A decade ago, the World Health Organization suggested that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”¹ A recent survey found that medication adherence rates over the course of 1 year were 24% for patients with depression, 36% with diabetes, 54% with epilepsy, 32% with dyslipidemia, and 42% with hypertension.² Poor adherence rates such as these contribute to the low rates of disease control in patients with diabetes, dyslipidemia, hypertension, and other chronic diseases.^3,4 Since chronic diseases are largely self-managed, effective patient self-management is critical to good health-related outcomes. To help patients self-manage their diseases, the family physician must work collaboratively with each patient to select, initiate, and modify therapy based upon the patient’s needs, interests, and capabilities. Just as there are important differences between children and adults, men and women often manifest diseases differently. In addition, men and women often deal with and manage their diseases in different ways. While “Men’s Health” is often considered to be a focus on the urogenital tract, we have sought to also focus on diseases that have a high prevalence in men, or where treatment in men may be different compared with women.

The first 2 articles in this supplement on men’s health concern 2 diseases increasingly encountered by men as they age. Dr. Martin Miner provides his thoughts about screening for and diagnosing benign prostatic hyperplasia, including strategies to promote patient report of symptoms and the role of the prostate specific antigen test. A case study is utilized to illustrate key considerations when selecting therapy and promoting patient self-management of benign prostatic hyperplasia. Dr. Gary Ruoff follows a patient from initial diagnosis of gout through selection of treatment for the acute flare and chronic treatment with urate-lowering therapy. A treatment plan is presented at each management step. In the next article, Dr. Richard Aguilar takes a case study approach to describe key risk factors for type 2 diabetes mellitus in men. He also discusses how men self-manage type 2 diabetes differently than women and provides insight as to how to address common psychosocial issues in men. Drs. Louis Kuritzky and José Díez review clinical experience with the two newest antiplatelet agents, prasugrel and ticagrelor. Answers are also provided to common questions and problems encountered with the use of antiplatelet agents in primary care. The next 2 articles focus on major modifiable risk factors contributing to cardiovascular disease. In the first, Dr. Michael Cobble focuses on patient assessment and treatment strategies to help men modify abnormal lipid levels and blood pressure for primary prevention of coronary heart disease. Finally, a more in-depth discussion of dyslipidemia is provided by Dr. Peter Toth, who begins by providing a brief overview of the current evidence regarding the long-term benefits of statin therapy, as well as his clinical perspective on the newest statin, pitavastatin. Dr. Toth also provides answers to many problems frequently encountered in the primary care management of patients with dyslipidemia using statin therapy.

It is my hope that the insights provided by these authors will be helpful to family physicians in managing their male patients with these common chronic diseases.

A decade ago, the World Health Organization suggested that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”¹ A recent survey found that medication adherence rates over the course of 1 year were 24% for patients with depression, 36% with diabetes, 54% with epilepsy, 32% with dyslipidemia, and 42% with hypertension.² Poor adherence rates such as these contribute to the low rates of disease control in patients with diabetes, dyslipidemia, hypertension, and other chronic diseases.^3,4 Since chronic diseases are largely self-managed, effective patient self-management is critical to good health-related outcomes. To help patients self-manage their diseases, the family physician must work collaboratively with each patient to select, initiate, and modify therapy based upon the patient’s needs, interests, and capabilities. Just as there are important differences between children and adults, men and women often manifest diseases differently. In addition, men and women often deal with and manage their diseases in different ways. While “Men’s Health” is often considered to be a focus on the urogenital tract, we have sought to also focus on diseases that have a high prevalence in men, or where treatment in men may be different compared with women.

The first 2 articles in this supplement on men’s health concern 2 diseases increasingly encountered by men as they age. Dr. Martin Miner provides his thoughts about screening for and diagnosing benign prostatic hyperplasia, including strategies to promote patient report of symptoms and the role of the prostate specific antigen test. A case study is utilized to illustrate key considerations when selecting therapy and promoting patient self-management of benign prostatic hyperplasia. Dr. Gary Ruoff follows a patient from initial diagnosis of gout through selection of treatment for the acute flare and chronic treatment with urate-lowering therapy. A treatment plan is presented at each management step. In the next article, Dr. Richard Aguilar takes a case study approach to describe key risk factors for type 2 diabetes mellitus in men. He also discusses how men self-manage type 2 diabetes differently than women and provides insight as to how to address common psychosocial issues in men. Drs. Louis Kuritzky and José Díez review clinical experience with the two newest antiplatelet agents, prasugrel and ticagrelor. Answers are also provided to common questions and problems encountered with the use of antiplatelet agents in primary care. The next 2 articles focus on major modifiable risk factors contributing to cardiovascular disease. In the first, Dr. Michael Cobble focuses on patient assessment and treatment strategies to help men modify abnormal lipid levels and blood pressure for primary prevention of coronary heart disease. Finally, a more in-depth discussion of dyslipidemia is provided by Dr. Peter Toth, who begins by providing a brief overview of the current evidence regarding the long-term benefits of statin therapy, as well as his clinical perspective on the newest statin, pitavastatin. Dr. Toth also provides answers to many problems frequently encountered in the primary care management of patients with dyslipidemia using statin therapy.

It is my hope that the insights provided by these authors will be helpful to family physicians in managing their male patients with these common chronic diseases.

A decade ago, the World Health Organization suggested that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”¹ A recent survey found that medication adherence rates over the course of 1 year were 24% for patients with depression, 36% with diabetes, 54% with epilepsy, 32% with dyslipidemia, and 42% with hypertension.² Poor adherence rates such as these contribute to the low rates of disease control in patients with diabetes, dyslipidemia, hypertension, and other chronic diseases.^3,4 Since chronic diseases are largely self-managed, effective patient self-management is critical to good health-related outcomes. To help patients self-manage their diseases, the family physician must work collaboratively with each patient to select, initiate, and modify therapy based upon the patient’s needs, interests, and capabilities. Just as there are important differences between children and adults, men and women often manifest diseases differently. In addition, men and women often deal with and manage their diseases in different ways. While “Men’s Health” is often considered to be a focus on the urogenital tract, we have sought to also focus on diseases that have a high prevalence in men, or where treatment in men may be different compared with women.

The first 2 articles in this supplement on men’s health concern 2 diseases increasingly encountered by men as they age. Dr. Martin Miner provides his thoughts about screening for and diagnosing benign prostatic hyperplasia, including strategies to promote patient report of symptoms and the role of the prostate specific antigen test. A case study is utilized to illustrate key considerations when selecting therapy and promoting patient self-management of benign prostatic hyperplasia. Dr. Gary Ruoff follows a patient from initial diagnosis of gout through selection of treatment for the acute flare and chronic treatment with urate-lowering therapy. A treatment plan is presented at each management step. In the next article, Dr. Richard Aguilar takes a case study approach to describe key risk factors for type 2 diabetes mellitus in men. He also discusses how men self-manage type 2 diabetes differently than women and provides insight as to how to address common psychosocial issues in men. Drs. Louis Kuritzky and José Díez review clinical experience with the two newest antiplatelet agents, prasugrel and ticagrelor. Answers are also provided to common questions and problems encountered with the use of antiplatelet agents in primary care. The next 2 articles focus on major modifiable risk factors contributing to cardiovascular disease. In the first, Dr. Michael Cobble focuses on patient assessment and treatment strategies to help men modify abnormal lipid levels and blood pressure for primary prevention of coronary heart disease. Finally, a more in-depth discussion of dyslipidemia is provided by Dr. Peter Toth, who begins by providing a brief overview of the current evidence regarding the long-term benefits of statin therapy, as well as his clinical perspective on the newest statin, pitavastatin. Dr. Toth also provides answers to many problems frequently encountered in the primary care management of patients with dyslipidemia using statin therapy.

It is my hope that the insights provided by these authors will be helpful to family physicians in managing their male patients with these common chronic diseases.

CASE KD is an 18-year-old high school basketball player who was knocked backwards during a game, hitting her head on the floor. She had immediate head and neck pain but no loss of consciousness; she was transported by EMS to the local emergency department (ED) for further evaluation. Results of head and neck CT scans were normal, and she was discharged home. Four days later, KD’s parents brought her to our office because she was experiencing ongoing headache, phonophobia, nausea, light-headedness, poor balance, increased sleepiness, and irritability.

The Centers for Disease Control and Prevention estimate that approximately 300,000 sports concussions occur yearly in the United States,¹ and that 135,000 of these cases are treated in EDs.² These numbers have not gone unnoticed in the consumer press. Over the past 18 months, Sports Illustrated, Newsweek, and Time^3-5 have published stories on sports-related concussion, helping to raise public awareness of its risks.

Recommendations for practitioners have changed. In 1997, the American Academy of Neurology⁶ published one-size-fits-all guidelines on managing concussion, using levels of symptomatology and loss of consciousness to grade the severity of concussion from 1 to 3. These guidelines were similar to the Cantu and Colorado guidelines of the early 1990s.^7,8 Since then, however, the diagnostic criteria and expert opinion about treatment and return to physical activity have changed. Indeed, several medical organizations^9-12 now recommend a more individualized approach to evaluation and management, which we describe here.

It begins with a definition

While there is no single agreed-upon characterization of “concussion,” the 3rd International Conference on Concussion in Sport (ICCS)¹² provides this definition:

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

1. Concussion may be caused either by a direct blow to the head, face, or neck or a blow elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.
2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.… In a small percentage of cases, however, postconcussive symptoms may be prolonged.
5. No abnormality on standard structural neuroimaging studies is seen in concussion.

Office evaluation
Obtain a thorough history and conduct a neurologic evaluation and musculoskeletal examination of the head and neck.

Clues to expected length of recovery

A patient with a concussion may lose consciousness after the impact, or have a brief convulsion that is not a seizure.¹³ In the periodimmediately after the injury, the patient may exhibit a constellation of such signs and symptoms as headache, confusion, a dazed look, dilated pupils, amnesia, poor balance, nausea, or vomiting. These features typically resolve over time, but may persist for weeks or months. Anterograde or retrograde amnesia may also occur. TABLE 1 details a more complete list of concussion symptoms. If the patient is a child or young adult, it is useful to have a parent present at the office visit to describe the patient’s mood, sleep, appetite, and overall health after the injury.

Factors that may portend a longer recovery include a previous concussion, retrograde or anterograde amnesia, younger age, and female sex.¹⁴

Dire problems beyond concussion. Complaints or historical elements inconsistent with concussion that should be considered red flags include any focal neurologic complaints, vomiting or headache that worsens after a period of improvement, or obtundation or disorientation that has worsened since the injury. With such findings, consider more serious head injuries and arrange for a more complete immediate neurologic work-up.

CASE Our neurologic examination yielded normal results. However, our patient was unable to balance correctly on one leg. The cognitive exam revealed a deficit in short-term memory. We diagnosed a concussion, advised her to refrain from sports, and prescribed cognitive rest. A return to school for half days would be considered once her symptoms began to resolve.

TABLE 1
Signs and symptoms commonly associated with concussion

Options for the neurologic exam
With a simple concussion, expect a normal neurologic examination, with the possible exception of the ability to balance. Head imaging is not necessary in the setting of suspected concussion, because results of computed tomography (CT) and magnetic resonance imaging (MRI) will likely be normal.¹²

Balance testing can assist in the diagnosis of concussion and the monitoring of recovery from injury.^15-17 The Balance Error Scoring System (BESS)¹⁵ is a validated and simple test that can be done in the office. The test involves 3 consecutive stances: (a) normal stance with feet comfortably apart and hands on hips, (b) with feet aligned heel to toe with the dominant leg in front, and (c) standing on the nondominant leg with the dominant leg flexed 30 degrees at the hip. Have the patient repeat each version of the test for 20 seconds with eyes closed, on a stable and then unstable surface (eg, foam mat).

It’s recommended that another staff member be present to spot the patient in case of a fall. A link to a complete description of the test and scoring details is provided in the Web resources box.

Assess cognitive function. One tool for assessing cognitive function is the Sports Concussion Assessment Tool 2 (SCAT2).¹² SCAT2 includes newer, as yet unvalidated sections and several sections that have been independently studied and proven useful in diagnosing concussion. Validated sections are the Maddocks questions, used only at the time and place of injury¹⁸ ; the modified BESS¹⁵ ; and the Standardized Assessment of Concussion (SAC).¹⁹ The SCAT2 and the SAC (which may be used separately) include questions that assist in evaluating short-term memory and attention, and are useful in the physician’s office.

Do computer-based tools help? Another option for cognitive assessment is computer-based neuropsychologic testing developed specifically for use with suspected concussion. Any of these programs can be used in the office by a trained practitioner. Schools may also use the programs under the supervision of an athletic trainer or team physician. Available programs are ImPACT, developed by the University of Pittsburgh (http://impacttest.com); the Cognitive Stability Index (CSI), by HeadMinder (http://www.headminder.com/site/csi/home.html); and the Computerized Cognitive Assessment Tool (CCAT), by CogState/Axon Sports (http://www.axonsports.com). Multiple studies have shown such programs to be useful in diagnosing and monitoring recovery from sports concussion.^20-23

However, among sports medicine practitioners, there seems to be a consensus that computer-based neuropsychologic testing is most useful when a baseline score exists. Baseline testing is usually done preseason on athletes in a healthy state. If a baseline score is not available, a patient’s postinjury score is compared with normative data produced by the developer of the individual test.

Few, if any, outcome studies have been conducted to determine whether computer-basedneuropsychologic testing provides any meaningful improvement in the care of athletes who have suffered concussions. There is also concern that few studies by independent sources have replicated the data disseminated by developers of the tests.^24,25 The most recent guidelines by the 3rd ICCS recommend using neuropsychologic testing only as an aid to an overall medical evaluation, not as the sole determinant of recovery from concussion.¹² Numerous studies now underway may help clarify the role of neuropsychologic testing in concussion.

CASE By the time of our follow-up exam 7 days later (11 days from injury), KD had returned to school for half days, but her phonophobia and headaches worsened at school and she had difficulty focusing on academic tasks. Neurologic, balance, and cognitive exams were all normal. We advised her to gradually return to school full time while abstaining from sporting activity.

At 16 days’ follow-up (20 days from injury), KD had returned to school full time and said she felt more like herself, although she continued to have daily headaches and phonophobia. All exam results were normal. Sports were still off limits, and we told her to expect at least 7 more days of respite before any return to exercise would be allowed.

At 23 days’ follow-up (27 days from injury), KD’s symptoms had completely resolved, and all exam results were normal. We prescribed a stepwise return to athletic activity over the next 10 days and discussed this plan with the school’s athletic trainer, who would supervise her return to play.

Individualize management

The one-size-fits-all approach previously recommended⁶ is no longer the standard of care. In your initial encounter with the patient (and parents, as appropriate), explain the nature of the injury, expected course of recovery, and requirements for a return to play. Also discuss the possibility of postconcussive syndrome and the risk of rare sequelae such as second impact syndrome.

If the patient is symptomatic or exhibits examination findings consistent with concussion, recommend immediate cessation of sports activity.^9-12 With a school-aged athlete, if symptoms reported by the patient or parents are significant, consider prescribing cognitive rest, which can be provided through quiet accommodations at school or perhaps even time off from school or exams.^12,24 In the early period of recovery, increased cognitive or physical activity can cause symptoms to worsen. With improvement, the patient may return to school half time to lessen the chance of a significant return of symptoms. If half days are tolerated, the patient may transition to full days. Make sure the diagnosis and expectations for recovery are communicated to the appropriate school officials so that necessary accommodationscan be made. If symptoms after the initial office visit are mild, a one-week return to school is appropriate to evaluate the patient’s recovery.

Allowing a return to sports. Once the patient is asymptomatic, and physical and cognitive test results are normal, discuss a return-to-play protocol with the patient (and with parents and athletic trainer or coach, as appropriate). Multiple sources^10,11,26 now recommend a stepwise return to play, as detailed by the 3rd ICCS ( TABLE 2 ).¹² Increase or decrease the length of the protocol depending on the patient and the specifics of the case.

There is little science to guide the treatment of children with concussion. However, given that their brains are still developing, it’s prudent to be more conservative than with older adolescents or adults. Multiple sources apart from the 3rd ICCS agree with this recommendation. Several authors suggest more cognitive rest and a longer return-to-play protocol in all cases.^10,27 In fact, the ICCS committee additionally recommends observing a symptom-free waiting period for pediatric athletes before even starting a return-to-play protocol.

McCrory et al²⁶ suggest that children under age 15 be treated more conservatively than those 15 and older. They suggest treating those 15 and older with the protocol for older adolescents. Specifying an age at which one should always make a decision for or against conservative care can be problematic. However, based on the recommendations above, it would seem reasonable to provide conservative treatment for children younger than high school age and perhaps even those in the early years of high school.

Consider legal implications. Become familiar with state laws that require certain steps in managing sports concussion. The Web site http://www.sportsconcussions.org/laws.html²⁸ lists states with sports concussion statutes, as well as states with bills working their way through the legislative system. Currently, 29 states are listed with laws; 14 more and the District of Columbia have pending legislation.

TABLE 2
Stepwise protocol for return to play

Anticipate complications
Most patients with concussions who are managed appropriately do well. However, complications can occur. The most serious complication is second impact syndrome, which usually occurs when concussion is unrecognized or not well managed. While not well understood, this condition is thought to result from a sudden increase in intracranial pressure after a second head injury in an athlete already suffering from concussion symptoms. The injury typically results in serious long-term neurologic deficits, or even fatality.²⁹ Second impact syndrome has been documented as occurring in the same game after an initial injury, as well as in subsequent games.²⁹

A more common, but less serious, complication is postconcussion syndrome.³⁰ This is an ill-defined condition in which the patient suffers from concussive symptoms for an extended period of time, generally for more than 3 months.³⁰ As with acute concussion, the constellation of symptoms ranges from headache to cognitive impairment. In cases of postconcussion syndrome, it is appropriate to consult with neuropsychologists, psychiatrists, or neurologists for assistance with symptoms and associated mood disorders. Similar to acute concussion management, it is generally recommended that athletes not be cleared to resume play while struggling with the symptoms of postconcussion syndrome.³⁰

There have also been recent reports of late-life sequelae in those who have sustained multiple concussions. Depression and dementia have been suggested in surveys of retired NFL players.^31,32 There have also been studies both suggesting¹⁴ and questioning^33,34 whether multiple concussions result in long-term cognitive deficits. While the evidence available at this time is not firm, there seems to be an increasing belief that multiple concussions can affect long-term cognitive abilities. For these reasons, use caution in making return-to-play decisions for patients with multiple concussions or concussions with long-lasting symptoms.

CORRESPONDENCE Aaron M. Lear, MD, 224 West Exchange Street, Suite 440, Akron, OH 44302; aaron.lear@akrongeneral.org

CASE KD is an 18-year-old high school basketball player who was knocked backwards during a game, hitting her head on the floor. She had immediate head and neck pain but no loss of consciousness; she was transported by EMS to the local emergency department (ED) for further evaluation. Results of head and neck CT scans were normal, and she was discharged home. Four days later, KD’s parents brought her to our office because she was experiencing ongoing headache, phonophobia, nausea, light-headedness, poor balance, increased sleepiness, and irritability.

The Centers for Disease Control and Prevention estimate that approximately 300,000 sports concussions occur yearly in the United States,¹ and that 135,000 of these cases are treated in EDs.² These numbers have not gone unnoticed in the consumer press. Over the past 18 months, Sports Illustrated, Newsweek, and Time^3-5 have published stories on sports-related concussion, helping to raise public awareness of its risks.

Recommendations for practitioners have changed. In 1997, the American Academy of Neurology⁶ published one-size-fits-all guidelines on managing concussion, using levels of symptomatology and loss of consciousness to grade the severity of concussion from 1 to 3. These guidelines were similar to the Cantu and Colorado guidelines of the early 1990s.^7,8 Since then, however, the diagnostic criteria and expert opinion about treatment and return to physical activity have changed. Indeed, several medical organizations^9-12 now recommend a more individualized approach to evaluation and management, which we describe here.

It begins with a definition

While there is no single agreed-upon characterization of “concussion,” the 3rd International Conference on Concussion in Sport (ICCS)¹² provides this definition:

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

1. Concussion may be caused either by a direct blow to the head, face, or neck or a blow elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.
2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.… In a small percentage of cases, however, postconcussive symptoms may be prolonged.
5. No abnormality on standard structural neuroimaging studies is seen in concussion.

Office evaluation
Obtain a thorough history and conduct a neurologic evaluation and musculoskeletal examination of the head and neck.

Clues to expected length of recovery

A patient with a concussion may lose consciousness after the impact, or have a brief convulsion that is not a seizure.¹³ In the periodimmediately after the injury, the patient may exhibit a constellation of such signs and symptoms as headache, confusion, a dazed look, dilated pupils, amnesia, poor balance, nausea, or vomiting. These features typically resolve over time, but may persist for weeks or months. Anterograde or retrograde amnesia may also occur. TABLE 1 details a more complete list of concussion symptoms. If the patient is a child or young adult, it is useful to have a parent present at the office visit to describe the patient’s mood, sleep, appetite, and overall health after the injury.

Factors that may portend a longer recovery include a previous concussion, retrograde or anterograde amnesia, younger age, and female sex.¹⁴

Dire problems beyond concussion. Complaints or historical elements inconsistent with concussion that should be considered red flags include any focal neurologic complaints, vomiting or headache that worsens after a period of improvement, or obtundation or disorientation that has worsened since the injury. With such findings, consider more serious head injuries and arrange for a more complete immediate neurologic work-up.

CASE Our neurologic examination yielded normal results. However, our patient was unable to balance correctly on one leg. The cognitive exam revealed a deficit in short-term memory. We diagnosed a concussion, advised her to refrain from sports, and prescribed cognitive rest. A return to school for half days would be considered once her symptoms began to resolve.

TABLE 1
Signs and symptoms commonly associated with concussion

Options for the neurologic exam
With a simple concussion, expect a normal neurologic examination, with the possible exception of the ability to balance. Head imaging is not necessary in the setting of suspected concussion, because results of computed tomography (CT) and magnetic resonance imaging (MRI) will likely be normal.¹²

Balance testing can assist in the diagnosis of concussion and the monitoring of recovery from injury.^15-17 The Balance Error Scoring System (BESS)¹⁵ is a validated and simple test that can be done in the office. The test involves 3 consecutive stances: (a) normal stance with feet comfortably apart and hands on hips, (b) with feet aligned heel to toe with the dominant leg in front, and (c) standing on the nondominant leg with the dominant leg flexed 30 degrees at the hip. Have the patient repeat each version of the test for 20 seconds with eyes closed, on a stable and then unstable surface (eg, foam mat).

It’s recommended that another staff member be present to spot the patient in case of a fall. A link to a complete description of the test and scoring details is provided in the Web resources box.

Assess cognitive function. One tool for assessing cognitive function is the Sports Concussion Assessment Tool 2 (SCAT2).¹² SCAT2 includes newer, as yet unvalidated sections and several sections that have been independently studied and proven useful in diagnosing concussion. Validated sections are the Maddocks questions, used only at the time and place of injury¹⁸ ; the modified BESS¹⁵ ; and the Standardized Assessment of Concussion (SAC).¹⁹ The SCAT2 and the SAC (which may be used separately) include questions that assist in evaluating short-term memory and attention, and are useful in the physician’s office.

Do computer-based tools help? Another option for cognitive assessment is computer-based neuropsychologic testing developed specifically for use with suspected concussion. Any of these programs can be used in the office by a trained practitioner. Schools may also use the programs under the supervision of an athletic trainer or team physician. Available programs are ImPACT, developed by the University of Pittsburgh (http://impacttest.com); the Cognitive Stability Index (CSI), by HeadMinder (http://www.headminder.com/site/csi/home.html); and the Computerized Cognitive Assessment Tool (CCAT), by CogState/Axon Sports (http://www.axonsports.com). Multiple studies have shown such programs to be useful in diagnosing and monitoring recovery from sports concussion.^20-23

However, among sports medicine practitioners, there seems to be a consensus that computer-based neuropsychologic testing is most useful when a baseline score exists. Baseline testing is usually done preseason on athletes in a healthy state. If a baseline score is not available, a patient’s postinjury score is compared with normative data produced by the developer of the individual test.

Few, if any, outcome studies have been conducted to determine whether computer-basedneuropsychologic testing provides any meaningful improvement in the care of athletes who have suffered concussions. There is also concern that few studies by independent sources have replicated the data disseminated by developers of the tests.^24,25 The most recent guidelines by the 3rd ICCS recommend using neuropsychologic testing only as an aid to an overall medical evaluation, not as the sole determinant of recovery from concussion.¹² Numerous studies now underway may help clarify the role of neuropsychologic testing in concussion.

CASE By the time of our follow-up exam 7 days later (11 days from injury), KD had returned to school for half days, but her phonophobia and headaches worsened at school and she had difficulty focusing on academic tasks. Neurologic, balance, and cognitive exams were all normal. We advised her to gradually return to school full time while abstaining from sporting activity.

At 16 days’ follow-up (20 days from injury), KD had returned to school full time and said she felt more like herself, although she continued to have daily headaches and phonophobia. All exam results were normal. Sports were still off limits, and we told her to expect at least 7 more days of respite before any return to exercise would be allowed.

At 23 days’ follow-up (27 days from injury), KD’s symptoms had completely resolved, and all exam results were normal. We prescribed a stepwise return to athletic activity over the next 10 days and discussed this plan with the school’s athletic trainer, who would supervise her return to play.

Individualize management

The one-size-fits-all approach previously recommended⁶ is no longer the standard of care. In your initial encounter with the patient (and parents, as appropriate), explain the nature of the injury, expected course of recovery, and requirements for a return to play. Also discuss the possibility of postconcussive syndrome and the risk of rare sequelae such as second impact syndrome.

If the patient is symptomatic or exhibits examination findings consistent with concussion, recommend immediate cessation of sports activity.^9-12 With a school-aged athlete, if symptoms reported by the patient or parents are significant, consider prescribing cognitive rest, which can be provided through quiet accommodations at school or perhaps even time off from school or exams.^12,24 In the early period of recovery, increased cognitive or physical activity can cause symptoms to worsen. With improvement, the patient may return to school half time to lessen the chance of a significant return of symptoms. If half days are tolerated, the patient may transition to full days. Make sure the diagnosis and expectations for recovery are communicated to the appropriate school officials so that necessary accommodationscan be made. If symptoms after the initial office visit are mild, a one-week return to school is appropriate to evaluate the patient’s recovery.

Allowing a return to sports. Once the patient is asymptomatic, and physical and cognitive test results are normal, discuss a return-to-play protocol with the patient (and with parents and athletic trainer or coach, as appropriate). Multiple sources^10,11,26 now recommend a stepwise return to play, as detailed by the 3rd ICCS ( TABLE 2 ).¹² Increase or decrease the length of the protocol depending on the patient and the specifics of the case.

There is little science to guide the treatment of children with concussion. However, given that their brains are still developing, it’s prudent to be more conservative than with older adolescents or adults. Multiple sources apart from the 3rd ICCS agree with this recommendation. Several authors suggest more cognitive rest and a longer return-to-play protocol in all cases.^10,27 In fact, the ICCS committee additionally recommends observing a symptom-free waiting period for pediatric athletes before even starting a return-to-play protocol.

McCrory et al²⁶ suggest that children under age 15 be treated more conservatively than those 15 and older. They suggest treating those 15 and older with the protocol for older adolescents. Specifying an age at which one should always make a decision for or against conservative care can be problematic. However, based on the recommendations above, it would seem reasonable to provide conservative treatment for children younger than high school age and perhaps even those in the early years of high school.

Consider legal implications. Become familiar with state laws that require certain steps in managing sports concussion. The Web site http://www.sportsconcussions.org/laws.html²⁸ lists states with sports concussion statutes, as well as states with bills working their way through the legislative system. Currently, 29 states are listed with laws; 14 more and the District of Columbia have pending legislation.

TABLE 2
Stepwise protocol for return to play

Anticipate complications
Most patients with concussions who are managed appropriately do well. However, complications can occur. The most serious complication is second impact syndrome, which usually occurs when concussion is unrecognized or not well managed. While not well understood, this condition is thought to result from a sudden increase in intracranial pressure after a second head injury in an athlete already suffering from concussion symptoms. The injury typically results in serious long-term neurologic deficits, or even fatality.²⁹ Second impact syndrome has been documented as occurring in the same game after an initial injury, as well as in subsequent games.²⁹

A more common, but less serious, complication is postconcussion syndrome.³⁰ This is an ill-defined condition in which the patient suffers from concussive symptoms for an extended period of time, generally for more than 3 months.³⁰ As with acute concussion, the constellation of symptoms ranges from headache to cognitive impairment. In cases of postconcussion syndrome, it is appropriate to consult with neuropsychologists, psychiatrists, or neurologists for assistance with symptoms and associated mood disorders. Similar to acute concussion management, it is generally recommended that athletes not be cleared to resume play while struggling with the symptoms of postconcussion syndrome.³⁰

There have also been recent reports of late-life sequelae in those who have sustained multiple concussions. Depression and dementia have been suggested in surveys of retired NFL players.^31,32 There have also been studies both suggesting¹⁴ and questioning^33,34 whether multiple concussions result in long-term cognitive deficits. While the evidence available at this time is not firm, there seems to be an increasing belief that multiple concussions can affect long-term cognitive abilities. For these reasons, use caution in making return-to-play decisions for patients with multiple concussions or concussions with long-lasting symptoms.

CORRESPONDENCE Aaron M. Lear, MD, 224 West Exchange Street, Suite 440, Akron, OH 44302; aaron.lear@akrongeneral.org

CASE KD is an 18-year-old high school basketball player who was knocked backwards during a game, hitting her head on the floor. She had immediate head and neck pain but no loss of consciousness; she was transported by EMS to the local emergency department (ED) for further evaluation. Results of head and neck CT scans were normal, and she was discharged home. Four days later, KD’s parents brought her to our office because she was experiencing ongoing headache, phonophobia, nausea, light-headedness, poor balance, increased sleepiness, and irritability.

The Centers for Disease Control and Prevention estimate that approximately 300,000 sports concussions occur yearly in the United States,¹ and that 135,000 of these cases are treated in EDs.² These numbers have not gone unnoticed in the consumer press. Over the past 18 months, Sports Illustrated, Newsweek, and Time^3-5 have published stories on sports-related concussion, helping to raise public awareness of its risks.

Recommendations for practitioners have changed. In 1997, the American Academy of Neurology⁶ published one-size-fits-all guidelines on managing concussion, using levels of symptomatology and loss of consciousness to grade the severity of concussion from 1 to 3. These guidelines were similar to the Cantu and Colorado guidelines of the early 1990s.^7,8 Since then, however, the diagnostic criteria and expert opinion about treatment and return to physical activity have changed. Indeed, several medical organizations^9-12 now recommend a more individualized approach to evaluation and management, which we describe here.

It begins with a definition

While there is no single agreed-upon characterization of “concussion,” the 3rd International Conference on Concussion in Sport (ICCS)¹² provides this definition:

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

1. Concussion may be caused either by a direct blow to the head, face, or neck or a blow elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.
2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.… In a small percentage of cases, however, postconcussive symptoms may be prolonged.
5. No abnormality on standard structural neuroimaging studies is seen in concussion.

Office evaluation
Obtain a thorough history and conduct a neurologic evaluation and musculoskeletal examination of the head and neck.

Clues to expected length of recovery

A patient with a concussion may lose consciousness after the impact, or have a brief convulsion that is not a seizure.¹³ In the periodimmediately after the injury, the patient may exhibit a constellation of such signs and symptoms as headache, confusion, a dazed look, dilated pupils, amnesia, poor balance, nausea, or vomiting. These features typically resolve over time, but may persist for weeks or months. Anterograde or retrograde amnesia may also occur. TABLE 1 details a more complete list of concussion symptoms. If the patient is a child or young adult, it is useful to have a parent present at the office visit to describe the patient’s mood, sleep, appetite, and overall health after the injury.

Factors that may portend a longer recovery include a previous concussion, retrograde or anterograde amnesia, younger age, and female sex.¹⁴

Dire problems beyond concussion. Complaints or historical elements inconsistent with concussion that should be considered red flags include any focal neurologic complaints, vomiting or headache that worsens after a period of improvement, or obtundation or disorientation that has worsened since the injury. With such findings, consider more serious head injuries and arrange for a more complete immediate neurologic work-up.

CASE Our neurologic examination yielded normal results. However, our patient was unable to balance correctly on one leg. The cognitive exam revealed a deficit in short-term memory. We diagnosed a concussion, advised her to refrain from sports, and prescribed cognitive rest. A return to school for half days would be considered once her symptoms began to resolve.

TABLE 1
Signs and symptoms commonly associated with concussion

Options for the neurologic exam
With a simple concussion, expect a normal neurologic examination, with the possible exception of the ability to balance. Head imaging is not necessary in the setting of suspected concussion, because results of computed tomography (CT) and magnetic resonance imaging (MRI) will likely be normal.¹²

Balance testing can assist in the diagnosis of concussion and the monitoring of recovery from injury.^15-17 The Balance Error Scoring System (BESS)¹⁵ is a validated and simple test that can be done in the office. The test involves 3 consecutive stances: (a) normal stance with feet comfortably apart and hands on hips, (b) with feet aligned heel to toe with the dominant leg in front, and (c) standing on the nondominant leg with the dominant leg flexed 30 degrees at the hip. Have the patient repeat each version of the test for 20 seconds with eyes closed, on a stable and then unstable surface (eg, foam mat).

It’s recommended that another staff member be present to spot the patient in case of a fall. A link to a complete description of the test and scoring details is provided in the Web resources box.

Assess cognitive function. One tool for assessing cognitive function is the Sports Concussion Assessment Tool 2 (SCAT2).¹² SCAT2 includes newer, as yet unvalidated sections and several sections that have been independently studied and proven useful in diagnosing concussion. Validated sections are the Maddocks questions, used only at the time and place of injury¹⁸ ; the modified BESS¹⁵ ; and the Standardized Assessment of Concussion (SAC).¹⁹ The SCAT2 and the SAC (which may be used separately) include questions that assist in evaluating short-term memory and attention, and are useful in the physician’s office.

Do computer-based tools help? Another option for cognitive assessment is computer-based neuropsychologic testing developed specifically for use with suspected concussion. Any of these programs can be used in the office by a trained practitioner. Schools may also use the programs under the supervision of an athletic trainer or team physician. Available programs are ImPACT, developed by the University of Pittsburgh (http://impacttest.com); the Cognitive Stability Index (CSI), by HeadMinder (http://www.headminder.com/site/csi/home.html); and the Computerized Cognitive Assessment Tool (CCAT), by CogState/Axon Sports (http://www.axonsports.com). Multiple studies have shown such programs to be useful in diagnosing and monitoring recovery from sports concussion.^20-23

However, among sports medicine practitioners, there seems to be a consensus that computer-based neuropsychologic testing is most useful when a baseline score exists. Baseline testing is usually done preseason on athletes in a healthy state. If a baseline score is not available, a patient’s postinjury score is compared with normative data produced by the developer of the individual test.

Few, if any, outcome studies have been conducted to determine whether computer-basedneuropsychologic testing provides any meaningful improvement in the care of athletes who have suffered concussions. There is also concern that few studies by independent sources have replicated the data disseminated by developers of the tests.^24,25 The most recent guidelines by the 3rd ICCS recommend using neuropsychologic testing only as an aid to an overall medical evaluation, not as the sole determinant of recovery from concussion.¹² Numerous studies now underway may help clarify the role of neuropsychologic testing in concussion.

CASE By the time of our follow-up exam 7 days later (11 days from injury), KD had returned to school for half days, but her phonophobia and headaches worsened at school and she had difficulty focusing on academic tasks. Neurologic, balance, and cognitive exams were all normal. We advised her to gradually return to school full time while abstaining from sporting activity.

At 16 days’ follow-up (20 days from injury), KD had returned to school full time and said she felt more like herself, although she continued to have daily headaches and phonophobia. All exam results were normal. Sports were still off limits, and we told her to expect at least 7 more days of respite before any return to exercise would be allowed.

At 23 days’ follow-up (27 days from injury), KD’s symptoms had completely resolved, and all exam results were normal. We prescribed a stepwise return to athletic activity over the next 10 days and discussed this plan with the school’s athletic trainer, who would supervise her return to play.

Individualize management

The one-size-fits-all approach previously recommended⁶ is no longer the standard of care. In your initial encounter with the patient (and parents, as appropriate), explain the nature of the injury, expected course of recovery, and requirements for a return to play. Also discuss the possibility of postconcussive syndrome and the risk of rare sequelae such as second impact syndrome.

If the patient is symptomatic or exhibits examination findings consistent with concussion, recommend immediate cessation of sports activity.^9-12 With a school-aged athlete, if symptoms reported by the patient or parents are significant, consider prescribing cognitive rest, which can be provided through quiet accommodations at school or perhaps even time off from school or exams.^12,24 In the early period of recovery, increased cognitive or physical activity can cause symptoms to worsen. With improvement, the patient may return to school half time to lessen the chance of a significant return of symptoms. If half days are tolerated, the patient may transition to full days. Make sure the diagnosis and expectations for recovery are communicated to the appropriate school officials so that necessary accommodationscan be made. If symptoms after the initial office visit are mild, a one-week return to school is appropriate to evaluate the patient’s recovery.

Allowing a return to sports. Once the patient is asymptomatic, and physical and cognitive test results are normal, discuss a return-to-play protocol with the patient (and with parents and athletic trainer or coach, as appropriate). Multiple sources^10,11,26 now recommend a stepwise return to play, as detailed by the 3rd ICCS ( TABLE 2 ).¹² Increase or decrease the length of the protocol depending on the patient and the specifics of the case.

There is little science to guide the treatment of children with concussion. However, given that their brains are still developing, it’s prudent to be more conservative than with older adolescents or adults. Multiple sources apart from the 3rd ICCS agree with this recommendation. Several authors suggest more cognitive rest and a longer return-to-play protocol in all cases.^10,27 In fact, the ICCS committee additionally recommends observing a symptom-free waiting period for pediatric athletes before even starting a return-to-play protocol.

McCrory et al²⁶ suggest that children under age 15 be treated more conservatively than those 15 and older. They suggest treating those 15 and older with the protocol for older adolescents. Specifying an age at which one should always make a decision for or against conservative care can be problematic. However, based on the recommendations above, it would seem reasonable to provide conservative treatment for children younger than high school age and perhaps even those in the early years of high school.

Consider legal implications. Become familiar with state laws that require certain steps in managing sports concussion. The Web site http://www.sportsconcussions.org/laws.html²⁸ lists states with sports concussion statutes, as well as states with bills working their way through the legislative system. Currently, 29 states are listed with laws; 14 more and the District of Columbia have pending legislation.

TABLE 2
Stepwise protocol for return to play

Anticipate complications
Most patients with concussions who are managed appropriately do well. However, complications can occur. The most serious complication is second impact syndrome, which usually occurs when concussion is unrecognized or not well managed. While not well understood, this condition is thought to result from a sudden increase in intracranial pressure after a second head injury in an athlete already suffering from concussion symptoms. The injury typically results in serious long-term neurologic deficits, or even fatality.²⁹ Second impact syndrome has been documented as occurring in the same game after an initial injury, as well as in subsequent games.²⁹

A more common, but less serious, complication is postconcussion syndrome.³⁰ This is an ill-defined condition in which the patient suffers from concussive symptoms for an extended period of time, generally for more than 3 months.³⁰ As with acute concussion, the constellation of symptoms ranges from headache to cognitive impairment. In cases of postconcussion syndrome, it is appropriate to consult with neuropsychologists, psychiatrists, or neurologists for assistance with symptoms and associated mood disorders. Similar to acute concussion management, it is generally recommended that athletes not be cleared to resume play while struggling with the symptoms of postconcussion syndrome.³⁰

There have also been recent reports of late-life sequelae in those who have sustained multiple concussions. Depression and dementia have been suggested in surveys of retired NFL players.^31,32 There have also been studies both suggesting¹⁴ and questioning^33,34 whether multiple concussions result in long-term cognitive deficits. While the evidence available at this time is not firm, there seems to be an increasing belief that multiple concussions can affect long-term cognitive abilities. For these reasons, use caution in making return-to-play decisions for patients with multiple concussions or concussions with long-lasting symptoms.

CORRESPONDENCE Aaron M. Lear, MD, 224 West Exchange Street, Suite 440, Akron, OH 44302; aaron.lear@akrongeneral.org

Join Community Oncology Editor-in Chief Dr David H. Henry for an audio tour of the May issue, featuring "Erwinia asparaginase for acute lymphoblastic leukemia in children with hypersensitivity to E. coli-derived asparaginase" and "Creating a community-based, patient-centered cancer survivorship program."

Join Community Oncology Editor-in Chief Dr David H. Henry for an audio tour of the May issue, featuring "Erwinia asparaginase for acute lymphoblastic leukemia in children with hypersensitivity to E. coli-derived asparaginase" and "Creating a community-based, patient-centered cancer survivorship program."

Join Community Oncology Editor-in Chief Dr David H. Henry for an audio tour of the May issue, featuring "Erwinia asparaginase for acute lymphoblastic leukemia in children with hypersensitivity to E. coli-derived asparaginase" and "Creating a community-based, patient-centered cancer survivorship program."

SAN DIEGO – Statin therapy is not only safe for patients with cirrhosis, it may slow the progression of their liver disease to hepatic decompensation and help them live longer, a study has shown.

The findings, reported at the annual Digestive Disease Week, should help allay fears that decreased hepatic clearance of statins could lead to complications in patients with advanced liver disease, as was previously hypothesized, said lead investigator Dr. Sonal Kumar.

"In fact, it seems the opposite may be true," said Dr. Kumar of Brigham and Women’s Hospital, Boston, referring to the results of her retrospective study in which statin therapy in cirrhosis patients was associated with a decreased risk of hepatic decompensation, a delay in the time to decompensation, and reduced all-cause mortality, compared with cirrhosis patients not taking statins.

The investigators were aware that some clinicians either do not initiate statin therapy or discontinue statins in patients with advanced liver disease because of perceived safety concerns. Dr. Kumar and her colleagues sought to determine the actual effect of statin therapy on the risk of hepatic decomposition in cirrhosis.

They identified all patients with biopsy-proven cirrhosis who had taken statins for a minimum of 3 months for treatment of dyslipidemia. A control population of cirrhosis patients not on statins was matched 2:1 for age, gender, and Child-Pugh class from the Partners HealthCare System Research Patient Data Registry, which includes demographic and diagnostic information on patients treated at Massachusetts General Hospital and Brigham and Women’s Hospital.

The primary outcomes of the study were hepatic decompensation, defined as the development of ascites, jaundice (bilirubin greater than 2.5 mg/dL), hepatic encephalopathy, or variceal hemorrhage, and time to decompensation. Mortality was a secondary outcome, Dr. Kumar explained.

The investigators created a Cox proportional hazards model for decompensation to control for age, Child-Pugh class, diabetes, coronary artery disease, and hepatocellular carcinoma, and they used conditional logistic regression to assess mortality, she said.

Of 243 cirrhosis patients included in the analysis, 81 were statin users and 162 were matched controls. "In each group, approximately 70% of patients were Child-Pugh A and 30% were Child-Pugh B/C, and the MELD [Model for End-Stage Liver Disease] score, albumin, presence of varices, and beta-blocker use were similar between groups," Dr. Kumar noted. In the statin group, which was followed for a mean of 1,756 days, decompensation was reported in 31 patients (38.2%), compared with 80 patients (50.62%) in the control group.

The control patients were followed for a mean of 1,503 days, and on Cox analysis, "statin therapy was the only factor significantly associated with lower decompensation risk, with a hazard ratio of 0.46." Additionally, Kaplan-Meier curves showed a significantly longer time to decompensation in patients receiving statin therapy, she said. In subgroup analyses, significantly longer time to decompensation was observed in Child-Pugh A and Child-Pugh B/C patients.

Overall mortality was significantly lower in the statin group, at 37.0%, than in the control group, at 50.6%, said Dr. Kumar. Statin use remained significantly associated with decreased mortality in multivariate analysis, with an odds ratio of 0.36, while coronary artery disease and hepatocellular carcinoma were associated with increased mortality, with respective odds ratios of 3.6 and 4.9.

There were no statistically significant differences in cause of death between the two groups, "however it is important to note that cause of death was not documented for approximately one-third of the study patients, so we cannot make definitive statements about whether patients on statins were less likely to die of liver-related or cardiovascular causes than patients in the control group," said Dr. Kumar.

The apparent hepatoprotective effect of statin therapy in cirrhosis patients may be a function of previously observed hemodynamic and molecular effects of statins, Dr. Kumar hypothesized. Sinusoidal endothelial dysfunction with decreased nitric oxide production contributes to increased hepatic resistance in cirrhosis, she explained. Just as statins improve endothelial dysfunction in the peripheral vasculature, they may also improve the vascular disturbances that contribute to portal hypertension in cirrhosis by selectively increasing nitric oxide availability in the liver, thus reducing pressures, she said.

The retrospective design of the study limits the conclusions that can be taken from it. Specifically, "we can’t say that all patients with liver disease should be prescribed statins," Dr. Kumar said. "What we can say is that statin therapy is safe in this population, it may be beneficial for its effects on the liver as well as the cardiovascular system, and clinicians should not hesitate to prescribe it for appropriate cardiovascular indications in cirrhosis patients." The findings also indicate that prospective studies are warranted to clarify the role of statins in advanced liver disease, she stressed.

Dr. Kumar disclosed no relevant financial conflicts of interest.

SAN DIEGO – Statin therapy is not only safe for patients with cirrhosis, it may slow the progression of their liver disease to hepatic decompensation and help them live longer, a study has shown.

The findings, reported at the annual Digestive Disease Week, should help allay fears that decreased hepatic clearance of statins could lead to complications in patients with advanced liver disease, as was previously hypothesized, said lead investigator Dr. Sonal Kumar.

"In fact, it seems the opposite may be true," said Dr. Kumar of Brigham and Women’s Hospital, Boston, referring to the results of her retrospective study in which statin therapy in cirrhosis patients was associated with a decreased risk of hepatic decompensation, a delay in the time to decompensation, and reduced all-cause mortality, compared with cirrhosis patients not taking statins.

The investigators were aware that some clinicians either do not initiate statin therapy or discontinue statins in patients with advanced liver disease because of perceived safety concerns. Dr. Kumar and her colleagues sought to determine the actual effect of statin therapy on the risk of hepatic decomposition in cirrhosis.

They identified all patients with biopsy-proven cirrhosis who had taken statins for a minimum of 3 months for treatment of dyslipidemia. A control population of cirrhosis patients not on statins was matched 2:1 for age, gender, and Child-Pugh class from the Partners HealthCare System Research Patient Data Registry, which includes demographic and diagnostic information on patients treated at Massachusetts General Hospital and Brigham and Women’s Hospital.

The primary outcomes of the study were hepatic decompensation, defined as the development of ascites, jaundice (bilirubin greater than 2.5 mg/dL), hepatic encephalopathy, or variceal hemorrhage, and time to decompensation. Mortality was a secondary outcome, Dr. Kumar explained.

The investigators created a Cox proportional hazards model for decompensation to control for age, Child-Pugh class, diabetes, coronary artery disease, and hepatocellular carcinoma, and they used conditional logistic regression to assess mortality, she said.

Of 243 cirrhosis patients included in the analysis, 81 were statin users and 162 were matched controls. "In each group, approximately 70% of patients were Child-Pugh A and 30% were Child-Pugh B/C, and the MELD [Model for End-Stage Liver Disease] score, albumin, presence of varices, and beta-blocker use were similar between groups," Dr. Kumar noted. In the statin group, which was followed for a mean of 1,756 days, decompensation was reported in 31 patients (38.2%), compared with 80 patients (50.62%) in the control group.

The control patients were followed for a mean of 1,503 days, and on Cox analysis, "statin therapy was the only factor significantly associated with lower decompensation risk, with a hazard ratio of 0.46." Additionally, Kaplan-Meier curves showed a significantly longer time to decompensation in patients receiving statin therapy, she said. In subgroup analyses, significantly longer time to decompensation was observed in Child-Pugh A and Child-Pugh B/C patients.

Overall mortality was significantly lower in the statin group, at 37.0%, than in the control group, at 50.6%, said Dr. Kumar. Statin use remained significantly associated with decreased mortality in multivariate analysis, with an odds ratio of 0.36, while coronary artery disease and hepatocellular carcinoma were associated with increased mortality, with respective odds ratios of 3.6 and 4.9.

There were no statistically significant differences in cause of death between the two groups, "however it is important to note that cause of death was not documented for approximately one-third of the study patients, so we cannot make definitive statements about whether patients on statins were less likely to die of liver-related or cardiovascular causes than patients in the control group," said Dr. Kumar.

The apparent hepatoprotective effect of statin therapy in cirrhosis patients may be a function of previously observed hemodynamic and molecular effects of statins, Dr. Kumar hypothesized. Sinusoidal endothelial dysfunction with decreased nitric oxide production contributes to increased hepatic resistance in cirrhosis, she explained. Just as statins improve endothelial dysfunction in the peripheral vasculature, they may also improve the vascular disturbances that contribute to portal hypertension in cirrhosis by selectively increasing nitric oxide availability in the liver, thus reducing pressures, she said.

The retrospective design of the study limits the conclusions that can be taken from it. Specifically, "we can’t say that all patients with liver disease should be prescribed statins," Dr. Kumar said. "What we can say is that statin therapy is safe in this population, it may be beneficial for its effects on the liver as well as the cardiovascular system, and clinicians should not hesitate to prescribe it for appropriate cardiovascular indications in cirrhosis patients." The findings also indicate that prospective studies are warranted to clarify the role of statins in advanced liver disease, she stressed.

Dr. Kumar disclosed no relevant financial conflicts of interest.

SAN DIEGO – Statin therapy is not only safe for patients with cirrhosis, it may slow the progression of their liver disease to hepatic decompensation and help them live longer, a study has shown.

The findings, reported at the annual Digestive Disease Week, should help allay fears that decreased hepatic clearance of statins could lead to complications in patients with advanced liver disease, as was previously hypothesized, said lead investigator Dr. Sonal Kumar.

"In fact, it seems the opposite may be true," said Dr. Kumar of Brigham and Women’s Hospital, Boston, referring to the results of her retrospective study in which statin therapy in cirrhosis patients was associated with a decreased risk of hepatic decompensation, a delay in the time to decompensation, and reduced all-cause mortality, compared with cirrhosis patients not taking statins.

The investigators were aware that some clinicians either do not initiate statin therapy or discontinue statins in patients with advanced liver disease because of perceived safety concerns. Dr. Kumar and her colleagues sought to determine the actual effect of statin therapy on the risk of hepatic decomposition in cirrhosis.

They identified all patients with biopsy-proven cirrhosis who had taken statins for a minimum of 3 months for treatment of dyslipidemia. A control population of cirrhosis patients not on statins was matched 2:1 for age, gender, and Child-Pugh class from the Partners HealthCare System Research Patient Data Registry, which includes demographic and diagnostic information on patients treated at Massachusetts General Hospital and Brigham and Women’s Hospital.

The primary outcomes of the study were hepatic decompensation, defined as the development of ascites, jaundice (bilirubin greater than 2.5 mg/dL), hepatic encephalopathy, or variceal hemorrhage, and time to decompensation. Mortality was a secondary outcome, Dr. Kumar explained.

The investigators created a Cox proportional hazards model for decompensation to control for age, Child-Pugh class, diabetes, coronary artery disease, and hepatocellular carcinoma, and they used conditional logistic regression to assess mortality, she said.

Of 243 cirrhosis patients included in the analysis, 81 were statin users and 162 were matched controls. "In each group, approximately 70% of patients were Child-Pugh A and 30% were Child-Pugh B/C, and the MELD [Model for End-Stage Liver Disease] score, albumin, presence of varices, and beta-blocker use were similar between groups," Dr. Kumar noted. In the statin group, which was followed for a mean of 1,756 days, decompensation was reported in 31 patients (38.2%), compared with 80 patients (50.62%) in the control group.

The control patients were followed for a mean of 1,503 days, and on Cox analysis, "statin therapy was the only factor significantly associated with lower decompensation risk, with a hazard ratio of 0.46." Additionally, Kaplan-Meier curves showed a significantly longer time to decompensation in patients receiving statin therapy, she said. In subgroup analyses, significantly longer time to decompensation was observed in Child-Pugh A and Child-Pugh B/C patients.

Overall mortality was significantly lower in the statin group, at 37.0%, than in the control group, at 50.6%, said Dr. Kumar. Statin use remained significantly associated with decreased mortality in multivariate analysis, with an odds ratio of 0.36, while coronary artery disease and hepatocellular carcinoma were associated with increased mortality, with respective odds ratios of 3.6 and 4.9.

There were no statistically significant differences in cause of death between the two groups, "however it is important to note that cause of death was not documented for approximately one-third of the study patients, so we cannot make definitive statements about whether patients on statins were less likely to die of liver-related or cardiovascular causes than patients in the control group," said Dr. Kumar.

The apparent hepatoprotective effect of statin therapy in cirrhosis patients may be a function of previously observed hemodynamic and molecular effects of statins, Dr. Kumar hypothesized. Sinusoidal endothelial dysfunction with decreased nitric oxide production contributes to increased hepatic resistance in cirrhosis, she explained. Just as statins improve endothelial dysfunction in the peripheral vasculature, they may also improve the vascular disturbances that contribute to portal hypertension in cirrhosis by selectively increasing nitric oxide availability in the liver, thus reducing pressures, she said.

The retrospective design of the study limits the conclusions that can be taken from it. Specifically, "we can’t say that all patients with liver disease should be prescribed statins," Dr. Kumar said. "What we can say is that statin therapy is safe in this population, it may be beneficial for its effects on the liver as well as the cardiovascular system, and clinicians should not hesitate to prescribe it for appropriate cardiovascular indications in cirrhosis patients." The findings also indicate that prospective studies are warranted to clarify the role of statins in advanced liver disease, she stressed.

Dr. Kumar disclosed no relevant financial conflicts of interest.

Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.

Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)

The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.

Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.

The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.

"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.

Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."

Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.

Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)

The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.

Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.

The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.

"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.

Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."

Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.

Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)

The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.

Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.

The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.

"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.

Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Nuance is not a commonly cited virtue of American discourse, as you well know if you’ve watched reality television of late, or, for that matter, any recent political debate. And that’s what makes me nervous about the recent decision by the U.S. Preventive Services Task Force (USPSTF) to recommend against routine screening for prostate cancer using prostate-specific antigen levels.

I’m neither a physician nor a biostatistician; rest assured, I won’t argue the science here. But I do worry about the psychological implications of a Grade D recommendation (considered "at least fair" evidence) that screening does more harm to men than good.

The task force’s report, published online May 21 in Annals of Internal Medicine (annals.org), makes some excellent points about the need for more reliable screening measures and real quality-of-life costs associated with false positive PSA results and aggressive treatment of what is, in many cases but not all, a slow-growing disease.

Its call for better research deserves special mention. Prostate cancer, in my opinion, has long been a neglected step-brother in cancer research funding, despite the fact that it kills more American men than does any other cancer, except lung cancer. Just because I was curious, I compared this week the number of hits on PubMed for the search terms "prostate cancer" and "screening" versus "breast cancer" and "screening." To be sure, it’s a crude measure of relative attention, but the disparate tally was striking: 55,758 to 129,451.

The task force report also offers physicians a brief, handy guide on how to talk with patients about the latest findings, including three generic "patient scenarios." I think that’s fine, as far as it goes, but what the guide fails to capture is the nuance of American attitudes toward screening, toward medicine in general (and especially large, impersonal task forces known by their acronyms), toward preventive health care, and toward prostate cancer itself.

It will be those attitudes physicians will encounter once patients, their partners, and families hear the recommendations in a 12-second sound bite, while channel-flipping on their way to an update on the Kardashian family.

There will be patients, I suspect, who will completely disregard the recommendations; a few, perhaps, because they’ve read of the scientific objections of many dubious urologists.

More, undoubtedly, will suspect a conspiracy between medicine and insurance companies bent on depriving patients of life-saving treatment in the interest of saving a few bucks.

Others won’t hear the word "screening," and will refuse to see the doctor when they suffer dysuria, hematuria, or pain, telling their annoying wives they heard on the news there’s no point in getting a test for that.

Some patients will insist on the PSA every year beginning in their 30s and will press for a biopsy if their numbers wobble a bit from year to year – a strategy they would have pursued regardless of recommendations to the contrary today, tomorrow, or in 10 years.

Unfortunately, black men will hear the news and may resist getting a PSA even in the face of a family history of prostate cancer and the deplorable under-representation of African American men in the studies on which the recommendation was made. (Just 4% of men enrolled in the U.S. Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (N. Engl. J. Med. 2009;360:1310-9) were non-Hispanic blacks; the ethnicity of those in the other trials wasn’t even reported, despite the fact that black men die of prostate cancer at a rate double that of white men.)

More than a few individuals will consider the recommendations against the backdrop of evidence that scientists call "anecdote" and regular folks call "Uncle Bill." If he died at 74, ravaged by bone pain, there’s a good bet that the nephews in the family will still be urging the doctor to check the box on the lab slip marked "PSA." If, on the other hand, Albert down the street had prostate surgery, and never regained the ability to urinate normally (or have an erection, it might be whispered), the new recommendations might be welcomed just fine.

My point is, the press conferences and headlines that trumpet controversial new cancer guidelines come and go, the acronym-laced logos repacked into boxes and the microphone cords looped into their cases. But the aftershocks ripple for months, as physicians in their small offices try to weigh in with their own beliefs and experiences, as they manage the fear, denial, and doubt that the patients bring in on their own.

Cost matters. Risks and benefits must be given appropriate weight. Medicine is, today as always, a journey negotiated in the partial fog of unknowns.

But when a recommendation is drastic and not universally agreed-upon by the medical community, my wish would be for a bit more nuance in the telling, to make more sense of it to us all.

Nuance is not a commonly cited virtue of American discourse, as you well know if you’ve watched reality television of late, or, for that matter, any recent political debate. And that’s what makes me nervous about the recent decision by the U.S. Preventive Services Task Force (USPSTF) to recommend against routine screening for prostate cancer using prostate-specific antigen levels.

I’m neither a physician nor a biostatistician; rest assured, I won’t argue the science here. But I do worry about the psychological implications of a Grade D recommendation (considered "at least fair" evidence) that screening does more harm to men than good.

The task force’s report, published online May 21 in Annals of Internal Medicine (annals.org), makes some excellent points about the need for more reliable screening measures and real quality-of-life costs associated with false positive PSA results and aggressive treatment of what is, in many cases but not all, a slow-growing disease.

Its call for better research deserves special mention. Prostate cancer, in my opinion, has long been a neglected step-brother in cancer research funding, despite the fact that it kills more American men than does any other cancer, except lung cancer. Just because I was curious, I compared this week the number of hits on PubMed for the search terms "prostate cancer" and "screening" versus "breast cancer" and "screening." To be sure, it’s a crude measure of relative attention, but the disparate tally was striking: 55,758 to 129,451.

The task force report also offers physicians a brief, handy guide on how to talk with patients about the latest findings, including three generic "patient scenarios." I think that’s fine, as far as it goes, but what the guide fails to capture is the nuance of American attitudes toward screening, toward medicine in general (and especially large, impersonal task forces known by their acronyms), toward preventive health care, and toward prostate cancer itself.

It will be those attitudes physicians will encounter once patients, their partners, and families hear the recommendations in a 12-second sound bite, while channel-flipping on their way to an update on the Kardashian family.

There will be patients, I suspect, who will completely disregard the recommendations; a few, perhaps, because they’ve read of the scientific objections of many dubious urologists.

More, undoubtedly, will suspect a conspiracy between medicine and insurance companies bent on depriving patients of life-saving treatment in the interest of saving a few bucks.

Others won’t hear the word "screening," and will refuse to see the doctor when they suffer dysuria, hematuria, or pain, telling their annoying wives they heard on the news there’s no point in getting a test for that.

Some patients will insist on the PSA every year beginning in their 30s and will press for a biopsy if their numbers wobble a bit from year to year – a strategy they would have pursued regardless of recommendations to the contrary today, tomorrow, or in 10 years.

Unfortunately, black men will hear the news and may resist getting a PSA even in the face of a family history of prostate cancer and the deplorable under-representation of African American men in the studies on which the recommendation was made. (Just 4% of men enrolled in the U.S. Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (N. Engl. J. Med. 2009;360:1310-9) were non-Hispanic blacks; the ethnicity of those in the other trials wasn’t even reported, despite the fact that black men die of prostate cancer at a rate double that of white men.)

More than a few individuals will consider the recommendations against the backdrop of evidence that scientists call "anecdote" and regular folks call "Uncle Bill." If he died at 74, ravaged by bone pain, there’s a good bet that the nephews in the family will still be urging the doctor to check the box on the lab slip marked "PSA." If, on the other hand, Albert down the street had prostate surgery, and never regained the ability to urinate normally (or have an erection, it might be whispered), the new recommendations might be welcomed just fine.

My point is, the press conferences and headlines that trumpet controversial new cancer guidelines come and go, the acronym-laced logos repacked into boxes and the microphone cords looped into their cases. But the aftershocks ripple for months, as physicians in their small offices try to weigh in with their own beliefs and experiences, as they manage the fear, denial, and doubt that the patients bring in on their own.

Cost matters. Risks and benefits must be given appropriate weight. Medicine is, today as always, a journey negotiated in the partial fog of unknowns.

But when a recommendation is drastic and not universally agreed-upon by the medical community, my wish would be for a bit more nuance in the telling, to make more sense of it to us all.

Nuance is not a commonly cited virtue of American discourse, as you well know if you’ve watched reality television of late, or, for that matter, any recent political debate. And that’s what makes me nervous about the recent decision by the U.S. Preventive Services Task Force (USPSTF) to recommend against routine screening for prostate cancer using prostate-specific antigen levels.

I’m neither a physician nor a biostatistician; rest assured, I won’t argue the science here. But I do worry about the psychological implications of a Grade D recommendation (considered "at least fair" evidence) that screening does more harm to men than good.

The task force’s report, published online May 21 in Annals of Internal Medicine (annals.org), makes some excellent points about the need for more reliable screening measures and real quality-of-life costs associated with false positive PSA results and aggressive treatment of what is, in many cases but not all, a slow-growing disease.

Its call for better research deserves special mention. Prostate cancer, in my opinion, has long been a neglected step-brother in cancer research funding, despite the fact that it kills more American men than does any other cancer, except lung cancer. Just because I was curious, I compared this week the number of hits on PubMed for the search terms "prostate cancer" and "screening" versus "breast cancer" and "screening." To be sure, it’s a crude measure of relative attention, but the disparate tally was striking: 55,758 to 129,451.

The task force report also offers physicians a brief, handy guide on how to talk with patients about the latest findings, including three generic "patient scenarios." I think that’s fine, as far as it goes, but what the guide fails to capture is the nuance of American attitudes toward screening, toward medicine in general (and especially large, impersonal task forces known by their acronyms), toward preventive health care, and toward prostate cancer itself.

It will be those attitudes physicians will encounter once patients, their partners, and families hear the recommendations in a 12-second sound bite, while channel-flipping on their way to an update on the Kardashian family.

There will be patients, I suspect, who will completely disregard the recommendations; a few, perhaps, because they’ve read of the scientific objections of many dubious urologists.

More, undoubtedly, will suspect a conspiracy between medicine and insurance companies bent on depriving patients of life-saving treatment in the interest of saving a few bucks.

Others won’t hear the word "screening," and will refuse to see the doctor when they suffer dysuria, hematuria, or pain, telling their annoying wives they heard on the news there’s no point in getting a test for that.

Some patients will insist on the PSA every year beginning in their 30s and will press for a biopsy if their numbers wobble a bit from year to year – a strategy they would have pursued regardless of recommendations to the contrary today, tomorrow, or in 10 years.

Unfortunately, black men will hear the news and may resist getting a PSA even in the face of a family history of prostate cancer and the deplorable under-representation of African American men in the studies on which the recommendation was made. (Just 4% of men enrolled in the U.S. Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (N. Engl. J. Med. 2009;360:1310-9) were non-Hispanic blacks; the ethnicity of those in the other trials wasn’t even reported, despite the fact that black men die of prostate cancer at a rate double that of white men.)

More than a few individuals will consider the recommendations against the backdrop of evidence that scientists call "anecdote" and regular folks call "Uncle Bill." If he died at 74, ravaged by bone pain, there’s a good bet that the nephews in the family will still be urging the doctor to check the box on the lab slip marked "PSA." If, on the other hand, Albert down the street had prostate surgery, and never regained the ability to urinate normally (or have an erection, it might be whispered), the new recommendations might be welcomed just fine.

My point is, the press conferences and headlines that trumpet controversial new cancer guidelines come and go, the acronym-laced logos repacked into boxes and the microphone cords looped into their cases. But the aftershocks ripple for months, as physicians in their small offices try to weigh in with their own beliefs and experiences, as they manage the fear, denial, and doubt that the patients bring in on their own.

Cost matters. Risks and benefits must be given appropriate weight. Medicine is, today as always, a journey negotiated in the partial fog of unknowns.

But when a recommendation is drastic and not universally agreed-upon by the medical community, my wish would be for a bit more nuance in the telling, to make more sense of it to us all.

FT. LAUDERDALE, FLA. – Sex and race appear to play a role in outcomes following congenital heart surgery in children and adolescents, according to a new analysis of data from almost 21,000 patients.

Black patients had significantly greater rates of mortality and complications and a significantly longer length of postoperative stay than other races, while female patients had a significantly shorter length of stay than males, Dr. Daniel J. DiBardino reported at the annual meeting of the Society of Thoracic Surgeons.

"The analysis of demographic and clinical data from nearly 21,000 patients in the congenital heart surgery database revealed important associations between gender, race, and outcome," said Dr. DiBardino, who is a cardiac surgeon at the Blair E. Batson Children’s Hospital in Jackson, Miss.

Dr. DiBardino’s study was chosen as a 2011 Richard E. Clark Paper by the Society of Thoracic Surgeons.

The researchers used data from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). Patients were included in the analysis if they were less than 18 years of age and had undergone cardiac surgery between 2007 and 2009.

Exclusion criteria included centers with more than 15% of data missing for key variables and centers with very small samples (less than five cases).

Data collection included demographics (age, sex, weight, and race) and preoperative data (noncardiac/genetic abnormalities and STS-defined risk factors). Race was classified as white, black, Hispanic, and other.

Operations were classified by STAT Mortality category, which is "a complexity stratification tool based on empiric data from 80,000 cases in STS and EACTS (European Association for Cardio-Thoracic Surgery) databases," said Dr. DiBardino.

The researchers looked at hospital mortality, postoperative length of stay, and complications. Multivariable analyses included dichotomous variables (mortality, complications) and a continuous variable (postoperative length of stay). Models were adjusted for age, weight, noncardiac/genetic abnormalities, any other STS preoperative risk factor, and STAT Mortality category.

In all, 20,399 patients were included from 49 centers. Of these, 54% were male. In terms of race, 55% were white, 17% were black, 16% were Hispanic, and 12% were other.

Based on unadjusted outcomes, there were no differences between the sexes for in-hospital mortality or complications. However, females had significantly shorter postoperative stays. In terms of race, white patients had significantly lower mortality, shorter length of stay, and fewer complications than any of the other racial groups.

In the adjusted multivariate analysis, there was no difference for mortality between the sexes. However, black patients had a significantly greater mortality risk with an odds ratio of 1.67.

Females did have a significantly shorter mean length of stay – 0.8 fewer days. In terms of race, black patients had a significantly longer mean length of stay by 2.4 hospital days, compared with white patients. Hispanic patients also had a significantly longer mean length of stay by almost 1 hospital day.

There was no difference between the sexes in terms of the occurrence of complications. In terms of race, "black patients experienced significantly more complications than other races with an odds ratio of 1.15," according to Dr. DiBardino.

The study is unique with the respect to the use of multivariable models. The researchers measured the association of sex and race with outcomes within each center and then combined the results, in order to mitigate the potential center effects.

"Our results cannot be explained by the possibility that patients of certain races might be disproportionately treated at centers with poorer outcomes in general."

The evaluation of complex relationships between clinical variables and socioeconomic and other factors affecting health care remains a significant challenge.

Since some pertinent socioeconomic data are not collected in the STS-CHSD, an analysis of a linked data set, which capitalizes on the strengths of both the CHSD and those of an administrative claims data set may be the next logical step, said Dr. DiBardino.

Dr. DiBardino and his coinvestigators reported that they have no relevant disclosures.

FT. LAUDERDALE, FLA. – Sex and race appear to play a role in outcomes following congenital heart surgery in children and adolescents, according to a new analysis of data from almost 21,000 patients.

Black patients had significantly greater rates of mortality and complications and a significantly longer length of postoperative stay than other races, while female patients had a significantly shorter length of stay than males, Dr. Daniel J. DiBardino reported at the annual meeting of the Society of Thoracic Surgeons.

"The analysis of demographic and clinical data from nearly 21,000 patients in the congenital heart surgery database revealed important associations between gender, race, and outcome," said Dr. DiBardino, who is a cardiac surgeon at the Blair E. Batson Children’s Hospital in Jackson, Miss.

Dr. DiBardino’s study was chosen as a 2011 Richard E. Clark Paper by the Society of Thoracic Surgeons.

The researchers used data from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). Patients were included in the analysis if they were less than 18 years of age and had undergone cardiac surgery between 2007 and 2009.

Exclusion criteria included centers with more than 15% of data missing for key variables and centers with very small samples (less than five cases).

Data collection included demographics (age, sex, weight, and race) and preoperative data (noncardiac/genetic abnormalities and STS-defined risk factors). Race was classified as white, black, Hispanic, and other.

Operations were classified by STAT Mortality category, which is "a complexity stratification tool based on empiric data from 80,000 cases in STS and EACTS (European Association for Cardio-Thoracic Surgery) databases," said Dr. DiBardino.

The researchers looked at hospital mortality, postoperative length of stay, and complications. Multivariable analyses included dichotomous variables (mortality, complications) and a continuous variable (postoperative length of stay). Models were adjusted for age, weight, noncardiac/genetic abnormalities, any other STS preoperative risk factor, and STAT Mortality category.

In all, 20,399 patients were included from 49 centers. Of these, 54% were male. In terms of race, 55% were white, 17% were black, 16% were Hispanic, and 12% were other.

Based on unadjusted outcomes, there were no differences between the sexes for in-hospital mortality or complications. However, females had significantly shorter postoperative stays. In terms of race, white patients had significantly lower mortality, shorter length of stay, and fewer complications than any of the other racial groups.

In the adjusted multivariate analysis, there was no difference for mortality between the sexes. However, black patients had a significantly greater mortality risk with an odds ratio of 1.67.

Females did have a significantly shorter mean length of stay – 0.8 fewer days. In terms of race, black patients had a significantly longer mean length of stay by 2.4 hospital days, compared with white patients. Hispanic patients also had a significantly longer mean length of stay by almost 1 hospital day.

There was no difference between the sexes in terms of the occurrence of complications. In terms of race, "black patients experienced significantly more complications than other races with an odds ratio of 1.15," according to Dr. DiBardino.

The study is unique with the respect to the use of multivariable models. The researchers measured the association of sex and race with outcomes within each center and then combined the results, in order to mitigate the potential center effects.

"Our results cannot be explained by the possibility that patients of certain races might be disproportionately treated at centers with poorer outcomes in general."

The evaluation of complex relationships between clinical variables and socioeconomic and other factors affecting health care remains a significant challenge.

Since some pertinent socioeconomic data are not collected in the STS-CHSD, an analysis of a linked data set, which capitalizes on the strengths of both the CHSD and those of an administrative claims data set may be the next logical step, said Dr. DiBardino.

Dr. DiBardino and his coinvestigators reported that they have no relevant disclosures.

FT. LAUDERDALE, FLA. – Sex and race appear to play a role in outcomes following congenital heart surgery in children and adolescents, according to a new analysis of data from almost 21,000 patients.

Black patients had significantly greater rates of mortality and complications and a significantly longer length of postoperative stay than other races, while female patients had a significantly shorter length of stay than males, Dr. Daniel J. DiBardino reported at the annual meeting of the Society of Thoracic Surgeons.

"The analysis of demographic and clinical data from nearly 21,000 patients in the congenital heart surgery database revealed important associations between gender, race, and outcome," said Dr. DiBardino, who is a cardiac surgeon at the Blair E. Batson Children’s Hospital in Jackson, Miss.

Dr. DiBardino’s study was chosen as a 2011 Richard E. Clark Paper by the Society of Thoracic Surgeons.

The researchers used data from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). Patients were included in the analysis if they were less than 18 years of age and had undergone cardiac surgery between 2007 and 2009.

Exclusion criteria included centers with more than 15% of data missing for key variables and centers with very small samples (less than five cases).

Data collection included demographics (age, sex, weight, and race) and preoperative data (noncardiac/genetic abnormalities and STS-defined risk factors). Race was classified as white, black, Hispanic, and other.

Operations were classified by STAT Mortality category, which is "a complexity stratification tool based on empiric data from 80,000 cases in STS and EACTS (European Association for Cardio-Thoracic Surgery) databases," said Dr. DiBardino.

The researchers looked at hospital mortality, postoperative length of stay, and complications. Multivariable analyses included dichotomous variables (mortality, complications) and a continuous variable (postoperative length of stay). Models were adjusted for age, weight, noncardiac/genetic abnormalities, any other STS preoperative risk factor, and STAT Mortality category.

In all, 20,399 patients were included from 49 centers. Of these, 54% were male. In terms of race, 55% were white, 17% were black, 16% were Hispanic, and 12% were other.

Based on unadjusted outcomes, there were no differences between the sexes for in-hospital mortality or complications. However, females had significantly shorter postoperative stays. In terms of race, white patients had significantly lower mortality, shorter length of stay, and fewer complications than any of the other racial groups.

In the adjusted multivariate analysis, there was no difference for mortality between the sexes. However, black patients had a significantly greater mortality risk with an odds ratio of 1.67.

Females did have a significantly shorter mean length of stay – 0.8 fewer days. In terms of race, black patients had a significantly longer mean length of stay by 2.4 hospital days, compared with white patients. Hispanic patients also had a significantly longer mean length of stay by almost 1 hospital day.

There was no difference between the sexes in terms of the occurrence of complications. In terms of race, "black patients experienced significantly more complications than other races with an odds ratio of 1.15," according to Dr. DiBardino.

The study is unique with the respect to the use of multivariable models. The researchers measured the association of sex and race with outcomes within each center and then combined the results, in order to mitigate the potential center effects.

"Our results cannot be explained by the possibility that patients of certain races might be disproportionately treated at centers with poorer outcomes in general."

The evaluation of complex relationships between clinical variables and socioeconomic and other factors affecting health care remains a significant challenge.

Since some pertinent socioeconomic data are not collected in the STS-CHSD, an analysis of a linked data set, which capitalizes on the strengths of both the CHSD and those of an administrative claims data set may be the next logical step, said Dr. DiBardino.

Dr. DiBardino and his coinvestigators reported that they have no relevant disclosures.

FT. LAUDERDALE, FLA. – Sex and race appear to play a role in outcomes following congenital heart surgery in children and adolescents, according to a new analysis of data from almost 21,000 patients.

Black patients had significantly greater rates of mortality and complications and a significantly longer length of postoperative stay than other races, while female patients had a significantly shorter length of stay than males, Dr. Daniel J. DiBardino reported at the annual meeting of the Society of Thoracic Surgeons.

"The analysis of demographic and clinical data from nearly 21,000 patients in the congenital heart surgery database revealed important associations between gender, race, and outcome," said Dr. DiBardino, who is a cardiac surgeon at the Blair E. Batson Children’s Hospital in Jackson, Miss.

Dr. DiBardino’s study was chosen as a 2011 Richard E. Clark Paper by the Society of Thoracic Surgeons.

The researchers used data from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). Patients were included in the analysis if they were less than 18 years of age and had undergone cardiac surgery between 2007 and 2009.

Exclusion criteria included centers with more than 15% of data missing for key variables and centers with very small samples (less than five cases).

Data collection included demographics (age, sex, weight, and race) and preoperative data (noncardiac/genetic abnormalities and STS-defined risk factors). Race was classified as white, black, Hispanic, and other.

Operations were classified by STAT Mortality category, which is "a complexity stratification tool based on empiric data from 80,000 cases in STS and EACTS (European Association for Cardio-Thoracic Surgery) databases," said Dr. DiBardino.

The researchers looked at hospital mortality, postoperative length of stay, and complications. Multivariable analyses included dichotomous variables (mortality, complications) and a continuous variable (postoperative length of stay). Models were adjusted for age, weight, noncardiac/genetic abnormalities, any other STS preoperative risk factor, and STAT Mortality category.

In all, 20,399 patients were included from 49 centers. Of these, 54% were male. In terms of race, 55% were white, 17% were black, 16% were Hispanic, and 12% were other.

Based on unadjusted outcomes, there were no differences between the sexes for in-hospital mortality or complications. However, females had significantly shorter postoperative stays. In terms of race, white patients had significantly lower mortality, shorter length of stay, and fewer complications than any of the other racial groups.

In the adjusted multivariate analysis, there was no difference for mortality between the sexes. However, black patients had a significantly greater mortality risk with an odds ratio of 1.67.

Females did have a significantly shorter mean length of stay – 0.8 fewer days. In terms of race, black patients had a significantly longer mean length of stay by 2.4 hospital days, compared with white patients. Hispanic patients also had a significantly longer mean length of stay by almost 1 hospital day.

There was no difference between the sexes in terms of the occurrence of complications. In terms of race, "black patients experienced significantly more complications than other races with an odds ratio of 1.15," according to Dr. DiBardino.

The study is unique with the respect to the use of multivariable models. The researchers measured the association of sex and race with outcomes within each center and then combined the results, in order to mitigate the potential center effects.

"Our results cannot be explained by the possibility that patients of certain races might be disproportionately treated at centers with poorer outcomes in general."

The evaluation of complex relationships between clinical variables and socioeconomic and other factors affecting health care remains a significant challenge.

Since some pertinent socioeconomic data are not collected in the STS-CHSD, an analysis of a linked data set, which capitalizes on the strengths of both the CHSD and those of an administrative claims data set may be the next logical step, said Dr. DiBardino.

Dr. DiBardino and his coinvestigators reported that they have no relevant disclosures.

FT. LAUDERDALE, FLA. – Sex and race appear to play a role in outcomes following congenital heart surgery in children and adolescents, according to a new analysis of data from almost 21,000 patients.

Black patients had significantly greater rates of mortality and complications and a significantly longer length of postoperative stay than other races, while female patients had a significantly shorter length of stay than males, Dr. Daniel J. DiBardino reported at the annual meeting of the Society of Thoracic Surgeons.

"The analysis of demographic and clinical data from nearly 21,000 patients in the congenital heart surgery database revealed important associations between gender, race, and outcome," said Dr. DiBardino, who is a cardiac surgeon at the Blair E. Batson Children’s Hospital in Jackson, Miss.

Dr. DiBardino’s study was chosen as a 2011 Richard E. Clark Paper by the Society of Thoracic Surgeons.

The researchers used data from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). Patients were included in the analysis if they were less than 18 years of age and had undergone cardiac surgery between 2007 and 2009.

Exclusion criteria included centers with more than 15% of data missing for key variables and centers with very small samples (less than five cases).

Data collection included demographics (age, sex, weight, and race) and preoperative data (noncardiac/genetic abnormalities and STS-defined risk factors). Race was classified as white, black, Hispanic, and other.

Operations were classified by STAT Mortality category, which is "a complexity stratification tool based on empiric data from 80,000 cases in STS and EACTS (European Association for Cardio-Thoracic Surgery) databases," said Dr. DiBardino.

The researchers looked at hospital mortality, postoperative length of stay, and complications. Multivariable analyses included dichotomous variables (mortality, complications) and a continuous variable (postoperative length of stay). Models were adjusted for age, weight, noncardiac/genetic abnormalities, any other STS preoperative risk factor, and STAT Mortality category.

In all, 20,399 patients were included from 49 centers. Of these, 54% were male. In terms of race, 55% were white, 17% were black, 16% were Hispanic, and 12% were other.

Based on unadjusted outcomes, there were no differences between the sexes for in-hospital mortality or complications. However, females had significantly shorter postoperative stays. In terms of race, white patients had significantly lower mortality, shorter length of stay, and fewer complications than any of the other racial groups.

In the adjusted multivariate analysis, there was no difference for mortality between the sexes. However, black patients had a significantly greater mortality risk with an odds ratio of 1.67.

Females did have a significantly shorter mean length of stay – 0.8 fewer days. In terms of race, black patients had a significantly longer mean length of stay by 2.4 hospital days, compared with white patients. Hispanic patients also had a significantly longer mean length of stay by almost 1 hospital day.

There was no difference between the sexes in terms of the occurrence of complications. In terms of race, "black patients experienced significantly more complications than other races with an odds ratio of 1.15," according to Dr. DiBardino.

The study is unique with the respect to the use of multivariable models. The researchers measured the association of sex and race with outcomes within each center and then combined the results, in order to mitigate the potential center effects.

"Our results cannot be explained by the possibility that patients of certain races might be disproportionately treated at centers with poorer outcomes in general."

The evaluation of complex relationships between clinical variables and socioeconomic and other factors affecting health care remains a significant challenge.

Since some pertinent socioeconomic data are not collected in the STS-CHSD, an analysis of a linked data set, which capitalizes on the strengths of both the CHSD and those of an administrative claims data set may be the next logical step, said Dr. DiBardino.

Dr. DiBardino and his coinvestigators reported that they have no relevant disclosures.

FT. LAUDERDALE, FLA. – Sex and race appear to play a role in outcomes following congenital heart surgery in children and adolescents, according to a new analysis of data from almost 21,000 patients.

Black patients had significantly greater rates of mortality and complications and a significantly longer length of postoperative stay than other races, while female patients had a significantly shorter length of stay than males, Dr. Daniel J. DiBardino reported at the annual meeting of the Society of Thoracic Surgeons.

"The analysis of demographic and clinical data from nearly 21,000 patients in the congenital heart surgery database revealed important associations between gender, race, and outcome," said Dr. DiBardino, who is a cardiac surgeon at the Blair E. Batson Children’s Hospital in Jackson, Miss.

Dr. DiBardino’s study was chosen as a 2011 Richard E. Clark Paper by the Society of Thoracic Surgeons.

The researchers used data from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). Patients were included in the analysis if they were less than 18 years of age and had undergone cardiac surgery between 2007 and 2009.

Exclusion criteria included centers with more than 15% of data missing for key variables and centers with very small samples (less than five cases).

Data collection included demographics (age, sex, weight, and race) and preoperative data (noncardiac/genetic abnormalities and STS-defined risk factors). Race was classified as white, black, Hispanic, and other.

Operations were classified by STAT Mortality category, which is "a complexity stratification tool based on empiric data from 80,000 cases in STS and EACTS (European Association for Cardio-Thoracic Surgery) databases," said Dr. DiBardino.

The researchers looked at hospital mortality, postoperative length of stay, and complications. Multivariable analyses included dichotomous variables (mortality, complications) and a continuous variable (postoperative length of stay). Models were adjusted for age, weight, noncardiac/genetic abnormalities, any other STS preoperative risk factor, and STAT Mortality category.

In all, 20,399 patients were included from 49 centers. Of these, 54% were male. In terms of race, 55% were white, 17% were black, 16% were Hispanic, and 12% were other.

Based on unadjusted outcomes, there were no differences between the sexes for in-hospital mortality or complications. However, females had significantly shorter postoperative stays. In terms of race, white patients had significantly lower mortality, shorter length of stay, and fewer complications than any of the other racial groups.

In the adjusted multivariate analysis, there was no difference for mortality between the sexes. However, black patients had a significantly greater mortality risk with an odds ratio of 1.67.

Females did have a significantly shorter mean length of stay – 0.8 fewer days. In terms of race, black patients had a significantly longer mean length of stay by 2.4 hospital days, compared with white patients. Hispanic patients also had a significantly longer mean length of stay by almost 1 hospital day.

There was no difference between the sexes in terms of the occurrence of complications. In terms of race, "black patients experienced significantly more complications than other races with an odds ratio of 1.15," according to Dr. DiBardino.

The study is unique with the respect to the use of multivariable models. The researchers measured the association of sex and race with outcomes within each center and then combined the results, in order to mitigate the potential center effects.

"Our results cannot be explained by the possibility that patients of certain races might be disproportionately treated at centers with poorer outcomes in general."

The evaluation of complex relationships between clinical variables and socioeconomic and other factors affecting health care remains a significant challenge.

Since some pertinent socioeconomic data are not collected in the STS-CHSD, an analysis of a linked data set, which capitalizes on the strengths of both the CHSD and those of an administrative claims data set may be the next logical step, said Dr. DiBardino.

Dr. DiBardino and his coinvestigators reported that they have no relevant disclosures.

The role of a coach is to provide objective and constructive feedback on what he or she observes, helping the practitioner to recognize what is successful and what can be improved. Coaches do not judge or instruct; instead, they guide and facilitate. They act as collaborators and partners to assist in developing a better understanding of their own performance, and they help them to use their experience, knowledge, and abilities to provide the best care possible (Nursing Standard 2009;23:48-55). The focus should always be on the surgeon and not what the coach would do in a similar situation.

Coaching can be valuable for surgeons at all stages of their career (J. Am. Coll. Surg. 2012;214:115-24). It is easy to imagine the role of a coach in smoothing the increasingly jarring transition from training to independent practice. But experience in other areas suggests that established practitioners can also benefit.

As one develops expertise, actions become more automated and more experienced practitioners spend less time examining their approaches and actions (Fitts, P.M.; Posner, M.I.; Human Performance. Brooks/Cole Publishing Co.: Belmont, Calif., 1967; Work 2006;26:93-6). A coach can serve as a catalyst to jump-start introspection and further practice improvement.

The Importance of Adult Learning Theory

Until recently, medical education has not encompassed the proven principles by which adults learn. In 2007, Boonyasai and colleagues developed a list of adult learning principles based on major educational theories that could be applied in medicine (JAMA 2007;298:1023-37):

• Enabling adult learners to be active participants.
• Providing content relating to the learner’s current experiences.
• Assessing learners’ needs and tailoring teaching to their past experience.
• Allowing learners to identify and pursue their own learning goals.
• Allowing learners to practice their learning.
• Supporting learners during self-directed learning.
• Providing feedback to learners.
• Facilitating learner self-reflection.
• Role-modeling behaviors.

A coaching program would almost by definition include at least the first eight principles, so this list is likely to be an effective approach for improving performance.

What Makes a Good Coach?

The best athletic coaches were not always the standout athletes. They did, however, almost always participate in the sport they coach at a very high level. This is because the characteristics of a good athletic coach to do not necessarily parallel the characteristics of a good athlete, but an intimate knowledge of the skill set is critical.

Similarly, the most experienced and skilled surgeons will not necessarily make the best coaches, but a surgical coach by definition must be a surgeon. A surgical coach must develop an easy rapport and a trusting relationship with each surgeon. The coach must be empathetic and tactful, but also flexible – able to ask probing questions and make constructive comments (Consult. Psychol. J. Pract. Res.;2001;53:240-50). The best surgical coaches are likely to be experienced, thoughtful, inquisitive, nonjudgmental, and well respected by their colleagues.

The coach described by Atul Gawande in "Personal Best," his article on surgical coaching, embodied all of those qualities and excelled as a surgical coach (Gawande A. Personal Best. Top Athletes and Singers Have Coaches. Should You? New Yorker Oct. 3, 2011). When we questioned him about his deftness in this new role, he credited the light hand (socially) that he developed from years of intraoperative consults.

Coaches need time and flexibility in their schedule. For this reason, surgeons who are nearing retirement or who are newly retired may be good candidates to serve as coaches. Many of these surgeons are likely to have the experience and respect required for surgical coaching. The key is to ensure that they also have the flexibility, openness, and lack of judgment.

Another potential pool of coaches may be surgeons interested in a more flexible lifestyle for personal reasons, such as childrearing or caregiving for an ill or elderly family member. Surgical coaching can provide a way to remain engaged in surgery and continue to contribute to the field without the same demands as a busy surgical practice.

Some Basic Principles

Jim Knight has developed a paradigm that he terms "partnership learning" to coach teachers (Knight, J. Instructional Coaching: A Partnership Approach to Improving Instruction. Corwin Press: Thousand Oaks, Calif., 2007). He contrasts this with the "dominator approach" upon which most traditional professional development is based – for example, the situation in which a person gives a PowerPoint presentation to convey an "expert opinion" to a roomful of people. Sound familiar?

Instead, Mr. Knight advocates the use of core principles that will foster a partnership, the cornerstone of coaching (Knight, J. Partnership Learning. University of Kansas Center for Research on Learning: Lawrence, Kan., 2002). Here are some ways they could apply to surgical coaching:

1. Equality – The opinions and approaches of the surgeon and the surgical coach are equally valuable.
2. Choice – At a minimum, the surgeon should be allowed to choose the specific case and setting for each coaching session.
3. Voice and dialogue – The surgeon should feel free to speak openly. Coaches should listen more than they talk. The coach should not control or dominate the interaction, but rather engage in a dialogue.
4. Reflection – "Reflection on action" after an operation is likely to be more effective than "reflection in action" in the operating room so that the surgeon can concentrate fully on dissecting his or her own performance. In addition, coaching sessions can take place in a private, confidential setting away from patients and other providers. The use of video as a "thinking device" to prompt open dialogue holds significant promise.
5. Praxis – Surgeons should be encouraged to explicitly think about how they will apply insights from the coaching session to their clinical practice.

Three other points deserve mention. Confidentiality and trust are critical, especially as surgeons acclimate to the idea of working with a coach. Additionally, the coaching style should be individualized and adapted to each surgeon throughout a coaching session. Such adaptability is an important characteristic of a successful coach. Finally, coaches should not have administrative oversight for the surgeon they are coaching. This is to ensure that the content of coaching sessions remain focused on performance improvement and not on performance evaluations or career development.

Will It Work?

There are very little empirical data on coaching in any discipline. What does exist tends to be exploratory and qualitative. However, Cornett and Knight describe several randomized trials, and a review in the field of education suggests that coaching will be successful (Cornett, J.; Knight, J. Research on Coaching:Approaches and Perspectives, 2009;192-216).

Researchers found that only 10% of teachers used a new skill in the classroom when they were provided with a verbal description. After modeling, practice, and feedback were added, the rate of adoption increased to 19%. It was only with the addition of peer coaching that an astounding 95% of teachers utilized the new skill. (Bush, R. N. Effective Staff Development in Making Our Schools More Effective: Proceedings of Three State Conferences. Far West Laboratories: San Francisco, 1984).

Other studies demonstrated that coaching increased skill transfer from 15% to 75%, compared with traditional approaches to professional development. Even more striking was the fact that these skills were still being used 6 months later. If we are even half as successful with coaching in surgery, results will be orders of magnitude better than any previous attempts at intraoperative performance improvement.

How Do We Move Forward?

The American College of Surgeons Division of Education – with its dedication to improving quality, safety, and education – is in a particularly strong position to develop surgical coaching and is exploring potential programs with us in Wisconsin and with others. Other surgical societies, including local and regional organizations, offer another opportunity to develop coaching programs. The state chapters of the American Academy of Pediatrics instituted a quality improvement initiative that included team coaching, and found several advantages to this approach over a national one (J. Contin. Educ. Health Profess. 2008;28:131-9).

Trust in, familiarity with, and participation in local/regional societies or state chapters is likely to increase acceptance and participation by practicing surgeons. The infrastructure of a regional society allows for participation across all practice settings – not just in large hospitals where a coach may be locally available – yet it is small enough to afford some level of familiarity, trust, and respect for the coach.

This type of cross-institutional collaboration may seem counterintuitive in light of the traditional competitive relationships of neighboring institutions; however, the success of programs such as the Surgical Care and Outcomes Assessment Program (SCOAP) in Washington State and the Michigan Surgical Collaboratives (MSQC and MSBC) suggests that as a discipline we are ready to work together to improve the quality and safety of surgical care.

Given the current paucity of data, we must continue to study any new programs or interventions, but surgical coaching seems like an idea whose time has come.

Acknowledgments

I would like to thank Atul Gawande, Yue-Yung Hu, Robert Osteen, and Michael Zinner for conversations and research that helped me formulate these ideas.☐

Dr. Greenberg is an associate professor of surgery, and director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin, Madison.

The role of a coach is to provide objective and constructive feedback on what he or she observes, helping the practitioner to recognize what is successful and what can be improved. Coaches do not judge or instruct; instead, they guide and facilitate. They act as collaborators and partners to assist in developing a better understanding of their own performance, and they help them to use their experience, knowledge, and abilities to provide the best care possible (Nursing Standard 2009;23:48-55). The focus should always be on the surgeon and not what the coach would do in a similar situation.

Coaching can be valuable for surgeons at all stages of their career (J. Am. Coll. Surg. 2012;214:115-24). It is easy to imagine the role of a coach in smoothing the increasingly jarring transition from training to independent practice. But experience in other areas suggests that established practitioners can also benefit.

As one develops expertise, actions become more automated and more experienced practitioners spend less time examining their approaches and actions (Fitts, P.M.; Posner, M.I.; Human Performance. Brooks/Cole Publishing Co.: Belmont, Calif., 1967; Work 2006;26:93-6). A coach can serve as a catalyst to jump-start introspection and further practice improvement.

The Importance of Adult Learning Theory

Until recently, medical education has not encompassed the proven principles by which adults learn. In 2007, Boonyasai and colleagues developed a list of adult learning principles based on major educational theories that could be applied in medicine (JAMA 2007;298:1023-37):

• Enabling adult learners to be active participants.
• Providing content relating to the learner’s current experiences.
• Assessing learners’ needs and tailoring teaching to their past experience.
• Allowing learners to identify and pursue their own learning goals.
• Allowing learners to practice their learning.
• Supporting learners during self-directed learning.
• Providing feedback to learners.
• Facilitating learner self-reflection.
• Role-modeling behaviors.

A coaching program would almost by definition include at least the first eight principles, so this list is likely to be an effective approach for improving performance.

What Makes a Good Coach?

The best athletic coaches were not always the standout athletes. They did, however, almost always participate in the sport they coach at a very high level. This is because the characteristics of a good athletic coach to do not necessarily parallel the characteristics of a good athlete, but an intimate knowledge of the skill set is critical.

Similarly, the most experienced and skilled surgeons will not necessarily make the best coaches, but a surgical coach by definition must be a surgeon. A surgical coach must develop an easy rapport and a trusting relationship with each surgeon. The coach must be empathetic and tactful, but also flexible – able to ask probing questions and make constructive comments (Consult. Psychol. J. Pract. Res.;2001;53:240-50). The best surgical coaches are likely to be experienced, thoughtful, inquisitive, nonjudgmental, and well respected by their colleagues.

The coach described by Atul Gawande in "Personal Best," his article on surgical coaching, embodied all of those qualities and excelled as a surgical coach (Gawande A. Personal Best. Top Athletes and Singers Have Coaches. Should You? New Yorker Oct. 3, 2011). When we questioned him about his deftness in this new role, he credited the light hand (socially) that he developed from years of intraoperative consults.

Coaches need time and flexibility in their schedule. For this reason, surgeons who are nearing retirement or who are newly retired may be good candidates to serve as coaches. Many of these surgeons are likely to have the experience and respect required for surgical coaching. The key is to ensure that they also have the flexibility, openness, and lack of judgment.

Another potential pool of coaches may be surgeons interested in a more flexible lifestyle for personal reasons, such as childrearing or caregiving for an ill or elderly family member. Surgical coaching can provide a way to remain engaged in surgery and continue to contribute to the field without the same demands as a busy surgical practice.

Some Basic Principles

Jim Knight has developed a paradigm that he terms "partnership learning" to coach teachers (Knight, J. Instructional Coaching: A Partnership Approach to Improving Instruction. Corwin Press: Thousand Oaks, Calif., 2007). He contrasts this with the "dominator approach" upon which most traditional professional development is based – for example, the situation in which a person gives a PowerPoint presentation to convey an "expert opinion" to a roomful of people. Sound familiar?

Instead, Mr. Knight advocates the use of core principles that will foster a partnership, the cornerstone of coaching (Knight, J. Partnership Learning. University of Kansas Center for Research on Learning: Lawrence, Kan., 2002). Here are some ways they could apply to surgical coaching:

1. Equality – The opinions and approaches of the surgeon and the surgical coach are equally valuable.
2. Choice – At a minimum, the surgeon should be allowed to choose the specific case and setting for each coaching session.
3. Voice and dialogue – The surgeon should feel free to speak openly. Coaches should listen more than they talk. The coach should not control or dominate the interaction, but rather engage in a dialogue.
4. Reflection – "Reflection on action" after an operation is likely to be more effective than "reflection in action" in the operating room so that the surgeon can concentrate fully on dissecting his or her own performance. In addition, coaching sessions can take place in a private, confidential setting away from patients and other providers. The use of video as a "thinking device" to prompt open dialogue holds significant promise.
5. Praxis – Surgeons should be encouraged to explicitly think about how they will apply insights from the coaching session to their clinical practice.

Three other points deserve mention. Confidentiality and trust are critical, especially as surgeons acclimate to the idea of working with a coach. Additionally, the coaching style should be individualized and adapted to each surgeon throughout a coaching session. Such adaptability is an important characteristic of a successful coach. Finally, coaches should not have administrative oversight for the surgeon they are coaching. This is to ensure that the content of coaching sessions remain focused on performance improvement and not on performance evaluations or career development.

Will It Work?

There are very little empirical data on coaching in any discipline. What does exist tends to be exploratory and qualitative. However, Cornett and Knight describe several randomized trials, and a review in the field of education suggests that coaching will be successful (Cornett, J.; Knight, J. Research on Coaching:Approaches and Perspectives, 2009;192-216).

Researchers found that only 10% of teachers used a new skill in the classroom when they were provided with a verbal description. After modeling, practice, and feedback were added, the rate of adoption increased to 19%. It was only with the addition of peer coaching that an astounding 95% of teachers utilized the new skill. (Bush, R. N. Effective Staff Development in Making Our Schools More Effective: Proceedings of Three State Conferences. Far West Laboratories: San Francisco, 1984).

Other studies demonstrated that coaching increased skill transfer from 15% to 75%, compared with traditional approaches to professional development. Even more striking was the fact that these skills were still being used 6 months later. If we are even half as successful with coaching in surgery, results will be orders of magnitude better than any previous attempts at intraoperative performance improvement.

How Do We Move Forward?

The American College of Surgeons Division of Education – with its dedication to improving quality, safety, and education – is in a particularly strong position to develop surgical coaching and is exploring potential programs with us in Wisconsin and with others. Other surgical societies, including local and regional organizations, offer another opportunity to develop coaching programs. The state chapters of the American Academy of Pediatrics instituted a quality improvement initiative that included team coaching, and found several advantages to this approach over a national one (J. Contin. Educ. Health Profess. 2008;28:131-9).

Trust in, familiarity with, and participation in local/regional societies or state chapters is likely to increase acceptance and participation by practicing surgeons. The infrastructure of a regional society allows for participation across all practice settings – not just in large hospitals where a coach may be locally available – yet it is small enough to afford some level of familiarity, trust, and respect for the coach.

This type of cross-institutional collaboration may seem counterintuitive in light of the traditional competitive relationships of neighboring institutions; however, the success of programs such as the Surgical Care and Outcomes Assessment Program (SCOAP) in Washington State and the Michigan Surgical Collaboratives (MSQC and MSBC) suggests that as a discipline we are ready to work together to improve the quality and safety of surgical care.

Given the current paucity of data, we must continue to study any new programs or interventions, but surgical coaching seems like an idea whose time has come.

Acknowledgments

I would like to thank Atul Gawande, Yue-Yung Hu, Robert Osteen, and Michael Zinner for conversations and research that helped me formulate these ideas.☐

Dr. Greenberg is an associate professor of surgery, and director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin, Madison.

The role of a coach is to provide objective and constructive feedback on what he or she observes, helping the practitioner to recognize what is successful and what can be improved. Coaches do not judge or instruct; instead, they guide and facilitate. They act as collaborators and partners to assist in developing a better understanding of their own performance, and they help them to use their experience, knowledge, and abilities to provide the best care possible (Nursing Standard 2009;23:48-55). The focus should always be on the surgeon and not what the coach would do in a similar situation.

Coaching can be valuable for surgeons at all stages of their career (J. Am. Coll. Surg. 2012;214:115-24). It is easy to imagine the role of a coach in smoothing the increasingly jarring transition from training to independent practice. But experience in other areas suggests that established practitioners can also benefit.

As one develops expertise, actions become more automated and more experienced practitioners spend less time examining their approaches and actions (Fitts, P.M.; Posner, M.I.; Human Performance. Brooks/Cole Publishing Co.: Belmont, Calif., 1967; Work 2006;26:93-6). A coach can serve as a catalyst to jump-start introspection and further practice improvement.

The Importance of Adult Learning Theory

Until recently, medical education has not encompassed the proven principles by which adults learn. In 2007, Boonyasai and colleagues developed a list of adult learning principles based on major educational theories that could be applied in medicine (JAMA 2007;298:1023-37):

• Enabling adult learners to be active participants.
• Providing content relating to the learner’s current experiences.
• Assessing learners’ needs and tailoring teaching to their past experience.
• Allowing learners to identify and pursue their own learning goals.
• Allowing learners to practice their learning.
• Supporting learners during self-directed learning.
• Providing feedback to learners.
• Facilitating learner self-reflection.
• Role-modeling behaviors.

A coaching program would almost by definition include at least the first eight principles, so this list is likely to be an effective approach for improving performance.

What Makes a Good Coach?

The best athletic coaches were not always the standout athletes. They did, however, almost always participate in the sport they coach at a very high level. This is because the characteristics of a good athletic coach to do not necessarily parallel the characteristics of a good athlete, but an intimate knowledge of the skill set is critical.

Similarly, the most experienced and skilled surgeons will not necessarily make the best coaches, but a surgical coach by definition must be a surgeon. A surgical coach must develop an easy rapport and a trusting relationship with each surgeon. The coach must be empathetic and tactful, but also flexible – able to ask probing questions and make constructive comments (Consult. Psychol. J. Pract. Res.;2001;53:240-50). The best surgical coaches are likely to be experienced, thoughtful, inquisitive, nonjudgmental, and well respected by their colleagues.

The coach described by Atul Gawande in "Personal Best," his article on surgical coaching, embodied all of those qualities and excelled as a surgical coach (Gawande A. Personal Best. Top Athletes and Singers Have Coaches. Should You? New Yorker Oct. 3, 2011). When we questioned him about his deftness in this new role, he credited the light hand (socially) that he developed from years of intraoperative consults.

Coaches need time and flexibility in their schedule. For this reason, surgeons who are nearing retirement or who are newly retired may be good candidates to serve as coaches. Many of these surgeons are likely to have the experience and respect required for surgical coaching. The key is to ensure that they also have the flexibility, openness, and lack of judgment.

Another potential pool of coaches may be surgeons interested in a more flexible lifestyle for personal reasons, such as childrearing or caregiving for an ill or elderly family member. Surgical coaching can provide a way to remain engaged in surgery and continue to contribute to the field without the same demands as a busy surgical practice.

Some Basic Principles

Jim Knight has developed a paradigm that he terms "partnership learning" to coach teachers (Knight, J. Instructional Coaching: A Partnership Approach to Improving Instruction. Corwin Press: Thousand Oaks, Calif., 2007). He contrasts this with the "dominator approach" upon which most traditional professional development is based – for example, the situation in which a person gives a PowerPoint presentation to convey an "expert opinion" to a roomful of people. Sound familiar?

Instead, Mr. Knight advocates the use of core principles that will foster a partnership, the cornerstone of coaching (Knight, J. Partnership Learning. University of Kansas Center for Research on Learning: Lawrence, Kan., 2002). Here are some ways they could apply to surgical coaching:

1. Equality – The opinions and approaches of the surgeon and the surgical coach are equally valuable.
2. Choice – At a minimum, the surgeon should be allowed to choose the specific case and setting for each coaching session.
3. Voice and dialogue – The surgeon should feel free to speak openly. Coaches should listen more than they talk. The coach should not control or dominate the interaction, but rather engage in a dialogue.
4. Reflection – "Reflection on action" after an operation is likely to be more effective than "reflection in action" in the operating room so that the surgeon can concentrate fully on dissecting his or her own performance. In addition, coaching sessions can take place in a private, confidential setting away from patients and other providers. The use of video as a "thinking device" to prompt open dialogue holds significant promise.
5. Praxis – Surgeons should be encouraged to explicitly think about how they will apply insights from the coaching session to their clinical practice.

Three other points deserve mention. Confidentiality and trust are critical, especially as surgeons acclimate to the idea of working with a coach. Additionally, the coaching style should be individualized and adapted to each surgeon throughout a coaching session. Such adaptability is an important characteristic of a successful coach. Finally, coaches should not have administrative oversight for the surgeon they are coaching. This is to ensure that the content of coaching sessions remain focused on performance improvement and not on performance evaluations or career development.

Will It Work?

There are very little empirical data on coaching in any discipline. What does exist tends to be exploratory and qualitative. However, Cornett and Knight describe several randomized trials, and a review in the field of education suggests that coaching will be successful (Cornett, J.; Knight, J. Research on Coaching:Approaches and Perspectives, 2009;192-216).

Researchers found that only 10% of teachers used a new skill in the classroom when they were provided with a verbal description. After modeling, practice, and feedback were added, the rate of adoption increased to 19%. It was only with the addition of peer coaching that an astounding 95% of teachers utilized the new skill. (Bush, R. N. Effective Staff Development in Making Our Schools More Effective: Proceedings of Three State Conferences. Far West Laboratories: San Francisco, 1984).

Other studies demonstrated that coaching increased skill transfer from 15% to 75%, compared with traditional approaches to professional development. Even more striking was the fact that these skills were still being used 6 months later. If we are even half as successful with coaching in surgery, results will be orders of magnitude better than any previous attempts at intraoperative performance improvement.

How Do We Move Forward?

The American College of Surgeons Division of Education – with its dedication to improving quality, safety, and education – is in a particularly strong position to develop surgical coaching and is exploring potential programs with us in Wisconsin and with others. Other surgical societies, including local and regional organizations, offer another opportunity to develop coaching programs. The state chapters of the American Academy of Pediatrics instituted a quality improvement initiative that included team coaching, and found several advantages to this approach over a national one (J. Contin. Educ. Health Profess. 2008;28:131-9).

Trust in, familiarity with, and participation in local/regional societies or state chapters is likely to increase acceptance and participation by practicing surgeons. The infrastructure of a regional society allows for participation across all practice settings – not just in large hospitals where a coach may be locally available – yet it is small enough to afford some level of familiarity, trust, and respect for the coach.

This type of cross-institutional collaboration may seem counterintuitive in light of the traditional competitive relationships of neighboring institutions; however, the success of programs such as the Surgical Care and Outcomes Assessment Program (SCOAP) in Washington State and the Michigan Surgical Collaboratives (MSQC and MSBC) suggests that as a discipline we are ready to work together to improve the quality and safety of surgical care.

Given the current paucity of data, we must continue to study any new programs or interventions, but surgical coaching seems like an idea whose time has come.

Acknowledgments

I would like to thank Atul Gawande, Yue-Yung Hu, Robert Osteen, and Michael Zinner for conversations and research that helped me formulate these ideas.☐

Dr. Greenberg is an associate professor of surgery, and director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin, Madison.