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CARLE SElECTED PAPERS

SUbJECT REvIEw laparscpic Repair f Traumatic Itraperitea

badder Rupture

Taktsu Cardimypathy: A Isiht ita Rare Disease

The vetera Heath Admiistratis Respse tMeeti the Uique needs f the Returi operatiEduri Freedm/operati Iraqi Freedm vetera

Eauati f the Thyrid ndue

oRIgInAl RESEARCH

gycemic Ctr ad Ciica outcmes fr PatietsAdmitted t ncritica Hspita Uits

Psychtherapeutic Iteretis i breast Cacer adChric Iess

ClInICoPATHologICAl ConFEREnCE

InFECTIoUS DISEASE Uriary Schistsmiasis: Case Reprt ad Reie

A JoURnAl oF PRACTICAl MEDICInE

SPRING/SUMMER 2009

vol. 52

no. 1


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contentscsp

SPRING/SUMMER2009 vol. 52, no.1

A JoURnAloF PRACTICAlMEDICInE

From theExecutive EditorRobert Zeiders, MD

Letter to the EditorMark D. Esarey, OD

Subject ReviewLaparoscopic Repair of Traumatic

Intraperitoneal Bladder RuptureEric Helfer, MDJ. Lynn Teague, MDJohn A. Aucar, MD . . . . . . . . . . . . . . . . . . . . . . . . . .1

Takotsubo Cardiomyopathy:An Insight into a Rare Disease

Vikesh Gupta, MDFarhad Farokhi, DO, FACC . . . . . . . . . . . . . . . . . . . . . . . . . .4

The Veteran HealthAdministrations Response

to Meeting the Unique Needsof the Returning Operation

Enduring Freedom/OperationIraqi Freedom Veteran

Richard N. Jones, MS, PA-CHillary Tharp, MSW, LCSWWilliam P. Marshall, MD . . . . . . . . . . . . . . . . . . . . . . . . . .8

Evaluation of theThyroid Nodule

Christopher Lansford, MD, FACS . . . . . . . . . . . . . . . . . . . . . . . . . .12

Original ResearchCharacteristics of Congestive

Heart Failure PatientsHospitalized at Carle FoundationHospital Enrolled in the Carle

Medicare Coordinated CareDemonstration

Suma Peter, MDNallu Reddy, MD

Nazneen Hashmi, MD

Cheryl Schraeder, RN, PhD, FAANChristine Kucera, BFAIDPaul Shelton, EdD. . . . . . . . . . . . . . . . . . . . . . . . . .23

Glycemic Control and Clinical

Outcomes for Patients Admittedto Noncritical Hospital Units

Laura Wardwell, BS

Michael G. Jakoby, MD, MA . . . . . . . . . . . . . . . . . . . . . . . . . .32

Psychotherapeutic Interventions

in Breast Cancer and Chronic

Illness

Suzanne Harris, PhDAlicia Price, PhD . . . . . . . . . . . . . . . . . . . . . . . . . .38

ClinicopathologicalConference

A 66-Year-Old Male with LowerExtremity Swelling and Dyspnea

Michael G. Jakoby, MD, MAJames Kumar, MD, MS . . . . . . . . . . . . . . . . . . . . . . . . . .43

Infectious DiseaseUrinary Schistosomiasis:Case Report and Review

Greg Maurer, MDFarah Gaudier, MDDiana BiggsRana Zaman, MD . . . . . . . . . . . . . . . . . . . . . . . . . .48

Case ReportThe Case of the Tell Tale Heart

Erich Hanel, MDBrad Peterson, MDAndrew Rudin, MDBharat Gopal, MD . . . . . . . . . . . . . . . . . . . . . . . . . .51


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Executive Editor

Robert Zeiders, MD

Managing Editor

Patricia G. Stevens

Associate Editor

Annette Fudge

Reference Editor

Morgann Thomas

Design & Production

Advertising Marketing & Communications Department

csp . 52, . 1Copyright 2009The Carle Foundation.

Carle Selected Papersis funded by Carle Development

Foundation and in part by acknowledged contributions.

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scientific or educational advancement. Carle Selected Papers

is published by the Carle Development Foundation.

The ideas and opinions expressed in Carle Selected Papers

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the institution with which the author is affiliated, unless

this is clearly specified. Publication of an advertisement or

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information currently provided by the manufacturer of each

drug to be administered to verify the dosage, the method

and duration of administration, or contraindications. It is

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Correspondence and submissions should be addressed to:

Carle Selected Papers Carle Foundation Hospital

Research Institute 611 W. Park Street Urbana, IL 61801

Electronic mail may be addressed to:

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SPRING/SUMMER2009


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Welcome to the spring/summer 2009 edition of Carle Selected Papers.

Please pay particular attention to the article from our regional VeteransAdministration Hospital, describing in detail the services available forveterans with their multiple problems. The Wall Street Journal on July 28, 2008reported that more than 22,000 veterans sought help during the past year froma special suicide hotline. Currently they receive more than 250 calls per daydouble the number of calls than when the line opened a year ago. In additionabout one in five of those returning from Iraq and Afghanistan have symptomsof post-traumatic stress disorder, placing them at higher risk for suicide. Wemust all be aware of these staggering statistics and how and where to gethelp for these troubled warriors.

Dr. Suzanne Harris paper on psychotherapeutic interventions focuses

on breast cancer patients but is equally applicable to those with other chronicillnesses. The techniques described therein have been proven to enhancequality of life when a patient survives these serious physical health problems.This help should be offered earlier in case management rather than later.Genitourinary schistosomiasis may seem exotic in a general medical journal,but it is less so when one considers the increasing immigration from aroundthe world to central Illinois.

There is also good information on cardiomyopathy, congestive heartfailure, diabetes mellitus management, thyroid nodules, and laparoscopicrepair of traumatic intraperitoneal urinary bladder rupture. Read all thearticles and be sure to take advantage of the free CME credit available bystudying with us.

Robert Zeiders, MDExecutive Editor

from the

executive editor


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Dear Doctors:

I read with interest the latest Carle Selected Papers, Volume 51 (Spring/Summer

2008). Specifically, I enjoyed your very useful article titled Assessing the Acuity

of the Elderly Driver: A Guide for the Practitioner. However, I wanted to

point out a few inaccuracies with regard to current Illinois law and minimum

vision thresholds.

First, vision tests are not required each year for drivers age 75 and over. In general,

a vision test is required for the initial license, at age 21, and every 4 years through

age 80. However, in the event the driver has no moving violations against his/her

license, the IL Secretary of States Safe Driver Renewal Program allows for one4-year renewal by mail or electronic means for drivers from age 2175. Therefore,

the maximum possible renewal frequency for drivers age 2175 is 8 years, while

for ages 7680, the maximum is 4 years. From age 8186, a vision test is required

every 2 years. For age 87 and over, a vision test is required every year. Next,

the horizontal field of vision must be at least 140 degrees, not 120. Last, while

a fundoscopy and a Useful Field of View test have clinical value, they have no

bearing on the vision thresholds required for drivers license renewal.

As an aside, a Vision Specialist Report may be submitted to report the virtual

acuity and visual field of the driver/patient. These reports may be used only by

a physician who performs a complete eye exam, including glaucoma testing and

refraction (in other words, an optometrist or ophthalmologist).

There are other nuances of Illinois law and JCAR rules that may impact renewal

for certain individuals. Such situations may include early renewal, progressive

defects, telescopic aids, and partial restrictions for daylight-only driving or

outside mirrors.

By the way, the preface provided by Dr. Zeiders also makes a valuable point.

Medical practitioners, including ophthalmologists and optometrists, are not

mandated to report drivers who fail to meet minimum vision thresholds in Illinois.

However, the questions of ethics and the doctors conscience remain.

I again want to thank you for including this important issue in your paper, and

want to offer any assistance you may need in the future regarding this, or any

other eye health or vision-related issue that may arise.

All best regards,

Mark D. Esarey, OD

Editors note: Carle Selected Papers greatly appreciates the corrections and added

information submitted by Dr. Esarey on this subject, and always welcomes the

participation of its readers.

letter tothe editor


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Carle Selected PapersCME ActivitySponsored by Carle Foundation Hospital

This CME activity in Carle Selected Papersallows subscribers to earnAMAPRA Category 1Credit. There is no charge for this CME activity.

The quiz questions are based on selected articles in this issue. Answers appear

in this issue.

This course has been planned and presented in accordance with the ACCMEEssential Areas and policies for Continuing Medical Education for physicians.Carle Foundation Hospital is accredited by the Illinois State Medical Societyto provide continuing medical education for physicians. Carle FoundationHospital designates this educational activity for a maximum of 1 AMA PRACategory 1Credit. Physicians should only claim credit commensurate withthe extent of their participation in the activity.

Objective:After reading a specific article(s) published in Carle Selected Papers,participants should be able to evaluate the appropriateness of the clinical

information as it applies to the provision of patient care.

Audience:This activity is designed for physicians who are involved in pro-viding or administering patient care and who wish to advance their currentknowledge of clinical medicine.

Disclosure:The following CME authors and committee members, Gupta,Farokhi, Lansford, Price, Harris, Jakoby, Kumar, Maurer, Gaudier, Biggs,Huffman, Zeiders and Zaman, have no relevant financial relationshipsto disclose.

Sponsorship:Carle Selected Papersis produced by The Carle Foundation,

a non-profit 501(3)(c) foundation. No commercial funds were used in theproduction of this issue.

Answers to this issues quiz are on page 54. This quiz has 19questions.


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Figure 2 (a and b). Intracorporeal suturing ofbladder injury with 2-0 polyglycolic acid (a) andcompleted repair under test by saline instillationthrough the Foley catheter (b)

DiscussionThe role of laparoscopy for trauma is still being defined.It carries the potential to reduce both the incidenceof nontherapeutic laparotomy and the morbidityassociated with therapy of specific injuries. There areseveral review articles characterizing laparoscopy byits diagnostic or therapeutic value in trauma. Patient

selection is a critical factor, since laparoscopy shouldonly be considered in the presence of hemodynamicstability.1,2

Complications related to laparoscopic access areinfrequent and generally reported in the range of 0.31%.Most of the literature pertaining to laparoscopic repairof bladder injury deals with the occurrence of bladderinjury during elective laparoscopic surgery. Threeprevious case reports describe laparoscopic repairof traumatic bladder rupture, two of which describea single case of laparoscopic repair for traumaticintraperitoneal bladder rupture. In the only articleencountered in the American literature, three casesare described utilizing laparoscopy for trauma, one ofwhich involved bladder repair.312

In the current case, the diagnosis of intraperitonealbladder rupture was made preoperatively. Solid organinjury can be effectively ruled out by CT scanning.Intestinal injury is rare, and difficult to diagnoseby preoperative imaging. The notable benefit oflaparoscopy was the reliable exclusion of an associatedsmall bowel injury, without requiring open explorationat the time of the planned bladder repair. The combined

incisions used for bladder repair and subsequentorthopedic repair produced relatively little morbiditycompared to a laparotomy incision. Intraperitonealbladder injuries usually require two layer closure toensure a watertight repair and surgeons not adeptat intracorporeal suturing may encounter a longerduration of the operation as compared to open repair.This limitation may be overcome with automaticsuturing devices which facilitate the use of minimallyinvasive techniques to place intracorporeal stitchesefficiently. 13

Besides the usual precautions, potential concernsabout using laparoscopy in the setting of trauma includegas embolization and aggravation of pneumothoraxin the presence of diaphragmatic injury. However,these concerns can be minimized in the stable andappropriately evaluated patient. Identification ofpatients that may benefit from laparoscopic repair of

intraperitoneal bladder rupture requires coordinationbetween the trauma and urologic services. Carefulpatient selection and operative planning has madelaparoscopy a feasible option for bladder repair, withless morbidity and faster convalescence relative tostandard surgical approaches. This case illustrates theuse of laparoscopy to provide these advantages with nodifference in surgical outcome.

Eric Helfer, MD is a physician in the Department ofUrology at Christie Clinic, Champaign, IL.

J. Lynn Teague, MD, FAAP is an Associate Professorof Clinical Surgery, Urology and Child Health at theUniversity of Missouri at Columbia.

John Aucar, MD, MSHI, FACS practices general andtrauma surgery at Carle Foundation Hospital and is theProgram Director of the developing General SurgeryResidency. He is also an Associate Professor of Surgery atthe University of Illinois College of Medicine at Urbana-Champaign.

References1. Villavicencio RT, Aucar JA. Analysisof laparoscopy in trauma. J Am Coll Surg1999;189(1):11-20.2. Sosa JL, Puente I. Laparoscopy in the evaluationand management of abdominal trauma. Int Surg1994;79:307-13.3. Magrina JF. Complications of laparoscopicsurgery. Clin Obstet Gynecol 2008;45(2):469-80.4. Taskin O, Wheeler JM. Laparoscopic repair ofbladder injury and laceration. J Am Assoc GynecolLaparosc 1995;2(2):227-9.5. Reich H, McGlynn F. Laparoscopic repair

of bladder injury. Obstet Gynecol 1990;76(5 Pt 2):909-10.6. Poffenberger RJ. Laparoscopic repair ofintraperitoneal bladder injury: a simple newtechnique. Urology 1996;47:248-9.7. Yin CS, Li YT, Chao TC, Yu MS. Laparoscopicloop ligatures for bladder repair during laparoscopicsurgery. Int J Gynaecol Obstet 1999;66(1):47-9.

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IntroductionTakotsubo cardiomyopathy is a well-established clinicalentity that becomes an important differential diagnosisin patients who present with acute coronary syndrome,especially postmenopausal women. The clinicalsuspicion of this condition is extremely important for

primary care physicians, particularly those practicingat centers with no cardiac catheterization facilities, asthis disease can be mistaken for an acute myocardialinfarction and patients may be subjected to hazards ofthrombolytic therapy. This syndrome has many othersynonyms such as stress or ampulla cardiomyopathy,apical ballooning syndrome (ABS) and brokenheart syndrome. This syndrome is characterized bydepressed wall motion of the apical segments of theleft ventricle with sparing of the basal segmentsleading to distinguished configuration of octopus trapduring systole on cardiac imaging.

Clinical FeaturesSigns and symptomsThe majority of patients are postmenopausal womenwith a recent emotional or physical stress in their lifesuch as loss of a relative, financial strain or diagnosisof a lethal medical illness. The symptoms of ABSare very similar to those experienced by patientswith acute coronary syndrome. The most commonsymptom is chest pain; however, a small subsetof patients can have dyspnea as their presenting

complaint. Upon examination these patients are mostlyhemodynamically stable but rare cases of cardiogenicshock and ventricular failure with hypotension havebeen reported in the literature. In a case series fromJapan, 67% of the patients had chest symptoms atpresentation and 15% presented with cardiogenicshock.1

Laboratory FindingsEKG findingsThe EKG findings can be varied in a patient with ABS.It can range from marked diffuse ST elevation (verysimilar to acute ST elevation myocardial infarction)to completely normal EKG. In those patients who

have diffuse ST elevation at the time of initialpresentation, the EKG shows complete resolutionof ST elevation, with T wave inversion over thenext 4872 hours. Other findings seen on EKG areST-segment depression, QT interval prolongation andpathological Q waves.

Cardiac markersThe cardiac enzymes (CPK-MB and troponins)are often elevated in patients with stress inducedcardiomyopathy but the elevation is only mild tomoderate. In a systematic review of 14 case studiesthe cardiac markers were elevated in 86.2% of thepatients.2

Imaging studiesLeft ventriculography and echocardiography showthe typical akinesis of the apical two-third portionof the left ventricle with depressed ejection fractionand apical ballooning in systole. In a systematicreview of case series the mean ejection fraction inthese patients was 2049%. The ejection fractionimproved to normal in the majority of these patients.

Some patients have evidence of dynamic leftventricular outflow tract (LVOT) obstruction withsystolic anterior motion of the mitral valve similarto hypertrophic cardiomyopathy. Nuclear imagingof the heart shows reversible perfusion defects andthe magnetic resonance imaging shows wall motionabnormalities in the left apical and mid ventricularwall not conforming to any single coronary artery.Though Takotsubo cardiomyopathy is primarilya disease of the left ventricle, right ventricular

Takotsubo Cardiomyopathy:An Insight into a Rare Disease

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dysfunction has also been reported in some patients.In a case series of 32 patients about 26% had evidenceof right ventricular involvement on cardiac magneticresonance imaging.2,3

Figure 1.Transthoracic echocardiogram onadmission. Apical 4 chamber view showing apical

ballooning of the left ventricle (left). Zoom detailof the same view (right).

Figure 2. Left ventriculograms. Diastolic (left) and

systolic (right) morphology of the left ventricle withthe typical appearance of apical ballooning in systole.

Coronary angiographyThe epicardial coronary arteries do not show anye/o critical obstructive lesions but there can be diffusecoronary vessel spasm due to catecholamine surgeresulting from stress. Abnormalities of the coronarymicrocirculation are quite common in patients withstress induced cardiomyopathy and may be the cause oftransient myocardial stunning seen in these patients.

Proposed Diagnostic Criteria forTakotsubo Cardiomyopathy

Mayo Clinic criteria (all four must be met):4

Transient, reversible akinesis or dyskinesis ofthe left ventricular apical and mid-ventricularsegments with regional wall motion abnormalitiesextending beyond a single vascular territory onleft ventriculography.

Absence of obstructive coronary artery stenosis50% of the luminal diameter or angiographicevidence of acute plaque rupture.

New electrocardiographic abnormalities consistingof ST segment elevation or T wave inversion.

Absence of: Recent head trauma Intracranial bleeding

Pheochromocytoma Obstructive epicardial coronary artery disease

Myocarditis Hypertrophic cardiomyopathy

PathophysiologyDespite numerous case reports of apical ballooningsyndrome, the exact pathophysiological mechanismresponsible for this condition has not been clearlydefined in literature. Various theories have beenpostulated for its causation. The most convincingtheory seems to be massive catecholamine surge,caused by stress precipitating this cardiomyopathy.The catecholamines further depress the myocardial

function by causing myocardial stunning. Akashi etal in their scintigraphic study on eight patients ofTakotsubo cardiomyopathy, demonstrated evidenceof reversible cardiac adrenergic dysfunction. Thishypothesis seems logical as low ejection fractionshave been demonstrated in other conditions withelevated serum catecholamine levels such as patientsof pheochromocytoma and subarachnoid hemorrhage.However this postulation is not flawless, and inclinical studies there has been no consistency in serumcatecholamine level elevation associated with thiscondition.5-8

Some authors have proposed diffuse epicardialcoronary artery spasm as being one of the underlyingmechanisms. However, this hypothesis is questionableas different case series have shown variable results.Tsuchihashi et al reported that coronary arteryvasospasm with acetylcholine could be induced in only21% of their patients. Akashi and coworkers foundthat acetylcholine challenge did not induce coronaryvasospasm in any of their patients.9

Another plausible mechanism seems to bedysfunction at the microvascular level. This theory

seems reasonable in the presence of nonoccludedepicardial coronaries in cases of Takotsubocardiomyopathy. Various angiographic measures ofmicrovascular dysfunction such as myocardial blushgrade and TIMI frame count have been found to beabnormal is such patients. Still, further larger studiesare needed to support this hypothesis.10-12

Development of dynamic intraventricular gradientat the level of left ventricular outflow tract or midventricle is another way to explain the pathogenesis

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1 Carle Selected PapersVol. 44 No. 1

of this condition. As a result of this gradient, there isincrease in wall stress which causes increased oxygendemand and myocardial ischemia. This can explainthe predisposition of elderly females to this conditionas they have sigmoid shaped interventricular septumdue to unfolding of aorta and hence are more likelyto develop the intraventricular gradient. However, inclinical studies this gradient has not been as frequentlyreported as it should have been if this was the onlymechanism for stress induced cardiomyopathy.13

Another question that remains unanswered aboutthis entity is why only the cardiac apex is selectivelyaffected. Lack of three layered myocardial structure,low elasticity reserve, limited coronary blood supply tothe cardiac apex and delayed functional recovery fromglobal dysfunction, are the possible mechanisms.1

ComplicationsSeveral complications can arise during the clinical courseof Takotsubo cardiomyopathy. While most patients can

be managed conservatively others, for example thosewith cardiac rupture, may require surgical intervention.Patients can experience any of the complicationsobserved in the condition of acute myocardialinfarction, such as ventricular arrhythmias, congestiveheart failure, cardiogenic shock, mitral regurgitationor left ventricular free wall rupture. However, evendespite the development of serious complications mostpatients have excellent recovery. 4,14,15

TreatmentAs the presentation of this condition is very similar

to acute coronary syndromes, the initial managementshould include standard therapy for ACS patientssuch as aspirin, beta blockers and heparin. Treatmentcan be changed once the diagnosis of Takotsubocardiomyopathy has been confirmed followingappropriate tests such as echocardiography andcoronary angiography. Although there have been no randomized studies,chronic beta blocker therapy in these patients seemsappropriate as this would prevent recurrences due tocatecholamine surges in future. The role of angiotensinconverting enzyme inhibitors or angiotensin receptor

blockers is controversial. Some authors have advocatedtheir use in these patients until there is completerecovery of myocardial function.

Left ventricular outflow tract obstruction shouldbe carefully looked for in these patients. In thepresence of significant dynamic left ventricular outflowobstruction without e/o heart failure, gentle IV fluidswith beta blocker therapy would be useful. Howeverthe presence of pump failure would mandate the use ofinotropes and intra-aortic balloon pump.16,17

There have been no studies on the role of combinedalpha and beta blockers in patients of stress inducedcardiomyopathy.

PrognosisMost of the patients show complete recovery. Theaverage recovery time is four to eight weeks and therecurrence rate is low. In a reported case series the

recurrence rate for Takotsubo cardiomyopathy was510%. The mortality rate is also very low and isestimated around 12%.

ConclusionTakotsubo cardiomyopathy is a disease of unknownetiology although most cases are precipitated by severeemotional stress. The symptoms present very similar toACS so diagnosis of this condition can be challenging.Chronic beta blocker therapy has been found to beuseful. Most patients recover from this condition withcomplete normalization of cardiac function.

Further prospective studies are needed to find theexact mechanism underlying this condition and tohelp define the guidelines for its management.

Vikesh Gupta, MD is an Internal Medicine resident atthe University of Illinois College of Medicine at Urbana-Champaign.

Farhad Farokhi, DO, FACC is board certified in cardiologyand electrophysiology and is an Electrophysiologist at CarleFoundation Hospital.

References1. Tsuchihashi K, Ueshima K, Uchida T, Oh-muraN, Kimura K, Owa M, et al. Transient left ventricularapical ballooning without coronary artery stenosis: anovel heart syndrome mimicking acute myocardialinfarction. Angina Pectoris-Myocardial InfarctionInvestigations in Japan. J Am Coll Cardiol2001;38(1):11-18.2. Gianni M, Dentali F, Grandi AM, Sumner G,Hiralal R, Lonn E. Apical ballooning syndrome ortakotsubo cardiomyopathy: a systematic review. EurHeart J 2006;27(13):1523-9.3. Haghi D, Athanasiadis A, Papavassiliu T,Suselbeck T, Fluechter S, Mahrholdt H, et al.Right ventricular involvement in takotsubocardiomyopathy. Eur Heart J 2006;27(20):2433-9.4. Bybee KA, Kara T, Prasad A, Lerman A, BarsnessGW, Wright RS, et al. Systematic review: transientleft ventricular apical ballooning: a syndrome thatmimics ST-segment elevation myocardial infarction.Ann Intern Med 2004;141(11):858-65.

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5. Akashi YJ, Nakazawa K, Sakakibara M, MiyakeF, Musha H, Sasaka K. 123I-MIBG myocardialscintigraphy in patients with "takotsubo"cardiomyopathy. J Nucl Med 2004;45(7):1121-7.6. Otsuka M, Kohno K, Itoh A. Periodic fluctuationof blood pressure and transient left ventricularapical ballooning in pheochromocytoma. Heart

2006;92(12):1837.7. Sanchez-Recalde A, Costero O, OliverJM, Iborra C, Ruiz E, Sobrino JA. Images incardiovascular medicine. Pheochromocytoma-relatedcardiomyopathy: inverted takotsubo contractilepattern. Circulation 2006;113(17):e738-9.8. Naredi S, Lambert G, Edn E, Zll S, RunnerstamM, Rydenhag B, et al. Increased sympathetic nervousactivity in patients with nontraumatic subarachnoidhemorrhage. Stroke 2000;31(4):901-6.9. Akashi YJ, Nakazawa K, Sakakibara M, Miyake F,Koike H, Sasaka K. The clinical features of takotsubo

cardiomyopathy. QJM 2003;96(8):563-73.10. Elesber A, Lerman A, Bybee KA, Murphy JG,Barsness G, Singh M, et al. Myocardial perfusion inapical ballooning syndrome correlate of myocardialinjury. Am Heart J 2006;152(3):469.e9-13.11. Bybee KA, Prasad A, Barsness G, Lerman A,Jaffe AS, Murphy JG, et al. Clinical characteristicsand thrombolysis in myocardial infarction framecounts in women with transient left ventricularapical ballooning syndrome. Am J Cardiol2004;94(3):343-6.12. Kurisu S, Inoue I, Kawagoe T, Ishihara M,

Shimatani Y, Nishioka K, et al. Myocardial perfusionand fatty acid metabolism in patients with tako-tsubo-like left ventricular dysfunction. J Am Coll Cardiol2003;41(5):743-8.13. Penas-Lado M, Barriales-Villa R, Goicolea J.Transient left ventricular apical ballooning andoutflow tract obstruction. J Am Coll Cardiol2003;42(6):1143-4.14. Park JH, Kang SJ, Song JK, Kim HK, Lim CM,Kang DH, et al. Left ventricular apical ballooning dueto severe physical stress in patients admitted to themedical ICU. Chest 2005;128(1):296-302.15. Sharkey SW, Lesser JR, Zenovich AG, MaronMS, Lindberg J, Longe TF, et al. Acute and reversiblecardiomyopathy provoked by stress in women fromthe United States. Circulation. 2005;111(4):472-9.16. Yoshioka T, Hashimoto A, Tsuchihashi K, NagaoK, Kyuma M, Ooiwa H, et al. Clinical implicationsof midventricular obstruction and intravenouspropranolol use in transient left ventricular apicalballooning (Tako-tsubo cardiomyopathy) Am Heart J2008;155(3):526.e1-7.

17. Ohba Y, Takemoto M, Nakano M, YamamotoH. Takotsubo cardiomyopathy with leftventricular outflow tract obstruction. Int J Cardiol2006;107(1):120-2.

CME Questions 1a-cPlease select the best answer for the following:

A 66-year-old woman presented to emergency withleft-sided chest pain. The pain started when she wasat the funeral ceremony of her mother. The initialEKG showed upsloping ST-T wave in V2-V4. Herinitial troponin I was elevated with normal CK andCK-MB. Her vitals were stable and cardio-respiratoryexamination was WNL. She was started on aspirin,heparin, beta blockers and eptifibatide. Transthoracicecho was done which revealed EF of 35% with regionalwall motion abnormalities in apical and anteroapicalregion. Subsequently coronary angiography was donewhich revealed normal coronaries. Left ventriculogramshowed calculated EF of 30% with apical hypokinesisand hyperkinesis of basal walls. She was discharged after48 hrs on aspirin and metoprolol with improvement inher symptoms.

1a. The discharge diagnosis of this patient would be: a. NSTEMI b. Transient LV apical ballooning (Takotsubo

cardiomyopathy) c. LV aneurysm d. Transmural MI e. None of the above

1b. Possible etiologies for the discharge diagnosisinclude:

a. Transmural ischemia due to coronary arteryembolization

b. MI c. Catecholamine excess d. Chest trauma

1c. Follow up echocardiogram in four weeks wouldmost likely demonstrate the following:

a. Persistent ballooning of the LV apex

b. Anterior wall motion abnormality c. Severe mitral regurgitation d. Normal LV function without wall motion

abnormalities

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IntroductionThe Veterans Health Administration (VHA)* isthe largest healthcare provider in the world. Anorganization that represents the greatest potentialfor providing healthcare for the 11 million veteranswho served in the armed forces, the VHA provides

inpatient and outpatient care between 171 medicalcenters, 354 outpatient clinics and 119 nursing homecare units. The VHA is divided into 22 componentstermed Veterans Integrated Service Network (VISN).The VA Illiana Healthcare System (VAIHCS) locatedin Danville, IL, serves veterans from central Illinoisand west central Indiana. The VAIHCS is a part ofVISN 11 which serves central Illinois, Indiana andmost of Michigan.1,2

Local VHA ServicesThe VHA system faces a daunting new challengein meeting the unique needs of the OperationEnduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. In addition to the 30,000 veteransalready served, VAIHCS has developed a specializedmulti-disciplinary team to manage the distinctiverequirements of our newest returning veterans. TheVAIHCS consists of one main campus located inDanville, IL with four community-based outpatientclinics (CBOC): Decatur, Springfield and Peoria, ILand West Lafayette, IN. (Figure 1) Inpatient servicesprovided at the Danville campus are psychiatry,

rehabilitation, palliative care, medical, surgical andlong-term care. In addition, VAIHCS has a largeprimary care service and several subspecialty services.Tertiary services are referred to the Richard RoudebushVA Medical Center in Indianapolis, IN.

The VHA is committed to providing efficient, high-quality care to the returning OEF/OIF veterans. As

of December 2006 over one million soldiers havereturned from overseas and are eligible to receivehealthcare within the VHA. Nationally the VHAhas already provided care for over 260,000 of them.Locally, VAIHCS has provided healthcare to over1300 veterans who have been discharged from militaryservice. Prevalent concerns for this new generation ofveterans include psychiatric issues, traumatic braininjury (TBI), and polytrauma.2

The Veteran Health Administrations Response to Meetingthe Unique Needs of the Returning Operation EnduringFreedom/Operation Iraqi Freedom Veteran

8 Carle Selected PapersVol. 52 No. 1 The Veteran Health Administrations Response to Meeting the Unique Needs

of the Returning Operation Enduring Freedom/Operation Iraqi Freedom Veteran

Richard N. Jones, MS, PA-C; Hillary Tharp, MSW, LCSW; William P. Marshall, MD

V ACentral OfficeWashington D.C.

VBAVeterans BenefitsAdministration

VHAVeterans HealthAdministration

Each State has aVeterans

Affairs Regional Office

1-800-827-1000

VISN 11Veterans in Partnership

1-734-222-4300

IL Veterans AffairsRegional Office

Chicago

VA IllianaHealthcare System

1-217-554-5121

Bob Michel VA Outpatient Clinic-Peoria, Illinois

Springfield Outpatient Clinic-Springfield, Illinois

Decatur Outpatient Clinic-Decatur, Illinois

West Lafayette Outpatient Clinic-West Lafayette, Indiana

For questions in reference to OEF/OIF Veterans

contact Hilary Tharp LCSW, OEF/OIF Program Manager

1-217-554-5121

*For the readers convenience a table of acronymsappears on page 10. (Table 4)

Figure 1.


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Richard Jones, MS, PA-C is a physician assistant at theIlliana Veterans Healthcare System in Danville, IL.Hillary Tharp, LCSW is the Operation Enduring Freedom/Operation Iraqi Freedom Program Manager at the IllianaVeterans Healthcare System in Danville, IL.

William Marshall, MD is a physician at the Illiana VeteransAffairs Hospital in Danville, IL and is Associate Chief ofStaff for Education and Research.

Acknowledgement: The authors would like to thankMrs. Debra Gouard and Mr. Blake Jones for theirefforts in preparing this manuscript.

The opinions expressed in this manuscript are the

authors and do not reflect the opinion or policies of

the VA Illiana Health Care System or the VHA.

References1. Rivers PA, Glover SH, Agho A. Emergingfactors shaping the future of the Veterans HealthAdministration. Health Serv Manage Res2002;15(1):27-39.2. Martin Em, Lu WC, Helmick K, French L,Wanden DL. Traumatic brain injuries sustainedin the Afghanistan and Iraq Wars. Am J Nurs2008;108(4):40-6.3. Wanden D. Military TBI during the Iraqand Afghanistan wars. J Head Trauma Rehabil2006;21(5):398-402.4. Doll D, Bowley DM. Veterans health-surviving acute injuries is not enough. Lancet2008;371(9618):1053-5.5. Ciechanowski P, Keaton W. Overview of posttraumatic stress disorder. Retrieved from www.uptodate.com on June 30, 2008.6. Sigford BJ. To care for him who shall haveborne the battle and for his widow and his orphan.(Abraham Lincoln): The Department of VeteransAffairs polytrauma system of care. Arch Phys MedRehab 2008;89(1):160-2.

7. Lew HL, Poole JH, Guillory SB, Salerno RM,Leskin G, Sigford B. Persistent problems aftertraumatic brain injury: the need for long-termfollow-up and coordinate care. J Rehabil Res Dev2006;43(2):vii-x.

11 Carle Selected PapersVol. 52 No. 1 The Veteran Health Administrations Response to Meeting the Unique Needs of

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Abstract

Thyroid nodules are common and treatment modali-ties range from observation to surgical resection.Because thyroid nodules are frequently found inciden-tally during routine physical examination or imagingperformed for another reason, physicians from a diverserange of specialties encounter this condition. Clinical

decision-making depends on proper evaluation ofthe thyroid nodule, which is described herein. Onlya small percentage of thyroid nodules require surgi-cal management. Diagnosis and treatment selectionrequire risk stratification by history, physical exami-nation and ancillary testing. Nodules causing airwaycompression or those at high risk for carcinoma shouldprompt evaluation for surgical treatment. In noduleslarger than 1 cm, fine-needle aspiration biopsy iscentral to the evaluation as it is accurate, low risk andcost effective. Subcentimeter nodules, usually foundincidentally on imaging obtained for another purpose,

can usually be evaluated by ultrasonography. Otherlaboratory and imaging evaluations have specific andmore limited roles. An algorithm for the evaluation ofthe thyroid nodule is presented.

Introduction

Fundamental to evaluation of the thyroid nodule isdifferentiating medical from surgical disease. Althoughnot mutually exclusive, five categories of thyroidnodules classify this broad spectrum of pathologyhyperplastic, colloid, cystic (containing fluid),inflammatory, and neoplastic, with the last being the

most feared. The indications for surgical managementof the thyroid are suspicion of malignancy, compressivesymptoms, hyperthyroidism, airway control (for acompressive goiter or anaplastic carcinoma), andcosmesis. Clinically significant airway compression,even for a benign goiter, indicates consideration ofsurgical treatment because with time, the thyroid willlikely grow, and in so doing will make delayed surgerymore technically difficult and risky. In contrast, primarytherapy for clearly benign noncompressive thyroid

lesions, such as a toxic multinodular goiter, remainsmedical, as the surgical risks to the parathyroids andrecurrent laryngeal nerves are much greater thanthe risks of medical therapy. The steps leading toa decision for operative intervention are the mostinvolved when evaluating a nodule with potentialfor malignancy. The challenge is largely because

thyroid nodules are common, yet thyroid carcinomais not. In the United States, approximately 275,000new thyroid nodules are detected each year, butonly 1 in 20 palpable nodules is malignant, andthe annual incidence of clinically detected thyroidcarcinoma is only 2 to 4 per 100,000 population.This knowledge alone may be of some comfort to thepatient whose asymptomatic nodule was unexpectedlyidentified by imaging, an operation, or routine physicalexamination. Nevertheless, three quarters of thyroidcarcinomas are asymptomatic. About 5% of adultsin the United States have a palpable thyroid nodule.

Nodules become more common as age increasesand as iodine intake decreases, and they occur morefrequently in women. Palpation of a small or deepnodule may be subtle and missed if the exam iscursory. Including nonpalpable nodules detectedby ultrasonography, nodule prevalence increasesfrom 30% in patients younger than 50 years of ageto 50% in patients greater than 60 years of age.Due to anatomic factors, approximately 90% of allthyroid nodules are not palpable. Furthermore, halfof patients with clinically apparent solitary nodulesare found to have nonpalpable multinodular goiters

on ultrasonography or surgical thyroidectomy. Anearlier perception that solitary nodules are more likelymalignant than a nodule within a multinodular goiteris now replaced with a general acceptance that therisk of cancer is similar in patients with solitary ormultiple nodules. Other types of nodules previouslyconsidered to be of low risk for cancer (long-standingnodules, nodules present in the hyperthyroid patient,and cystic lesions) have also been demonstrated tohave at least an average risk of cancer. Evaluating the

Evaluation of the Thyroid Nodule

12 Carle Selected PapersVol. 52 No. 1 Evaluation of the Thyroid Nodule

original researchChristopher Lansford, MD, FACS


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1 Carle Selected PapersVol. 44 No. 1 4 Carle Selected PapersVol. 50 No. 2 Basal/Bolus Insulin is Superior to Prevalent Methods of Diabetes Management


Table 1. Clinical Indicators of Thyroid Carcinoma Risk and Surgical IndicationFindings Risk Remarks

MEN 2/RET protooncogene mutation High Prophylactic total thyroidectomy indicated

Airway compression High Iodine ablation usually ineffective

Vocal cord paralysis High Preoperative FNA useful for counseling and preparation

History of neck irradiation High History may reveal exposure

Pediatric or elderly patient High Preoperative FNA optional

FNA read as malignancy High FNA is 80% accurate overall

FNA read as follicular neoplasm High FNA cannot distinguish follicular adenoma vs carcinoma;surgery recommended

Metastatic disease on isotope scan High Pathognomonic for carcinoma

Rapid growth over days/weeks Moderate-high Consistent with neoplasm

Cystic nodule Moderate Malignancy rate is double that for solid nodules, but FNAis often inaccurate

FNA non-diagnostic more than once Moderate Evaluate technique, consider other risk factors andsurgery

Euthyroid state Moderate See text

Rapid growth over hours Moderate Suggests hemorrhage and 10% chance of cancer

Male gender Moderate A nodule is twice as likely to be cancer in men

Neck lymphadenopathy Moderate Consider other causes, consider thyroglobulin andcalcitonin assay of lymph node FNA

Hot or cold nodule on isotope scan Low See Figure and text

Hyper- or hypothyroid state Low Consider medical thyroidopathies

Figure 1.

Algorithm for evaluation of the thyroid nodule. Surgery broadly includes open biopsy (eg, to obtain tissue for diagnosis

if needed), partial and total thyroidectomies. VMA = vanillylmandelic acid, PTH = parathyroid hormone level, RAI =

radioactive iodine, Ca++ = calcium level.

* FNA is used on nodules >1 cm in maximal dimension. Subcentimeter nodules may be observed, including yearly

serial ultrasonography, or biopsied if suspicious.

Verify hypothyroidism with T4 and T3.

A vasoactive tumor or primary hyperthyroidism alters the surgical plan.


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Furthermore, one third of these nonpalpable noduleswere greater than 20 mm in diameter, underscoringlimitations of palpation. Following initial evaluation,the use of selected radiographic studies can be helpfulin managing thyroid masses. Specifically, thyroidultrasound (US) is an invaluable instrument inevaluating thyroid nodular disease. It is noninvasive,

may be more readily available than the FNAB in aprimary care setting, and provides information thatmay suggest malignancy or benign disease. If thelesion is less than 1 cm in maximal dimension, USis helpful for serial measurements during a period ofconservative observation. Alternatively, if the lesionis greater than 1 cm but not palpable, US can guide anFNAB, reducing the incidence of missing the nodule.While nodule size is not predictive of malignancy,the use of 1 cm as a size threshold for use of FNABis based on the indolent process of most thyroidcarcinomas and the lack of evidence suggesting that

treatment of subcentimeter microcarcinomas improvesoutcomes. Ultrasound can also evaluate the thyroidbed for local recurrence after treatment. In addition,ultrasonography is accurate in identifying metastaticneck and paratracheal lymph nodes. Although certainsonographic findings such as hypoechogenicity, solidcomposition, microcalcifications, irregular or ill-defined margins, an absent sonolucent rim (or halo),evidence of invasion or regional lymphadenopathy,and Doppler evidence of increased blood flow in thecenter of the nodule are associated with an increasedrisk of malignancy, US usually cannot distinguishbetween benign and malignant lesions accurately.Since the vast majority of papillary microcarcinomasdo not grow during long-term follow-up and donot become clinically significant thyroid carcinoma,modalities that increase test sensitivity could increaseunnecessary worry and intervention significantly bylowering specificity. Thus, using screening US mayincrease detection of microadenomas but may notimprove patients outcomes. However, when USfindings suggest carcinoma, further evaluation by FNABis indicated. While US is commonly needed, unless it

is indicated for one of the above reasons, its use addscost and time to the evaluation, potentially delayingtherapy without adding benefit. Unfortunately, UScannot penetrate bone and is thus unable to evaluatesubsternal nodules. Ultrasound can be used to followa nodule found incidentally by another method, suchas computed tomography (CT) or magnetic resonanceimaging (MRI), when it cannot be palpated. Whenindicated, CT or MRI can be used to image thesubsternal thyroid. A thyroid incidentaloma is a

nonpalpable thyroid nodule found incidentally insurgery or by imaging studies performed for anotherpurpose. The high prevalence of thyroid nodulesand the low individual risk, as described above,make the management of incidentalomas both routineand potentially challenging. Inspection for locallyaggressive characteristics and metastatic nodes on the

original imaging study may help stratify risk. Nodulesgreater than 1 cm generally need some intervention,such as FNAB, depending on other risk factors. (Figureand Table) Routine use of CT or MRI is not indicatedin the evaluation of a thyroid nodule, but each isuseful in selected circumstances. Either CT or MRIcan accurately determine substernal extension andinvasion of surrounding structures, such as esophagus,larynx, or trachea, and should be used only if invasionor substernal extension is suspected. Although morereadily available at most centers, CT imaging withcontrast dye delivers an iodine load that can delay

postoperative thyroid scanning for 4 to 8 weeks andcan also cause a subclinically hyperthyroid patient toenter thyroid storm; thus, it should be avoided whenpossible.13,24,52-59

Isotope Scanning:Although many patients with thyroidnodules undergo radioactive iodine or technetium 99(99 mTC) scanning, there are few modern indicationsfor its use. Ninety-five percent of nodules are coldon radioactive iodine scanning. The frequency ofmalignancy in cold nodules is 1015% vs 4% in hotnodules. Thus, both hot and cold nodules are likely tobe benign, and malignancy is only slightly more likely incold than hot nodules. This test is therefore not helpfulin discriminating benign from malignant nodulardisease. Furthermore, in a series of 158 consecutivepatients with papillary thyroid carcinoma wherethyroidectomy was preceded by radioactive iodineimaging, 41% had no lesion identified on scanning.Indications for radioactive iodine scanning include usein the hyperthyroid patient, as it can help differentiatebetween a toxic nodule greater than 1 cm in maximaldimension and the diffuse pattern in Graves disease.

Additionally, when Hashimotos is suspected, someclinicians use radioactive iodine scanning to evaluatea nodule because a small, firm lobe of Hashimotoscan otherwise be misdiagnosed as a nodule. Thisfinding would circumvent the need for an FNABwith its high false-positive rate in this condition. Theability of isotope scanning to detect metastatic disease(when the cancer is iodine-avid) may be the greatestdiagnostic utility of this modality. Occasionally, apatient may be referred for an incidental thyroid



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recommended only for nodules identified as benign byFNAB in the hyperthyroid patient. Thyroglobulin hasno preoperative role. A proposed evaluation algorithmis presented in the Figure.

Christopher Lansford, MD, FACS is a surgeon specializingin OtolaryngologyHead & Neck Surgery and Facial Plasticand Reconstructive Surgery at Carle Clinic Association,Urbana, IL.

References1. Salab GB. Pathogenesis of thyroid nodules:histologic classification? Biomed Pharmacother2001;55(1):39-53.2. Castro MR, Gharib H. Thyroid nodules and cancer:when to wait and watch, when to refer. Postgrad Med2000;107(1):113-24.3. Mazzaferri EL. Thyroid cancer in thyroid nodules:finding a needle in the haystack. Am J Med1992;93(4):359-62.4. Singer PA, Cooper DS, Daniels GH, Ladenson PW,Greenspan FS, Levy EG, et al. Treatment guidelinesfor April 2006, patients with thyroid nodules andwell-differentiated thyroid cancer. American ThyroidAssociation. Arch Intern Med 1996;156(19):2165-72.5. Wong CK, Wheeler MH. Thyroid nodules: rationalmanagement. World J Surg 2000;24(8):934-41.6. Meko JB, Norton JA. Large cystic/solid thyroidnodules: a potential false-negative fine-needleaspiration. Surgery 1995;118(6):996-1004.7. Brander A, Viikinkoski P, Nickels J, Kivisaari

L. Thyroid gland: US screening in a random adultpopulation. Radiology 1991;181(3):683-7.8. Tan GH, Gharib H, Reading CC. Solitarythyroid nodule. Comparison between palpationand ultrasonography. Arch Intern Med1995;155(22):2418-23.9. Burguera B, Gharib H. Thyroid incidentalomas.Prevalence, diagnosis, significance, and management.Endocrinol Metab Clin North Am 2000;29(1):187-203.10. McCall A, Jarosz H, Lawrence AM, PaloyanE. The incidence of thyroid carcinoma in solitarycold nodules and in multinodular goiters. Surgery

1986;100(6):1128-32.11. Blum M, Hussain MA. Evidence and thoughtsabout thyroid nodules that grow after they have beenidentified as benign by aspiration cytology. Thyroid2003;13(7):637-41.12. Belfiore A, La Rosa GL, La Porta GA, GiuffridaD, Milazzo G, Lupo L, et al. Cancer risk in patientswith cold thyroid nodules: relevance of iodineintake, sex, age, and multinodularity. Am J Med1992;93(4):363-9.

13. Nam-Goong IS, Kim HY, Gong G, Lee HK,Hong SJ, Kim WB, et al. Ultrasonography-guidedfine-needle aspiration of thyroid incidentaloma:correlation with pathological findings. ClinEndocrinol (Oxf) 2004;60(1):21-8.14. Belfiore A, Garofalo MR, Giuffrida D, Runello F,Filetti S, Fiumara A, et al. Increased aggressiveness of

thyroid cancer in patients with Graves disease. J ClinEndocrinol Metab 1990;70(4):830-5.15. de los Santos ET, Keyhani-Rofagha S,Cunningham JJ, Mazzaferri EL. Cystic thyroidnodules. The dilemma of malignant lesions. ArchIntern Med 1990;150(7):1422-7.16. McHenry CR, Slusarczyk SJ, Khiyami A.Recommendations for management of cystic thyroiddisease. Surgery 1999;126(6):1167-72.17. Hegeds L. The thyroid nodule. N Engl J Med2004;351(17):1764-71.18. King AD, Ahuja AT, King W, Metreweli C.

The role of ultrasound in the diagnosis of a large,rapidly growing, thyroid mass. Postgrad Med J1997;73(861):412-4.19. Hung W. Solitary thyroid nodules in 93 childrenand adolescents. A 35-years experience. Horm Res1999;52(1):15-8.20. Raab SS, Silverman JF, Elsheikh TM, ThomasPA, Wakely PE. Pediatric thyroid nodules: diseasedemographics and clinical management as determinedby fine needle aspiration biopsy. Pediatrics1995;95(1):46-9.21. Black BM, Hayles AB, Kennedy RL, Woolner LB.

Nodular lesions of the thyroid gland in children. JClin Endocrinol Metab 1956;16(12):1580-94.22. Rallison ML, Dobyns BM, Keating FR Jr, RallJE, Tyler FH. Thyroid nodularity in children. JAMA1975;233(10):1069-72.23. Shapiro NL, Bhattacharyya N. Population-based outcomes for pediatric thyroid carcinoma.Laryngoscope 2005;115(2):337-40.24. Harvey HK. Diagnosis and management of thethyroid nodule. An overview. Otolaryngol Clin NorthAm 1990;23(2):303-37.25. Rojeski MT, Gharib H. Nodular thyroiddisease. Evaluation and management. N Engl J Med1985;313(7):428-36.26. Hamming JF, Goslings BM, van Steenis GJ, vanRavenswaay Claasen H, Hermans J, van de Velde CJ.The value of fine-needle aspiration biopsy in patientswith nodular thyroid disease divided into groups ofsuspicion of malignant neoplasm on clinical grounds.Arch Intern Med 1990;150(1):113-6. Erratum in:Arch Intern Med 1990;150(5):1088.



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of Medicine called for vast improvements in chroniccare delivery and coordination. The Centers forMedicare & Medicaid Services (CMS), through thefee-for-service (FFS) Medicare program, have initiatedprograms that are testing different delivery modelswhich emphasize the use of evidence-based practicefor selected chronic diseases based on the principles of

case and disease management that the FFS Medicareprogram does not provide. One such program is theMedicare Coordinated Care Demonstration (MCCD).The CMS selected 15 sites to test whether this typeof care coordination approach, using a prospective,randomized clinical trial design, could improve patientoutcomes without increasing costs for beneficiarieswith complex medical problems. Carle FoundationHospital, Urbana, Illinois, was selected as an MCCDsite and began enrolling patients in April, 2002. TheMCCD study protocol was approved by the Carle IRB(01-25).22,23

The Carle MCCD targets patients with diagnosestypically associated with high healthcare costs.Eligible applicants are Medicare recipients who livein a 13-county service area (11 Illinois and twoIndiana counties) and have one or more of thefollowing chronic conditions: atrial fibrillation (Afib),CHF, CAD, chronic obstructive pulmonary disease/asthma (COPD), or diabetes mellitus (DM). Thepurpose of Carles MCCD is to evaluate whether amultidisciplinary, coordinated primary care approachcan improve medical treatment plans, reduce avoidablehospital admissions, and promote self-care behaviorsand clinical health status outcomes without increasingprogram costs. The intervention, based on the corecomponents of the Chronic Care Model, providescare and disease management services to patientsfrom primary care teams comprised of primary carephysicians (PCP), registered nurses, and patients.24-26

A primary focus of the intervention is to develop thepatients ability to self manage their chronic condition(s)with support from a nurse case manager (NCM) viaassessment, planning, education, coordination, andpsychosocial support. Patient, NMC and PCP decision

supports include having access to appropriate bloodtests, trended reports of laboratory test results andother health measures, and disease specific, evidence-based medical and nursing guidelines maintainedby a board of MCCD Medical Directors. Electronicclinical information systems allow for timely accessto individual patient and panel information, andthe tracking of patient contacts and interventions.On average, each NCM has a caseload of 150200patients.

Research Questions:This study addressed the following research questions:1. What are the characteristics (demographic, health

and clinical status, service utilization) of MCCDpatients in the intervention group with CHF whowere hospitalized at Carle Foundation Hospital atleast once during the study period?

2. What characteristics (demographic, health andclinical status, service utilization) are predictive ofhospital readmissions for MCCD patients in theintervention group with CHF?

3. What characteristics (demographic, health andclinical status, service utilization) are predictiveof all-cause mortality for MCCD patients in theintervention group with CHF?

Study DesignA retrospective analysis (medical record review) of arandomized clinical trial.

Study SampleThe study sample consisted of all patients whovoluntarily enrolled in the Carle MCCD between April19, 2002, and April 30, 2003, and met the followingcriteria: (1) were randomized into the interventiongroup; (2) had a verified diagnosis of CHF, indicatedin their medical record or by their PCP; and (3) werehospitalized one or more times at Carle FoundationHospital between April 19, 2002 through the end ofDecember, 2005. A total of 191 intervention patientswere hospitalized at least once during the studyperiod, and 125 were hospitalized at Carle FoundationHospital. The study group consisted of 120 (96%) ofthese identified patients; two patients had incompleteutilization information, and three could not be locatedin Carles electronic medical record (EMR) system.

Data Collection and MeasurementThe data analyzed in this study included Medicare claimsand utilization files for hospital admissions, emergencydepartment (ED) visits, nursing home admissions,and physician visits; the Medicare common working

file for mortality; patient self-reported conditions andbackground information collected at enrollment (age,gender, name of PCP, marital status, race, educationalattainment, living arrangement, self-rated health,limitations in activities of daily living, other healthconditions, preventive health behaviors, and numberof daily prescription medications); medical recordreview for the verified health conditions necessary forenrollment; and detailed patient hospital information(dates of admission and discharge, type of admission,and disposition status at discharge).

24 Carle Selected PapersVol. 52 No. 1 Characteristics of Congestive Heart Failure Patients Hospitalized

at Carle Foundation Hospital Enrolled in the Carle Medicare Coordinated Care Demonstration


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These patients had high utilization patterns in theprevious year before enrolling in the MCCD; 49% hadbeen hospitalized at least once, 28% had experiencedmultiple hospitalizations, 51% had at least one EDvisit, and 12% had at least one admission to a nursinghome. Surprisingly, 30% had not seen a physician inthe past 12 months.

Table 2 displays the overall health service utilizationpatterns of the 120 patients during the study period.Patients were enrolled an average of 30 months.

During this time period 66% (N=79) experienced twoor more hospitalizations with 53% (N=63) hospitalizedat Carle Foundation Hospital. They averaged threehospitalizations per person for a total of 11 hospitaldays. Other utilization measures were also high: 68%had at least one ED visit for an average of 2.1 visitsper person, and 34% had at least one nursing home

admission. Each patient averaged eight physician visitsduring the study period.



Table 3 displays the results of the EMR reviewsconducted by the physician co-investigators. Over50% of admissions came through the ED. The patientsweight at either admission or discharge was almostnever documented for any hospitalization, and rarelywas the patients ejection fraction documented (about10% of the time). Documentation was also missing

(over 80% of the time) noting a scheduled physicianfollow-up appointment after discharge. However, over70% of patients had a follow-up visit about 10 days

after hospital discharge. For those individuals whohad a second hospitalization, their average time toadmission was approximately six months, but 22% werere-hospitalized within 30 days. For those individualswho had a third hospitalization, their average timefrom second hospital discharge to admission was sevenmonths, but 41% were re-hospitalized within 30 days.

At the follow-up visit after hospital discharge thepatients physician seldom adjusted or changed theirmedication regime.

Characteristics Values

Months Enrolled in the Study Period, mean SD 29.7 13.1

Health Service Utilization, N (%):

2 Hospitalizations 79 (65.8)

2 Hospitalizations at CFH 63 (52.5)

Hospitalizat ions/person, mean SD 2.7 2.1

Hospital Days/person, mean SD 11.4 11.2

Any ED Visits 81 (67.5)

ED Visits/person, mean SD 2.1 2.9

Any Nursing Home Admissions 41 (34.2)

Nursing Home Days/person, mean SD 11.7 23.6

Any Home Health Visits 48 (40.0)

Home Health Visits/person, mean SD 5.7 11.9

Physician Visits/person, mean SD 7.9 10.0

Table 2. Health Service Utilization Characteristics of MCCD Intervention

Patients with CHF Who Were Hospitalized One or More Times at Carle

Foundation Hospital During the Study Period

Notes: N = number; % = percentage; SD = standard deviation


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Research Question 2: What characteristics (demographic,

health and clinical status, service utilization) are

predictive of hospital readmissions for MCCD patients

in the intervention group with CHF?A total of 63 individuals (53%) were hospitalized twoor more times at Carle Foundation Hospital duringthe study period. These patients averaged 3.6 + 2.2hospitalizations (range 211), and 15.3 + 12.6 hospitaldays (range 270). Results of the logistic regression

model predicting significant characteristics for hospitalreadmissions are shown in Table 4. Patients on BetaBlockers at the time of their first hospital discharge had

a 61% reduction in the likelihood of readmission (oddsratio [OR], 0.39; 95% confidence interval [CI], 0.15 0.98; P= .048), and patients that had a follow-up visitwith their physician after their first hospital dischargehad a 6% reduction in the likelihood of readmission(OR, 0.94; 95% CI, 0.89 0.99; P= .012).

Characteristics First Second Third Hospitalization Hospitalization Hospitalization

N Patients 120 63 29Age at Hospitalization, mean SD 77.6 9.0 77.6 9.2 75.2 8.7

Age 80, N (%) 47 (39.2) 26 (41.3) 9 (31.0)

Urgent Admission, N (%) 95 (79.2) 51 (81.0) 23 (79.3)

ED Admission, N (%) 67 (55.8) 36 (57.1) 18 (62.1)

Hospital Days/person, mean SD 3.9 3.1 4.8 4.0 4.9 4.5

Discharge Status, N (%):

Home 78 (65.0) 40 (63.5) 18 (62.1)

Inpatient Mortality 3 (2.5) 4 (6.3) 2 (6.9)

Nursing Home 27 (22.5) 13 (20.6) 8 (27.5)

Unknown 10 (8.3) 6 (9.5) 1 (3.4)

Patient Weight, N (%):

Documented at Admission 2 (1.7) 0 (0) 0 (0)

Documented at Discharge 0 (0) 0 (0) 1 (3.4)Documentation of Ejection Fraction, N (%): 16 (13.3) 7 (11.1) 3 (10.3)

Medications, N (%):

Documented Taking ACE Inhibitor at Discharge 75 (62.5) 34 (54.0) 16 (55.2)

Documented Taking Beta Blocker at Discharge 56 (46.7) 29 (46.0) 17 (58.6)

Hospital Discharge on Weekend, N (%) 45 (37.5) 27 (42.9) 17 (58.6)

Physician Follow-up Appointment Documented, N (%) 17 (14.2) 12 (19.0) 3 (10.3)

Physician Follow-up Appointment Status, N (%):

Cancelled 1 (1.0) 2 (3.2) 0 (0)

Completed 85 (70.8) 47 (74.6) 20 (69.0)

Deceased (In Hospital or Before Appointment) 6 (5.0) 3 (4.8) 3 (10.3)

Missed (No Show) 2 (1.7) 1 (1.6) 0 (0)

Never Scheduled 9 (7.5) 2 (3.2) 1 (3.4)

Rehospitalized Before Appointment 15 (12.5) 3 (4.8) 4 (13.8)

Days to Visit, mean SD 11.1 8.9 10.4 9.9 9.0 5.9

Medications Changed or Adjusted 17 (14.2) 7 (11.1) 1 (3.4)

Days to Next Hospitalization, mean SD 182 233 221 311


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Research Question 3: What characteristics (demographic,health and clinical status, service utilization) are

predictive of all-cause mortality for MCCD patients in

the intervention group with CHF?

A total of 42 individuals (35%) died during the studyperiod. These patients were enrolled in the MCCD foran average of 20 months. Results of the Cox proportionalhazard model predicting significant characteristics of all-cause mortality are shown in Table 5. Patients on ACEInhibitors at the time of their first hospital dischargehad a 58% reduction in the likelihood of all-causemortality (hazard ratio [HR], 0.42; 95% CI, 0.20 0.88;

P= .022), and patients on Beta Blockers at the time oftheir first hospital discharge also had a 58% reductionin the likelihood of all-cause mortality (HR, 0.42; 95%CI, 0.21 0.86; P= .018). Patients that had a follow-up visit with their physician after their first hospitaldischarge had an 8% reduction in the likelihood ofall-cause mortality (HR, 0.92; 95% CI, 0.87 0.97;P = .004), and patients who were discharged to anursing home after their first hospitalization had a 98%increase in the likelihood of all-cause mortality (HR,1.98; 95% CI, 1.04 3.79; P= .039).

Characteristics Hazard Ratio 95% Confdence

PValue Interval

Age 80 Years at First Hospitalization 0.95 0.47 1.93 .896

Male 0.74 0.37 1.47 .389

COPD 0.61 0.27 1.38 .231

Taking ACE Inhibitor at First Hospital Discharge 0.42 0.20 0.88 .022

Taking Beta Blocker at First Hospital Discharge 0.42 0.21 0.86 .018

First Hospital Discharge on Weekend 0.78 0.38 1.58 .486

Nursing Home Admission at First Hospital Discharge 1.98 1.04 3.79 .039

Patient Follow-up Physician Visit After First Hospital Discharge 0.92 0.87 0.97 .004

Table 5. Cox Proportional Hazard Results of Characteristics Predictive of All-cause Mortality of MCCD

Intervention Patients with CHF

Characteristics Odds Ratio 95% Confdence

PValue Interval

Age 80 Years at First Hospitalization 0.59 0.24 1.45 .252

Male 0.89 0.41 1.94 .769

COPD 0.84 0.33 2.12 .709

Taking ACE Inhibitor at First Hospital Discharge 0.65 0.26 1.62 .352

Taking Beta Blocker at First Hospital Discharge 0.39 0.15 0.98 .048

First Hospital Discharge on Weekend 1.24 0.54 2.82 .616

Any Nursing Home Admission 2.21 0.94 5.18 .068

Patient Follow-up Physician Visit After First Hospital Discharge 0.94 0.89 0.99 .012

Total Months Enrolled in the MCCD 1.03 1.00 1.07 .051

Table 4. Logistic Regression Results of Characteristics Predictive of Multiple Hospital Admissions of MCCD

Intervention Patients with CHF


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study outcomes. A second limitation was that we onlyabstracted information from the patients EMR, anddid not review paper copies of the clinic or hospitalrecord. Some of the non-documented, missing patientinformation may have been contained in these records.A third limitation was that we were limited in theanalysis to only those variables that had been collected

as part of the original study or were readily availablefrom the EMR system. From the EMR we were notable to identify specific diagnoses or conditions thatmight have provided further insight into reasons formultiple hospital admissions and/or mortality. Finally,the results may not be generalizable to other patientpopulations with CHF in different geographical areasor patients hospitalized in different hospitals. Otherhospitals may have different forms or types of EMRsystems that are capable of capturing or trackingdifferent kinds of information.

ConclusionThis retrospective study identified several significantpredictors of multiple hospital admissions and all-causemortality in patients with CHF. The results suggestthat an evidence-based approach to care, especiallythrough medication therapy and regular physicianfollow-up and continuity, can reduce the likelihood ofrepeat hospitalizations and increase survival time. Thefindings highlight the opportunities and difficultiesthat providers face with patient education, symptomidentification, and treatment plan adherence in anincreasing elderly patient population with CHF.

Completed as an Addendum to Carle IRB MedicareCoordinated Care Demonstration Study 01-25

Suma Peter, MD, Department Head, Geriatrics,Carle Clinic, Urbana, IL; Program Director, GeriatricFellowship, Carle Foundation Hospital, Urbana, IL

Nallu Reddy, MD, Fellow in Geriatrics, Carle FoundationHospital, Urbana, IL

Nazneen Hashmi, MD, Fellow in Geriatrics, CarleFoundation Hospital, Urbana, IL

Cheryl Schraeder, RN, PhD, FAAN, Head, HealthSystems Research Center, Carle Foundation Hospital,Urbana, IL; Director, Carle Medicare Coordinated CareDemonstration

Christine Kucera, BFAID, Systems Developer, HealthSystems Research Center, Carle Foundation Hospital,Urbana, IL

Paul Shelton, EdD, Outcomes Analyst, Health SystemsResearch Center, Carle Foundation Hospital, Urbana, IL

References1. Tsao L, Gibson CM. Heart failure: an epidemic ofthe 21st century. Crit Pathw Cardiol 2004;3:194-204.2. Rosamond W, Flegal K, Friday G, Furie K, Go

A, Greenlund K, et al. Heart disease and strokestatistics -2007 update. A Report From the AmericanHeart Association Statistics Committee and StrokeStatistics Subcommittee [published erratum appearsin Circulation 2007;115(5):e172]. Circulation2007;115(5):e69 - e171.3. Gwadry-Sridhar FH, Flintoft V, Lee SD, Lee H,Guyatt GH. A systematic review and meta-analysisof studies comparing readmission rates and mortalityrates in patients with heart failure. Arch Intern Med2004;164(21);2315-20.4. Lee DS, Austin PC, Rouleau JL, Liu PP,

Naimark D, Tu JV. Predicting mortality amongpatients hospitalized for heart failure: Derivationand validation of a clinical model. JAMA2003;290(19):2581-87.5. Levy D, Kenchaiah S, Larson MG, Benjamin EJ,Kupka MJ, Ho KK, et al. Long-term trends in theincidence of and survival with heart failure. N Engl JMed 2002;347(18):1397-402.6. Aghababian RV. Acutely decompensated heartfailure: Opportunities to improve care and outcomesin the emergency department. Rev Cardiovasc Med2002;3(Suppl 4):S3-9.7. Berkowitz R, Blank LJ, Powell SK. Strategies to reducehospitalization in the management of heart failure.Lippincotts Case Manag 2005;10(Suppl 6):S1-15.8. Francis GS, Tang WH. Pathophysiology ofcongestive heart failure. Rev Cardiovasc Med2003;4(Suppl 4):S14-20.9. Fuat A, Hungin AP, Murphy JJ. Barriers toaccurate diagnosis and effective management ofheart failure in primary care: qualitative study. BMJ2005;326(7382):196-201.10. Ezekowitz JA, van Walraven C, McAlister FA,

Armstrong PW, Kaul P. Impact of specialist follow-upin outpatients with congestive heart failure. CMAJ2005;172(2):189-94.11. Bonow RO, Bennett S, Casey DE Jr, GaniatsTG, Hlatky MA, Konstam MA, et al. ACC/AHAclinical performance measures for adults with chronicheart failure: a report of the American College ofCardiology/American Heart Association Task Forceon Performance Measures endorsed by the HeartFailure Society of America. J Am Coll Cardiol2005;46(6):1144-78.




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Average FSG levels and glycemic variability are

also significantly associated with patient dispositionat hospital discharge. Patient places of origin weredetermined, and discharge outcomes were grouped intofour categories: home to home, home to extended carefacility (ECF), ECF to ECF, or death in the hospital.When controlled for age, CCI, APACHE II scoreand hospital diabetes regimen, average FSG values(P = .0167) and glycemic variability (P = .0173)were shown to correlate significantly with dischargedisposition.8

Basal/Bolus Insulin Improves Glycemic

Control and Clinical OutcomesDespite studies demonstrating its limitations, slidingscale insulin (SSI) remains the most popular strategyfor managing diabetes on noncritical care hospitalunits. A recent study at Carle Foundation Hospitalfound that approximately 90% of patients admitted tothe internal medicine service were managed with SSIalone or in combination with a patients home diabe-tes regimen. On the Johns Hopkins University inter-nal medicine service, 40% of diabetic patients man-aged with SSI experienced hyperglycemia, defined as

an FSG > 300 mg/dL, 25% had multiple FSG measure-ments exceeding 300 mg/dL, and 23% experienced atleast one episode of hypoglycemia (FSG < 60 mg/dL). A University of Colorado study found that SSIreturned FSG to the premeal range of 90130 mg/dLin only 12% of over 600 FSG measurements. Finally,there were no differences in glycemic control or clini-cal outcomes for diabetic patients admitted to the fam-ily practice service at the Medical University of SouthCarolina and managed with either SSI alone or SSI incombination with home diabetes medications.11-14

The introduction of rapid-acting insulin analogs such

as insulin lispro (Humalog) and long-acting insulinanalogs such as insulin glargine (Lantus) or insulindetemir (Levemir) permits the use of basal/bolus in-sulin regimens that mimic endogenous insulin releaseby a non-diabetic pancreas. (Figure 3) The pharma-cokinetic properties of insulin analogs allow greaterease and flexibility in titrating doses to the desiredglycemic effect and in principle should result in bet-ter glycemic control than prevalent modes of hospitaldiabetes management.

Figure 1. Figure 2.

Figure 3.

33 Carle Selected PapersVol. 52 No. 1 Glycemic Control and Clinical Outcomes for Patients Admitted to Noncritical Care Hospital Units

P= .02

Insulin effect


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Recent studies demonstrate that basal/bolus insulin issuperior to conventional management of diabetes ongeneral hospital services. In 2005, a group of diabeticpatients (N = 116) admitted to the internal medicineservice at Carle Foundation Hospital were managedwith a basal/bolus insulin regimen utilizing insulinglargine (Lantus) as basal insulin and insulin aspart

(Novolog) as prandial insulin. All ambulatory diabe-tes medications were stopped. Average FSG fell byover 40 mg/dL in the first 24 hours after admission forprotocol-managed patients, a highly and statisticallysignificant improvement (P= .0002) that persisted tohospital discharge (P= .0009). (Table 1) There wasno improvement in glycemic control among a cohortof historical control patients (N = 176) admitted tothe internal medicine service at Carle FoundationHospital during a similar period in 2004 and managedmostly with SSI and patients home diabetes regimens.Hypoglycemia occurred more often in the basal/bolus

insulin protocol group compared to historical controls(4.5% vs 2.2%) but was still quite infrequent. The sixmonth results of a recently completed Carle Founda-tion Hospital diabetes team study also demonstrate thesuperiority of basal/bolus insulin to prevalent diabetesmanagement practices. Average FSG improved by 3050 mg/dL from baseline after the diabetes team assumedresponsibility for diabetes care and implemented basal/bolus insulin management.8-11(Table 2)

Other groups have recently published findings similarto our results. Diabetic patients (N = 130) admittedto the general medicine services at Grady Hospital inAtlanta, Georgia and Jackson Memorial Hospital inMiami, Florida were randomized to management with

SSI or a basal/bolus insulin regimen utilizing insulinglargine and insulin glulisine (Apidra). The averageFSG curves began to separate in favor of basal/bolusinsulin 24 hours after admission, and the difference inaverage FSG between the two groups was statisticallysignificant in favor of basal/bolus insulin by the fourthhospital day. The Northwestern University GlucoseManagement Service implemented a basal/bolus insu-lin protocol on the general surgery service and docu-mented an approximately 20 mg/dL improvement inaverage FSG compared to historical controls that wasstatistically significant. 15-16

Our 2005 study of basal/bolus insulin on generalmedicine appears to be the only one that measuredclinical endpoints. Compared to historical controls,hospital LOS was nearly one day shorter for insulinprotocol managed patients (4.5 vs 3.6 days, P= .02).(Table 3) Hospital charges in 2005 dollars were ap-proximately $1700 less for insulin protocol treatedpatients, though this difference was not statisticallysignificant given the relatively small size of the study.Hospital disposition, the likelihood of discharge tohome or an extended care facility, was no different

between the two groups. Multiple studies now demon-strate that basal/bolus insulin therapy clearly controlshyperglycemia better than typical approaches at dia-betes management on general hospital services, andour groups study at Carle Foundation Hospital foundthat a basal/bolus insulin regimen also shortened hos-pital LOS. 11


Admissions 24 Hour Discharge

Protocol 197 104a,b,c 154 67b 159 62c

Control 166 68a 159 61 166 69

a P= .0051 for comparison of admission finger-stickglucose between groups

b P= .0002 for comparison of 24-hour protocol finger-stickglucose to admission

c P= .0009 for comparison of protocol discharge finger-stickglucose to admission

All other comparisons NS

Table 1. Glycemic Control for Basal/Bolus InsulinProtocol Patients and Historical Control Patients in

the Carle Foundation Hospital Basal/Bolus Insulin

Study (Finger-stick Glucose, Mean SD, mg/dL)

N Before After PValue

Consult Consult

All 268 199 67 159 38 < .0001Surgery 68 185 56 153 35 .0001

Medicine 132 210 72 163 38 < .0001

Table 2. Glycemic Control for Patients on the General

Medicine and Surgery Services at Carle Foundation

Hospital Before and After Management by the Hospital

Diabetes Care Team

Average SD of finger-stick glucose, comparison by t-test with Welch correction


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Hospital Admission as anOpportunity to Improve Ambulatory

Glycemic ControlMany diabetic patients are under suboptimal glycemiccontrol at time of hospital admission. In the CarleFoundation Hospital basal/bolus insulin study, aver-age HbA1c in the insulin protocol group was 7.8%and 35% of patients had an HbA1c equal to or greaterthan 8% within three months of admission. AverageHbA1c for patients admitted to the Carle FoundationHospital general medicine or family practice servicesin 2004 and included in our study of the relationshipsbetween glycemic control and clinical outcomes was7.4%, with 27% of patients presenting with HbA1cequal to or greater than 8%. Finally, patients managedby the Carle Foundation Hospital diabetes team in thefirst six months of the study had an average HbA1c of8.4%, and 49% of these patients had a HbA1c of equalto or greater than 8%.8

Though many diabetic patients are admitted to thehospital with failed ambulatory treatment regimens,these regimens are often continued without modifica-tion when patients are discharged home. In the CarleFoundation Hospital 2004 general medicine and familypractice cohort, over half of patients (84/154, 54.5%)

with HbA1c of equal to or greater than 8% at time ofadmission were discharged on their failed home diabe-tes regimen without any modifications. This may bein part due to perception that patients are unwillingto change diabetes treatment or start insulin while inthe hospital. However, a study of elderly patients (N =57, average age 70 years) admitted to the hospital onoral diabetes medications and in poor glycemic con-trol (average HbA1c 9.7%) found equal acceptancefor continuation of oral medications, changing to atwice daily regimen of NPH insulin, or changing to

basal/bolus insulin therapy. In the outpatient follow-up of the Diabetes and Insulin-Glucose Infusion inAcute MI Study (DIGAMI), 86% of patients in theintensive treatment arm were discharged on four shotsof insulin per day, and 72% were still compliant withtheir insulin regimen a year later. Available studies ofhospitalized diabetic patients with poor glycemic con-

trol demonstrate that they are willing to change theirtreatment regimen and take insulin if necessary. 17,18

One of the prespecified endpoints of the CarleFoundation Hospital diabetes care team study was todetermine the potential for implementing ambulatorybasal/bolus insulin regimens for patients with subop-timal glycemic control prior to hospital admission.A significant majority of patients (80%) agreed to adischarge basal/bolus regimen of insulins aspart andglargine compared to only 50% who were managedwith any type of insulin regimen at time of hospitaladmission (P< .0001). Average HbA1c for the en-

tire group of diabetes team patients for whom mea-surements were available three months after hospitaldischarge (N = 56) improved by 0.7% from admission(P=.011). (Figure 4) Paired measurements at hospitaladmission and three months after discharge were avail-able for 39 patients; HbA1c improved for 32 patients(82%), and the average HbA1c decrease for paireddata points was 1.2%. Only a small number of patientsdischarged on basal/bolus insulin (23, 11.5%) stoppedtheir regimen three months after hospital discharge.8

Figure 4.

Just as basal/bolus insulin was demonstrated to benefitpatients with Type 1 diabetes in the Diabetes Controland Complications Trial, basal/bolus insulin providessignificant clinical benefit for patients with Type 2 dia-betes. In the DIGAMI study, mortality in the inten-


Protocol Control P

Length of Stay 3.6 3.0 4.5 3.4 .02

Disposition (%)

Home 68 75 .23

Extended Care 29 24 .34

Deceased 2 1 .65

Transfer 1

Hospital Charges

(2005 dollars) 13,901 18,323 15,561 19,183 .46

Table 3. Clinical Outcomes for Basal/Bolus Insulin

Protocol Patients and Historical Controls in the

Carle Foundation Hospital Basal/Bolus Insulin Study

P= .011 for comparison


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Introduction

A diagnosis of cancer or other chronic medicalconditions is usually accompanied by change in one ormore areas: emotional, physical, family and social life,lifestyle, and financial. Many of the changes createadditional stress over and above the medical concerns

and do not always resolve with the passage of time.For some patients, the experience of a chronic medicalcondition is permanently life-alteringfor better andfor worse. While accessing the best in available medical care isroutine for most people, it is less likely that they willlook for resources to help with some of the stresses thatare not addressed by their physicians. The services ofpsychiatry and psychology are often recommended onlyif the patient appears to be experiencing significantadverse effects, usually symptoms of depression oranxiety that interfere with daily function. For patientswho experience the common stresses that occurwith medical conditions, support groups are often themain resource available in the community.

One focus of health psychology research over the pastfifteen years has been the experience of chronic illnessfrom the patients perspective; this research includesboth identifying specific factors that enhance well-being or create stress as well patient interventions thatincrease positive experiences and decrease negativeones. Examples of such research areas include:

Quality of life issues such as emotional distress,

social support, and the role of optimism/pessimism in adjustment Issues related to treatment adherence Management of treatment-related symptoms

such as nausea and pain Physiological changes that may affect medical

outcome as a result of psychologically-basedtreatment

This article presents an overview of one particularresearch-based approach, Cognitive-Behavioral Stress

Management (CBSM) developed by Michael Antoni,PhD and colleagues at the University of Miami,Florida. The CBSM protocol has been studied withpatients undergoing treatment for breast cancer,prostate cancer, and HIV/AIDS. This i

Carl Foundation Hospital: vol-52-no-1-full

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