digging up bones - arkmed.org

NUMBER 6 NOVEMBER 2014 • 97

Vol.111 • No. 6 NOVEMBER 2014

Independence County Physicians Reinvent Local Medical Society

DIGGING UP BONES

98 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY VOLUME 111

Arkansas

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Volume 111 • Number 6 November 2014

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104

P E O P L E + E V E N T S 118

108

COMMENTARY

102SANDY JOHNSON, MD

STUDYCASE 112TB or not TB; Don’t Miss The Obvious

by Naveen Patil, MD; Asween Marco, MD; Hamida Saba, MD;

Rohan Samant, MD; Leonard Mukasa, MD

SCIENTIFIC ARTICLE

Jagpal Singh Klair, MD, JS1; Girotra M, MD1,2; Medarametla S, MD3; Shah HR3, MD

Sudden onset abdominal pain and distension: An imaging sparkler

110

116

Is YouTube and Stroke a Bad Liaison?by Harsh Gupta, MD; Kaustubh Limaye, MD;

Konark Malhotra, MD; Rajan Patel, MD; Nathan Taillac, MD; Ju Dong Yang; Archana Hinduja

by CASEY L. PENN

Politics, Healthcare and SpinRobert H. Hopkins, Jr., MD


DIGGING UP BONES

Cover Photo by Robert Seat.

WHAT HAVE WE DONE FOR YOU LATELY? 100DAVID WROTEN, EXECUTIVE VICE PRESIDENT

107


A County Medical Society Rediscovers its PurposePlease pay close attention to the feature

article this month about the Independence

County Medical Society. There was a time

when county medical societies were ac-

tive. It was a way for physicians to social-

ize together, welcome new physicians to the

community and most importantly, to discuss

issues facing the practice of medicine and

provide a means of forming a consensus

in how to respond to those issues. Today,

most of the 58 county medical societies that

existed 30 years ago are dissolved. Only a

handful remain and most of them are virtu-

ally inactive. What an opportunity is being

missed to stay informed and take charge!!

Read the story. So much can be achieved

when community physicians work together

for a common cause.

DAVID WROTENEXECUTIVE VICE PRESIDENT

The rescheduling of hydrocodone combination products (HCPs) from Schedule III to Schedule became effective on October 6. Prior to that, AMS

took several steps to get a feel for the impact and

potential changes that clinics could make to ease

the transition as well as providing a fact sheet

(prepared by the AMA) that went into more detail

about the rule change and changes that needed to

be made.

We also reached out to our new PA/APRN In-

terest Group to determine how this rule would im-

pact what they do for AMA physician members and

patients. The PA/APRN Interest Group is comprised

of physician assistants and advance practice reg-

istered nurses who work for AMS members. The

group is currently only about 40 strong, but grow-

ing. Membership is free and this issue is a good ex-

ample of why the leadership of AMS wanted to form

the group. Many of them currently write prescrip-

tions for HCPs, most frequently it appears, for short

term pain management following surgery. Since

Arkansas law prevents either professions from

writing Schedule II prescriptions, this will place the

responsibility for writing these prescriptions on the

physician. AMS is discussing a potential legislative

solution that would provide an exemption (from the

Schedule II prohibition) for these limited products.

Obviously that cannot happen until 2015.

Contrary to popular belief, Schedule II pre-

scriptions can be issued electronically. The prob-

lem is that both the prescriber’s system and the

dispenser’s system must be “certified.” Appar-

ently, this is not the case for many prescription

systems at this time and until they are upgraded

to a certified systems, electronic prescribing for

Schedule II’s will continue to be elusive.

Peer ReviewMost of you probably know that the Peer Re-

view Fairness Act passed by the Arkansas General

Assembly in 2013 has been challenged in Court by

three well-known hospital systems. The case in in

Circuit Judge Tim Fox’ court. The statute, designed

to improve due process and limit conflicts of inter-

est in peer review proceedings will be defended by

the Arkansas Attorney General. AMS filed a mo-

tion to intervene in the case. While there was no

objection by the plaintiffs and our intervention was

welcomed by the AG’s office, Judge Fox denied the

motion with no explanation.

WHAT HAVE WE DONE FOR YOU LATELY?

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ARKANSAS MEDICAL SOCIETY2014-2015 OFFICERS

Alan Wilson, MD, Crossett President

G. Edward Bryant, MD, West Memphis President-elect

William D. Dedman, MD, CamdenVice President

Omar T. Atiq, MD, Pine BluffImmediate Past President

Chad Rodgers, MD, Little RockSecretary

Frankie Griffin, MD, Van BurenTreasurer

Michael Saitta, MD, Fayetteville Speaker, House of Delegates

Anthony D. Johnson, MD, Little RockVice Speaker, House of Delegates

Dennis Yelvington, MD, StuttgartChairman of the Board of Trustees

David WrotenExecutive Vice President

Nicole RichardsCommunications Coordinator

Jeremy HendersonArt Director

EDITORIAL BOARDFrankie Griffin, MDOrthopedic Surgery

Robert Hopkins, MDPediatrics/Internal Medicine

David Hunton, MDSurgery

Laura Sisterhen, MDPediatrics

Sandra Johnson, MDDermatology

Issam Makhoul, MDOncology

EDITOR EMERITUSAlfred Kahn Jr., MD (1916-2013)

One of our great team members at our clinic introduced me to this acronym and I really like it. Since we are in the middle

of fall sports, including football, I thought this would be a great time to reflect on the team approach to the practice of medicine. When I was a child, my parents encouraged me to play team sports. I learned not only the sport but also so much more. I learned to value working hard and playing hard with others in order to accomplish more. I learned to always give my best since others are relying on me. I still treasure those skills, friendships and memories. Now, as an adult, I am blessed to work with an amazing team at Johnson Dermatology. While it may not be as glamorous as being a professional athlete, it still continues to fulfill a lifelong dream for me.

There is no “I” in team. You may think that as the health care provider, you and I are the only ones who matter. Who knows, you may be right. However, at our clinic we emphasize a team approach. We know that it is important to make the right diagnosis and prescribe the right treat-ment. But there is so much more than that to having a great medical experience. We think that the provider is like the quarterback calling out the plays. We usually get the credit when things go right but also the criticism when things don’t go quite right. We also know that it takes a good offensive line to allow us time to do our job as well as receivers to catch what we throw. It also takes a good defense and special teams. We hope we have good coaches to guide us and fans/people cheering us on. Similar to a coach giving feedback about how to get better, we need our patients to give us feedback. We regularly perform satisfaction surveys in our clinic in hopes that our patients will tell us how to improve. We want to hear their criticisms and critiques. I would much rather our patients tell us when there is a prob-lem instead of telling their friends, by social media or even worse by not returning to our clinic. It is painful to me when I see or hear negative comments about our team or me per-

sonally (which is usually the case or how I take it). But then again growth is never easy. Similar to working out, a little muscle soreness is needed to get stronger.

Also, the patient experience is based on how they con-tact us by phone or online, how they are greeted when they come to the clinic, how they are treated by the clinical as-sistant, how they leave the clinic, how they are notified of their bill, and multiple other ways in addition to the actual care we provide for them. If one person on the health care team is not up to par then the patient will not have the best experience and the whole team suffers. Most of the com-plaints I see about our team (and other providers) is about billing. No one likes to pay their bill. Please see my prior article about “How much will this cost?”

Aside from my husband Brad (not the football player) and myself, our team consists of an amazing group of in-dividual people that I am honored to call teammates and friends. I am also honored that one of my friends joined us last year as our dermatopathologist. The team of Johnson Dermatology shares a common goal of providing the highest level of comprehensive dermatological care to our commu-nity. We started with a team of ten people eight years ago. Now we are a team of 35 and are honored that six of the original ten are still with us (two moved and two retired). We try to attract good people to our team since we all know that you cannot train values to skilled people but you can train skills to valuable people. With assistance from the clinic, many of our valued people have earned certificates and de-grees. Since I am limited in this article, I will not comment on each team member but I would like to at least encourage you to read theskinnyonskin.net. It is an entertaining and educational blog written by our nurse practitioner Nina. Yes, I am honored to work with two amazing mid-level provid-ers in the same building. They truly are intelligent, caring individuals who provide excellent care with us and under our supervision. I am grateful for our team. I hope you are enjoying your team. Woo Pig Sooie.”

TEAM. Together Everyone Achieves More.BY SANDY JOHNSON, MD

COMMENTARY


Independence County physi-

cians have rediscovered the

purpose and the value of hav-

ing an active county medical

society. In recent months, the Inde-

pendence County Medical Society has

reconvened, elected a president and discussed the

issues facing physicians in its region.

Rediscovery certainly implies some forgot-

ten heyday. There was a time in Arkansas history

when medical societies were the scene to make.

According to Arkansas Medical Society Executive

Vice President David Wroten, county societies used

to be the primary avenue to fellowship, camarade-

rie, relationship building, and policy discussions.

County societies, through their connection to the

physicians hosting them, held much influence in

communities across this state.

This is not the case anymore. While Pulaski

County Medical Society (PCMS) is still an active

society, along with a few others, county societies

have been on the decline in recent years. [PCMS

(http://pulaskicms.org), which dates back to 1866,

was the first county society to form in Arkansas and

is the largest county medical society (the Arkansas

Medical Society came along in 1875).]

“Times have changed,” said Wroten. “It’s unfor-

tunate. Most have dissolved entirely. Physicians are

now more involved with their families. They social-

ize with a broader group of friends, not necessarily

involved in medicine, thus they have less time and

interest in going to a county medical society meeting.”

Living Up to Its Name

Meanwhile, Independence County Medical Soci-

ety (ICMS) is bucking this trend. Within the past six

months, it has been gaining strength through num-

bers. Jeff Angel, MD, practices at Medical Park Ortho-

paedic and Sports Medicine Clinic in Batesville and

has attended the recent meetings. “We have been ac-

tive recently with great attendance at meetings,” said

Dr. Angel. “It’s been a good thing to see the engage-

ment of the local physicians.”

Current ICMS President Ron McCann, MD, ac-

knowledged that, in the past, the local medical society

functioned mostly as a social club. “I started in prac-

tice 18 years ago. Attendance of meetings dwindled,

and we became a society in name only,” he said. “It

wasn’t conducive to growth at all.”

Over the years, while ICMS grew more stilted as

a group, the medical community surrounding it was

booming. Over time, this led to more physicians who,

though close in proximity, rarely interact. Dr. McCann

explained, “With the development of a strong hospital-

ist program, many primary care docs decreased their

time at the hospital. Physician extenders decreased

the amount of time specialists spent at the hospital.

Electronic medical records, teleradiology, and text

messaging allowed for the centralization of data and

the decentralization of medical care. The physician

could practice more isolated from his peers.”

It is this realization by physicians – that they have

practiced blindly of one another – that has served to

bring about ICMS’s refreshing transformation, Dr. Mc-

Cann indicated. With all of the rapid changes hap-

pening in the nation’s delivery of health care, physi-

cians were beginning to feel pushed – rather than led

– toward certain actions or implementations in their

practices.

“We don’t [always] understand, but we don’t

want to get left behind,” explained Dr. McCann. “My

description of it is this: You’re on a float trip, and you

look ahead and see all these turtles on a log. As you

get closer and closer, they’re all sitting there. But, as

soon as one goes off, they all go off. It’s the same kind


DIGGING UP BONES

by CASEY L. PENN

Photos by Robert Seat


of thing. No one wants to be left behind, but no one is

quite sure what the danger is.”

Independence County physicians reunited re-

cently over uncertainty related to the sudden, discus-

sion by the area’s hospital about the formation of a

CIN (clinically integrated network). When White River

Medical Center began pushing the need for a CIN,

physicians began to grow concerned for a number of

reasons – the main one being they did not understand

the issue nor the sudden urgency.

“The CIN wasn’t viewed as a pro-physician

thing,” recalled Dr. McCann of initial talk of the idea.

“There was little interest by the medical staff to form

a CIN, but there was a palpable concern of the un-

known. It was nothing nefarious on the part of the

hospital — they were doing what they were being

advised, too. However, physicians were being told it

was a necessary thing, and we needed to know what

we were embracing.”

Elaborating on the struggle physicians may feel

about what to embrace — or how to react to what

they feel is embracing them, Dr. McCann used jest.

“You know that when I grew up, I wanted to be …

well, I wanted to do paperwork. You know, I wanted to

meet random metrics,” he quipped. “But a lot of the

other guys went into it for patient care. And, when you

have anything related to patient care, the physician is

the common denominator. The metrics all touch us, so

there is always something that is being asked of us.

It’s easy for individual physicians to be lobbied. You get

two, [which] leads to two more.”

The need was there for physicians to meet to-

gether to talk freely about CINs. “A meeting was

planned,” said Dr. McCann, crediting the idea for that

meeting to Jay Jeffrey, MD, who serves AMS also as a

district trustee on the Board. Wroten and others from

AMS attended the meeting as well. “Physicians were

all in one room (not administrators); you had all ears

on what was said. People could interject, and it was

a lively discussion as opposed to a sterile, three-line

text or small email. A lively discussion ensued. Myths

were corrected, rumors dispelled, and people left with

a general feeling of camaraderie.”

It went well, and with that, a new trend was born

in Independence County. There have been follow-up

meetings on CIN (the topic is still under consideration

by the hospital), and there have been separate meet-

Current ICMS President Ron McCann, MD

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ings, too. Topics have included how to better influence

the legislation that governs physicians.

Seth Barnes, MD, an Internal Medicine physician

at White River Diagnostic Clinic and a member of the

AMS Board of Trustees, suggested to the group the

need to be more politically involved. “He told us, ‘We’re

reactive instead of proactive,’ Dr. McCann recalled. To

comply with that request, the new president contacted

lobbyist Jerry Cox. “I knew Cox, a lobbyist for Focus on

the Family and a nice guy, and I asked him to talk to us

about how physicians can affect legislation. We know

this is what AMS is doing, but we wondered, ‘How can

we shore up our little area?’

“Jerry spoke to us about how a group of doc-

tors (we had about 45 there that night) could engage

legislators to help shape the laws that affect us. The

talk was excellent, and there was guarded interest

in having the Independence County Medical Society

invite our local candidates to talk with us – [so we

could] share our concerns with them about tort re-

form and bureaucratic overhead.”

“We’ve had some good talks and plan to keep

moving forward to become more politically involved,”

added Dr. Barnes. “Clear rapport with our represen-

tatives in government is key to effective legislation

that makes sense to physicians and patients. We

possess a lot of power, we just need to sharpen and

focus that power for the betterment of the profession

and patient care.”

Scott Smith, AMS Governmental Affairs Director,

works constantly towards this very goal. He would

love to see more counties emulate what is happening

in Independence County. “A huge impact can be made

when county medical societies work together to assist

their state medical society on legislative issues,” he

said. “As Tip O’Neill stated, ‘All politics is local.’ That

is right on the money. With a large number of physi-

cians back home rallying around a legislative issue,

it makes it very difficult for legislators to ignore orga-

nized medicine’s voice.”

Wroten agreed. “A major advantage of having

some level of local structure is that it gives the physi-

cians a voice and venue to address what is happening

locally while also bringing bigger issues to our atten-

tion,” he said.

For legislative and other reasons, the physicians

of ICMS are convinced there are benefits to continuing

to assemble in some form or fashion. Just how the

group will manifest itself in the future remains to be

seen. “I don’t know if the county medical society will

work best as a militia – coming together rarely, but

with a specific problem to solve – or as a club with

planned routine meetings,” said Dr. McCann. “Either

way, the Independence County Medical Society is alive

and well.”

Dr. McCann urges societies around the state to

take notice and at least to have an initial meeting to

look at where things stand for the physicians in their

counties. “You want to establish that backbone so that

when there’s a problem, someone can say, hey, I’m

going to call a meeting. My personal opinion is, it’s

more important now than in the past. Now, we’re able

to practice medicine without seeing each other much

at all. When you start losing personalities, you start

losing the fact that ‘Hey, I really like these guys – and

those guys I don’t like it’s probably just because they

disagree with me but they have good reasons and I

need to hear those arguments.’”

For more information about Independence Coun-

ty Medical Society, contact Dr. Ron McCann at 870-

307-2325.


I am absolutely WORN OUT with

the partisan political bickering

which has filled the airwaves

and print media in Arkansas

since early summer, in prepara-

tion for the fall 2014 elections. The sole positive which I can perceive in this

onslaught is the cash infusion into the Arkansas

economy; I can think of many more positive uses

for this money, but I was not consulted. This flow

of ‘advo-mercials’ [my new ‘term for the year’]

must have some demonstrable efficacy, or the

ads would not be so plentiful. I would like to

borrow a few moments of your time to consider

our political landscape and the current state of

healthcare in Arkansas…

I am a supporter of healthcare reform and

access to affordable care for all Arkansans. The

healthcare reform legislation passed by our con-

gress (2010), signed into law by our president

(March 23, 2010), and upheld—mostly—by our

courts (June 28, 2012) has made some positive

changes in healthcare for Arkansans; but it cer-

tainly is not perfect. I am not a particular fan of

any of the above groups or individuals, nor do I

like the way that the ‘deal was done;’ but I also

cannot claim to understand how party politics

and political ideology trump our constitutional

goals (1787) to ”…establish justice, insure

domestic tranquility, provide for the common

defense, promote the general welfare, and se-

cure the blessings of liberty to ourselves and our

posterity…” If expanding healthcare access is

not ‘promoting the general welfare;’ I can cite

few alternate interventions which would more

greatly improve the wellbeing of our populace.

It is critical to recognize that we have not

—and will not—see the fully-implemented law

in effect until January 2015. To this point the

greatest benefit is, in brief, expanded insurance

coverage of Arkansans. The ability of young

people to stay on their parents’ plans to age 26;

Medicaid expansion/Private Option; elimination

of pre-existing condition exclusions and lifetime

limits on coverage; and private insurance ac-

cess (with and without subsidy) have allowed

hundreds of thousands of Arkansans to now

have health coverage; ‘not so shabby’ for a state

of approximately 3 million people. Medicaid

expansion alone completed enrollment of over

194,000 Arkansans by August 31!

The ACA mandated changes in Medicare are

also positive, in aggregate, for Arkansans. These

changes include coverage for expanded preven-

tive services, reduction in the part D ‘donut hole,’

and support for care coordination. Yes, there

was a reduction in payment to insurers for Medi-

care Advantage plans; in my view these plans

were a bad deal for the US government from the

start, but that is another story.

These positives have brought challenges

that we will need to continue to work on: there

are not enough providers in many areas of Ar-

kansas; the ‘in network’ provider lists are very

limited for some plans and regions; a number

of patients lost coverage that they had and pre-

ferred to keep; not all plans [e.g. legacy plans]

cover the preventive service elements required

by the law, at least until January 2015; and the

current law still does not cover all Arkansans.

Yes, a recent Congressional Budget Office analy-

sis indicated that Arkansas Medicaid expansion

may cost the federal government more than

originally predicted; but our Private Option ex-

pansion is making such a positive impact for

Arkansans that it is a model for other states, and

we have recently heard that insurance premi-

ums in our state may DECLINE in 2015… When

was the last time any of us heard that???

Fellow Arkansans, I encourage you to join

me and look past the advo-mercials. Think

about your families, friends, employees and pa-

tients, and consider what healthcare reform has

done for our state in the last ten months, when

you go to the polls in November. I will certainly

do so; and I will also continue to hope for a ‘truth

serum,’ sensitive enough to identify half-truths,

for politicians; and hope that our media outlets

will consider requiring a ‘fact check’ for all po-

litical—and perhaps for all—direct to consumer

advertising!

Title‘Patient Protection and Affordable Care Act’ =

‘Healthcare Reform’ =‘ACA’ = ‘Obamacare’

Popular Perception[More] Positive <---------------------------->[More] Negative

Politics, Healthcare and SpinROBERT H. HOPKINS, JR., MD


Change is inevitable. “The problem with real change is that it requires real change,”

Newt Gingrich has said. After the Arkansas Foundation for Medical Care (AFMC) has served for more than 30 years as Arkansas’ quality improvement organization, the Centers for Medicare & Medicaid Services (CMS) has recently transformed the Quality Improvement Organization (QIO) program to better facilitate and guide health care quality improvement efforts throughout the country. AFMC, along with other long-standing QIOs, has been impacted by this change.

CMS announced significant changes earlier this year to the structure of the QIO program, from a QIO in every state to a regional or multi-state approach. Under the new structure, regional QIOs are not permitted to serve in both the Medicare case review and quality im-provement roles. A summary of CMS’ major changes are listed below:n In separating medical case review

from quality improvement work, CMS created two separate struc-tures that are:• Medical case review to be

performed by Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs)

• Quality improvement and technical assistance to be performed by Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs)

n BFCC-QIOs are now organized among five geographic areas across the United States.

n QIN-QIOs have been regionalized and cover three to six states.

n The QIO contract cycle has been extended from three to five years.

MEDICAL CASE REVIEWOn May 9, 2014, CMS awarded the

Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) Program contracts to:n Ohio-based KEPRO for 33 states

and the District of Columbian Maryland-based LIVANTA for 17

states, the U.S.Virgin Islands and Puerto Rico

Effective August 1, 2014, all beneficiary quality review case work and appeals are now conducted by a new BFCC-QIO. KEPRO serves as Arkansas’ BFCC-QIO.

QUALITY IMPROVEMENTAfter undergoing a highly competi-

tive request-for-proposal process, the TMF Health Quality Institute, located in Austin, Texas, was awarded one of the 14 QIN-QIO national contracts. TMF’s QIN-QIO region encompasses

Texas, Arkansas, Missouri, Oklahoma and Puerto Rico. TMF’s QIN-QIO will lead quality improvement efforts across these states and Puerto Rico by working side-by-side with providers, patients and stakeholders to achieve the triple aim of: better health for populations, better care for individuals and lower costs through quality improvement.

The QIN-QIOs have four key roles:n Champion results-oriented change at

the local level that is data driven and actively engages patients and other partners. These changes are proactive and intentional innovations that spread sustainable best practices.

n Facilitate learning and action networks (LAN) that support an “all teach, all learn” environment. The focus for improvement is at the bedside level, using interventions such as hand washing.

n Teach and advise/consult as technical experts, and manage knowledge so learning is never lost.

n Communicate effectively to optimize learning, patient activation and sustained behavior change.

Although many of the business aspects of the QIO will be central-ized to the “prime” organization of the QIN-QIO, quality improvement efforts will continue at the local level. AFMC’s health care professionals will continue to work alongside providers, hospitals, nursing homes and com-

11th Scope of Work update

THE ARKANSAS FOUNDATION FOR MEDICAL CARE, INC. (AFMC) WORKS COLLABORATIVELY WITH PROVIDERS, COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO PROMOTETHE QUALITY OF CARE IN ARKANSAS THROUGH EDUCATION AND EVALUATION. FOR MORE INFORMATION ABOUT AFMC QUALITY IMPROVEMENT PROJECTS, CALL 1-877-375-5700.

A CLOSER LOOK AT QUALITY

EDITORIAL PANELLynda Beth Milligan, MD, FAAFP, CPE, CHCQM; Michael Moody, MD; David Nelsen, MD, MS;

Steven Strode, MD, MEd, MPH; J. Gary Wheeler, MD, MPS

BY JULIA KETTLEWELL, MPH, BSN, RNP

A C L O S E R L O O K A T Q U A L I T Y


A CLOSER LOOK AT QUALITYA C L O S E R L O O K A T Q U A L I T Y

munities, as they have for more than 40 years. AFMC will continue to work at the local level to prevent and treat chronic diseases, including:n Improve cardiac health and reduce

cardiac healthcare disparitiesn Reduce disparities in diabetes caren Improve prevention coordination

through health information technology

Another area of focus for the next five years is patient safety initiatives with a three-part goal to: n Reduce healthcare-associated infec-

tions in hospitalsn Reduce healthcare-acquired condi-

tions in nursing homesn Improve care coordination

Physicians and hospitals can con-tinue to participate in quality improve-ment programs designed to result in better care at lower cost. Quality improvement assistance will be offered to educate and provide best practices for both physician value-based modifier and feedback programs, and for hospi-tal value-based purchasing.

Another structural change to the QIO program is the creation of Value

Incentives and Quality Reporting Centers (VIQRCs). These centers will provide some of the support that QIOs have traditionally provided to hospitals. This support has been centralized into six different categories. The VIQRCs are:1. Outreach and Education Hospital

Inpatient-Psych and Cancer2. Outreach and Education

Ambulatory Surgery Centers (ASC) and Outpatient

3. Coordination and Policy Advisory Contractor

4. Monitoring and Evaluation/Analytics5. Validation Support6. Appeals

CMS has awarded two of the VIQRCs to date. The Inpatient Support Contract was awarded to Florida Medical Quality Assurance, Inc. (FMQAI) on June 16, 2014. Under this contract FMQAI will provide education and direct support to stakeholders of these quality programs:n Hospital Inpatient Quality

Reporting (HIQR)n Electronic Health Records (EHR) In-

centive Program for Eligible Hospitals and Critical Access Hospitals (CAH)

n Hospital Value-Based Purchasing (HVBP)

n Prospective Payment System-Exempt Cancer Hospital Quality Reporting (PCHQR)

n Inpatient Psychiatric Facility Quality Reporting (IPFQR)

The Validation Support Contractor was awarded to Mathematica Policy Research (MPR) effective July 8, 2014. MPR will provide support to CMS to ensure the accuracy of Hospital Inpa-tient Quality Reporting and Outpa-tient Quality Reporting program data.

The remaining four VIQRCs have not been awarded to date.

What do all of the changes mean to Arkansas providers, hospitals, nursing homes, stakeholders, partners and beneficiaries? AFMC will continue to engage with Arkansas physicians, health care providers and stakeholders to foster improvement initiatives through LANs. These networks will continue to serve as information hubs to monitor data, engage relevant organizations, facilitate learning and sharing of best practices, reduce disparities, and elevate the voice of the patient. s

Ms. Kettlewell is the assistant vice president for quality programs with the Arkansas Foundation for Medical Care.

TMF partners

Texas(TMF)

Oklahoma(OklahomaFoundation forMedical Care)

Missouri(Primaris)

Arkansas(ArkansasFoundationfor Medical Care)

Puerto Rico(Quality ImprovementProfessional ResearchOrganization)


IMAGE CASEA 60-year-old caucasian man with

hypertension and mental deficits from fetal

alcohol syndrome was admitted with nausea

and sudden onset diffuse abdominal pain, which

started on the day of presentation. He complained

of having diarrhea 3 days prior, but had not had

any bowel movement since past 24 hours and his

abdomen was distended. He denied any previous

similar episodes, hematemesis, melena, recent

travels, chest pain, dyspnea or dizziness. Patient

denied any tobacco/alcohol/illegal substance use.

Home medications consisted of only lisinopril

and his family history was non-contributory. On

examination, he was tachycardia (HR 105/min), but

otherwise his vitals were stable. Cardio-pulmonary

exam was unremarkable. Abdomen was soft but

distended, tympanitic with tinkling bowel sounds,

and was minimal tender to palpation, without any

peritoneal signs. The blood work showed normal

hemogram, electrolytes, kidney and liver function

tests. An abdominal radiograph and computed

tomography (CT) of abdomen was obtained which

is shown in Figure 1.

The CT shows classic sigmoid volvulus with

closed-loop obstruction.

Sigmoid volvulus (SV) is the third leading

cause of colonic obstruction in adults. Though

the etiology and precipitating factors are not

completely understood, it is known to occur in

the setting of redundant sigmoid loop that rotates

around its narrow and elongated mesentery1. This

malrotation of redundant sigmoid loop can occur in

people with underlying constipation or congenitally

elongated colon1. Its usual presentation is acute

with symptoms typical of small bowel obstruction

(crampy abdominal pain, abdominal distention,

constipation, nausea, vomiting, inability to pass

bowel movement and gas).2 Plain abdominal

radiography (Figure 2) is diagnostic in most cases,

however, CT (Figure 1, 3) or magnetic resonance

imaging (MRI) can be used for confirmation, when

needed.1

Treatment of choice in uncomplicated patients

is emergent endoscopic reduction of the rotated

sigmoid loop, however, endoscopic reduction only

changes an emergency into an elective situation,

and an elective definitive surgery should follow

it. Resection of the redundant sigmoid colon has

been considered as the definitive and curative

Sudden onset abdominal pain and distension: An imaging sparkler

Jagpal Singh Klair, MD, JS1; Girotra M, MD1,2; Medarametla S, MD3; Shah HR3, MD1Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock

2Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock3Department of Radiology, University of Arkansas for Medical Sciences, Little Rock

SCIENTIFIC ARTICLE

Keywords: sigmoid volvulus, bowel ob-

struction, ischemic bowel, endoscopy

ABSTRACTWe present a case of a middle-aged patient

presenting with acute onset abdominal pain

and distension who had signs of bowel

obstruction on physical exam. He was afebrile,

hemodynamically stable with no peritoneal

signs. Abdominal radiograph and CT scan

were pathognomic for sigmoid volvulus.

Through this case report we want to discuss

the presentation, diagnosis, management

options for sigmoid volvulus and importance

of features suggestive of ischemic bowel that

necessitates different management options.

Key words: abdominal pain, volvulus, CT

scan, ischemic bowel Figure 1: Non Contrast-enhanced axial CT image shows mesenteric fat (arrow) separating the sigmoid walls


procedure, though there has been

increasing effort to find a non-

resection alternative.2,3

Furthermore, it is essential to

look for clinical features concerning

for decreased viability of the

reduced colon, in other words,

for presence of ischemic bowel.

These include hematochezia, fever,

leukocytosis, marked abdominal

tenderness, hypotension/shock,

metabolic acidosis or failure of

endoscopic reduction. Presence of

any of the above findings should

necessitate emergent laparotomy

after adequate resuscitation and

stabalization.3

Patient outcome in this case: Patient underwent

a decompression colonoscopy

with rectal tube placement, and

colonoscopy was diagnostic in

confirming sigmoid redundancy as

well as therapeutic in reducing the

loop. His symptoms improved within a few hours

and upon stabilization, surgery was consulted for

a laparoscopic low anterior resection, which will

be performed on out-patient basis. The patient

ambulated well, his diet was escalated and repeat

abdominal XR showed resolved volvulus.

REFERENCES:

1. Margolin DA, Whitlow CB. The pathogenesis

and etiology of colonic volvulus. Semin Colon

Rectal Surg 2007; 18: 79–86.

2. Osiro SB, Cunningham D, Shoja MM et al. The

twisted colon: a review of sigmoid volvulus.

Am Surg. 2012 Mar;78(3):271-9.

3. Raveenthiran V, Madiba TE, Atamanalp SS et

al. Volvulus of the sigmoid colon. Colorectal

Dis. 2010 Jul;12(7 Online):e1-17.

Figure 3: Non Contrast-enhanced axial CT image shows transition point (arrow).

Figure 2: Scout image classic for sigmoid volvulus shows distended sigmoid loop with inverted U configuration and coffee bean sign.

Questions

1. What is the diagnosis based on

imaging shown?

(a) Colon Carcinoma

(b) Sigmoid volvulus

(c) Meckel’s diverticulitis

(d) Ogilvie’s Syndrome

(e) Intussusception

2. What is the next step in the

management of this patient?

(a) Conservative management

(b) Laparotomy repair

(c) Endoscopic reduction

(d) Laparoscopic repair

Answers

Question 1: (b)

Question 2: (c)


STUDYCASE

TB or not TB; Don’t Miss The Obvious

AbstractTuberculosis (TB) is one of the leading

causes of morbidity and mortality in the world.

Its classic forms include cavitary and miliary TB.

The non-specific clinical presentation of TB and

similarity of its signs and symptoms with other

pulmonary diseases makes its diagnosis difficult,

especially in low burden settings like Arkansas.

We emphasize the importance of early diagnosis

and describe two cases where a delay resulted

in complications and a prolonged treatment plan

for the patients.

BackgroundTuberculosis (TB) is an infectious disease

caused by the Mycobacterium tuberculosis com-

plex: M. tuberculosis, M. canettii, M. africanum, M.

bovis, and M. microti. According to the World Health

Organization, 8.6 million people developed TB and

1.3 million people died from the disease in 2012.

TB is primarily an airborne disease and most com-

monly affects the lungs. Risk factors for TB include

prolonged contact with someone having active tu-

berculous disease, birth in a TB endemic country,

immunosuppressive diseases, homelessness, poor

ventilation and substance abuse. Characteristic

symptoms of TB are chronic cough of 2-3 weeks

duration or longer, fever, night sweats, hemoptysis,

anorexia and weight loss while the most common

signs include infiltrates, bronchial breathing, rales or

crepitations. The difficulty in the diagnosis of tuber-

culosis is compounded by the fact that its signs and

symptoms are similar to those caused by many other

diseases, such as pneumonia, histoplasmosis, lung

cancer, sarcoidosis, pneumoconiosis and hemosid-

erosis to name a few. Some of the classical types of

tuberculosis include the cavitary and miliary patterns

of disease. For the period 2009-2013, 387 TB cases

were reported in Arkansas. Of these, 13 (3.4%) were

reported after death, and 24 (6.2%) died during treat-

ment: a strong evidence of delayed diagnosis. In this

report, we describe two cases that encapsulate the

problems associated with a delay in TB diagnosis.

Cavitary tuberculosisCavitation is the hallmark of postprimary TB. It

occurs in 40-87% of pulmonary TB cases and is very

infectious. Cavitary lung disease has been shown to

be an independent risk factor for the prediction of

disease relapse after a six-month course of treat-

ment. It has been established that the baseline re-

lapse rate of 2% in non-cavitary TB cases increases

to 5% in patients with cavitary disease. According

to the United States Public Health Service Study, 22

patients who were culture positive two months post

therapy in addition to having cavitary disease had a

relapse rate of 21%. An important challenge in the

treatment of cavitary tuberculosis is treatment fail-

ure and subsequent drug resistance, with literature

indicating that patients with cavitary disease have

a higher risk of drug resistance as compared to pa-

tients without cavitary disease. Radiographically, it

is seen as a main cavity in the upper lobes of either

or both lungs with consolidative changes around it.

This area is highly oxygenated, thereby providing a

suitable environment for the proliferation of M. tu-

berculosis, resulting in higher bacterial loads in their

sputum. Cavitations can also be present in the apical

segment of the lower lobe.

Naveen Patil, MD;1,2 Asween Marco, MD;1 Hamida Saba, MD;2 Rohan Samant, MD;2 Leonard Mukasa, MD;1,2

1Arkansas Department of Health(1) and University of Arkansas for Medical Sciences(2)

Figure 1


Miliary tuberculosis The widespread dissemination of M. tuberculo-

sis via the lymphohematogenous route is called mili-

ary TB. It can occur shortly after initial inhalation of

the TB bacilli as primary TB, or years after initial expo-

sure. 1-3% of all TB cases result from miliary TB. Mili-

ary TB can affect the entire body, especially the bone

marrow, liver, spleen and retina, and makes up about

10-20% of all extrapulmonary cases. The incidence

of miliary TB is high in immunocompromised patients

and can be fatal if not diagnosed and treated early,

especially in infants. In the United States, African-

Americans, adults over 65 years of age and pregnant

women are most at risk for developing miliary TB.

Its clinical presentation is non-specific, leading

to potential delays in diagnosis and complications like

acute respiratory distress syndrome and disseminat-

ed intravascular coagulation. Hence, if there is a high

index of suspicion for miliary TB, treatment should be

initiated even before a diagnosis is confirmed. There

can be a lag period of a few weeks between the

radiographic appearance of disease and the actual

time of dissemination. Radiographically, up to 30%

of cases have a normal chest X-ray. The specificity

of radiographs to correctly diagnose miliary disease

ranges from 97-100%, while the sensitivity is 59-

69%. Typically, a faint reticulonodular pattern con-

sisting of widespread, non-calcified nodular opacities

evenly distributed throughout both lungs can be seen.

High Resolution Computed Tomography (HRCT) is a

more sensitive technique for diagnosis of miliary TB

in the early stage of the disease.

Case Report 1A 69-year-old Caucasian male was admitted

to the hospital with a two-month history of fatigue,

weakness, cough, worsening shortness of breath,

loss of appetite and weight loss. His chest radiograph

(Figure1) taken in February 2013, showed diffuse

pulmonary infiltrates with bilateral upper lobe cavi-

ties and consolidation. The patient did have a chest

radiograph on his previous admission in October

2012 with similar findings, but these changes had

worsened over this period. He did not tolerate a bron-

choalveolar lavage on his previous admission and a

trans thoracic biopsy of the cavitary area revealed

granulomatous changes with chronic inflammation,

but no further work up was initiated. His T-SPOT®.

TB (Oxford Immunotec Inc., Marlborough, MA) test

was negative on both admissions. During the lat-

est admission, his sputum smear showed 4+ acid-

fast bacilli (AFB) and the GeneXpert MTB/RIF assay

(Cepheid Inc., Sunnyvale, CA, USA) was positive for

Mycobacterium tuberculosis complex and showed

no rifampin resistance. Laboratory work, including

complete blood count and liver profile was normal.

The patient was started on the standard four-drug tu-

berculosis therapy (rifampin, isoniazid, pyrazinamide

and ethambutol). His culture turned positive after 4

weeks and sensitivities showed the organism to be

susceptible to all primary TB drugs. Due to the delay

in diagnosis and treatment, the patient had a compli-

cated and prolonged 18-month course of treatment.

Case Report 2A 76-year-old Caucasian female was admitted

to the hospital in early 2013 with a two-week his-

tory of shortness of breath and increased heart rate.

She was recently diagnosed with hyperthyroidism

and was started on methimazole. She was found to

have atrial fibrillation with rapid ventricular rate. Im-

aging found that she had a large pericardial effusion

and several pulmonary nodules in her right lung. She

was discharged on prednisone, amiodarone, meto-

prolol along with methimazole. She returned three

months later with worsening shortness of breath

and imaging revealed bilateral reticulonodular infil-

trates. Her QuantiFERON®-TB Gold In-Tube (QFT-G-

IT) assay (Cellestis Ltd., Carnegie, Victoria, Australia)

was positive but no work-up for TB was initiated. A

blood culture showed no growth and a diagnosis of

hypersensitivity pneumonitis (HSP) was made. The

patient was discharged and continued on steroids.

She was readmitted a month later with weakness

and shortness of breath. Her chest radiograph (Fig

2) and Computerized Tomography (CT) scan (Fig 3)

revealed a reticlulonodular pattern with random dis-

tribution of tiny nodules consistent with miliary dis-

ease. Sputums were 3+ for AFB and the GeneXpert

MTB/RIF assay was positive and showed no rifampin

resistance. Sputum culture from the previous admis-

sion also turned positive for M. tuberculosis after four

weeks. Laboratory work, including complete blood

count and liver profile was normal. Susceptibility test-

Figure 2

The majority of TB cases are patients with cavitary pulmonary disease and disease transmission is more frequent among this population.


ing showed the organism to be sensitive to all pri-

mary TB drugs. On further investigation, the patient`s

mother had terminal cancer three decades prior and

was diagnosed with TB just before her death. The

patient was the primary caregiver for her mother and

had received nine months of self-administered iso-

niazid prophylaxis at that time with which she was

non-compliant. Due to a similar delay in diagnosis

and treatment, the patient had a complicated and

prolonged 15-month course of treatment.

DiscussionA significant advancement in the diagnosis of

active tuberculosis has been the introduction of the

GeneXpert MTB/RIF assay. The GeneXpert MTB/RIF

assay enables laboratory confirmation of M. tuber-

culosis within two hours, in addition to determining

resistance to rifampin. The Arkansas Department

of Health`s Public Health Laboratory offers this test

free of charge to all healthcare institutions for their

suspected TB patients. Screening tools for M. tuber-

culosis have undergone a sea of change in the past

few years, but the potential remains for the develop-

ment of new, cost-effective methods of diagnosis.

The utilization of new blood tests that can examine

the immune response to TB antigens is a big addition

to the TB diagnostic arsenal. These tests are called

Interferon Gamma Release Assays (IGRA), with the

most common methods being ELISA (QFT-G-IT) and

ELISPOT (T-SPOT®). TB. The IGRA’s have replaced the

labor intensive Tuberculin Skin Test (TST), in many

developed countries, as a source of screening and

diagnosing TB. Since these tests are not very sensi-

tive, a negative test should not preclude a diagnosis

of TB, especially in the elderly and immunocompro-

mised, as demonstrated in Case Report 1.

TB is generally not on the radar of the treat-

ing physician due to its decreasing incidence in

developed countries over the past few years. It is

important for clinicians to keep in mind that the age

cohort born before 1950 carries a high risk of hav-

ing been exposed to TB, which was endemic in the

United States, given there was no TB treatment dur-

ing that period. In our patients, the diagnosis of TB

was missed, despite obvious signs like upper lobe

infiltration, miliary pattern, cavities, and pathology

showing granulomatous changes. TB should be on

the differential diagnosis of providers in patients with

the above signs and symptoms. The use of GeneX-

pert MTB/RIF assay is crucial in the rapid diagnosis

of patients in such settings.

ConclusionDespite the existence of effective methods for

the control of TB around the world, the disease re-

mains one of the dominant infectious diseases. The

majority of TB cases are patients with cavitary pul-

monary disease and disease transmission is more

frequent among this population. Delayed TB diag-

nosis in Arkansas, resulting in severe morbidity and

mortality is of concern. Physicians should be edu-

cated to consider TB in their differential diagnosis so

that they do not miss the obvious.

References1. WHO. Global Tuberculosis Report 2013; Geneva:

World Health Organization.

2. Pai, Madhukar, Jessica Minion, Frances Ja-

mieson, Joyce Wolfe, and ART Marcel Behr.

“Diagnosis of active tuberculosis and drug

resistance.” Canadian Tuberculosis Stan-

dards (2014).

3. Ko, Jeong Min, Hyun Jin Park, and Chi Hong

Kim. “Pulmonary Changes of Pleural Tubercu-

losis: Up-to-Date CT Imaging.” CHEST Journal.

July 2014.

4. Vernon A., Khan A., Bozeman L., Wang Y. C.

(1998) Update on US Public Health Service

(USPHS) study 22: a trial of once weekly isonia-

zid (INH) & rifapentine (RFP) in the continuation

phase of TB treatment. Am. J. Respir. Crit. Care

Med. 157:A467.

5. Sharma SK, Mohan A, Sharma A, Mitra DK. Mili-

ary tuberculosis: new insights into an old dis-

ease. Lancet Infect Dis. Jul 2005; 5 (7): 415-30.

6. Blumberg HM, Burman WJ, Chaisson RE, Daley

CL, Etkind SC, Friedman LN, et al. American

Thoracic Society/Centers for Disease Control

and Prevention/Infectious Diseases Society of

America: Treatment of tuberculosis. Am J Respir

Crit Care Med. Feb 15 2003;167 (4): 603-62.

7. Thomas M. Habermann, Amit K. Ghosh (2008)

Mayo Clinic Internal Medicine: Concise Text-

book, Mayo Clinic Scientific Press, Rochester,

789.

8. Diel, R., et al. “Interferon-γ release assays for

the diagnosis of latent Mycobacterium tubercu-

losis infection: a systematic review and meta-

analysis.”European Respiratory Journal 37.1

(2011): 88-99.

9. Patil N, Saba H, Marco A, Samant R, Mukasa L.

Initial experience with GeneXpert MTB/RIF as-

say in the Arkansas Tuberculosis Control Pro-

gram. AMJ 2014, 7, 5, 203-207.

10. Berzkalns, Anna, Joseph Bates, Wen Ye, Leon-

ard Mukasa, Anne Marie France, Naveen Patil,

and Zhenhua Yang. “The Road to Tuberculosis

(Mycobacterium tuberculosis) Elimination in Ar-

kansas; a Re-Examination of Risk Groups.” PloS

one 9, no. 3 (2014): e90664.

Figure 3



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We Also Welcome Guest Commentaries and Manuscripts

INTRODUCTIONIn the United States, stroke ranks fourth amongst

the leading causes of death.1 Approximately 610,000 out of 795,000 strokes that occur annually in the United States are first time strokes.2 Early recognition of its signs and symptoms is crucial because IV rt-PA (intravenous recombinant tissue plasminogen activa-tor) can be administered only if patients present to the hospital in a timely manner. Zerwic et al’s study on patients who had an ischemic stroke revealed that 60.5% of the participants were able to identify one risk factor accurately, 55.3% were able to identify at least one stroke symptom, and only 31.6% of partici-pants were able to access the emergency department in less than 2 hours.3 In 2005, only 3.6% out of 2156 participants were able to identify rtPA, and only 9% of those who were able to identify the therapy were able to state the importance of administration within 3 hours.4

The Internet provides a convenient and com-monly-used means for the spread of healthcare in-formation. With the wealth of information shared by the Internet about stroke, it is worth investigating the accuracy and adequacy of information provided.

The website YouTube is an online media of communication with an average of 4 billion hours of video watched per month.5 Research has been performed to assess the reliability of information on YouTube regarding various disease conditions includ-ing prostate cancer, kidney stones, and myocardial infarction.6, 7, 8 YouTube as an information source for stroke has yet to be objectively evaluated. We be-lieve stroke education to be particularly important as timely intervention in the acute setting can re-duce the long-term disability and health care costs. In this study we will explore the information provided on YouTube concerning acute stroke symptoms, treatment, complications and preventive measures.

MATERIALS AND METHODS:

The website www.youtube.com was searched between Dec.10 and Dec.12, 2013 for the terms “Stroke,” “Cerebrovascular accident,” “Brain attack,” “Transient Ischemic Attack,” and “Stroke Survival.” Inclusion Criteria:

(1) English language(2) Less than ten minutes in length(3) Relevant to the search criteria(4) Found within the first ten pages of search results Exclusion Criteria: (1) Language other than English (2) Lacking audio (3) More than 10 minutes in length(4) Irrelevant to the search criteria(5) Videos beyond the tenth page of search results(6) Duplicate videos (videos in parts were

considered one)

Two hundred and one videos were included in our study after considering these criteria. Videos were then assessed for their content, including: risk factors, causes, symptoms, diagnosis, discussion about IV-rtPA, prevention, and rehabilitation. Videos were clas-sified based on the number of views, likes, dislikes, duration, and source (patient or physician or others). Videos were assessed again by the second author for the above criteria to measure the degree of agreement between the two researchers and ensure consistent analysis. The kappa coefficient of agreement was used to observe the degree of agreement between two of the authors who analyzed the video. Data were report-ed as the mean with standard deviation or the median with interquartile range for continuous variables and as a percentage for categorical variables. Comparison of different groups was performed by using analysis of variance (ANOVA) for continuous variables or chi-square test for categorical variables. Statistical analy-ses were performed using JMP statistical software version 10.0 (SAS Institute Inc., Cary, NC). The differ-ences were considered statistically significant when the p-value(s) were less than 0.05. P-values have not been adjusted for multiple comparisons.

RESULTS:We first divided the 201 analyzed videos by the

presence or absence of IV-rtPA discussion and by source (patient experience, physician, and others). Others included videos from sources such as news, advertisements, songs, and layperson. The division of videos based on discussion of rtPA is presented in Table 1. Only 9% (18 videos) of the analyzed videos discussed the possibility of administering IV-rtPA, and most of these came from physicians (14 vid-eos). Videos that discussed the possibility of IV-rtPA therapy were longer in duration when compared to the other videos (p<0.01). There were more likes, dislikes, and views for the videos that did not dis-cuss IV-rtPA, but this association was not significant (p>0.01). The discussion about symptoms, signs, risk factors, and preventive measures was almost similar in both the groups.

Table 2 demonstrates the categorization of videos ac-cording to the source. Out of the 201 videos analyzed, most of the videos came from physicians (94 videos, 47%). The maximum number of views was of other sources and this was statistically significant (p<0.01). There were more likes and dislikes for the videos that came from other sources, but only the number of likes was significantly significant (p<0.01). There was more discussion of risk factors, prevention, pathophysiolo-gy, symptoms, signs, possibility of administering rtPA, and the different types of strokes in the group where the source of information was physicians, but only discussion of the different types of strokes was statis-tically significant (p<0.01). The mean duration of the videos was longer when the patient’s experience was mentioned, but this was not statistically significant. DISCUSSION:

Patients’ use of the Internet for independently seeking medical information is becoming more common alongside the ever-increasing prevalence of internet access, particularly through the use of in-ternet-capable mobile devices. YouTube is a popular website where anyone can upload and view videos, many of which contain medical information and ad-vice. Videos on YouTube concerning stroke are up-loaded from a variety of sources including physicians and patients and differ in the accuracy and scope of information presented.

Is YouTube and Stroke a Bad Liaison?

Keywords: Stroke, Stroke YouTube, YouTube rtPAIV-rtPA = intravenous recombinant tissue plasminogen activator

by Harsh Gupta, MD1; Kaustubh Limaye, MD1; Konark Malhotra, MD2;Rajan Patel, MD3; Nathan Taillac, MD1; Ju Dong Yang4; Archana Hinduja1

1Department of Neurology, University of Arkansas for Medical Sciences, 2Department of Neurology, Allegheny General Hospital, Pittsburgh, PA, 3St. Matthews Medical University, West Bay, Cayman Islands, 4Department of Internal Medicine, University of Arkansas for Medical Sciences


In our analysis we found that the majority of the videos did not discuss rtPA, which is particularly concerning these days given the significant improve-ment in symptoms after its administration and the time-sensitive nature of its administration. Only 62 out of 201 videos analyzed discussed risk factors and preventive measures of stroke. This suggests that the videos on YouTube lack information about preventive measures. YouTube is, however, a good tool to convey the symptoms and signs of stroke as majority of the videos discussed about the same (178 out of 201). It is imperative to know the warning signs and symptoms of stroke so that immediate care can be provided to the patients.

Videos from other sources, such as news, advertise-ments, songs, and laypersons had the most views and likes, suggesting that people may prefer videos that provide entertainment rather than videos whose sole purpose is educational. Only 49 out of 201 videos

discussed the different types of strokes such as isch-emic or hemorrhagic. Risk factors, prevention, signs, symptoms, pathophysiology, types of stroke (such as ischemic or hemorrhagic), and IV-rtPA discussion were featured primarily in videos that were uploaded by physicians. This indicates that the majority of the highest quality videos did not come from patients’ ex-periences or other sources. The videos that discussed rtPA were longer in duration when compared to others and had less likes and views. The most likely expla-nation for this finding is that viewers prefer to watch videos that are shorter in duration. LIMITATION:

Our study has some limitations. We did not in-clude videos that were in languages other than Eng-lish, and videos greater than 10 minutes in length were excluded. The videos were viewed between certain time periods so there is a possibility of missing potential videos that may have been added on a later

date. The information available on YouTube does not reflect the information available on the Internet, and videos available on other websites were not included in the study.

CONCLUSION:In this study, we aimed to assess the information

about stroke on YouTube. Our study suggests that You-Tube provides a good and reliable source to learn the signs and symptoms of stroke but it features insuffi-cient information about the use of IV-rtPA, risk factors, and prevention. The presence of easily accessible and educational videos on YouTube provides an opportu-nity for medical professionals to extend patient educa-tion outside the time constraints of office and hospital encounters. The limited number of these higher qual-ity videos among others of inadequate accuracy and breadth of information, however, suggests that refer-ring patients to the Internet for additional information must be done with caution. Patients receiving risk-mitigating therapy for cerebrovascular events, such as aspirin or anti-hypertensives, would likely benefit from a list of pre-approved stroke educational videos.

REFERENCES:1. http://www.cdc.gov/nchs/data/nvsr/nvsr60/

nvsr60_04.pdf

2. Bhatt A, Safdar A, Chaudhari D, et al. Medicole-gal Considerations with Intravenous Tissue Plas-minogen Activator in Stroke: A Systematic Re-view. Stroke Res Treat. 2013;2013:562564. Epub 2013 Sep.

3. Zerwic J, Hwang SY, Tucco L. Interpreta-tion of symptoms and delay in seeking treat-ment by patients who have had a stroke: explorato-ry study. Heart Lung. 2007 Jan-Feb;36(1):25-34.

4. Kleindorfer D, Khoury J, Broderick JP, et al. Tem-poral trends in public awareness of stroke: warn-ing signs, risk factors, and treatment. Stroke. 2009 Jul;40(7):2502-6. doi: 10.1161/STROKEAHA.109.551861. Epub 2009 Jun 4.

5. http://www.youtube.com/yt/press/statistics.html

6. Pant S, Deshmukh A, Murugiah K, Kumar G, Sachdeva R, Mehta JL. Assessing the cred-ibility of the “YouTube approach” to health in-formation on acute myocardial infarction. Clin Cardiol. 2012 May;35(5):281-5. doi: 10.1002/clc.21981. Epub 2012 Apr 6.

7. Sood A, Sarangi S, Pandey A, Murugiah K. You-Tube as a source of information on kidney stone disease. Urology. 2011 Mar;77(3):558-62. doi: 10.1016/j.urology.2010.07.536. Epub 2010 Dec 4.

8. Steinberg PL, Wason S, Stern JM, Deters L, Kowal B, Seigne J. YouTube as source of prostate can-cer information. Urology. 2010 Mar;75(3):619-22. doi: 10.1016/j.urology.2008.07.059. Epub 2009 Oct 7.

Table 1 represents the division of videos based on the discussion of IV-rtPA (intravenous recombinant tissue plasminogen activator)

Discussion Discussed rtPA (N=18, 9%)

rtPA not discussed(N=183, 91%) P value

by Physician 14(78%) 80(44%)

by Patient 1(5%) 53(29%)

by Others 3(17%) 50(27%)

Views* 483 [273-3700] 767 [121-3768] 0.45

Likes $ 3.6 (4.6) 11.2 (33.5) 0.34

Dislikes $ 0.1 (0.2) 0.4 (1.1) 0.16

Duration * 4.1 [2.3-7.7] 2.5 [1.4-4.5] <0.01

Symptoms/Signs discussed 17 (94%) 161 (88%) 0.37

Risk Factors and Prevention discussed

6 (33%) 56 (31%) 0.81

*Median and interquartile range, $Mean and standard deviation

Table 2 represents the categorization of videos based on the source.Patient description(N=54, 27%)

Physician description(N=94, 47%)

Others (N=53, 26%) P value

Views* 549 [101-1620] 383 [110-2349] 4116 [622-17218] <0.01

Likes$ 2232 (4632) 5598 (24791) 32230(99513) <0.01

Dislike$ 0.13 (0.39) 0.36 (0.10) 0.66 (1.35) 0.03

Risk Factors and Prevention

11 (20%) 38 (40%) 13 (25%) 0.02

Duration* 3.2 [2.1-5.1] 2.4 [1.3-4.6] 2.5 [1.2-6.1] 0.70

Pathophysiology 2 (4%) 14 (15%) 10 (19%) 0.03

rtPA discussed 1 (2%) 14 (15%) 3 (6%) 0.01

Symptoms/Signs discussed

52 (96%) 79 (84%) 47 (89%) 0.05

Types 3 (6%) 27 (29%) 19 (36%) <0.01*Median and interquartile range, $Mean and standard deviation


P E O P L E + E V E N T S 14

AMS Fall Meeting

October 30-31The Lodge at Mount Magazine

All members are invited to discuss issues that could be considered at the 2015 legislative session. Get involved in your association and make a difference!

11th Annual AMS Insurance Conferences

November 5 and 6Little Rock

Chenal Country Club

Workshop: “Managing

Landmines for Practice Leaders”

Tuesday, December 2, 9am – 4pmHeld at the IIAA Building

North Little Rock

Topics will include Stark, Clinically Integrated Networks, Stage II Meaningful Use, HIPAA, Risk Analysis, ICD-10, Customer Service and Episodes of Care

Watch for Registration materials!

MARK YOURCALENDAR

OBITUARIES

LITTLE ROCK – Junius Bracy Cross, MD, passed away September 5, 2014. He served in World War II as a medic. Following the war he married his high school sweetheart, Sarah Riley Cross and set up his medical practice in Little Rock as an Ophthalmologist. Dr. Cross served on the faculty of UAMS and most recently served on the Jones Eye Institute Advisory Board. Dr. Cross was one of a number of doctors who pioneered the Doctor’s Building and Doctor’s Hospital where he served as Chief of Staff. He enjoyed 49 years of marriage to Sarah. After her death, Dr. Cross received the gift of a second love with his marriage to Fern Cross who became his sweetheart and soul mate of 15 years. Dr. Cross is survived by his wife, Fern Cross; his children and step children: son, Junius Bracy Cross, Jr. and wife, Deborah D. Cross, daughters, Suzanne Cross Hearn and husband, Tyrrell Hearn, India Cross Cheairs; step-children, Bill Downs and wife, Stephanie Downs, Gael Downs Hancock and husband, John Hancock along with several grandchildren and great-grandchildren.

MALVERN – Robert H. White, MD, 78, passed away September 10, 2014. Dr. White was a graduate of the University of Arkansas at Fayetteville, and attended medical school in Little Rock. He retired from the Army National Guard in 1997 after 36 years in the military. While in the service, he was a flight surgeon. Dr. White set up his medical practice in Malvern in 1961, and became very active in the community. He was a member of the American Medical Association, the Hot Spring County Medical Society, and a charter member of the Academy of Family Practice. Dr. White was also a member of the Arkansas Medical Society and a member of the Fifty Year Club. He is survived by his wife, Dean Barnes White, and by four children, Steve White (Julie), Mike White (Julie), Scott White (Adriana), and Dawn Loomis (Doug) along with 13 grandchildren and two great-grandchildren.

2015 “DOCTOR OFTHE DAY” PROGRAM

Watch Your Mail!2015 Dues statements will hit the mail soon. Please return them as soon as possible or

renew online at www.arkmed.org.

The Society will again sponsor the “Doctor of the Day” program for the 2015 session of the

Arkansas legislature. This program has been provided by the Society for a number of years and has

enhanced the effectiveness of our political efforts. The legislative session will convene on January 12, 2015, and continues for a minimum of 60 days, but the time can be extended by action of the

legislature if needed.

Volunteers are needed each Monday through Friday. We are asking for you to volunteer your

services one day during the session to provide physician coverage for our legislators. The “Doctor of the Day” can attend legislative committee meetings and has floor privileges in the House and

Senate. The “Doctor of the Day” should plan to be at the Capitol Infirmary in the State Capitol from

approximately 9:00 a.m. until 3:30 p.m. Please contact Laura Hawkins at the AMS office at 501-

224-8967 or 800-542-1058 if you have questions about the program. Thank you for your continued

support of the Arkansas Medical Society and the AMS Department of Governmental Affairs.



Mutual Interests. Mutually Insured.

Who would you trust to be there when you need to defend your professional reputation? Looking at the numbers, there is no comparison. When it comes to your medical professional liability insurance, it pays to do your homework.

For more information, contact Sharon Theriot at [email protected] or call 1-800-342-2239.

Follow us on Twitter @SVMIC www.svmic.com

ARKANSAS MUTUAL

Industry Experience 38 years 6 years

Arkansas Experience 25 years 6 years

A.M. Best Rating A (Excellent) Not rated

A.M. Best Rating HistoryA (Excellent) or better for 30 consecutive years

None

OperationsManaged 100% in-house with some of the lowest expenses in the country

Managed pursuant to a contractual agreement with an affiliated entity that is partially owned by management of Arkansas Mutual and outside investors

Percentage of premium spent on operating expenses

17% 66%

Surplus as regards policyholders

$496.7M $2.8M

Total dividends returned to Arkansas physicians

$13.5M $0

Dividends returned to Arkansas physicians in the last five years

$8.6M $0

Dividends returned to Arkansas physicians in the last five years as a percentage of premium

9% 0%

This chart contains information extracted from the December 31, 2013 Statutory Annual Statements of each company and from other publicly available sources.

digging up bones - arkmed.org

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