Lit Bits: March 14, 2009

From the recent medical literature...

1. Care by Hospitalists in US Growing

NEW YORK (Reuters Health) Mar 11 - In the last 10 years, there has been a marked increase in the proportion of hospitalized patients being managed by hospitalist physicians, according to a report in The New England Journal of Medicine for March 12.

The findings, based on an analysis of Medicare data, indicate that from 1995 to 2006, the percentage of claims for internist services provided by hospitalists rose from 9.1% to 37.1%. At the same time, the percentage of hospitalized patients treated by any general internist, both hospitalist and non-hospital-based clinicians, climbed from 46.4% to 61.0%.

"The rapid growth of care by hospitalists exemplifies the dynamic nature of medical care in the United States in recent years," Dr. Yong-Fang Kuo, from the University of Texas Medical Branch, Galveston, and co-researchers comment.

From a 5% sample of Medicare beneficiaries, the researchers identified 120,226 internal medicine physicians who provided care to older patients at 5800 US hospitals during the study period. Hospitalists were defined as clinicians who derived at least 90% of their Medicare claims from services provided to hospitalized patients.

From 1995 to 2006, the percentage of internists who were hospitalists increased from 5.9% to 19.0%, the authors report.

On multivariate analysis, the authors found that the likelihood of receiving care from a hospitalist rose by 29.2% each year from 1997 to 2006.

An analysis of 2006 data showed that the extent of hospitalist care varied greatly by geographic region. Hospital-referral areas with the highest percentages of hospitalist care were St. Cloud, Minnesota (85.6%), Mesa, Arizona (84.0%), and Appleton, Wisconsin (81.6%).

N Engl J Med 2009;360:1102-1112.

http://content.nejm.org/cgi/content/short/360/11/1102

2. Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department

Green SW, at al. Ann Emerg Med. 2009; in press

Study objective
Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

Methods
We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.

Results
In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose ≥2.5 mg/kg or total dose ≥5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class ≥3), and the choice of intravenous versus intramuscular route.

Conclusion
Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

3. Tailoring the Use of Plain Abdominal X-rays in the ED

Smith J E, et al. Emerg Med J 2009: 26:160-163.

Most useful in three circumstances:
• Acute abdominal pain: if bowel obstruction suspected
• Oesophageal foreign body suspected (depending on local protocol for metal detector)
• Sharp/poisonous foreign body suspected

Full-text (free): http://emj.bmj.com/cgi/content/full/26/3/160

4. Clopidogrel and Proton-Pump Inhibitors

Risk for adverse cardiac events was elevated in patients taking both medications.

Prior biochemical studies have suggested that proton-pump inhibitors (PPIs) reduce the inhibitory effect of clopidogrel on platelet aggregation. A recent FDA review raised concerns about this issue, but data were insufficient to make a specific recommendation. In this study, a Veterans Affairs database was used to retrospectively assess this interaction clinically in 8205 patients discharged with acute coronary syndromes (ACS); 5244 (64%) were taking both clopidogrel and a PPI, and the rest were taking clopidogrel alone. Medication use was assessed by pharmacy prescription data.

At a mean follow-up of roughly 18 months, death or rehospitalization for ACS had occurred in 1561 patients (30%) taking both medications and 615 (21%) of patients taking only clopidogrel. In analyses adjusted for about 25 demographic and clinical variables, risk for death or rehospitalization was roughly 25% higher in patients taking both medications (86% higher for recurrent ACS, 49% higher for revascularization procedures, but no difference for death alone).

Comment: As with any retrospective analysis, there are confounders for which statistical adjustment might not be fully adequate, so prospective clinical trials are needed to confirm this result. However, based on plausible biological mechanisms (e.g., inhibition by PPIs of the cytochrome P450 enzyme system responsible for the active metabolite of clopidogrel), clinicians should be more parsimonious in their use of PPIs for specific indications, rather than using them for routine prophylaxis, as is often done.

— Thomas L. Schwenk, MD. Published in Journal Watch General Medicine March 12, 2009.
Citation: Ho PM et al. JAMA 2009 Mar 4; 301:937.

5. Images in EM

Young Girl With Lump on Forehead
http://www.annemergmed.com/article/S0196-0644(08)00940-2/fulltext

Adolescent Male With Vision Loss and Headache http://www.annemergmed.com/article/S0196-0644(08)01393-0/fulltext

6. A New Drug to Cure Insomnia from Shift Work or Jet Lag?

Tasimelteon, a melatonin agonist, shows promise.

After an abrupt advance in sleep time, tasimelteon improved sleep initiation and maintenance concurrently with a shift in endogenous circadian rhythms. Tasimelteon may have therapeutic potential for transient insomnia in circadian rhythm sleep disorders.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61812-7/abstract

7. Exercise Dose and Quality of Life: A Randomized Controlled Trial

Martin CK, et al. Arch Intern Med. 2009;169(3):269-278.

Background: Improved quality of life (QOL) is a purported benefit of exercise, but few randomized controlled trials and no dose-response trials have been conducted to examine this assertion.

Methods: The effect of 50%, 100%, and 150% of the physical activity recommendation on QOL was examined in a 6-month randomized controlled trial. Participants were 430 sedentary postmenopausal women (body mass index range, 25.0-43.0 [calculated as weight in kilograms divided by height in meters squared]) with elevated systolic blood pressure randomized to a nonexercise control group (n = 92) or 1 of 3 exercise groups: exercise energy expenditure of 4 (n = 147), 8 (n = 96), or 12 (n = 95) kilocalories per kilogram of body weight per week. Eight aspects of physical and mental QOL were measured at baseline and month 6 with the use of the Medical Outcomes Study 36-Item Short Form Health Survey.

Results: Change in all mental and physical aspects of QOL, except bodily pain, was dose dependent (trend analyses were significant, and exercise dose was a significant predictor of QOL change; P less than .05). Higher doses of exercise were associated with larger improvements in mental and physical aspects of QOL. Controlling for weight change did not attenuate the exercise-QOL association.

Conclusion: Exercise-induced QOL improvements were dose dependent and independent of weight change.

8. Which Is Better for Diagnosing Vaginitis: Clinical Judgment or DNA Analysis?

DNA analysis was more accurate than clinical diagnosis, but managing patients with vaginitis remains difficult.

Lowe NK, et al. Obstetrics & Gynecology 2009;113:89-95.

Abstract
OBJECTIVE: To estimate the accuracy of the clinical diagnosis of the three most common causes of acute vulvovaginal symptoms (bacterial vaginosis, candidiasis vaginitis, and trichomoniasis vaginalis) using a traditional, standardized clinical diagnostic protocol compared with a DNA probe laboratory standard.

METHODS: This prospective clinical comparative study had a sample of 535 active-duty United States military women presenting with vulvovaginal symptoms. Clinical diagnoses were made by research staff using a standardized protocol of history, physical examination including pelvic examination, determination of vaginal pH, vaginal fluid amines test, and wet-prep microscopy. Vaginal fluid samples were obtained for DNA analysis. The research clinicians were blinded to the DNA results.

RESULTS: The participants described a presenting symptom of abnormal discharge (50%), itching/irritation (33%), malodor (10%), burning (4%), or others such as vulvar pain and vaginal discomfort. According to laboratory standard, there were 225 cases (42%) of bacterial vaginosis, 76 cases (14%) of candidiasis vaginitis, 8 cases (1.5%) of trichomoniasis vaginalis, 87 cases of mixed infections (16%), and 139 negative cases (26%). For each single infection, the clinical diagnosis had a sensitivity and specificity of 80.8% and 70.0% for bacterial vaginosis, 83.8% and 84.8% for candidiasis vaginitis, and 84.6% and 99.6% for trichomoniasis vaginalis when compared with the DNA probe standard.

CONCLUSION: Compared with a DNA probe standard, clinical diagnosis is 81-85% sensitive and 70-99% specific for bacterial vaginosis, Candida vaginitis, and trichomoniasis. Even under research conditions that provided clinicians with sufficient time and materials to conduct a thorough and standardized clinical evaluation, the diagnosis and, therefore, subsequent treatment of these common vaginal problems remains difficult.

9. Taking Multivitamins? Don’t Expect to Prevent Cancer or Cardiovascular Disease

Multivitamin supplements did not affect CVD risk, cancer risk, or overall mortality in WHI participants.

http://archinte.ama-assn.org/cgi/content/abstract/169/3/294

10. Fit and Function of the Laryngeal Mask Airway Supreme

In a study of 100 women, the mask was easy to insert, had high leak resistance, and allowed easy insertion of a nasogastric tube.

The Laryngeal Mask Airway Supreme (LMAS) is a new (2007), single-use airway device that the manufacturer claims to provide easier insertion and higher seal pressure than other laryngeal mask airways and to allow access for nasogastric tube insertion. Researchers evaluated these claims in a prospective study of 100 women without anticipated difficult airways who underwent LMAS insertion after induction of general anesthesia for elective surgery. If an air leak was heard after the cuff was inflated, the mask was repositioned (inserted more deeply or moved to one side or the other) until no leak was present. If ventilation was not possible, the mask was removed and reinserted.

Mask insertion was successful in 94 patients on the first attempt and in 5 on the second attempt. One patient was too small to accommodate the device. Median insertion time was 10 seconds. Repositioning was required and successful in 13 patients. Nasogastric tube insertion was successful in all patients on the first attempt. LMAS positioning was assessed using a fiber-optic scope and was scored as "optimal" in all patients, both immediately after insertion and at the end of surgery. Mean seal leak pressure was 28 cm H2O. Eleven patients had unexpected vocal cord narrowing, three patients had increased inspiratory pressure, and two patients developed stridor. No patient required mask removal or surgery to be stopped. After mask removal, nine patients had minor upper airway trauma (slight blood on the mask edge), and eight complained of mild sore throat.

Comment: The LMAS combines the following advantages of other LMA models: a semirigid curved shaft (like the intubating LMA Fastrach), a port for nasogastric tube insertion (like the LMA ProSeal), and single-use design (like the LMA Unique). In addition, the LMAS has a higher seal pressure than the standard LMA does (useful in cases with high inspiratory resistance, such as patients with asthma, chronic obstructive pulmonary disease, pulmonary edema, and obesity). If additional studies confirm that the LMAS is reliably easy to place, it might become the preferred LMA model for prehospital and emergency department use when the ability to intubate is not required.

— Ron M. Walls, MD, FRCPC, FAAEM. Published in Journal Watch Emergency Medicine March 6, 2009. Citation: Timmermann A, et al. Anesthesiology 2009 Feb; 110:262.

11. Long-Term Survival Benefits of Early Evidence-Based Treatment for AMI

Rates of 12-year survival among patients who survived for at least 28 days after AMI have improved in association with increased use of evidence-based treatments.

Full-text (free): http://www.bmj.com/cgi/content/full/338/jan26_2/b36

12. The Use of Penicillin Skin Testing to Assess the ED Prevalence of Penicillin Allergy

Raja AS, et al. Ann Emerg Med. 2009; in press.

Study objective
Patient-reported penicillin allergies are often unreliable and can result in unnecessary changes in antibiotic therapy. Although penicillin allergy skin testing is commonly performed in allergy clinics, it has not been used in emergency departments (EDs) to verify self-reported allergies. We hypothesize that ED-based testing is possible and that the false-positive rate of patients with self-reported penicillin allergy are greater than 90%.

Methods
This prospective observational cohort study enrolled a convenience sample of ED patients with a self-reported penicillin allergy. Patients were enrolled by one of 2 emergency physicians who performed skin prick and intracutaneous tests with penicillin major and minor determinants. The total testing time was 30 minutes. The proportion of false-positive self-reported allergies was computed with 95% confidence intervals (CIs) by using the score method.

Results
A total of 150 patients (mean age 42 years; SD 16 years; 46% men; 47% black) were enrolled. The false-positive rate for self-reported penicillin allergy was 137 of 150 (91.3%; 95% CI 85.3% to 95.1%). There were no adverse reactions associated with penicillin skin testing. Compared with patients with a false-positive penicillin allergy result (confirmed by negative penicillin skin testing result), patients reporting a true penicillin allergy confirmed by positive penicillin skin test results tended to be more frequently men (61.5% versus 44.5%; Δ 17.0%; 95% CI −13.5% to 42%), black (69.2% versus 44.5%; Δ 24.7%; 95% CI −6.9% to 46.8%), and have no family history of drug allergy (7.7% versus 17.5%; Δ9.8%; 95% CI −20.9% to 20.4%), but self-reported other drug allergies more frequently (61.5% versus 38.7%; Δ 22.9%; 95% CI −7.7% to 47.5%).

Conclusion
Penicillin skin testing is feasible in the ED setting. A substantial number of patients who self-report a penicillin allergy do not exhibit immunoglobulin E-mediated sensitization to penicillin major and minor determinants. Penicillin testing in the ED may allow the use of more appropriate antibiotics for patients presenting with a history of penicillin allergy.

13. Weekend Admission Tied to Worse Outcomes for Bleeding Peptic Ulcers

Don’t Get Sick on Saturday

NEW YORK (Reuters Health) Mar 06 - Patients who are admitted on a weekend for bleeding peptic ulcers have worse survival than their peers admitted on a weekday, according to the results of two studies appearing in Clinical Gastroenterology and Hepatology for March.

By contrast, weekend admission for hemorrhage due to bleeding varices is not associated with increased mortality, findings from one of the studies shows.

Prior research has shown that a number of medical conditions have poorer outcomes when patients are admitted on weekends. Whether the same held true for upper gastrointestinal hemorrhage was unclear, although the limited availability of urgent endoscopic intervention on weekends suggests that this may be the case.

In the first study, Dr. Ashwin N. Ananthakrishnan, from the Medical College of Wisconsin, Milwaukee, and colleagues took up this topic by analyzing data from the Nationwide Inpatient Sample 2004, which featured 28,820 discharges with acute variceal hemorrhage and 391,119 with acute nonvariceal hemorrhage.

With nonvariceal hemorrhage, weekend admission increased in-hospital morality by 21% and reduced the likelihood of early (within 1 day of admission) endoscopy by 36%.

With variceal hemorrhage, by contrast, weekend admission did not increase mortality, but it did reduce the odds of early endoscopy at nonteaching hospitals.

Early endoscopy was linked to both shorter hospital stays and to lower hospital charges, the report indicates.

In the second study, Dr. Abdel Aziz M. Shaheen, from the University of Calgary, Alberta, focused solely on bleeding from peptic ulcer disease. Their study, which incorporated data from the 1993-2005 US Nationwide Inpatient Sample, featured 237,412 admissions to 3166 hospitals for peptic ulcer-related bleeding.

Mortality was higher in weekend- versus weekday-admitted cases: 3.4% vs. 3.0%. Likewise, weekend-admitted patients were more likely to undergo surgery, had longer hospital stays, and incurred greater hospital charges.

The average time to endoscopy was 2.21 days for weekend-admitted cases versus 2.06 days for those admitted on a weekday (p less than 0.0001). Thirty percent of weekend cases underwent endoscopy the same day compared with 34% of weekday cases (p less than 0.0001).

Multivariate analysis confirmed that weekend admission was an independent predictor of increased mortality.

"Although wait times for endoscopy are prolonged in patients hospitalized on the weekend, this delay does not appear to mediate the observed weekend effect for mortality," Dr. Shaheen's team states. "Future studies," they add, "should explore alternative processes of care that might mediate this effect in patients with bleeding peptic ulcers."

Clinical Gastroenterol Hepatol 2009;7:296-310.

14. Pauses in Pre-Shock Chest Compression Reduce Likelihood of Resuscitation Success

NEW YORK (Reuters Health) Mar 05 - Pauses of a few seconds in pre-shock chest compression decrease the likelihood of return of spontaneous circulation during out-of-hospital cardiac arrest, according to a report in the February 6th issue of BMC Medicine.

"The fact that interruptions in chest compressions are detrimental has been known, but our results show that literally every second counts," Dr. Kenneth Gundersen from the University of Stravanger, Norway, told Reuters Health. "The pauses necessary to perform tasks like mouth-to-mouth and signal analysis should be kept as short as absolutely possible and all unnecessary pauses avoided."

Dr. Gundersen and colleagues investigated the effect of interruptions of chest compressions on the probability of return of spontaneous circulation calculated from the electrocardiogram (ECG) using data from 530 defibrillation attempts given to 86 patients.

The probability of return of spontaneous circulation decreased in a steady manner with increasing pauses in chest compression, the authors report, with each second without perfusion contributing negatively to the likelihood of return of spontaneous circulation.

Regardless of the baseline probability of return of spontaneous circulation, the researchers note, about 23% of the chance of return of spontaneous circulation will be lost with increasing the pre-shock pause in chest compressions from 3 to 27 seconds.

This represents about a 1% relative decrease in the chance of return of spontaneous circulation for each second of pre-shock pause in chest compressions, the investigators say.

"I believe that to reduce interruptions in chest compressions clinically requires regular training of CPR skills for relevant personnel," Dr. Gundersen said. "I further believe that our results in a convincing way show the importance of minimizing interruptions in chest compressions and that it therefore can be used to achieve an increased focus on this particular aspect of CPR quality."

"My current main research focus is on developing a new type of statistical model for the influence of CPR on the probability of return of spontaneous circulation following defibrillation during ventricular fibrillation/ventricular tachycardia," Dr. Gundersen added. "The primary objective of this research is to identify which CPR quality variables (e.g., compression depth, compression force, ventilation rate) that best reflect the effectiveness of CPR, and what values of the relevant variables maximize the effect."

BMC Med 2009;7:6. http://www.biomedcentral.com/1741-7015/7/6/abstract

15. Thrombolysis May Benefit Some Patients Who Wake With Stroke

March 5, 2009 — Results of a retrospective case series suggest that certain patients who wake with stroke symptoms may still benefit from intervention using intravenous (IV) or intra-arterial (IA) thrombolysis.

Researchers at the University of Texas–Houston report off-label use of thrombolysis in 46 patients with acute ischemic stroke appeared to be safe, with a rate of symptomatic intracerebral hemorrhage of 4.3%, and was associated with higher rates of excellent and favorable outcome, although mortality was also significantly higher than those who were not treated.

A second comparison of treated wake-up patients with those treated within the 3-hour time window after symptom onset showed no differences in safety and clinical outcomes.

"It's the first evidence that treating these patients who routinely do not get treated is potentially safe, and there's some implication that maybe they should not be excluded solely based on waking up with their symptoms," first author Andrew D. Baretto, MD, from University of Texas–Houston Health Science Center, told Medscape Neurology & Neurosurgery.

The findings are published in the March issue of Stroke. Senior author on the paper is Sean I. Savitz, MD, also from the University of Texas–Houston.

Contraindication

In general, patients who wake with stroke symptoms are not considered candidates for thrombolytic therapy, because the time of stroke onset cannot be established reliably. Tissue plasminogen activator (tPA) is approved by the Food and Drug Administration (FDA) for use in patients who present within 3 hours of a known symptom onset.

However, it is estimated that between 16% and 28% of patients who have a stroke each year wake up with their symptoms, Dr. Barreto said. "There are many patients for whom that is the only exclusion," he said. "You know everything else about these patients, all the labs are favorable, and then you find out he woke up with his symptoms," he said.

In some of these cases, when the computed tomography (CT) scan still shows radiologic features of a relatively recent ischemic event, their group has offered off-label, compassionate treatment with tPA, he said. In this study, they reviewed demographics, safety, and outcomes in these cases and compared them with wake-up stroke cases who did not receive thrombolysis, as well as outcomes in patients who met the 3-hour FDA-approved window for treatment.

The rest of the article: http://www.medscape.com/viewarticle/589161

16. MRI Helpful in Diagnosing Acute Appendicitis in Pregnant Patients

March 3, 2009 — Magnetic resonance (MR) imaging aids in the diagnosis of acute appendicitis in pregnant patients and may be able to obviate the need for computed tomography (CT) and itsundesirable radiation exposure in this situation, according to a retrospective study reported in the March 2009 issue of Radiology.

The investigators hypothesized that MR imaging has the potential to reduce the negative laparotomy rate (NLR) while maintaining an acceptable perforation rate (PR). Currently, ultrasound is the favored technique for examination of women with abdominal pain, and CT scan is reserved for patients with inconclusive ultrasound examinations. The present study is the first to examine the impact of MR imaging on surgical outcomes in a large series of pregnant women suspected of having acute appendicitis.

"[T]he aim of our study was to assess the effects of MR imaging [in this group of patients,] using the NLR and PR as objective measures of outcome and to assess the need for CT in this setting," write Ivan Pedrosa, MD, and colleagues at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts.

In this single-center retrospective review of 148 consecutive pregnant patients with clinical symptoms suggesting acute appendicitis, mean age was 29 years (range, 15 – 42 years). Mean gestational age was 20 weeks (range, 4 – 37 weeks). All subjects underwent MR imaging between March 2002 and August 2007; 140 subjects underwent ultrasonography before MR imaging. CT was performed on 4 patients (3%).

Fourteen patients (10%) had acute appendicitis, and MR imaging correctly identified all of these patients. In contrast, ultrasound was positive for acute appendicitis in 5 (36%) of 14 patients, while ultrasound was interpreted as normal in 7 (50%) of the 14 acute appendicitis patients. Perforation — the most serious consequence of acute appendicitis — occurred in 3 of the 14 patients with acute appendicitis, for a PR rate of 21%.

Of the 134 patients without acute appendicitis, MR yielded negative results for 125 patients and false-positive results for 9 patients. There were no false-negative results for MR imaging, suggesting that it is a valid technique for ruling out acute appendicitis. In those without acute appendicitis, ultrasound was able to visualize the normal appendix in 2 (less than 2%) of 126 cases compared with 116 (87%) of 134 cases for MR imaging.

"The improved visualization of the normal appendix with MR imaging is a major attribute that assists in clinical decision making," write the authors.

Surgical exploration was performed in 27 patients (18%), and 8 had negative laparotomy results, for an NLR of 30%. The authors note that if the decision to avoid exploratory laparotomy had been based on negative MR findings, the NLR would have declined to 7%, while maintaining an acceptable PR of 21%. The authors expect further declines in NLR as surgeons and obstetricians gain confidence in the negative predictive value of a normal appendix visualized by MR imaging.

The study had several limitations, including the small number of patients with acute appendicitis, the potential for bias inherent in a retrospective review, and the inability to generalize results to centers that do not have MR imaging available at all times. Also, residents on call interpreted some of the ultrasound studies, while radiologists read the MR images, which may have led to more favorable MR results.

"In conclusion, when examining pregnant patients for clinically suspected [acute appendicitis], the use of MR imaging yields favorable combinations of the NLR and the PR compared with values previously reported in the literature," the authors write. "With use of MR imaging, the radiation exposure associated with CT examinations can be minimized and in many cases avoided."

The authors have disclosed no relevant financial relationships.

Radiology. 2009;250:749–757.

17. Physicians Increasingly Support a Single-Payer National Health Insurance System

Laurie Barclay, MD. February 13, 2009 — US physicians increasingly support a single-payer national health insurance system, according to the results of a survey reported online January 29 in the Journal of General Internal Medicine.

“Many politicians may mistakenly believe that single-payer national health insurance lacks support among key stakeholders such as doctors,” lead author Danny McCormick, from Harvard Medical School and Cambridge Health Alliance (CHA), said in a news release. “Our finding that support for single-payer national health insurance now approaches that of tax-based incremental reforms suggests that a Medicare-for-all-type plan may be more politically viable than conventional wisdom suggests.”

The goal of this US nationally representative mail survey was to evaluate physician opinion regarding financing options for expanding coverage for and access to healthcare.

Between March 2007 and October 2007, US physicians involved in direct patient care were asked to rate their support for reform options such as financial incentives to encourage people to buy health insurance and single-payer national health insurance, as well as to rate their views of several aspects of access to healthcare.

Of 3300 physicians sent the survey, 1675 (50.8%) responded; 49% prefer either tax incentives or penalties to promote the purchase of health insurance; 42% prefer a government-run, taxpayer-financed single-payer national health insurance program, which increased from 26% in a study 5 years previously; and only 9% prefer the current, employer-based financing system.

Regarding access to healthcare, 89% of physicians surveyed believe that all Americans should receive needed medical care regardless of ability to pay; 33% believe that the uninsured currently have access to needed care; and 19.3% believe that even the insured lack access to needed care. Opinions regarding access were independently associated with support for single-payer national health insurance.

"Surveys show that a majority of Americans support a single-payer system. It's not surprising that increasing numbers of doctors do,” said coauthor David Bor, MD, also from Harvard Medical School and Cambridge Health Alliance. “Single payer is the only proposal that can cover all Americans, for all needed care, without driving up healthcare costs. National health insurance would eliminate the massive administrative costs and hassles imposed by our current multiplicity of private insurers.”

Limitations of this study include modest response rate; the possibility that physicians strongly interested in health policy issues may have been more likely to respond; lack of generalizability to all physicians’ views; and possible misinterpretation of question meaning or bias related to question wording and response option content.

“Although a plurality of physicians favored incremental health care reform proposals based on the use of tax credits and penalties, a substantial proportion of physicians preferred an entirely different health care financing system — a government-run, taxpayer-financed single-payer [national health insurance] program,” the study authors write. “Physicians play a central role in the health care system and these views could be influential in reforming the financing of the American health care system.”

The Department of Medicine at the Cambridge Hospital funded this study. The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online January 29, 2009.

18. Initial Clinical Experience With a 64-MDCT Whole-Body Scanner in an Emergency Department: Better Time Management and Diagnostic Quality?

Rieger M, et al. J Trauma. 2009;66:648-657

Background: The objective of this study was to assess time management and diagnostic quality when using a 64-multidetector-row computed tomography (MDCT) whole-body scanner to evaluate polytraumatized patients in an emergency department.

Methods: Eighty-eight consecutive polytraumatized patients with injury severity score (ISS) ≥ 18 (mean ISS = 29) were included in this study. Documented and evaluated data were crash history, trauma mechanism, number and pattern of injuries, injury severity, diagnostics, time flow, and missed diagnoses. Data were stored in our hospital information system. Seven time intervals were evaluated. In particular, attention was paid to the acquisition interval, the reformatting and evaluation time as well as the CT time (time from CT start to preliminary diagnosis). A standardized whole-body CT was performed. The acquired CT data together with automatically generated multiplanar reformatted images (direct MPR) were transferred to a 3D rendering workstation. Diagnostic quality was determined on the basis of missed diagnoses. Head-to-toe scout images were possible because volume coverage was up to 2 m. Experienced radiologists at an affiliated workstation performed radiologic evaluation of the acquired datasets immediately after acquisition.

Results: The acquisition interval was 12 minutes ± 4.9 minutes, the reformatting and evaluation interval 7.0 minutes ± 2.1 minutes, and the CT time 19 minutes ± 6.1 minutes. Altogether, 7 of 486 lesions were recognized but not communicated in the reformatting and evaluation interval, and 10 injuries were initially missed and detected during follow-up.

Conclusion: This study indicates that 64-MDCT saves time, especially in the reformatting and evaluation interval. Diagnostic quality is high, as reflected by the small number of missed diagnoses.

19. Health Care and the American Recovery and Reinvestment Act

Steinbrook R. N Engl J Med 2009;360:1057-1060.

On February 17, 2009, four weeks after his inauguration, President Barack Obama signed into law a $787 billion economic stimulus package. The economic impact of the American Recovery and Reinvestment Act of 2009, as the measure is officially known, will not be apparent for months. Nonetheless, the bill's approval — even before any new senior officials of the Department of Health and Human Services (DHHS) were in place — has jump-started the Obama administration's plans for health care…

Full-text: http://content.nejm.org/cgi/content/full/360/11/1057

20. Randomized Controlled Trial of Ultrasound-Guided Peripheral Intravenous Catheter Placement Versus Traditional Techniques in Difficult-Access Pediatric Patients

Doniger SJ, et al. Pediatr Emerg Care 2009;25:154-159.

Objectives: We hypothesized that the use of ultrasound guidance would improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED). Our secondary hypotheses were that ultrasound guidance would reduce the number of attempts, the number of needle redirections, and the overall time to catheter placement.

Methods: This was a prospective randomized study of pediatric ED patients younger than 10 years old requiring intravenous access, presenting between August 2006 and May 2007. Inclusion criteria were 2 unsuccessful traditional attempts at peripheral intravenous access or history of difficult access. Exclusion was critical illness or instability. Patients were randomized to undergo peripheral intravenous catheter placement using continued traditional approaches or real-time, dual-operator ultrasound-guided technique. Measured outcomes were success of cannulation, number of attempts, number of needle redirections, and overall time to catheter placement.

Results: Fifty patients were enrolled, with 25 patients randomized to each group. The overall success rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%, with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The ultrasound-guided group required less overall time (6.3 vs 14.4 minutes, difference of -8.1 minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs 3; P = 0.004), and fewer needle redirections (median, 2 vs 10; P less than 0.0001) than traditional approaches.

Conclusions: In a sample of pediatric ED patients with difficult access, ultrasound-guided intravenous cannulation required less overall time, fewer attempts, and fewer needle redirections than traditional approaches.