Volume 95 No. 5 May 2012 a newborn Male, delivered by Caesarean section after induction at 41 weeks of gestation for failure to progress, was admitted to the Women and Infants’ Hospital (WIH) Neonatal Intensive Care Unit (NICU) with a large vascular mass on his left knee (Figure 1). Routine prenatal US had been normal and the pregnancy had been uneventful. Physical examination at delivery was otherwise unremarkable. In addition to the WIH NICU team, the baby was followed clinically by pediatric surgical and interventional members of the Hasbro Children’s Hospital Vascular Anomalies Clinic (HVAC). On day two in the NICU, the patient developed signs of congestive heart failure. A chest radiograph demonstrated pulmonary edema and mild cardiomegaly (not shown). On day 14, the lesion began to bleed briskly.
Daniel Aghion, MD, Pradeep Chopra, MD, Adetokunbo A. Oyelese, MD, PhD approximately 250,000 surgeries for low back pain are performed annually in the USA. Approximately 40% of patients undergoing lumbar surgery continue to report significant pain after surgery, and a significant portion of these will result in failed back syndrome (FBS). FBS is defined as persistent or recurrent chronic pain after one or more surgical procedures on the lumbosacral spine. The incidence of true FBS is as high as 15%. Unfortunately, the diagnosis of FBS does not point to the actual cause for treatment failure. Multiple factors can contribute to the development of this syndrome such as residual or recurrent disc herniation, persistent post-operative radiculopathy, joint instability, scar tissue, or muscular deconditioning. Furthermore, patients may be predisposed to FBS due to systemic disorders such as diabetes, autoimmune disease, psychiatric disease, or vascular disease. Overall, it is clear that both biological and psychological issues play a significant role in the outcome of lumbar spine surgery. The specific causes of FBS have been a topic of much debate. Patients with this syndrome can be divided into one of two groups: 1. Patients in whom surgery was never indicated, or the surgery performed carried a low likelihood of achieving the desired result. 2. Patients in whom the surgery was indicated but the surgical procedure was inadequately or incompletely performed, failing to achieve the intended result. There have been several studies that have suggested that up to 95% of FBS cases are related to inappropriate surgery on patients with myofascial pain from muscle denervation, symptoms of fibromuscular dysplasia, or quadratus lumborum, iliopsoas and gluteal muscle syndromes which may mimic the pain distribution of a herniated disc. Operative intervention in these cases would carry a low likelihood of success and as such, surgery should not be entertained in these scenarios. Furthermore, it has been generally agreed that patients with predominantly radicular pain will have better outcomes following surgery than those with predominant complaints of back pain. This is because it is usually more straightforward to identify the source of pain or “pain generator” on an MRI in the case of a pinched nerve causing radicular symptoms than it is to identify the pain generator causing low back pain. Thus, many patients with asymptomatic but abnormal appearing degenerated discs on MRI or with myofascial pain may be subjected to inappropriate lumbar surgery with resulting poor outcomes.
gaIt and balance both declIne wIth normal, or non-pathological aging. Gait and posture tend to become parkinsonian, meaning “looks like Parkinson’s disease.” This connotes a stooped posture, reduced armswing, reduced stride length and a tendency towards a flat foot strike However, a large number of pathological changes may develop contributing to this normal decline. Some of these involve the nervous systems, central or peripheral, and some involve non-neurological systems which not neurologically controlled. It is obvious that gait difficulties and imbalance contribute to reduced quality of life. It is uncommon to meet a patient in a nursing home who walks normally. Gait impairment and the risk of falls is one major contributing factor to nursing home placement. Falls are common in the elderly. There are different definition for “fall,” but the World Health Organization definition of a fall (E880-E888 in ICD 9 and W00-W19 in ICD 10) requires the person to come to rest “inadvertently” at a lower level than intended. I consider trips and slips as different although possible indicators of a falling tendency. We all may slip on ice, or trip over a plug, but it is an indicator of a problem if it is recurrent, suggesting a problem correcting the loss of balance. Over 30% of community dwelling people over 65 fall at least once each year and falls were the leading cause of traumatic death and morbidity in the elderly. The death rate from falls skyrockets with age, increasing from ten per 100,000 per year for ages 65-74, to 147 per 100,000 per year for those over age 85. The financial costs alone are astronomical and increasing. The claim that “falls among older adults are preventable,” is akin to stating that cigarette smoking or drug addiction or obesity is preventable. The correct statement is, and should be, “falls in the elder can be reduced.” They cannot be prevented, partly due to impaired cognitive function that often accompanies gait disorders in the elderly. My own experience, from talking to patients and from reviewing doctor notes is that many patients do not have their walking evaluated during their routine primary care physician (PCP) appointments. In a study of hospitalized patients, often admitted after a fall, gait was not documented on the chart. The reasons for this are manifold, but I believe that two, which are virtually never discussed, are: doctors have not been taught how to evaluate gait and that most doctors lack a vocabulary for gait, and therefore have difficulty describing what they see. Walking requires the ability to stand, maintain position (keeping center of gravity over the feet) and advance. The overall controlling mechanism is the brain, but, obviously, the feet, ankles, knees and hips must be able to bear the weight; the muscles must be sufficiently strong. The inner ear must be able to determine the direction of gravity’s pull. Binocular vision is important for judging distance and compensating for other impaired sensory systems. The peripheral nerves must convey information from the environment in to the spinal cord, and then out to the appropriate muscles at the appropriate time (“garbage in, garbage out”). And aging affects each of these systems, often in very unequal ways. Determining an exact cause of a gait abnormality is sometimes impossible, although identifying which systems contribute to the process is usually not that difficult to determine.
noted. Delirium is especially common in nursing homes after brief hospital admissions because the average length of duration of the delirium is 21 days, while the average hospital length of stay at most general medical hospitals is approximately five days. Therefore, many patients are being discharged to nursing homes while still delirious. In one study, 72% of 214 patients in nursing homes who were hospitalized for delirium still had delirium at the time of discharge back to the nursing home. The delirium persisted for 55% of the patients at one month and 25% at three months after discharge. The rates of delirium in patients who are ill and elderly, but cared for at home are much lower, than for those treated in the hospital.
Chang Liu, MA, Rosa Baier, MPH, Rebekah Gardner, MD, and Amal Trivedi, MD, MPH although elecTronic medical recordS (EMRs) may improve quality of care and reduce healthcare spending, uptake remains low in the United States. 8 A 2009 national survey of hospitals found that only 2.9% of hospitals had a comprehensive, electronic system and an additional 7.9%, a basic system. The same year, a physician-level study found that 43.9% of physicians were using basic EMRs, though only a subset, 6.3% of physicians, had a fully-functional system. Interestingly, physicians cite costs as both the most important barrier and financial incentives as the most important facilitator of EMR adoption. 11, 12 Although some published research casts doubt on the impact of financial incentives on healthcare quality improvement initiatives, studies have shown that financial incentives are key to EMR adoption. 11 For physicians, incentives address a fundamental imbalance, where physicians assume the costs of EMR implementation and maintenance, yet nearly all the financial benefits accrue to payers and purchasers. This misalignment has prompted calls for greater financial support from payers and regulators. However, to our knowledge, no peer-reviewed study has assessed the effectiveness of financial incentives on EMR adoption and use. Recognizing the significant role of financial incentives in accelerating EMR adoption, the Federal American Recovery and Reinvestment Act (ARRA) of 2009 provides $20 billion in Medicare and Medicaid incentive payments to physicians and hospitals whose use of certified EMRs meets a minimum set of requirements (“meaningful use”). State government and commercial health plans are also engaged in local efforts to provide incentives (financial and nonfinancial) for physicians to purchase and use EMRs. As the first and only state to systematically assess and publicly report EMR adoption for every licensed physician providing direct patient care, Rhode Island provides an opportunity to assess the relationship between eligibility for financial incentives and EMR adoption. Blue Cross & Blue Shield of Rhode Island (BCBSRI) and UnitedHealthcare of New England (UHC), the state’s two largest commercial health plans representing 96% of the non-elderly, commercial market, began offering EMR-based payments to office-based primary care physicians (PCPs) in 2008 and 2009, respectively. BCBSRI increased primary reimbursements for all evaluation and management services by 5% to 13% and UHC offered fixed-sum payments for office-based PCPs with EMRs meeting pre-specified standards. We hypothesize that these efforts may be associated with greater EMR adoption than the rates reported in national studies, particularly among those office-based PCPs eligible for the health plans’ payments. We therefore evaluated the association between physician specialty, practice site, and EMR adoption. Using the state’s comprehensive survey, we assessed EMR implementation and functionality use among Rhode Island physicians after the initiation of health plan incentive payments.
Melissa M. Amick, PhD the number of drivers over the age of 75 will dramatically increase over the next few decades. Adults age 85 and older have the highest rate of driver fatalities. Individuals age 70 and older have the greatest motor vehicle fatality rates per mile driven compared to all but the riskiest age group, those 25 years and younger. Advanced age is also a risk factor for motor vehicle crashes. Since driving safety declines as older adults age, clinicians caring for this population may be increasingly called upon to evaluate the driving safety of their elderly patients.
Volume 95 No. 6 June 2012 disclosure of Financial interests Karl Meisel, MD, and/or his spouse/significant other have no financial interests to disclose. Joseph Friedman, MD, discloses the following interests – Lectures: Teva, Ingelheim Boehringer; General Electric; Consulting: United Biosource; Bubaloo, Halsted, Reitman LLC; EMD Serono; Genzyme; Teva; Acadia; Addex Pharm; Schwarz Pharma; Research: MJFox; NIH: Cephalon; EMD Serono; Teva; Acadia; Royalties: Demos Press CorrespondenCe Karl Meisel, MD Dept of Neurology, UCSF 505 Parnassus, San Francisco, CA 94143-0114 phone: (415) 353-8897 fax: (415) 353-8705 e-mail: karl.meisel@ucsfmedctr.org
mAny refugee Children Arrive to the united stAtes With elevated blood lead levels (BLLs) compared to U.S. born children. Immigrant and refugee children are at high risk for lead poisoning due to previous lead exposure in their country of origin, malnutrition and iron deficiency. Upon arrival to Rhode Island most refugees are initially placed in housing units in the Providence area located near essential services at Rhode Island Hospital, the International Institute of RI, and the Diocese of Providence. However, housing units in these Providence neighborhoods are at high risk for lead hazards, thereby putting refugees at high risk for lead poisoning. A study from New Hampshire published in 2004, found that of the 242 refugee children who were resettled in that state during October 1, 2003 – September 30, 2004, 92 received two blood lead level tests, one upon arriving to the United States and the second, 3-6 months after the initial screening. While most children had BLLs below ten micrograms per deciliter (<10 μg/ dL) at the initial screening, 37 (40%) of the 92 children who had two screenings had BLLs >10 μg/dL at the second screening, suggesting that the children experienced lead exposures in the US. Further investigation revealed environmental exposures to lead as well as a lack of awareness among refugee families on the sources and hazards of lead exposure. Based on the results of the New Hampshire study and subsequent recommendations from the Centers for Disease Control and Prevention (CDC), the Rhode Island Department of Health (HEALTH) issued lead screening guidelines specific to the pediatric refugee population in 2006. The HEALTH guidelines require that refugee children up to the age of 16 years receive a health screening within 30 days of their arrival that includes a BLL test. Children whose initial lead screening results in a BLL <10 μg/dL should have a repeat test 3-6 months later. Children with a BLL of 10 μg/dL or greater at any testing point are classified as having elevated BLLs. Children whose initial lead screening results in a BLL between 10 – 19 μg/dL should have a repeat test within three months (90 days) and receive lead education and/or non-medical case management by a lead center as recommended. Children who have an initial BLL test of 20 μg/dL or greater are considered “significantly lead poisoned” and should receive additional medical evaluation and treatment immediately. A previous analysis of blood lead screening data performed by Sunil Hebbar found that between 2004 and 2008, refugees experienced more lead exposures compared to other Providence children. For this period, annual prevalence rates ranged from 14 to 40% for refugee children; prevalence rates for Providence for the same period ranged from four to nine percent. Since the initial analysis was performed, many changes have occurred which have impacted the lead exposures of the refugee population. For example, the housing and foreclosure crisis has reduced the availability of safe and healthy housing; increased the cost to maintain rental units, and increased attention on the placement of newly arrived refugees. This report provides an updated analysis of the prevalence of lead poising among refugee children in Rhode Island from 2008 to 2011, addresses concerns about lead-safe housing placements for refugee children, and offers a recommendation to lower the lead level of concern from 10 μg/dL to 5 μg/dL.
an 86 year -old woman with history o F inflammatory breast cancer and osteoporosis presented with progressive right leg weakness and discomfort. Her medication regimen included monthly Zometa (zoledronate) infusion. She was not on corticosteroids. The patient underwent a right thigh MR imaging examination which demonstrated an incomplete mid femoral diaphyseal insufficiency-type stress fracture with lateral cortical thickening and triangular ridging (cortical beaking), incomplete transverse fracture line and
Thomas P. O’Toole, MD, Lauren Buckel, MPH, Stephen Redihan, BS, Stacey DeOrsey, MSW, and Daniel Sullivan, MSW the reCeNt eCoNomIC dowNturN aNd limited “jobless recovery” has placed an increasing number of individuals at-financial risk. In Rhode Island the unemployment rate has consistently ranked among the highest in the country, exceeding 12% throughout much of the recession. The loss of jobs coupled with the out-migration of younger workers to more areas with more robust economies has concentrated need among those remaining while at the same time reducing the tax base and resources available to assist them. What is less well known is how medical costs are considered during economic downturns and in the context of other competing basic needs, particularly when those costs are “fixed” and health care or medications are considered less urgently. Medical debts are the second most common cause of personal bankruptcy and cost has a direct effect on where and when an individual seeks care. In this paper we report on data from the “Making Ends Meet” initiative at the Providence Veterans Administration Medical Center which was launched in November, 2008. Patients at the VA who self-identified in response to posted fliers within the hospital as being affected by current economic conditions were asked to completed a survey and meet with a social worker. They initially had a telephone screening and received an information packet of available VA and community resources. All respondents were then offered assistance navigating the care system, pursuing food, housing and utility assistance programs, and stress-management counseling through scheduled group and individual sessions with the social work staff. Our findings help define the role hospitals play as part of the safety net during recessionary periods.
