Alcohol Abuse Kicks Infection Risk up 15X // Cognitive Behavioral Therapy Powerful Pain Treatment // and More!

Alcohol Abuse Kicks Infection Risk up 15X

Wael Barsoum, M.D., president of Cleveland Clinic, Florida, is wading into an area where few orthopedic surgeons tread. Recognizing that treating certain patients means going beyond the normal scope of duty, Dr. Barsoum embarked on a project to assess how the misuse of alcohol affects outcomes after hip and knee arthroplasty. He told OTW, “We really know very little about how patients who drink to excess fare after these surgeries. The issue is not that physicians don’t understand the importance of the problem, but it is difficult to accurately assess a person’s history in terms of alcohol consumption in a preoperative office visit, and important information which would help the surgeon in this regard may be missing from his/her medical record. Not much work has been done in this area; of the two papers we found, one involved 60 patients and another involved 185 patients. This study was able to access information on 8.3 million patients who underwent THA or TKA, making it landmark research.”

“We utilized records from the National Hospital Discharge Survey and divided patients into two groups: those who misused alcohol (50, 861) and those who did not (8, 321, 371). The tradeoff with these databases is large numbers of patient records at the expense of granular detail. In this case, we used ICD-9 codes to identify patients who were coded as having alcohol dependence or alcohol abuse, which are fairly difficult to define and undoubtedly underreported.”

“If a patient tells you that he or she consumes one to two alcoholic drinks per day, it is typically safe to assume that they actually drink more than that. There have been times when I asked a patient, ‘Do you drink alcohol?’ and the person has said, ‘Yes, but not much.’ Upon digging a little deeper, however, it turns out that they’re drinking a case of beer a day. It’s like the times I have asked someone, ‘Are you diabetic?’ and he or she replies, ‘no.’ ‘So why do you take insulin?’ I ask. ‘Oh, it’s for my sugar.’ It comes down to their understanding of what is considered normal in terms of alcohol consumption.”

“In our study, we found vast differences in discharge status, comorbidities and perioperative complications. Those who misused alcohol were nine times more likely to leave against medical advice and had longer hospital stays. And orthopedic surgeons should be prepared for the fact that these patients are much more likely to have complications. Those who misused alcohol had a higher rate of total complications than those who did not (33% versus 22%). And ‘misusers’ had significantly higher rates of all complications except urinary tract infection, pulmonary embolism, and deep vein thrombosis. Also critical is that patients who misused alcohol had a 15x higher risk of infection. We need to keep a closer eye on the incisions, and even bring these patients back one week postoperatively to check them out.”

“Finally, alcohol misusers were 23% more likely to have a blood transfusion. To address this, we should be giving patients something to minimize the risk of blood transfusion (a less aggressive anticoagulant, give them a topical hemosealant, etc.).”

So what to do with those who drink more than average? “Anecdotally, these patients tend to start getting frustrated early in their hospitalization; some facilities deal with this by letting patients drink alcohol in the hospital. The other option is to do something preoperatively to minimize the drinking, perhaps giving the patient a benzodiazepine such as Librium. The other option is to ignore it, although clearly our research shows that this is not the best option for the patient in terms of his/her surgical outcome.”

“If a patient at our facility is not interested in reducing their alcohol intake before surgery, then we allow them to have alcohol while in the hospital. While at first glance it sounds like an odd solution, honestly, it is safer because the alternative—benzodiazepines—are not something familiar to most patients. We always link the issue of providing alcohol with a very honest conversation about why we are taking this route, as well as the risks involved.”

“It may be that higher risk patients should be sent to a higher acuity environment. But know that ignoring the problem will only create more issues. You need to have a strategy regarding alcohol misuse.”

Cognitive Behavioral Therapy Powerful Acute Pain Treatment

When psychiatrists at Harvard Medical School set out to study the relationship between depression and physical pain in patients recovering from musculoskeletal trauma, they were pleasantly surprised. The team, led by Ana-Maria Vranceanu, Ph.D., also included David Ring, M.D., Ph.D., chief of the Hand and Upper Extremity Service at Massachusetts General Hospital.

The team set out to estimate the prevalence of clinical depression and posttraumatic stress disorder (PTSD) at two points in time following the occurrence of a musculoskeletal trauma. They also wanted to study the relationship of these psychological variables to at Time 1 (1-2 months) to musculoskeletal disability and pain intensity at Time 1 and Time 2 (5-8 months).

Regarding clinical depression, 35 of the 152 patients met the criteria at Time 1, and 29 of the 136 patients at Time 2. As for PTSD, 43 of the 152 patients met the criteria at Time 1 and 25 of the 136 patients at Time 2.

Catastrophic thinking (as measured with use of the Pain Catastrophizing Scale) at Time 1 was the sole significant predictor of pain at rest, pain during activity, and disability (as measured with use of the Short Musculoskeletal Function Assessment Questionnaire—SMFA) at Time 2.

Bottom line: The researchers found that catastrophic thinking is strongly associated with pain intensity and disability in patients recovering from musculoskeletal trauma.

Asked what led to this work, Dr. Vranceanu told OTW, “During my clinical internship in behavioral medicine I was introduced to Dr. David Ring, who was interested in the psychosocial aspects of orthopedic pain. At that point I started becoming involved in clinical work with patients with hand and arm pain within the orthopedic practice, as part of a multidisciplinary team. At the same time, David and I started a research program of psychosocial factors in hand and arm pain, that since then has exploded to patients with orthopedic trauma as well as general orthopedic pain.”

“I was pleasantly surprised as to how powerful evidence based skills interventions like Cognitive Behavioral Therapy (CBT) are for patients with acute pain. We know that although CBT works for chronic pain, effect sizes are relatively small and engagement in treatment is limited. With patients with acute pain, treatment can be as short as two sessions, and average four sessions, thus much more cost effective. I was and continue to be amazed by the wonderful work on psychosocial factors done by Dr. David Ring, as well as his keen knowledge and passion for this line of work.”

“Psychosocial treatments delivered early on in patients at risk for chronic pain work, prevent transition to chronic pain, and are cost effective. Using a biopsychosocial framework that accounts for the mind body interaction, combined with empathy and a shared decision making can greatly increase patient outcomes as well as patient satisfaction.”

Whoa Surgeon…Don’t Forget to Treat the Pathology

“Focus on function and pathology, ” says Keith Baldwin, M.D. An attending surgeon at the Children’s Hospital of Philadelphia (CHOP), Dr. Baldwin is an expert on neuromuscular conditions and director of orthopedic trauma at CHOP. He tells OTW, “My training and experience as a physical therapist have given me a window into the ways the physicians and physical therapists can collaborate for the benefit of their patients. While orthopedic rehabilitation is not a true discipline, it is central to what every orthopedist does. This is only going to be more true as we move forward with the use of quality metrics outcome measures and readmission assessments when it comes to payment decisions.”

“A clear, personalized rehabilitation program goes a long way toward reducing the risk of postoperative complications and improving outcome. Whether you are a joint surgeon or a spine surgeon or anything else, you must think about all you do in terms of this question, ‘How does what I am doing help people live their lives 3-4 months after surgery, and how does it improve their function?’ Reflect on whether your procedure is a step in the rehab process…or is it the thing that will cause the person to need rehab? As a research director at CHOP and heavily involved at the University of Pennsylvania, I try to get joint and sports surgeons to think about the disease they are treating as opposed to the joint they are treating. Joint surgery is only one thing that can be used to treat, say, osteoarthritis. But typically, orthopedic surgeons are not focused on the pathology; they are action-oriented people, and are focused on what they can do to correct the problem, rather than the problem itself.”

“When we were opening an outcomes center at ‘Penn’ I emphasized that we shouldn’t be collecting surgical outcomes, but rather outcomes of disease at various severity. For example, we shouldn’t be only looking at rotator cuff patients who had shoulder scopes, but that we should collect data on everyone and see which patients had single row with such-and-such technique, who had physical therapy, etc. Obama and the federal government are not interested in whether your shoulder scope worked…they are interested in how all people with rotator cuff tears do. Insert any pathology for that statement and you will get some idea of the issue. For a certain severity of problem, we must show for example that surgery as a portion of the entire treatment is a useful tool in the treatment of that pathology over the natural history or conservative treatment. Ideally, we are trying to understand the whole pathology rather than just being a technician.”