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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

Keep Current on Recent Research

You may not have time to read all the research you’d like to, but in just a few minutes you can add to your knowledge with ACFAS’ Scientific Literature Reviews.

This month you’ll find quick reads on topics such as extraskeletal osteochondroma of the foot, treatment of chronic lateral ankle instability, and hyaluronic acid as a treatment for ankle osteoarthritis.

These reviews have been prepared for you from the Journal of the Chinese Medical Association, Current Reviews in Musculoskeletal Medicine, Injury and other research publications by podiatric residents at St. John Hospital.

Find recent research at your fingertips with Scientific Literature Reviews.
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Foot and Ankle Surgery

Management of Tarsal Navicular Stress Fractures

Researchers set out to provide a statistical analysis of previously reported tarsal navicular stress fracture studies regarding the outcomes and effectiveness of conservative and surgical management. A systematic review of the published literature was conducted utilizing MEDLINE through Ovid, PubMed, ScienceDirect, and EBSCOhost. Reports of studies that provided the type of tarsal navicular stress fracture (ie, complete or incomplete), type of treatment, result of that treatment, and the time required to return to full activity were selected for analysis. Cases were separated and compared based on three different types of treatment: conservative, weightbearing permitted (WBR); conservative, non-weightbearing (NWB); and surgical treatment. Results of the analysis showed that there was no statistically significant difference between NWB conservative treatment and surgical treatment regarding outcome, but there is a statistical trend favoring NWB management (96 percent successful outcomes) over surgery (82 percent successful outcomes). Weightbearing as a conservative treatment was shown to be significantly less effective than either NWB or surgical treatment.

From the article of the same title
American Journal of Sports Medicine (05/01/10) Vol. 38, No. 5, P. 1048; Torg, Joseph S.; Moyer, James; Gaughan, John P.; et al.

Midterm Results From a Multicenter Registry on the Treatment of Infrainguinal Critical Limb Ischemia Using a Heparin-bonded ePTFE Graft

Researchers reported midterm results of infrainguinal bypasses performed with a heparin-bonded expanded polytetrafluoroethylene (ePTFE) graft in patients presenting with critical limb ischemia. Over a seven-year period ending in 2008, 425 patients presenting with critical limb ischemia underwent infrainguinal revascularization using a heparin-bonded ePTFE graft in seven Italian vascular centers. Preoperative, intraoperative, and follow-up data were collected in a multicenter registry. Intervention consisted of a femoral to below-knee bypass in 324 patients, whereas the remaining 101 patients had a femoral to above-knee bypass. In patients with below-knee bypass, distal target vessels were the popliteal artery in 238 cases, the tibioperoneal trunk in 38 cases, and a tibial vessel in the remaining 48 cases (anterior tibial artery in 20 cases, posterior tibial artery in 23 cases, and peroneal artery in five). Cumulative estimated 36-month primary and secondary patency, limb salvage, and survival rates were 61 percent, 70 percent, 83 percent, and 83 percent, respectively. The factors associated with poorer limb salvage rates during follow-up were the presence of ischemic ulcers or gangrene, the presence of only one patent tibial vessel, redo surgery, and the postoperative treatment with antiplatelet therapy in comparison to oral anticoagulants. The researchers concluded that the use of a heparin-bonded ePTFE graft was an excellent alternative to autologous saphenous vein when it is absent, unsuitable, or of poor quality.

From the article of the same title
Journal of Vascular Surgery (05/01/10) Vol. 51, No. 5, P. 1167; Pulli, R.; Castelli, P.; Dorrucci, V.; et al.

Osteosynthesis of Displaced Intra-articular Fractures of the Calcaneum: A Long-term Review of 47 Cases

Researchers carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders' classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. There were 18 excellent (38.3 percent), 17 good (36.2 percent), three fair (6.3 percent) and nine poor (19.2 percent) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler's angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders' classification. The researchers concluded that prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler's angle.

From the article of the same title
Journal of Bone and Joint Surgery - British Volume (05/01/10) Vol. 92, No. 5, P. 693; Makki, D.; Alnajjar, H. M.; Walkay, S.

Practice Management

Depression Symptoms Increase During Residency

Fewer than 4 percent of doctors in training have major depression when they enter residency, but approximately 25 percent do by the end of the first year, according to research published online by the Archives of General Psychiatry. Stressful life events, work hours, and genetic predisposition were among the factors associated with depressive symptoms among residents, according to the study. "It's a really serious matter. ...We have to find ways to reduce the chances of developing depression and treating it once it comes on," said lead study author Srijan Sen, an assistant professor in the department of psychiatry at the University of Michigan Medical School. "Residency programs should look for this in their interns. [Identifying depression] can improve interns' health, and it could potentially help the health of the patients they're treating."

From the article of the same title
American Medical News (04/29/10) Moyer, Christine S.

Optimizing Your Greatest Asset: Your Time

Time is the most important asset in a medical practice. Managing time well is not only key to the mental well being of practitioners, but to profitability as well. To better manage time, start by reviewing your schedule each day and consult your staff to elicit feedback and execute any needed changes right away. Look for anomalies in the schedule, and review charts of patients coming in for a follow-up visit so their situation is fresh in your mind. Start the day on time, and make sure that staff has prepped exam rooms the day before, using a checklist to make sure each room is ready. Establish an agenda at the beginning of each appointment and have a nurse find out the patient's priorities. Resist the temptation to bunch work, like answering all messages at the end of the day.

From the article of the same title
Medical Economics (04/23/10) Woodock, Elizabeth

Studies: When Doctors Take More Responsibility, Care Becomes Cheaper

Some health and policy experts have believed for some time that medical homes excel at reducing health care costs and improving patient outcomes, a belief that is being supported by a new study in the journal Health Affairs. Medical homes, where primary care doctors are responsible for coordinating care for individual patients, are viewed as a model for lowering costs while maintaining quality. A study by researchers from the Group Health Research Institute shows that medical homes produce significant cost savings. Over two years, the doctors in a medical home in the Seattle-area had 29 percent fewer ER visits and 6 percent fewer hospitalizations.

While there are startup costs for medical homes, lead researcher Dr. Rob Reid says for every $1 invested in the medical home system, Group Health saved $1.50 by keeping patients out of the ER and the hospital. Medical home patients also reported better experiences. Medical homes are similar to managed care organizations like Kaiser Permanente, but patients can self-refer to certain specialists, and the method rewards doctors, not just the organization, for improving health outcomes.

Reid says the payment system in medicine must be changed to reward better outcomes and boost primary care, that electronic medical records and e-health should be a focus, and that medical teams need to replace lone doctors as primary care providers. Group Health's doctors are paid on salary, but have financial incentives available, like increased payments if their patients are more satisfied or receive better quality scores for care.

From the article of the same title
Kaiser Health News (05/04/10) Villegas, Andrew

Health Policy and Reimbursement

High-Risk Insurance Pools Divide the States

Twelve states have chosen not to administer a new high-risk pool program that begins in July, while 21 states and the District of Columbia will run their own. The pools are designed as a short-term way to provide insurance for people with pre-existing health conditions who have been turned down by insurers. Consumers in the 12 states that chose not to administer their own program will still have access to the program, because the federal government will step in to run their pools. Several of the states that declined to run the pools said they were concerned they would be forced to pay for the program if it exhausted its federal funding. A report from HHS found the program would burn through the $5 billion set aside for it as soon as 2011, though the money is supposed to last until 2014.

From the article of the same title
Wall Street Journal (05/01/10) Adamy, Janet

Sebelius Calls on Governors and State Insurance Commissioners to Examine Premium Increases

Health and Human Services Secretary Kathleen Sebelius has called for a national inquiry into the data used by health insurer WellPoint to justify raising health insurance rates. WellPoint recently withdrew a request for up to a 39 percent price increases on individual plans in California after an actuary hired by the state found several mistakes in the filing. In investigating the rate filing, mathematical mistakes were found, including overestimating future medical costs and double-counting the effect of policyholders aging.

From the article of the same title
BusinessWire (05/05/10)

Teaching Physicians the Price of Care

Doctors in training have traditionally been insulated from information about the cost of the tests and treatments they order for patients, learning to order tests and treatments based on their knowledge of diseases and of scientific evidence. Until recently, most medical schools included little information on financial factors, like how the insurance system works and how treatment costs affect patients’ behavior. As a result, most physicians enter practice with little sense of how to make the most cost-effective choices for patients or how their own decisions affect the patient’s medical bills and national healthcare costs.

But rising costs and the national debate over healthcare reform are forcing medical schools and residency programs to address the financial side of their profession. Accrediting organizations now require such teaching, and students and residents are beginning to understand that they need to understand the financial as well as the medical side of their chosen profession.

From the article of the same title
New York Times (05/03/10) Okie, Susan

Technology and Device Trends

Baxter to Recall Infusion Devices

Following a request from the FDA, Baxter International announced a recall of about 200,000 Colleague brand infusion pumps currently on the market due to a history of malfunctions that have contributed to patient injuries and deaths. Among the problems associated with the pumps are overinfusion, underinfusion, and electrical shock hazards. In the past, Baxter has notified users that the pumps could suddenly sound an alarm and stop delivering drugs and could also overheat and cause a fire if not cleaned properly. The pumps were cited as causing 16 injuries and several deaths in 2005, when the FDA seized more than 7,000 of the pumps and the company agreed to fix the problems. Baxter will exchange the recalled pumps for Sigma Spectrum pumps.

From the article of the same title
Wall Street Journal (05/04/10) P. B6; Dooren, Jennifer Corbett; Burton, Thomas M.

Surgical Robot Examined in Injuries

The da Vinci surgical robot is being examined after being used in several surgeries where injuries occurred at Wentworth-Douglass Hospital in Dover, N.H. While there is no evidence to suggest the injuries were caused by technical malfunctions, surgeons who use the da Vinci stress that it requires considerable practice. Comparing the rate of complications from robotic surgeries at Wentworth-Douglas to that of other hospitals is impossible because most hospitals do not disclose such information due to peer-review regulations designed to preserve doctors' anonymity.

From the article of the same title
Wall Street Journal (05/04/10) Carreyrou, John

99mTc-Anti-CD3 Scintigraphy Aids Differential Diagnosis of Rheumatic Diseases

Researchers have found that 99mTc-anti-CD3 scintigraphy is useful for the differential diagnosis of rheumatic diseases. This conclusion was based on an evaluation of 2,044 joints from 77 patients with rheumatic diseases. Diagnosis criteria were established for 99mTc-anti-CD3 scintigraphy uptake in different diseases. Rheumatoid arthritis and juvenile idiopathic arthritis showed joint uptake with progressive increase in late images. Gouty arthritis showed joint uptake with decrease during late images. Joint uptake was low or absent in patients with osteoarthritis, although when present the joint uptake decreased during the examination.

From "Use of 99mTc-Anti-CD3 Scintigraphy in the Differential Diagnosis of Rheumatic Diseases"
Rheumatology (05/01/10) Vol. 49, No. 5, P. 933; Lopes, Flavia Paiva Proenca Lobo; de Azevedo, Mario Newton Leitao; Marchiori, Edson; et al.

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May 12, 2010