice of ‘balanced billing’ are expected to take effect by Oct. 15 if approved by the Office of Administrative Law and not stopped with a lawsuit.” The regulations, “more than five years in the works, make the practice illegal and allow state regulators to take action against providers who bill insured patients.” Cindy Ehnes, director of the state Department of Managed Health Care, said that            “[c]onsumers, employers and taxpayers pay millions of dollars each year in healthcare premiums in exchange for a promise to protect them from unexpected bills when a health emergency strikes.” Ehnes continued, “The practice of balanced billing breaks this promise to consumers and is unacceptable.”

USA Today , 8/11/08 reports that “brown recluse bites are on the rise across the country, especially in the Midwest and Southeast, says Gary Wasserman, chief of toxicology at Children’s Mercy Hospitals and Clinics in Kansas City, Mo.”

In 2007, that “hospital treated 29 patients who had been bitten by a brown recluse — the usual rate is 10 to 12 a year.” Moreover, “[s]ince April, the hospital has treated 12 patients; three were admitted to the intensive care unit.” The brown recluse “is dormant part of the year, which means bites usually occur from April until October.”

 A 19-year-old woman has had a blue-black nodule next to her left eye since birth. After recent accidental trauma, the lesion has enlarged. What is your clinical impression (http://www.consultantlive.com/display/article/10162/1151011)?

Answer:  Cellular blue nevus
Biopsy results confirmed a benign cellular blue nevus, B. These nevi are evenly colored gray, bluish, or black and have symmetrical, smooth borders. Congenital or acquired, single or multiple blue nevi can arise at any location; however, they more often occur on the buttocks than on the face. These lesions are more common in women than in men. Although they are benign, blue nevi occasionally can become invasive.

Medical News Today, 8/8/08 (http://www.consultantlive.com/display/article/10162/1151011):  The American Physical Therapy Association (APTA) is urging parents and caregivers to ensure that babies get enough “tummy time” throughout the day while they are awake and supervised, in light of a recent survey of therapists who say they’ve noticed an increase in motor delays in infants who spend too much time on their backs while awake.

In the national survey of 400 pediatric physical and occupational therapists, conducted on behalf of Pathways Awareness, a non-profit group dedicated to early detection of motor delays in children, two-thirds of those surveyed say they’ve seen an increase in early motor delays in infants over the past six years. The survey was conducted with the assistance of APTA’s Section on Pediatrics and the Neuro-Development Treatment Association (NDTA).

Those physical therapists who saw an increase in motor delays said that the lack of “tummy time,” or the amount of time infants spend lying on their stomachs while awake, is the number one contributor to the escalation in cases.

APTA spokesperson Judy Towne Jennings, PT, MA, a physical therapist and researcher from Fairfield, Ohio, said, “We have seen first-hand what the lack of tummy time can mean for a baby: developmental, cognitive, and organizational skills delays, eye-tracking problems, and behavioral issues, to name just some complications.” She added, “New parents are told of the importance of babies sleeping on their backs to avoid SIDS, but they are not always informed about the importance of tummy time.”

Jennings explains that because new parents now use car seats that also serve as infant carriers – many of which fasten directly into strollers and swings without having to remove the baby from the seat — this generation of babies spends prolonged periods of time in one position. She recommends that awake babies be placed in a variety of positions, including on their tummies, as soon as they return home from the hospital. “Ideally, babies should be placed on their tummies after every nap, diaper change and feeding, starting with 1-2 minutes,” she said. Jennings is co-author of the research, “Conveying the Message about Optimal Infant Positions,” Physical and Occupational Therapy in Pediatrics, Volume 25, Number 3, 2005.

In 1992, the American Academy of Pediatrics launched its successful “Back to Sleep” campaign, which helped reduce the number of sudden infant death syndrome (SIDS) cases by educating parents on the importance of putting infants to sleep on their backs, rather than on their stomachs. While putting infants to sleep on their backs is still vitally important in reducing infant deaths, according to APTA, many physical therapists believe that there should be more education to parents on the importance of “tummy time” while babies are awake and supervised.

APTA spokesperson Colleen Coulter-O’Berry, PT, MS, PCS, a physical therapist at Children’s Healthcare of Atlanta, said flattening of the baby’s skull is another side effect of too much time spent on the back. “Since the early 1990s, we have seen a significant decrease in SIDS cases, while simultaneously witnessing an alarming increase in skull deformation,” she said. Coulter-O’Berry cites a recent study published in Cleft Palate-Craniofacial Journal 45(2): 208-16, in which it was reported that several risk factors for misshapen heads were more common among babies born after the “Back to Sleep” initiative. The study, which took place at Children’s Hospital and Regional Medical Center in Seattle, Washington, found that prior to 1992, the prevalence of misshapen heads among infants was reportedly 5 percent. In recent years, craniofacial centers and primary care providers reported a dramatic increase of up to 600 percent in referrals for misshapen heads.

She also points out that the combination of babies sleeping on their backs, as well as spending an inordinate amount of time in infant carriers that double as car seats, puts pressure on the head which can create a flattening of the skull. In extreme cases, babies are fitted with a custom-molded band that gently guides the baby’s head into a more normal shape.

According to Coulter-O’Berry, parents can increase tummy time by incorporating exercises into routine activities such as carrying, diapering, feeding, and playing with baby. “Increasing the amount of time your baby lies on his or her tummy promotes muscle development in the neck and shoulders; helps prevent tight neck muscles and the development of flat areas on the back of the baby’s head; and helps build the muscles baby needs to roll, sit and crawl,” she said. Coulter-O’Berry is co-author of Tummy Time Tools, an informative brochure that provides caregivers ideas and activities to ensure that babies get enough tummy time throughout the day. The brochure is now offered on the APTA Web site, http://www.apta.org/consumers.

Karen Karmel-Ross, PT, PCS, LMT, pediatric clinical specialist at University Hospitals Case Medical Center, Rainbow Babies and Children’s Hospital in Cleveland, Ohio and national lecturer on muscular torticollis (neck muscle imbalance), says that one way to engage in tummy time is to spend time during each diaper change encouraging the infant to find, focus and follow the caregiver’s face or a toy with their eyes looking up, down, left and right. “It’s important to get our infants out of devices that constrain mobility and onto their tummies so they can focus on neck muscle balance as they interact with their caregivers,” she said.

Intro:  This may be something to discuss with your patients who show up with poor dental hygiene:  a connection between periodontal disease and diabetes.  You can’t say cause and effect just yet, but it may scare some patients into seeing their dentist, assuming they have the $$ to see a dentist. 

Medical News Today, 8/10/08 (https://education.cmellc.com/CMEActivities/tabid/54/ctl/ActivityController/mid/380/activityid/1325/Default.aspx):

Periodontal disease may be an independent predictor of incident Type 2 diabetes, according to a study by researchers at Columbia University Mailman School of Public Health. While diabetes has long been believed to be a risk factor for periodontal infections, this is the first study exploring whether the reverse might also be true, that is, if periodontal infections can contribute to the development of diabetes. The full study findings are published in the July 2008 issue of Diabetes Care.

The Mailman School of Public Health researchers studied over 9,000 participants without diabetes from a nationally representative sample of the U.S. population, 817 of whom went on to develop diabetes. They then compared the risk of developing diabetes over the next 20 years between people with varying degrees of periodontal disease and found that individuals with elevated levels of periodontal disease were nearly twice as likely to become diabetic in that 20 year timeframe. These findings remained after extensive multivariable adjustment for potential confounders including, but not limited to, age, smoking, obesity, hypertension, and dietary patterns.

“These data add a new twist to the association and suggest that periodontal disease may be there before diabetes,” said Ryan T. Demmer, PhD, MPH, associate research scientist in the Department of Epidemiology at the Mailman School of Public Health and lead author. “We found that over two decades of follow-up, individuals who had periodontal disease were more likely to develop Type 2 diabetes later in life when compared to individuals without periodontal disease.”

Also of interest, the researchers found that those study participants who had lost all of their teeth were at intermediate risk for incident diabetes. “This could be suggestive that the people who lost all of their teeth had a history of infection at some point, but subsequently lost their teeth and removed the source of infection,” noted Dr. Demmer. “This is particularly interesting as it supports previous research originating from The Oral Infections and Vascular Disease Epidemiology Study (INVEST) which has shown that individuals lacking teeth are at intermediate risk for cardiovascular disease” said Moïse Desvarieux, MD, PhD, director of INVEST, associate professor and Inserm Chair of Excellence in the Department of Epidemiology at the Mailman School and senior author of the paper.

The contributory role of periodontal disease in the development of Type 2 diabetes is potentially of public health importance because of the prevalence of treatable periodontal diseases in the population and the pervasiveness of diabetes-associated morbidity and mortality. However, observes Dr. Demmer, more studies are needed both to determine whether gum disease directly contributes to type 2 diabetes and, from there, that treating the dental problem can prevent diabetes. In addition to Dr. Desvarieux, David R. Jacobs Jr., PhD, professor in the Department of Epidemiology and Community Health at the University of Minnesota, also contributed to the research.

From Consultant: 

Venus Lake of the Lip (http://www.consultantlive.com/display-cme/article/10162/1154156?pageNumber=2)

A mass disfigures the left upper lip near the corner of the mouth. This mass, which is not ulcerated and appears to lie below the lip mucosa/skin, looks as though it would feel soft, and on palpation it did. A dark blue, almost black hue is attenuated by the intervening epithelium. The color is confined to the center of the mass, most prominently just beneath the vermilion border. This lesion is a venous lake, an innocuous dilatation of surface vein(s) found on the lips and ears of aged persons.  The remainder of the lip area appears healthy.

The cheek and uppermost philtrum look pinker than normal and a bit telangiectatic; these findings are consistent with solar injury. Tiny excoriations dot the anterior neck at the bottom of the photograph but are unrelated to the venous lake. The chin sports minute shaving cuts, one almost healed. Perioral skin appears normal.

Medical News Today, 8/11/08

Prostatitis And Inflammatory Conditions Of The Prostate

Objectives

* Provide an overview of the prostatitis syndromes
* Present a practical approach to diagnosis
* Summarize current treatment options

Materials and Methods

The recent literature on the prostatitis syndromes was reviewed with particular reference to randomized controlled clinical trials (RCTs). Published expert and consensus opinions were utilized together with the evidence-based findings from RCTs to arrive at a current consensus on diagnosis and treatment of the enigmatic prostatitis syndromes.

Findings

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a prevalent condition in urologic and primary care practices and it has been estimated that it represents the commonest office diagnosed and treated urologic condition in men younger than 50 years. CP/CPPS has a detrimental effect on quality of life (QOL) and it diagnosis and treatment represents a significant economic burden to the healthcare system. It is probable that as many as 10-16% of men carry a lifetime risk of being diagnosed with CP/CPPS.

The common symptoms of CP/CPPS are irritative voiding symptoms and pelvic/perineal/scrotal pain (symptoms reminiscent of Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) in women). This overlap and the similarity to symptoms of LUTS/BPH (lower urinary tract symptoms/benign prostatic hyperplasia) led to the 1999 NIH-NIDDK classification of the prostatitis syndromes and the validation of the patient self-administered NIH Chronic Prostatitis Symptom Index (CPSI). The latter has proven useful in day to day clinical practice (similar to the IPPS for LUTS/BPH) as well as in research studies.

The pillars for the diagnosis of CP/CPPS are a focused history and physical examination, search for an inflammatory/bacterial etiology and symptom evaluation using the NIH CPSI. This questionnaire has nine questions related to the domains of voiding, quality of life and pain.

The utility of Meares-Stamey and Nickel prostate localization tests (expressed prostatic secretions, post-massage voided urine) have been recently questioned as it is now known that prostatic inflammation poorly correlates with microscopic prostate inflammation, immune mediators, symptoms or response to treatment.

Only about 5% men with CP/CPPS have bacteriologically documented infection and these patients benefit from antibiotic treatment especially when newly-diagnosed. Men with culture-positive CP/CPPS who have Category 2 Chronic Bacterial Prostatitis may benefit from antibiotic treatment with one of the fluoroquinolones (that penetrate the prostate) especially if newly-diagnosed. Alpha-blockers are useful in men with Category 3 CP/CPPS with negative cultures. Like with antibiotics, newly-diagnosed, alpha-blocker naïve patients benefit most from long courses (3-6 months) of alpha-blocker therapy. Randomized controlled trials have not shown significant benefit for either alpha-blockers or antibiotics in chronic, pre-treated CP/CPPS patients.

Adjuvant therapy with a variety of oral drugs is frequently necessary. – including anti-inflammatory agents, phytotherapeutic drugs, Tricyclic anti-depressants, analgesics, muscle relaxants, pentosanpolysulfate, finasteride etc. Complimentary therapies such as acupuncture, psychological counseling, and pelvic floor physical therapy are commonly employed in combination with alpha-blockers/antibiotics as part of a multi-modality treatment paradigm.

Rarely used are the minimally invasive surgical treatments such as transurethral microware thermotherapy, transurethral needle ablation.

Summary

The last decade has witnessed a flourishing of research into the prostatitis syndromes that has resulted in the development of a validated patient self-administered questionnaire and a more scientific understanding of the etiology and pathophysiology of these male syndromes. Bacterial prostatitis is rare. However, the mainstays of treatment especially in newly-diagnosed, treatment-naïve patients are long courses of oral antibiotics and alpha-blockers.

References

1. McNaughton-Collins M, Stafford RS, O’Leary MP et al: How common is prostatitis? A national survey of physical visits. J Uro 1998: 159:1224-1228.
2. Krieger N, Nyberg L, Nickel J C: NIH consensus definition and classification of prostatitis. JAMA 1999; 282: 236-237.
3. Litwin MS, McNaughton-Collins M, Fowler F, et al: The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. J Urol 1999: 162(2): 369-375.
4. Nickel JC. The three A’s of chronic prostatitis therapy: antibiotics, alpha-blockers and anti-inflammatory. What is the evidence?: BJU International 2004; 94(9): 1230-1233,
5. Nickel JC: Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A decade of change. AUA Update Series, Lesson 34. 25:309-316, 2006

Presented by: Grannum R. Sant, MD, at the Masters in Urology Meeting – July 31, 2008 – August 2, 2008, Elbow Beach, Bermuda

Intro:  Just another reminder about how unsafe the emergency department can be even when police is close by. 

HealthCare Security Weekly, 8/11/08:  A hospital security officer who was allegedly attacked by a patient on Saturday, August 2, has died from his injuries.

Monte Ruby, a security guard at the Cox North hospital, was kicked in the head by a man Springfield, MO police brought to the emergency room for treatment, reported WOLR-KSFX Ozarks. The man who attacked Ruby, 41-year-old Jeffrey Bolden, is charged with felony assault on an officer, a charge that may now be changed to manslaughter or murder.

On August 6, CoxHealth announced that Ruby died from the injuries to his brain stem and spine that left him in a coma, reported KY3 Springfield News. Bolden ran from police on August 2 and they used a K-9 unit to track him down. Police took him to the hospital because of minor injuries from the dogs. Police said Ruby was trying to calm Bolden, who was agitated, unruly, and handcuffed to a hospital bed while being treated for bites from a Springfield police dog. A city police officer accompanied Bolden to the hospital, the news station said.

Police arrested Bolden for assaulting his father and trying to set himself and his father’s home on fire. Police said he couldn’t get a lighter to work after he doused himself with gasoline. Bolden fled from his father’s house when police showed up and hid in a brushy lot until police used dogs to find him, KY3 Springfield News reported.