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    <recommendedItem id="20100101_19_402"
                     title="Minimally Invasive Surgery Takes Toll on MDs, Poll Shows (CME/CE)"
                     score="0.009"
                     href="http://www.medpagetoday.com/Surgery/GeneralSurgery/tb/18306?impressionId=1265773163944"
                     
      &lt;p&gt;Four out of five surgeons agree: Laparoscopic procedures cause substantial discomfort and pain for the surgeons who perform them.&lt;/p&gt;
&lt;p&gt;More than 80% of surgeons completing an online questionnaire reported pain or stiffness in the hands, neck, back, or legs after performing minimally invasive surgeries, according to Adrian Park, MD, of the University of Maryland Medical Center in Baltimore, and colleagues.&lt;/p&gt;
&lt;p&gt;For most symptoms, the strongest predictor was high case volume, the researchers reported online in the &lt;em&gt;Journal of the American College of Surgeons&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Park and colleagues warned of &quot;an impending epidemic&quot; of occupational injuries among clinicians specializing in minimally invasive surgeries, as such procedures become more common.&lt;/p&gt;
&lt;p&gt;&quot;Now, especially in the face of an impending shortage of general surgeons in the U.S., the last thing that we as a society can afford is surgical careers shortened by occupationally related symptoms and conditions,&quot; they asserted.&lt;/p&gt;
&lt;p&gt;The researchers recommended more research into the ergonomics of laparoscopic surgery, as well as better implementation of existing guidelines meant to reduce injuries associated with the awkward postures and long surgical times often required with these procedures.&lt;/p&gt;
&lt;p&gt;&quot;That research must more clearly and emphatically define the ergonomic impact of minimally invasive surgery on the practicing surgeon (then set about improving it) is now all too painfully clear,&quot; Park and colleagues concluded.&lt;/p&gt;
&lt;p&gt;The researchers invited some 2,000 board-certified members of the Society of American Gastrointestinal and Endoscopic Surgeons (of which Park is currently secretary) to complete the online survey.&lt;/p&gt;
&lt;p&gt;The response rate was 14.4%, with 317 surgeons identified as actively and regularly involved in laparoscopic practices participating.&lt;/p&gt;
&lt;p&gt;Of these, 272 reported experiencing physical symptoms or discomfort that they believed were the result of performing minimally invasive procedures.&lt;/p&gt;
&lt;p&gt;This rate of reported symptoms is markedly higher than that found in earlier studies and surveys, in which the prevalences were in the range of 15% to 60%, Park and colleagues noted.&lt;/p&gt;
&lt;p&gt;They speculated that the current survey, as the most recent, may better reflect the accumulation of injuries over time as surgeons&apos; careers doing minimally invasive surgery have grown longer.&lt;/p&gt;
&lt;p&gt;Fortunately, they found, symptoms were generally not persistent. Only 10.8% of respondents indicated that pain or discomfort continued beyond the immediate aftermath of surgery.&lt;/p&gt;
&lt;p&gt;The largest class of symptoms were those occurring during surgery, with 20.8% of surgeons saying they had symptoms only during procedures and 27.8% reporting symptoms both during and immediately after surgery.&lt;/p&gt;
&lt;p&gt;Another 22.4% indicated that symptoms occurred only immediately after surgery and not persistently.&lt;/p&gt;
&lt;p&gt;About 15% chose &quot;nothing bothers me&quot; in the questionnaire.&lt;/p&gt;
&lt;p&gt;Age appeared to be a factor in the incidence of some complaints, although the pattern was not what might be expected. In particular, hand pain was most common among surgeons younger than 40 and in those older than 60, whereas it was least frequent among surgeons in their 50s.&lt;/p&gt;
&lt;p&gt;Park and colleagues did not report specific hazard ratios or correlation coefficients for case volume as a predictor of symptoms, but they indicated that it was associated with complaints more strongly than other factors such as age, career duration, gender, and height.&lt;/p&gt;
&lt;p&gt;About three-quarters of respondents attributed symptoms to instrument design. Some 40% indicated that operating room table setup and the display monitor location were also contributing factors.&lt;/p&gt;
&lt;p&gt;On the other hand, more than 180 respondents said they had slight or no awareness of published recommendations on surgical ergonomics, such as guidelines published last year in the journal &lt;em&gt;Surgical Endoscopy&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Among those reporting any level of knowledge about the guidelines, only 60% indicated that they had applied it in their practices, Park and colleagues indicated. But more than 90% of surgeons who said they had high awareness of ergonomic guidelines reported putting it to use.&lt;/p&gt;
&lt;p&gt;The researchers said future studies should address other issues not covered adequately in the survey, such as the effects of different monitor positions and instrument designs, as well as whether surgeon discomfort during laparoscopic surgery leads to adverse patient outcomes.&lt;/p&gt;
&lt;p&gt;Park and colleagues also suggested that similar research be conducted on open surgery.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No external funding for the study was reported.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_222"
                     title="Benefits of Cutting Down on Salt Quantified (CME/CE)"
                     score="-0.004"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265773163944"
                     
      &lt;p&gt;Cutting daily salt intake by 3 grams a day  --  about 30% of the current average  --  could prevent 32,000 strokes and 54,000 myocardial infarctions a year, if a computer model developed by researchers at the University of California, San Francisco accurately depicts the clinical impact of salt reduction.&lt;/p&gt;
&lt;p&gt;The results of the analysis, which used a computer simulation of heart disease in U.S. adults ages 35 to 84, also suggest that even a 1 gram per day reduction in salt over the next decade would be a more cost-effective strategy for treating hypertension than use of even the cheapest antihypertensive, wrote Kirsten Bibbins-Domingo, MD, PhD, and colleagues in a paper published online by the &lt;em&gt;New England Journal of Medicine.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Lee Goldman, MD, MPH, of Columbia University, who co-authored the paper, told &lt;em&gt;MedPage Today&lt;/em&gt; that their study builds on what has long been known about the adverse health effects of salt on a society that believes it to be the spice of life.&lt;/p&gt;
&lt;p&gt;For example, Goldman said that most people seeking a healthy choice will check food labels and restaurant menus for calorie counts and trans fats, but will not pay attention to salt.&lt;/p&gt;
&lt;p&gt;This is not the first time a call for salt reduction has been issued. As recently as last November, a meta-analysis published in &lt;em&gt;BMJ &lt;/em&gt;suggested that cutting salt intake in half  --  a reduction of about 5 grams a day or roughly a teaspoonful  --  would lower the stroke rate by 23% and reduce overall cardiovascular disease by as much as 17%.&lt;/p&gt;
&lt;p&gt;Americans, like those in many Western countries, take in an average of about 10 g of salt a day; whereas the World Health Organization recommends only 5 g per day, and the U.S. Department of Agriculture recommends daily intake be limited to 5.8 g.&lt;/p&gt;
&lt;p&gt;Bibbins-Domingo and colleagues reported that a 3 gram per day reduction in dietary salt would &quot;save 194,00 to 392,00 quality-adjusted life-years and $10 billion to $24 billion in healthcare costs annually.&quot;&lt;/p&gt;
&lt;p&gt;In an editorial that accompanied the study, Lawrence J. Appel, MD, MPH, and Cheryl A.M. Anderson, PhD, MPH, of Johns Hopkins University, wrote that &quot;the evidence supporting the call to reduce salt intake as a means of preventing cardiovascular disease is compelling.&quot;&lt;/p&gt;
&lt;p&gt;They concluded with this admonition: &quot;As we deliberate healthcare reform, let us not neglect this inexpensive, yet highly effective public health intervention for the prevention of disease.&quot;&lt;/p&gt;
&lt;p&gt;It should be noted that Appel was also first author on a position paper from the American Society of Hypertension that also called for salt reduction as public policy.&lt;/p&gt;
&lt;p&gt;Franz H. Messerli, MD, director of the hypertension program at St. Luke&apos;s-Roosevelt Hospital and a colleague of Goldman&apos;s, said the computer model used in the study was impressive but probably underestimates the benefit of reducing dietary salt &quot;because salt reduction has been shown to have a direct (blood pressure independent) effect on the heart, the brain, the kidneys, and also reduces stomach cancer and osteoporosis  --  factors that were not considered in this analysis.&quot;&lt;/p&gt;
&lt;p&gt;But Messerli found it difficult to lead the victory parade, noting &quot;this is a modeling study and statements such as &apos;A modest reduction of 1 gm per day would be more cost-effective than using medication to lower blood pressure in all persons with hypertension&apos; are to be taken with a good grain of salt.&quot;&lt;/p&gt;
&lt;p&gt;Messerli&apos;s measured response was not echoed by his colleagues in the hypertension world.&lt;/p&gt;
&lt;p&gt;For example, Henry Black, MD, president of the American Society of Hypertension, and director of hypertension research at the New York University School of Medicine said that, although the paper extended the findings of many other studies, it is &quot;more comprehensive and is especially useful by comparing the benefits of [sodium] and [salt] reduction to those of other widely accepted public health approaches that the public and governmental bodies have embraced, including drug treatment.&quot;&lt;/p&gt;
&lt;p&gt;Clyde Yancy, MD, president of the American Heart Association, said that while the study was a computer modeling analysis that may be as good as it gets because &quot;it would be impossible to do a randomized trial in large numbers of high versus low sodium consumption, and the use of modeling with reasonable assumptions represents a solid if not ideal alternative.&quot;&lt;/p&gt;
&lt;p&gt;Moreover, Yancy argued that &quot;the costs and effort involved in setting and/or changing policy&quot; require strong imperatives, and he thought the data reported today &quot;provide that imperative.&quot;&lt;/p&gt;
&lt;p&gt;Three grams of salt comes to about a teaspoonful, but Goldman said it was foolish to think of sodium reduction in terms of such measurements because so much sodium comes from processed foods and from restaurant food. Achieving the needed reduction requires a concerted national effort.&lt;/p&gt;
&lt;p&gt;Bibbins-Domingo noted that their study was limited &quot;by any uncertainty concerning the data entered into the model.&quot;&lt;/p&gt;
&lt;p&gt;Also they noted that they did not &quot;account fully for the possible effects of salt reduction that are unrelated to control of blood pressure  --  for example, potential improvements in outcomes for the increasing numbers of patients with heart failure or prevention of other serious conditions, such as end-stage renal disease.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported in part by a grant from the American Heart Association Western States Affiliate and a grant from the University of California, San Francisco Clinical and Translational Sciences Institute.&lt;/p&gt;&lt;p&gt;The authors said they had &quot;no potential conflicts of interest relevant to this article.&quot;&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20090101_10_91"
                     title="Pulmonary Artery Catheters Are a Washout"
                     score="-0.005"
                     href="