Jack L. Paradise, MD, now retired, was the medical director of the Ambulatory Care Center at the Children’s Hospital of Pittsburgh. He was also a professor in the pediatrics department at the University of Pittsburgh School of Medicine. Dr. Paradise’s primary research was focused on indications for tonsillectomy and adenoidectomy, and on the diagnosis, management, and clinical significance of otitis media.
Why did you develop the Paradise Criteria? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
When in pediatric practice in a new, union-sponsored health plan in Appalachia, I was often called upon to render judgment as to whether or not tonsillectomy was indicated for individual children for whom a recommendation for tonsillectomy had been made by other physicians. This procedure was instituted because health plan administrators believed that tonsillectomy often was being performed on children without appropriate indications. Accordingly, payment for tonsillectomy by the health plan was made contingent on prior approval by me or by another member of a health-plan-designated group of consultants. In that role, I came to realize that there were then no evidence-based criteria for tonsillectomy. Recommendations by recognized authorities varied widely and were based entirely on clinical experience and/or opinion. When I left practice to head an ambulatory care program in a large teaching hospital, I saw an opportunity to address the question of criteria for tonsillectomy systematically.
Shannon N. Acker, MD, is a pediatric surgeon at the University of Colorado. Dr. Acker’s primary research is focused on trauma and surgical complications in adolescents.
Why did you develop the SIPA? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
Children have a remarkable ability to compensate for hypovolemic shock and are able to maintain a normal blood pressure until they reach cardiovascular collapse. Because shock index incorporates not only blood pressure but also heart rate, we hypothesized that an age adjusted shock index would help us to identify these children before the point of cardiovascular collapse. Our motivation to create SIPA came from an ongoing desire to improve pediatric trauma care and our desire to more accurately identify severely injured children prior to the point of cardiovascular collapse.
Current guidelines for children are logical. Current guidelines for adolescent/adults follow from an assumption that I am happy to argue against.
All guidelines recommend not to test or treat for Centor scores (with or without McIsaac modification) of 0 or 1. The pre-test probabilities are very low and most positive tests are false positives. Unfortunately, many urgent care centers and emergency departments perform a rapid strep test prior to the treating practitioner spending 3-5 minutes doing a quick history and exam. Testing wastes resources in 40-50% of patients presenting with a sore throat complaint and leads to unnecessary antibiotics. This is the biggest mistake that I see!
The controversy for adolescents/adults with pharyngitis and Centor scores of 2-4 involves the concept of lack of proof. Why treat pharyngitis with antibiotics?
There are 5 potential reasons to treat pharyngitis with antibiotics:
Brandon Webb, MD, is an infectious disease physician in the division of epidemiology and infectious diseases at Intermountain Healthcare in Utah. He has also served as an adjunct assistant professor at the University of Utah School of Medicine. Dr. Webb’s research interests include bacterial pneumonia, antimicrobial stewardship, and transplant infectious diseases.
Andrew Shorr, MD, MPH, is an associate director of pulmonary and critical care medicine and the chief of the Pulmonary Clinic at MedStar Washington Hospital Center in Washington, DC. Dr. Shorr’s research interests include resistant pathogens and healthcare-associated bacteremia, and he has published more than 140 original studies.
Why did you develop the BAP-65 Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
I think we were interested in developing the score for two reasons: one, as a purely academic exercises, given that we have risk scores for PE and risk scores for pneumonia, clearly one of the pulmonary disease states where patients are sicker than they look is in COPD. So it was a clear hole in the range of pulmonary-critical care disease states that didn’t have some pulmonary risk stratification tool. And when you tie that together with the fact that COPD is a leading reason for admission in general, you can understand.
Dr. Michael Fine, professor of medicine at the University of Pittsburgh, led the team that developed the Pneumonia Severity Index (PSI) and began studying the prognosis and other clinical aspects of community-acquired pneumonia (CAP) in the early 1990s.
His interest in predicting mortality in CAP started while he served as chief resident in internal medicine at the University of Pittsburgh. His mentor, Dr. Wishwa Kapoor, then hired him after his general internal medicine fellowship in the Harvard Generalist Faculty Development Program. At the time Dr. Fine transitioned from fellowship to faculty at the University of Pittsburgh, the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality, AHRQ) had a well-funded portfolio of research projects called PORT (Patient Outcome Research Teams) studies. Continue reading “Predicting Mortality in Community Acquired Pneumonia – Dr. Robert Centor Interviews PSI Creator Dr. Michael Fine”→
Counseling patients with diabetes on lifestyle change during primary care office visits is motivated by good intentions. We as primary care doctors are interested in prevention, lifestyle changes can positively affect many patients with diabetes, and patients do best when engaged in managing their disease1. But it’s difficult to show with data that brief physician encounters are effective at producing any of these outcomes. Continue reading “Diabetes Management: Why Can’t We Do This with Lifestyle Alone?”→
Simon J. Griffin, DM, is professor of general practice at the University of Cambridge, Group Leader in the MRC Epidemiology Unit and an assistant general practitioner at Lensfield Medical Practice in Cambridge, UK. He leads the Prevention of Diabetes and Related Metabolic Disorders Programme. Professor Griffin’s research interests include prevention and early detection of chronic conditions such as diabetes.
Haywan Chiu, DPM, is a practicing podiatrist in Albuquerque, New Mexico. He has a special interest in the diabetic foot. Haywan runs Diabetic Foot Guardian, an easily digestible resource for patients regarding feet and diabetes.
Callus Debridement Can Be Diagnostic
Calluses form when shear forces and pressure induce the epidermis to reinforce itself. In patients with diminished pain sensation such as in diabetic neuropathy, continued friction from shear forces and pressure evolves the callus into a blister, then a blood blister (figure 1). When I see a bloody foot callus, I know that at some point, there was a break in the dermis. I don’t know if it has healed on its own or if it has expanded into a full blown ulcer because I can’t see past the callus. In fact, some calluses can be so thick I can’t even see the blood underneath! The only way to find out what’s hiding is to debride the callus.