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Articles by J Freeman
Total Records ( 6 ) for J Freeman
  G Sharma , Y. F Kuo , J Freeman , D. D Zhang and J. S. Goodwin
 

Background  Comanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes. We examined the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States.

Methods  We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for 1 of 15 inpatient surgical procedures from 1996 to 2006 (n = 694 806). We also calculated the proportion of Medicare beneficiaries comanaged by medicine physicians (generalist physicians or internal medicine subspecialists) during hospitalization. Comanagement was defined by relevant physicians (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patients were hospitalized.

Results  Between 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by a medicine physician: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). The percentage of patients experiencing comanagement was relatively unchanged from 1996 to 2000 and then increased sharply. The increase was entirely attributable to a surge in comanagement by generalist physicians. In a multivariable multilevel analysis, comanagement by generalist physicians increased 11.4% per year from 2001 to 2006. Patients with advanced age, with more comorbidities, or receiving care in nonteaching, midsize (200-499 beds), or for-profit hospitals were more likely to receive comanagement. All of the growth in comanagement was attributed to increased comanagement by hospitalist physicians.

Conclusions  Medical comanagement of Medicare beneficiaries hospitalized for a surgical procedure is increasing because of the increasing role of hospitalists. To meet this growing need for comanagement, training in internal medicine should include medical management of surgical patients.

  J Freeman
 

The exercise electrocardiogram (ECG) is widely considered the best available test for screening asymptomatic adults without known cardiovascular (CV) disease prior to initiating a vigorous exercise programme due to its prognostic value, widespread availability and low cost. Observational studies have demonstrated an increased relative risk of CV events with positive screening exercise ECG tests in men with diabetes, advanced age, or multiple cardiac risk factors. Recent observational studies have not demonstrated similar prognostic value for exercise ECG testing in asymptomatic healthy women. Despite the predictive ability of exercise ECG testing in several groups, there have been no studies demonstrating a significant impact of screening on morbidity and mortality in completely asymptomatic patients, leading to significant discordance in consensus guidelines on screening. One prospective observational study is ongoing in Italy that may for the first time demonstrate the ability to decrease incident CV events using preparticipation screening exercise ECG testing in adult athletes with targeted exclusion from athletics. Until more conclusive data is available the authors currently recommend screening exercise ECG testing in asymptomatic men with diabetes and asymptomatic men over age 45 with two or more CV risk factors prior to initiating a vigorous exercise programme. Consideration should also be given to screening asymptomatic patients younger than 45 with particularly strong risk factor exposure or elderly patients with fewer than two risk factors.

  L Sawle , M Mathews , J Freeman and J. Marsden
 

Lumbopelvic pain (LPP) often results from trauma or overuse that can lead to conditions including adductor tears, sacroiliac joint dysfunction and osteitis pubis. Such injuries are often refractory to treatment and can limit the return to competitive sport. Previous research shows that selective compressive forces applied transversely to the pelvis can result in improved lumbopelvic stability and reduced pain, and, compression shorts may aid in preventing athletic lumbopelvic injury. This study applies transverse and diagonal compressive forces to the pelvis in athletes with LPP, and investigates the effects on pain and function. Participants with athletic LPP were screened using five clinical tests. They were included if at least two tests provoked pain. Transverse and diagonal circumferential forces were applied via a belt. Four belt arrays (anterior superior iliac spines (ASIS), right-left across the pelvis, left-right across the pelvis and in combination) and a "no-belt condition" were assessed with the order of presentation randomised. A force of 50 N was applied (determined using a load cell lying in series with the belt). The effect of the belt array on rest pain, pain associated with an active straight leg raise (ASLR) and a 1-m broad jump was assessed using a numerical rating scale. During resisted bilateral hip adduction the onset of pain was indicated using a hand held switch; the maximal force of adduction determined via a load cell. Data were analysed using paired t tests. Preliminary data on 12 participants (9 females, mean 37±10 years) indicate that different belt arrays can alleviate pain both at rest and during active tasks. Pain during ASLR (ipsilateral to the pain) improved with combined belts compared to an ASIS belt (p=0.025). Preliminary results suggest the direction and angle of force application relative to the laterality of pain is important in determining the degree and pattern of pain relief. A larger sample is needed to confirm this (required sample of 31 based on effect size of 0.51 and 80% power). Results will inform the design of a dynamic elastomeric fabric orthosis whose effect on athletic LPP and function will be assessed.

  L Sawle , M Mathews , J Freeman and J. Marsden
 

The aim was to evaluate effectiveness of a customised dynamic elastomeric fabric orthosis (DEFO) in aiding return to sport after lumbopelvic injury. Relevance: athletic lumbopelvic dysfunction (LPD) is a common problem. Pelvic belts have been used in the management of LPD, but with limited success. The authors designed a DEFO to aid LPD management and evaluated its effectiveness using a series of single case studies. Participants were one female and two male athletes, experiencing LPD during sport or at rest were recruited from local gyms and sports clubs. Three single case studies (AB design) with a randomised onset of intervention. Fifteen daily assessments were undertaken, with at least six during each phase. In the intervention phase participants wore the DEFO during pain-provoking activities. Measures were self-reported pain (Numerical Rating Scale): at rest, during resisted bilateral hip adduction, an active straight leg raise and a broad jump. Maximal resisted hip adduction was measured via a load cell. In each phase measures were repeated twice, separated by a 10-min rest. At baseline regular shorts were worn during both tests; during the intervention phase participants first wore the regular shorts and then the DEFO. Training diaries were kept. At 1 month participants were retested and completed a questionnaire about DEFO use. Visual analysis of trend, level and slope was undertaken on all data. Mean (±2 SD) was plotted for force data and pain scores, preceded by celeration lines. In two cases, force production significantly increased during the intervention phase. In all cases, during intervention, pain scores significantly reduced for all activities. Questionnaire data and diaries indicated enhanced sports participation with DEFO use. Preliminary evidence is provided supporting the use of this customised DEFO to aid the management of athletic lumbopelvic pain. This orthosis may support physiotherapeutic management of athletic LPD. Further work examining its impact on performance is required.

  V Agrawal , J Ye , J McCann , B Hehn , J Freeman , S Allen and G. Braden
 

We present an interesting case of a young female smoker who was hospitalized for shortness of breath and acute renal insufficiency (serum creatinine = 2.8 mg/dL). Few weeks prior to admission, she was discovered to have a right lung mass, and a biopsy confirmed lung adenocarcinoma. Her work-up revealed an unremarkable urinalysis quantitatively and on microscopic analysis. Renal ultrasound demonstrated enlarged bilateral unobstructed kidneys, while a nuclear scan showed increased activity in both kidneys. Renal biopsy established the diagnosis of diffuse metastatic infiltration of both kidneys from primary lung adenocarcinoma. Her renal function worsened despite initiation of chemotherapy. Carcinomatous infiltration of the kidneys is an extremely rare and unusual cause of renal injury that must be suspected in a patient with cancer and large kidneys.

 
 
 
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