Monday, April 23, 2012

Lit Bits: April 23, 2012

From the recent medical literature... 

1. Diagnosing and Treating Acute Appendicitis 

A. Preventing Unnecessary Appendectomies with CT, Ultrasound 

Troy Brown. Medscape Medical News. April 16, 2012 — Young children and girls older than 10 years appear to have fewer unnecessary appendectomies when diagnostic computerized tomography (CT) and/or ultrasound are used. These imaging techniques appear to have limited value in boys older than 5 years, however, according to a 5-year retrospective review of children with a diagnosis of appendicitis seen in the emergency departments (EDs) of 40 children's hospitals. 

Richard G. Bachur, MD, chief of the Division of Emergency Medicine at Children's Hospital Boston, Massachusetts, and colleagues report their findings in an article published online April 16 in Pediatrics. 

Dr. Bachur and colleagues determined the accuracy of CT and ultrasound for diagnosing appendicitis by calculating negative appendectomy rates (NARs) for each imaging method, stratified by sex and age (younger than 5 years, 5 - 10 years, and  over 10 years of age). A negative appendectomy is the surgical removal of a normal appendix. 

The researchers wanted to compare CT with ultrasound imaging because CT, which performs better, also exposes patients to ionizing radiation. Because radiation exposure is associated with an increased lifetime cancer risk, ultrasound is an attractive alternative, especially in children. 

NARs were calculated by dividing the number of ED patients who underwent appendectomy without a final diagnosis of appendicitis by the total number of ED patients who underwent appendectomy. 

The investigators calculated the associations between CT and ultrasound imaging and the outcome of negative appendectomy using linear regression analysis that used the hospital-level NAR as the dependent variable and the hospital-level imaging rate as the independent variable, weighted by the number of appendectomies done at each hospital. They performed this analysis on each age and sex subgroup, adjusting for patient volume at each institution. 

From a total of 8,959,155 ED visits, 55,227 children were given a final diagnosis of appendicitis. Of those children, 35,335 (64.0%) had uncomplicated appendicitis, 13,166 (23.8%) had a perforated appendix, and 6.26 (12.2%) had a perforated appendix with abscess formation. Of the 52,290 patients who underwent an appendectomy, 96.4% received a final diagnosis of appendicitis, leaving a NAR of 3.6%. 

Hospital-Level Analysis 

CT rates were higher than ultrasound rates for each sex and age subgroup. In each subgroup, girls received more imaging than boys did, and children younger than 5 years were most likely to undergo both CT and ultrasound. The highest NARs were in children younger than 5 years and girls older than 10 years. There was a significant association between rate of CT and/or ultrasound use by individual institutions and the institutional NAR in all subgroups except children younger than 5 years. The CT rate alone was not associated with institutional NAR for any subgroup studied. The lowest NARs were found in boys older than 5 years, regardless of imaging method. 

Patient-Level Analysis 

Boys older than 5 years have lower NARs than boys younger than 5 years. Preappendectomy CT was significantly associated with lower NARs in boys younger than 5 years only, and ultrasound use was associated with higher NARs in boys younger than 5 years. 

In girls younger than 5 years, CT was significantly associated with lower NARs, but there was no difference in NAR if ultrasound was used. 

NARs were significantly higher in girls older than 10 years (5.5%) compared with boys (1.1%), independent of imaging (adjusted odds ratio, 5.2; 95% confidence interval, 4.4 - 6.1). 

The Bottom Line 

"The current study's findings extends to the clinical management by suggesting that age and gender must be incorporated into any evaluation algorithms," the authors write. 

Because boys older than 5 years have the lowest NARs regardless of imaging method, the authors feel that CT and ultrasound imaging have limited value in this subgroup. "Of note, the paradoxically higher NAR for boys younger than 5 years who had an ultrasound (compared with those who did not have an ultrasound) might reflect an attempt to rely on ultrasound over CT when the diagnosis is especially difficult in this age group," the authors write. 

"[T]he higher NAR for those girls older than 10 years likely stems from the presence of gynecologic conditions where secondary findings noted by imaging may mimic appendicitis," write the authors. "Despite this relatively high rate of negative appendectomy, the use of imaging among postpubertal girls is associated with the greatest absolute reduction in negative appendectomies as previously recognized," they write. 

The authors conclude that CT and ultrasound reduce the higher NARs found in children younger than 5 years and girls older than 10 years, but appear to be of limited value in boys older than 5 years with suspected appendicitis and no other clinical issues. 

The authors have disclosed no relevant financial relationships. 

Pediatrics. Published online April 16, 2012. Abstract:  

B. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials 

Varadhan KK, et al. BMJ 2012;344:e2156 

Objective To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis. 

Design Meta-analysis of randomised controlled trials. 

Population Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations. 

Interventions Antibiotic treatment versus appendicectomy. 

Outcome measures The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions. 

Results Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I2=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I2=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis.

Conclusion Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis. 

2. Teaching Tool Cuts Stress Test Admissions 

By Crystal Phend, Senior Staff Writer, MedPage Today. Published: April 10, 2012 


This study from the Mayo Clinic found significantly fewer low-risk patients evaluated in the emergency department for chest pain elected to undergo stress testing if they were presented with a decision aid instead of usual care. 

Note that these patients were more likely than the usual care group to complete a follow-up appointment within 72 hours. 

On Hess EP, et al. The Chest Pain Choice Decision Aid: A randomized trial. Circ Cardiovasc Qual Outcomes 2012; 5: DOI: 10.1161/CIRCOUTCOMES.111.964791 

Low-risk chest pain patients presenting to the emergency department are less likely to undergo potentially unnecessary stress testing when given a decision aid illustrating their low chance of a heart attack, a randomized trial found. 

An absolute 19% fewer patients decided on admission to the observation unit for stress testing after being given a pictograph and description of choices compared with those who were not given the teaching tool (58% versus 77%, P less than 0.0001), Erik P. Hess, MD, of the Mayo Clinic in Rochester, Minn., and colleagues reported. 

No major adverse cardiac events occurred during 30 days after discharge across the low-risk cohort in the Chest Pain Choice trial, they wrote online in Circulation: Cardiovascular Quality and Outcomes. 

Such patients often spend time in observation units or monitored beds for further cardiac investigation at a "very low" risk threshold to avoid missing a diagnosis of acute coronary syndrome, the researchers explained. 

However, for patients at low risk for acute coronary syndrome that leads to false-positive test results, unnecessary further procedures, and increased cost, the researchers noted. 

These results -- the first from a trial of shared decision making for acute coronary syndromes in the emergency department -- suggested that informed patients prefer not to go down that road, they said. 

However, when clinicians are given the opportunity to make decisions based on their own risk tolerance, they more frequently ordered diagnostic investigations, Hess' group wrote. "[If] doing so requires withholding information, limiting patient autonomy, and transferring additional charges to the patient, this may not be ethically justifiable." 

A recent study in intermediate-risk angina patients also showed that emergency department interventions helped, in that case boosting follow-through with recommended stress testing by scheduling appointments before patients left the ED. 

Hess' prospective trial included 204 patients in the emergency department being considered for admission for monitoring and cardiac stress testing within 24 hours despite lack of elevated troponin T levels, known coronary artery disease, or other risk factors (about 17% of total patients presenting with chest pain for which troponin testing was ordered). 

They were randomized to usual care or a decision aid showing a pictograph with two of 100 people in the same situation having a heart attack over 45 days and explaining that their options were:

a. Observation unit admission and stress testing

b.  Scheduling a follow-up visit at the same center 24 to 72 hours later

c.  Consulting with their own primary care physician

d.  Letting the emergency physician decide

For the primary endpoint, patients who got the decision aid answered more questions correctly on a questionnaire assessing their knowledge (3.6 versus 3.0 out of 7, mean difference 0.67, 95% confidence interval 0.34 to 1.0). 

More of those given the decision aid also knew their pre-stress test probability of having an acute coronary syndrome within 45 days (25% versus 1%, mean difference 24%, 95% CI 22% to 26%). 

That intervention group also was significantly more engaged in decision making about getting a stress test, with mean scores on the Observing Patient Involvement scale of 26.6 versus 7.0 in the usual care group. 

The decision aid group also reported significantly less difficulty in making decisions regarding their care but no less trust in their physicians. 

Helpfulness, clarity, and amount of information were judged more positively by the decision aid group than those getting usual care only (P=0.0051 to P less than 0.0001). 

Clinicians, too, almost universally found the decision aid helpful (98%). Of the 51 who used it for their patients in the study, 63% said they wanted to use it again if given the opportunity. 

After leaving the emergency department, fewer in the decision aid group actually got cardiac stress testing within 30 days (75% versus 91%, P=0.002). 

They were more likely to follow through with outpatient care, though. 

Follow-up visits were done as planned by 34 of 39 in the decision aid group versus six of 16 in the usual care arm (87% versus 38%) and were more likely to be within 72 hours of the emergency department visit (97% versus 17%). 

The researchers cautioned that the study wasn't powered to detect a difference in major cardiovascular events between groups, nor would its results apply to patients who present with possible acute coronary syndromes who have symptoms instead of chest pain, such as shortness of breath, fatigue, or vomiting. 

Also, "the decision aid may be more difficult to implement in healthcare settings with less-reliable access to outpatient follow-up," they wrote. Confirmation in a larger, multicenter trial is needed, they noted. 

The project was funded by a grant from the Foundation for Informed Medical Decision Making. 

3. Quality of Care for Myocardial Infarction at Academic and Nonacademic Hospitals 

Belle L, et al. Amer J Med 2012;125:365-373. 

Background: Whether academic hospitals provide better quality of care for patients with acute myocardial infarction is widely debated. The aim of this study was to compare processes of care and mortality between academic and nonacademic hospitals in the contemporary era of acute myocardial infarction management. 

Methods: We analyzed the original data from a prospective cohort study of 3059 patients, including 1714 with ST-segment elevation and 1345 with non-ST-segment elevation myocardial infarction, enrolled at 39 and 183 academic and nonacademic hospitals, respectively, in France. 

Results: Unadjusted 1-year mortality for academic and nonacademic hospitals was 10% versus 15% for patients with ST-segment elevation myocardial infarction (P=.01) and 13% versus 14% for patients with non-ST-segment elevation myocardial infarction (P=.75). Patients treated in academic or nonacademic hospitals with percutaneous coronary intervention capability were more likely to receive reperfusion and recommended drug therapies than those treated in nonacademic hospitals without percutaneous coronary intervention capability. After adjusting for baseline characteristics, the hazards of death associated with admission to nonacademic hospitals with and without percutaneous coronary intervention capability relative to academic hospitals were 1.13 (95% confidence interval [CI], 0.79-1.62) and 1.65 (95% CI, 1.09-2.49) for those with ST-segment elevation myocardial infarction and 0.95 (95% CI, 0.66-1.36) and 1.06 (95% CI, 0.72-1.58) for those with non-ST-segment elevation myocardial infarction, respectively. Further adjustment for receipt of acute reperfusion and recommended drug therapies eliminated all differences in mortality between the study groups. 

Conclusion: Admission to academic hospitals was associated with a more frequent use of recommended therapies, conveying a survival advantage for patients with ST-segment elevation myocardial infarction. 

4. Incidence of Bacteremia in Infants Aged 1 Week to 3 Months 

Incidence of bacteremia in previously healthy full-term infants was 2.2%, and Escherichia coli was the most common pathogen. 

Greenhow TL, et al. Pediatrics. 2012 Mar;129(3):e590-6.  

BACKGROUND: Bacteremia in young infants has remained an important ongoing concern for decades. Despite changes in prenatal screening and infant immunizations, the current epidemiology of this problem has received little attention. 

METHODS: We conducted a retrospective analysis of all blood cultures collected at Kaiser Permanente Northern California on full-term, previously healthy infants presenting for care between 1 week to 3 months of age for whom a blood culture was drawn from January 1, 2005, through December 31, 2009. 

RESULTS: During the study period, 4255 blood cultures were collected from 160 818 full-term infants. Only 2% of all blood cultures were positive for pathogens (93/4255), whereas 247 positive cultures were due to contaminants. The incidence rate of true bacteremia was 0.57 in 1000 full-term births. The most common pathogen was Escherichia coli (56%). Ninety-eight percent of infants with E coli bacteremia had a urinary tract infection. Group B Streptococcus and Staphylococcus aureus were the second and third most common pathogens, respectively. There were no cases of Listeria monocytogenes bacteremia or meningococcemia and only 1 case of enterococcal bacteremia. Ampicillin resistant pathogens accounted for 36% of organisms. 

CONCLUSIONS: Our study indicates bacteremia in young infants occurs infrequently and in only 2.2% of those who had a blood culture drawn. On the basis of the epidemiology of pathogens found in this large cohort, these data suggest a change in currently recommended presumptive antibiotic coverage in 1-week to 3-month-old infants with suspected bacteremia. Greenhow TL et al. Pediatrics 2012 Mar; 129:e590 

5. For the Elderly, Emergency Rooms of Their Own 

By Anemona Hartocollis. New York Times. April 9, 2012 

Phyllis Spielberger, a retired hat seller at Bendel’s, picked at a plastic dish of beets and corn as her husband, Jason, sat at the foot of her hospital bed, telling her to eat.  

Although she had been rushed to Manhattan’s busy Mount Sinai Hospital by ambulance when her leg gave out, the atmosphere she encountered upon her arrival was eerily calm.  

There were no beeping machines or blinking lights or scurrying medical residents. A volunteer circulated among the patients like a flight attendant, making soothing conversation and offering reading glasses, Sudoku puzzles and hearing aids. Above them, an artificial sun shined through a skylight imprinted with a photographic rendering of a robin’s-egg-blue sky, puffy clouds and leafy trees.  

Ms. Spielberger, who is in her 80s, was even getting into the spirit of the place, despite her unnerving condition. “It’s beautiful,” she said. “Everything here is wonderful.”  

Yet this was an emergency room, one specifically designed for the elderly, part of a growing trend of hospitals’ trying to cater to the medical needs and sensibilities of aging baby boomers and their parents. Mount Sinai opened its geriatric emergency department, or geri-ed, two months ago, modeling it in part after one at St. Joseph’s Regional Medical Center in Paterson, N.J., which opened in 2009.  

Holy Cross Hospital in Silver Spring, Md., opened one of the first geriatric emergency departments, which it calls a seniors emergency center, in 2008, and its parent organization, Trinity Health System, runs 12 nationwide, primarily in the Midwest, and plans to open six or seven more by June, a spokeswoman said.  

Dr. Mark Rosenberg, chairman of emergency medicine at St. Joseph’s, said he had consulted on more than 50 geriatric emergency rooms to be opened across the country, from Princeton, N.J., to California, overcoming initial resistance from doctors and nurses who saw assignments to the units as scut work.  

“They thought it was a bedpan unit, focused on nursing home patients,” Dr. Rosenberg said. “When they finally realized this was the unit that gave better health care to their parents and grandparents, they jumped onboard.”  

Hospitals also have strong financial incentives to focus on the elderly. People over 65 account for 15 percent to 20 percent of emergency room visits, hospital officials say, and that number is expected to grow as the population ages. 

Under the Affordable Care Act, the health insurance overhaul passed by Congress in 2010, hospitals’ Medicare payments will be tied to scores on patient satisfaction surveys and how frequently patients have to be readmitted to the hospital. (The Supreme Court is considering whether to overturn another section of the law, and if it does, whether it would have to throw out the entire law.)  

Even in their early stages, patient satisfaction ratings for Mount Sinai’s geri-ed are “off the scoreboard,” said Dr. Andy Jagoda, the hospital’s chairman of emergency medicine.  

Patients who are picked up by ambulance can choose which hospital to go to, if circumstances and travel time allow… 

6. Brief ED Intervention Cuts Alcohol Consumption in Risky Drinkers 

By Megan Brooks. Reuters Health Information. NEW YORK (Reuters Health) Apr 13 - A brief intervention performed by emergency department staff reduced alcohol consumption and episodes of impaired driving in problem drinkers over the next six to 12 months in a randomized study conducted at Yale New Haven Hospital in Connecticut. 

Contrary to the investigators' hypothesis, a follow-up "booster" phone call made one month after the ED intervention offered no added benefit over the one-time intervention in the ED setting. 

"This intervention uses motivational interviewing techniques to change behavior," Dr. Gail D'Onofrio of the department of emergency medicine, Yale University School of Medicine in New Haven, Connecticut, told Reuters Health. 

The "Brief Negotiation Interview," taught during a two-hour training program, includes raising the subject of alcohol use with the ED patient, asking about changing his or her drinking behavior, negotiating a drinking goal with the patient, and asking them to sign a drinking agreement. The whole intervention takes about seven minutes to complete. 

The US Preventive Services Task Force recommends screening and brief intervention for at-risk drinkers, but studies in ED settings have been inconclusive, Dr. D'Onofrio and colleagues point out in a report online March 30 in the Annals of Emergency Medicine. 

The investigators enrolled in their study 889 adults who presented to the ED and were identified as hazardous and harmful drinkers based on questions embedded in a 17-item general health questionnaire. 

They randomly allocated 297 of them to the Brief Negotiation Interview, 295 to the Brief Negotiation Interview with booster phone call one month later, 148 to standard care, and 149 to a standard care-no assessment group (control), which was used to study the impact of research assessments on drinking outcomes. Participants received $20 at the index visit and the 6- and 12-month assessments. 

The researchers report that the two intervention groups and the standard care group decreased their alcohol consumption over time. However, reductions from baseline to 12 months in mean number of drinks consumed per week were greater in the Brief Negotiation Interview with booster and the Brief Negotiation Interview groups (7.4 and 5.5, respectively) compared with the standard care group (3.3). 

There were also greater reductions in the number of monthly binge episodes in the two intervention groups (2.8 and 2.1, respectively) compared with the standard care group (1.4). 

At 12 months, the reductions in rates of driving after drinking more than three drinks were also greater with Brief Negotiation Interview alone (dropping from 38% at baseline to 20% at one year) and with the booster (dropping from 39% to 31%) relative to standard care (dropping 43% to 42%). 

As mentioned, the booster phone call offered no significant benefit over the one-time ED intervention alone. 

The researchers also report that the intervention worked best in participants older than 26 years, whereas drinking and binge episodes in younger individuals showed a "strong rebounding trend" toward baseline at 12 months. This suggests that additional modifications to the intervention in either content or intensity may be needed for this group. 

The researchers note that the study was conducted at a single teaching hospital associated with an academic institution. On the other hand, they say, they trained a large number of emergency practitioners with a variety of training and experience. 

Dr. D'Onofrio told Reuters Health that this brief intervention is now being used in many EDs and primary care settings. "We continue to incorporate it into our daily practice. As part of a SAMHSA (Substance Abuse and Mental Health Services Administration) grant, I have trained over 400 residents at Yale New Haven Hospital in the technique. This includes medicine, psychiatry, pediatrics, OB/GYN, and emergency medicine," she said. 

A strength of the study, according to its authors, is the use of interactive voice response technology, which allows for the collection of data without patient-staff interaction, which can yield more accurate data. 

"We also examined the effect of assessment reactivity by adding the standard care-no assessment group. However, contrary to our original hypothesis, our assessment had no significant effect on drinking reductions, thus supporting the effectiveness of the Brief Negotiation Interview itself," the authors note. 

The current study, they conclude, "adds to the evidence in support of brief interventions for general ED patients." Such interventions can be used for a variety of purposes, such as "helping patients adhere to medical regimens," Dr. D'Onofrio said. 

The study was funded by the National Institute on Alcohol Abuse and Alcoholism. 

7. New Tx Sought for Resistant Kawasaki Disease 

By Nancy Walsh, Staff Writer, MedPage Today. Published: April 03, 2012 

SAN DIEGO -- Resistance to standard treatment with intravenous immune globulin (IVIG) appears to be more prevalent among children with Kawasaki disease, a researcher reported here. 

In a cohort of 400 patients, 10% had coronary artery aneurysms, and 20% were IVIG resistant, with an overlap of 22%, which is a "definite concern," according to Adriana H. Tremoulet, MD, of the Kawasaki Disease Research Center at the University of California San Diego. 

IVIG resistance manifests as persistent or recrudescent fever above 100.4° F and occurring 36 hours after the end of an initial IVIG infusion, Tremoulet explained at the Society of Hospital Medicine meeting. 

"Our experience has been that if you have persistent fever, the risk of getting a coronary artery aneurysm is almost as if the child hasn't been treated at all," she said. 

In most centers, the initial second-line approach has been to give a second course of IVIG, with subsequent options including steroids, cyclosporine, and infliximab. 

"For steroids, the question has arisen as to whether this treatment can be involved in remodeling the coronary aneurysm, so we really steer clear of steroids in kids with coronary artery abnormalities," she said. 

They have now begun using cyclosporine more often in highly resistant patients as they have gained experience with the drug, a greater understanding of appropriate dosage, and the importance of patient follow up. 

"We didn't know how to use cyclosporine [because] that's something the rheumatologists do," Tremoulet said. 

She and her colleagues have been following IVIG resistance rates among their patients since 1998, and when the incidence spiked to 38.3% in 2006, they decided to explore the use of the tumor necrosis factor (TNF) inhibitor infliximab. TNF-α is a key player in the inflammation and aneurysm formation in Kawasaki disease. 

Initially they conducted a phase I safety study of infliximab in patients who had failed IVIG, and found no major allergic reactions or serious adverse events. 

However, they wondered if this approach was, as a Japanese aphorism has it, "closing the barn door after the sheep have been stolen," she said. 

So they undertook a phase III study in which all children would receive IVIG, and half would also be given a single dose of infliximab. 

The goal is to enroll 196 patients, with the primary outcome being a decrease in IVIG resistance rate from 20% to 5% and the secondary outcome being a reduction in coronary artery abnormalities. 

"A lot of people have been concerned about using infliximab because of the black box warnings, and concerns about cancer and tuberculosis with prolonged use," Tremoulet said. "But it's very important to understand that these kids are previously healthy and are receiving a single dose, as opposed to children and adults with conditions such as arthritis where they also receiving other immunosuppressive drugs. 

Thus far, 177 patients have been enrolled, and the hope is that full enrollment will be met by early summer. 

A further area of research in Kawasaki disease has arisen from the observation that the disease clusters both in place and time. 

Japan has 10 times the number of cases compared with the U.S., with the usual seasonal pattern being a higher number of cases in January to June. 

To explore possible climatic reasons for clustering, the authors have begun a collaboration with the Scripps Institute of Oceanography at UCSD. Climate scientists at Scripps determined that in 1982 and 1986, years when there were Kawasaki disease epidemics in Japan, there had been changes in trophosperic wind patterns. 

Similar findings were seen in 2006 and 2007 in San Diego, where a further observation was that clusters of Kawasaki disease seemed to occur when areas of low pressure were found over the city. 

They have also worked with climatologists in Barcelona, who have hypothesized that tropospheric winds may carry an aerosolized agent possibly originating in Central Asia that, when inhaled by susceptible children, causes Kawasaki disease. 

Tremoulet and a consortium of hospitalists in California, Oregon, Washington, and Hawaii are now forming the WIND (Western U.S. investigation of Kawasaki disease) study, which will use real-time surveillance of disease outbreaks, correlated with large-scale climate variables. 

"The goal will be to determine if a regional climate pattern precedes the onset of a cluster, so that ultimately we can have fewer patients whose disease went unrecognized and they go on to have a myocardial infarction at age 20 or 30," she said. 

Tremoulet, A, et al. Kawasaki Disease: Finding the needle in the haystack. Society of Hospital Medicine 

8. Thirty-Day Readmissions — Truth and Consequences 

Joynt KE, et al. N Engl J Med 2012; 366:1366-1369.  

Reducing hospital readmission rates has captured the imagination of U.S. policymakers because readmissions are common and costly and their rates vary — and at least in theory, a reasonable fraction of readmissions should be preventable. Policymakers therefore believe that reducing readmission rates represents a unique opportunity to simultaneously improve care and reduce costs. As part of the Affordable Care Act (ACA), Congress directed the Centers for Medicare and Medicaid Services (CMS) to penalize hospitals with “worse than expected” 30-day readmission rates. This part of the law has stimulated hospitals, professional societies, and independent organizations to invest substantial resources in finding and implementing solutions for the “readmissions problem.” 

Although a focus on readmissions may have good face validity, we believe that policymakers' emphasis on 30-day readmissions is misguided, for three reasons. First, the metric itself is problematic: only a small proportion of readmissions at 30 days after initial discharge are probably preventable, and much of what drives hospital readmission rates are patient- and community-level factors that are well outside the hospital's control. Furthermore, it is unclear whether readmissions always reflect poor quality: high readmission rates can be the result of low mortality rates or good access to hospital care. Second, although improving discharge planning and care coordination is a laudable goal, there are better, more targeted policies that are more likely to be effective in achieving it. Finally, because hospitals are expending so much energy on reducing readmissions, they have probably forgone quality-improvement efforts related to more urgent issues, such as patient safety. An evidence-based, holistic approach to quality improvement is far more likely to achieve what policymakers, clinicians, and the public all want: better care at lower cost. 

With regard to the first problem, preventability, a recent systematic review reported that on average, just 27% of readmissions were preventable (moreover, only 12% were deemed preventable in studies that used clinical data, as compared with 59% in those that used administrative data only).1 In a recent study of Ontario hospitals that involved careful chart review, van Walraven and colleagues found that less than a fifth of urgent rehospitalizations were preventable,2 an estimate in keeping with the proportion of total hospital admissions in the United States generally deemed to be preventable. Perhaps even more important, the van Walraven study showed that although the total number of readmissions varied substantially among hospitals, the rate of preventable readmissions did not2 — a finding suggesting that readmissions may be a poor marker of hospital performance. 

The growing body of evidence suggests that the primary drivers of variability in 30-day readmission rates are the composition of a hospital's patient population3 and the resources of the community in which it is located — factors that are difficult for hospitals to change. We know that some of the most important drivers of readmissions are mental illness, poor social support, and poverty, which are often deeply ingrained. Therefore, readmission rates have weak signaling value for identifying high-quality hospitals. The current scheme to penalize hospitals with high readmission rates is likely to disproportionately affect institutions that care for poor or minority populations or those with a high burden of mental illness. 

Given that readmissions result from a complex interplay among patients, hospitals, and communities, asking hospitals to focus their effort on this measure will lead them to expend substantial energy yet have little effect. We suspect this is the reason that, despite the tremendous focus on readmissions, we have seen little improvement over the past decade (see graphNational Trends in 30-Day Readmission Rates, 2002–2009.). 

In fact, there are several factors influencing readmission rates that we would not want hospitals to change… 

The remainder of the essay can be found here:  

9. Assessing the Credibility of the "YouTube Approach" to Health Information on Acute Myocardial Infarction 

Pant S, et al. Clin Cardiol. 2012 Apr 6. doi: 10.1002/clc.21981. [Epub ahead of print] 

BACKGROUND: This study was designed to assess the credibility of YouTube video information on acute myocardial infarction by exploring the relationship between accuracy of information on the topic, source of expertise, and perceived credibility of the message. 

HYPOTHESIS: Health information videos in YouTube possess a diverse mix of information and can easily mislead online information seekers. 

METHODS: The Web site was queried for the following search terms: "acute myocardial infarction," "heart attack," "acute coronary syndrome," and "ST-elevation myocardial infarction." The resulting videos were categorized according to the source of the video and content was analyzed for discussion of different aspects of disease, ranging from pathophysiology to treatment. 

RESULTS: Only 6% of videos touched upon all aspects of acute myocardial infarction. These were mostly from professional societies, were of long duration, and were among the least viewed. Videos that described personal experiences were "liked" or "disliked" most and had the majority of comments. Only 17% of the videos discussed the preventive aspects of the disease and stressed weight-loss and exercise programs. Videos that stressed prevention were advertisements for specific weight-loss programs (45%) and diet pills (30%). Very few videos stressed other risk factors. A large number of videos were irrelevant. 

CONCLUSIONS: YouTube is a popular platform across the globe for sharing video information, including videos related to health and disease. However, the information on this platform is not regulated and can easily mislead those seeking it. We suggest that authoritative videos should come from reputable sources such as professional societies and/or academic institutions and should provide unbiased and accurate information on all aspects of diseases like acute myocardial infarction. Clin. Cardiol. 2011 DOI: 10.1002/clc.21981 The authors have no funding, financial relationships, or conflicts of interest to disclose. 

10. Choosing Wisely: Helping Physicians and Patients Make Smart Decisions about Their Care 

Cassel CK, et al. JAMA 2012; Published online April 4, 2012.  

While the United States grapples with the challenge of health care costs that contribute to high rates of poor-quality care, burdens to business competitiveness, and looming government deficits, clearly there are areas in which health care spending does not add to the health of individuals and communities. The polarizing political environment makes it difficult to conduct rational public discussions about this issue, but clinicians and consumers can change the nature of this debate to the potential benefit of patients, the medical profession, and the nation. The initial focus should be on overuse of medical resources, which not only is a leading factor in the high level of spending on health care but also places patients at risk of harm. In fact, some estimates suggest that as much as 30% of all health care spending is wasted.1​ 

To reduce unnecessary tests and procedures, physicians will need to play a leading role—their decisions account for about 80% of health care expenditures.2 Yet physicians do not always have the most current effectiveness data, and despite acting in good faith, they can recommend diagnostic or therapeutic interventions that are no longer considered essential. Also, research shows that physicians may need help communicating these matters to their patients. This may be especially difficult when clinicians and consumers are deluged with advertising and promotion. Clinicians often report feeling compelled to accommodate patients' requests for interventions they know are unnecessary.3​,4 At the same time, patients need trustworthy information to help them better understand that more care is not always better care, and in some cases can actually cause more harm than good.  

A major goal of health care reform is enhancing “patient-centered care.” Patients, and consumer groups representing them, express increasing interest in forging true partnerships with their clinicians, with real-time access to their own medical records, to science-based comparative effectiveness information, and to health care delivery environments built to enhance both comfort and personalization of medical care. Patient engagement, as 1 of the 6 major initiatives of the National Priorities Partnership of the National Quality Forum, promises more informed and involved patients as decision makers. To make good on this promise requires transparent and credible information about the relative value and risk of various medical diagnostic and therapeutic interventions.  

To help reduce waste in the US health care system and promote physician and patient conversations about making wise choices about treatments, 9 medical specialty societies have joined the ABIM (American Board of Internal Medicine) Foundation and Consumer Reports in the first phase of the Choosing Wisely campaign, including the following: American Academy of Allergy, Asthma & Immunology; American Academy of Family Physicians; American College of Cardiology; American College of Physicians; American College of Radiology; American Gastroenterological Association; American Society of Clinical Oncology; American Society of Nephrology; and the American Society of Nuclear Cardiology.  

As part of Choosing Wisely, each society has developed a list of 5 tests, treatments, or services that are commonly used in that specialty and for which the use should be reevaluated by patients and clinicians. Those lists were released on April 4, 2012, at a national event in Washington, DC. Additionally, other societies, consumer organizations, and physician organizations have asked how they can become part of this effort to engage physicians and patients in conversations about tests and procedures that should rarely be used. 

11. More on RBC Transfusion: A Clinical Practice Guideline from the AABB 

Carson JL, et al. Ann Intern Med 2012; published online March 26, 2012 

Description: Although approximately 85 million units of red blood cells (RBCs) are transfused annually worldwide, transfusion practices vary widely. The AABB (formerly, the American Association of Blood Banks) developed this guideline to provide clinical recommendations about hemoglobin concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children.  

Methods: These guidelines are based on a systematic review of the literature on randomized clinical trials evaluating transfusion thresholds. We performed a literature search from 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay.  

Recommendation 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).  

Recommendation 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).  

Recommendation 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).  

Recommendation 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence). 

12. Stable Patients with Gunshot Wounds to the Torso Can Be Discharged Within 24 Hours 

Among patients who failed a trial of observation, all injuries requiring surgical intervention were detected within 24 hours. 

Inaba K, et al. Prospective evaluation of selective nonoperative management of torso gunshot wounds: When is it safe to discharge? J Trauma Acute Care Surg. 2012 Apr;72(4):884-91. 

BACKGROUND: Selective nonoperative management (NOM) has been increasingly used for torso gunshot wounds (GSWs). The optimal observation time required to exclude a hollow viscus injury is not clear. The purpose of this study was to determine the safe period of observation before discharge. 

METHODS: All patients aged 16 years and older sustaining a torso GSW undergoing a trial of NOM were prospectively enrolled (January 2009 to January 2011). Patient demographics, initial computed tomography (CT) results, time to failure of NOM, operative procedures, and outcomes were collected. Failure of NOM was defined as the need for operation. 

RESULTS: A total of 270 patients sustained a GSW to the torso. Of those, 25 patients (9.3%) died in the emergency department and were excluded leaving 245 patients available for the analysis. Mean age was 26.5 years ± 9.9 years (16-62 years), 92.7% (227) were men, and mean Injury Severity Score scale was 13.8 ± 11.3 (1-45). Overall, 115 patients (46.9%) underwent immediate exploratory laparotomy based on clinical criteria (72.2% had peritonitis, 27.8% hypotension, 10.4% unevaluable, and 4.3% evisceration), and 130 patients (53.1%) underwent evaluation with CT for possible NOM. Of those, 39 patients (30.0%) had a positive CT and were subsequently operated on. All had significant intra-abdominal injuries requiring surgical management. A total of 91 patients (70.0%) underwent a trial of NOM (47 had equivocal CT findings and 44 had a negative examination). Of these, 8 patients (8.8%) failed NOM and underwent laparotomy (all had equivocal CT scans). Two patients had a nontherapeutic laparotomy; the remainder had stomach (50.0%), colon (25.5%), and rectal (12.5%) injuries. The mean time from admission to development of clinical or laboratory signs of NOM failure was 2 hours:43 minutes ± 2 hours:23 minutes (0 hour:31 minutes-6 hours:58 minutes). All patients failed within 24 hours of admission. 

CONCLUSION: In the initial evaluation of patients sustaining a GSW to the torso, clinical examination is essential for identifying those who will require emergency operation. For those undergoing a trial of NOM, all failures occurred within 24 hours of hospital admission, setting a minimum required observation period before discharge. 

13. Association between Helicopter vs Ground Emergency Medical Services and Survival for Adults with Major Trauma 

Galvagno Jr, SM, et al. JAMA 2012;307(15):1602-1610.  

Context Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted.  

Objective To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries.  

Design, Setting, and Participants Retrospective cohort study involving 223 475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007-2009 versions of the American College of Surgeons National Trauma Data Bank.  

Interventions Transport by helicopter or ground emergency services to level I or level II trauma centers.  

Main Outcome Measures Survival to hospital discharge and discharge disposition.  

Results A total of 61 909 patients were transported by helicopter and 161 566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17 775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score–matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14-1.17; P less than .001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13-1.17; P less than .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P less than .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P less than .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P less than .001).  

Conclusion Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders. 

14. Images in Clinical Medicine 

Left Main Coronary Artery Thrombosis

Digital Mucous Cyst


15. Diagnosis of Intussusception by Physician Novice Sonographers in the ED 

Riera A, et al. Ann Emerg Med. 2012; in press.  

Study objective: We investigate the performance characteristics of bedside emergency department (ED) ultrasonography by nonradiologist physician sonographers in the diagnosis of ileocolic intussusception in children. 

Methods: This was a prospective, observational study conducted in a pediatric ED of an urban tertiary care children's hospital. Pediatric emergency physicians with no experience in bowel ultrasonography underwent a focused 1-hour training session conducted by a pediatric radiologist. The session included a didactic component on sonographic appearances of ileocolic intussusception, review of images with positive and negative results for intussusceptions, and a hands-on component with a live child model. On completion of the training, a prospective convenience sample study was performed. Children were enrolled if they were to undergo diagnostic radiology ultrasonography for suspected intussusception. Bedside ultrasonography by trained pediatric emergency physicians was performed and interpreted as either positive or negative for ileocolic intussusception. Ultrasonographic studies were then performed by diagnostic radiologists, and their results were used as the reference standard. Test characteristics (sensitivity, specificity, positive and negative predictive values) and likelihood ratios were calculated. 

Results: Six pediatric emergency physicians completed the training and performed the bedside studies. Eighty-two patients were enrolled. The median age was 25 months (range 3 to 127 months). Thirteen patients (16%) received a diagnosis of ileocolic intussusception by diagnostic radiology. Bedside ultrasonography had a sensitivity of 85% (95% confidence interval [CI] 54% to 97%), specificity of 97% (95% CI 89% to 99%), positive predictive value of 85% (95% CI 54% to 97%), and negative predictive value of 97% (95% CI 89% to 99%). A positive bedside ultrasonographic result had a likelihood ratio of 29 (95% CI 7.3 to 117), and a negative bedside ultrasonographic result had a likelihood ratio of 0.16 (95% CI 0.04 to 0.57). 

Conclusion: With limited and focused training, pediatric emergency physicians can accurately diagnose ileocolic intussusception in children by using bedside ultrasonography. 

16. Knowledge of radiation exposure in common radiological investigations: a comparison between radiologists and non-radiologists 

Lee RK, et al. Emerg Med J 2012;29:306-308.  

Background Radiological examinations are commonly requested for patients to aid clinical diagnosis. However, many doctors do not realise how much radiation dosage their patients are exposed to during radiological investigations. This study aims to assess and compare the knowledge of radiologists and non-radiologists about radiation doses of common radiological investigations.  

Methods A prospective questionnaire study of doctors about the dosage of commonly performed radiological investigations in a university teaching hospital in Hong Kong. Participants were asked to indicate the average dose of radiation (in mSv) for a standard chest x-ray exposure. Doctors were then asked to estimate the doses of radiation (measured in chest x-ray equivalents) for various radiological procedures. The results of radiologists and non-radiologists were compared.  

Results 158 doctors (25 radiologists and 133 non-radiologists) completed the questionnaire. The overall accuracy was 40% for radiologists and 16% for non-radiologists. One-third of non-radiologists could not distinguish radiological examinations with or without ionising radiation. No non-radiologists correctly stated the radiation dose (in mSv) of a conventional chest x-ray, and 77% underestimated the dose of radiological examinations. For radiologists, only 32% were correct for the radiation dose of a conventional chest x-ray while 7% underestimated the radiation doses.  

Conclusion Knowledge of radiation doses of investigation is generally inadequate among radiologists, and particularly poor in non-radiologists. Underestimation of radiation doses may expose patients to increasing radiological investigation and exposure to radiation hazards. Awareness of the radiation hazard of radiological examinations should be raised among medical professionals. 

17. Review of the Flu: Rapid Diagnosis and Treatment 

A. Accuracy of Rapid Influenza Diagnostic Tests: A Meta-analysis  

Chartrand C, et al. Ann Intern Med. 2012;156:500-511. 

Rapid influenza diagnostic tests (RIDTs) are immunochromatographic assays that detect influenza viral antigens. This review examined the accuracy of RIDTs in adults and children with influenza-like illness and evaluated factors associated with higher accuracy. Among 159 studies involving 26 RIDTs, RIDTs have a high specificity and positive likelihood ratio and modest and highly variable sensitivity for detecting influenza. Influenza can be ruled in but not ruled out through the use of RIDTs. 

B. Antivirals for Treatment of Influenza: A Systematic Review and Meta-analysis of Observational Studies  

Hsu J, et al. Ann Intern Med 2012; 156:512-524. 

Antiviral therapy may reduce complications and mortality associated with influenza, but there have been concerns that randomized trials might not reflect that. This review of 74 observational studies found that oral oseltamivir may reduce mortality in high-risk populations compared with no treatment. Either oral oseltamivir or inhaled zanamivir might reduce hospitalizations and symptom duration. Costs and targeting strategies, however, were not evaluated. The studies focused on drug-sensitive infections, so the results may not be applicable if antiviral-resistant viruses are prevalent. Antivirals might improve outcomes in some situations, but more evidence is needed to guide decision making about when and in whom to use particular agents. 

18. Quinolones Tied to Detached Retina   

The risk of retinal detachment was found to be higher among patients currently taking oral fluoroquinolones, although the absolute risk remained small, a case-control study showed. 

Etminan M, et al. JAMA 2012;307(13):1414-1419.  

Context Fluoroquinolones are commonly prescribed classes of antibiotics. Despite numerous case reports of ocular toxicity, a pharmacoepidemiological study of their ocular safety, particularly retinal detachment, has not been performed.  

Objective To examine the association between use of oral fluoroquinolones and the risk of developing a retinal detachment.  

Design, Setting, and Patients Nested case-control study of a cohort of patients in British Columbia, Canada, who had visited an ophthalmologist between January 2000 and December 2007. Retinal detachment cases were defined as a procedure code for retinal repair surgery within 14 days of a physician service code. Ten controls were selected for each case using risk-set sampling, matching on age and the month and year of cohort entry.  

Main Outcome Measure The association between retinal detachment and current, recent, or past use of an oral fluoroquinolone.  

Results From a cohort of 989 591 patients, 4384 cases of retinal detachment and 43 840 controls were identified. Current use of fluoroquinolones was associated with a higher risk of developing a retinal detachment (3.3% of cases vs 0.6% of controls; adjusted rate ratio [ARR], 4.50 [95% CI, 3.56-5.70]). Neither recent use (0.3% of cases vs 0.2% of controls; ARR, 0.92 [95% CI, 0.45-1.87]) nor past use (6.6% of cases vs 6.1% of controls; ARR, 1.03 [95% CI, 0.89-1.19]) was associated with a retinal detachment. The absolute increase in the risk of a retinal detachment was 4 per 10 000 person-years (number needed to harm = 2500 computed for any use of fluoroquinolones). There was no evidence of an association between development of a retinal detachment and β-lactam antibiotics (ARR, 0.74 [95% CI, 0.35-1.57]) or short-acting β-agonists (ARR, 0.95 [95% CI, 0.68-1.33]).  

Conclusion Patients taking oral fluoroquinolones were at a higher risk of developing a retinal detachment compared with nonusers, although the absolute risk for this condition was small. 

19. Which Doctors Are Happiest? Healthiest? 

Medscape Poll: What Doctors Are Like When the White Coat Comes Off 

 By Daniel J. DeNoon. WebMD Health News. March 22, 2012 -- Which doctors are happiest? Which are healthiest? How many doctors are churchgoers? How many doctors are overweight? And where do they go on vacation? 

Welcome to Medscape/WebMD's 2012 Physician Lifestyle Report. It's a peek at what doctors do when the white coats come off. More than 29,000 doctors, representing 25 specialties, replied to the online poll from Jan. 12-27, 2012. 

So what are doctors really like? The poll isn't scientific, but it offers interesting insights into what your doctor does outside the office, clinic, and hospital.  

The Happiest Doctors 

Medscape asked doctors to rate their happiness on a five-point scale, with 5 being as happy as can be. 

Rheumatologists -- specialists in arthritis, joints, muscles, and bones -- topped the list with an average self-reported happiness rating of 4.09. They were followed closely by dermatologists (4.06), urologists (4.04), ophthalmologists (4.03), and emergency medicine doctors (4.01). 

The least happy doctors are a three-way tie between neurologists, gastroenterologists, and internal medicine doctors. They rated their happiness at 3.88 -- hardly unhappy, but trailing the pack. 

The next least happy docs are oncologists, general surgeons, and plastic surgeons at 3.89 on the happiness scale. 

That's still pretty happy. Why? A clue comes from doctors' financial report card: 61% of those in practice say they have adequate or more than adequate savings for their stage of life, while only 7% say they are in unmanageable debt. 

And it isn't all about money. More than 4 out of 5 doctors say they are religious, and more than 40% actively practice or attend religious services. 

The Healthiest Doctors 

When asked to rate their own health on a five-point scale, dermatologists report being the healthiest of all doctors with a 4.23 average rating. 

They're followed by plastic surgeons (4.22), diabeticians/endocrinologists (4.20), orthopedists (4.19), and cardiologists (4.17). 

The "least healthy doctors" -- critical care doctors -- are still pretty healthy, giving themselves as 3.98 rating. Just above them are pediatricians (4.01), obstetricians/gynecologists (4.02), pathologists (4.02), and psychiatrists (4.02). 

Doctors' Weight, Doctors' Exercise 

More than 1 in 3 male doctors and over 1 in 4 female doctors say they are overweight. And obesity isn't just a problem for patients: 5.33% of male doctors and 6.21% of female doctors admit to being obese. 

This may be linked to how much time doctors find for exercise. Even when they are in their 20s, over half of doctors say they exercise less than twice a week. 

By age 41 to 50, more doctors are taking their own advice, and the fraction exercising less than twice a week drops to 40%. By age 61 to 70, only 28% of doctors get this little exercise. 

Where Doctors Go on Vacation 

When it's vacation time, both male and female doctors like to go to faraway places. Foreign travel is among the top 10 vacation plans for 50% of male doctors and 57% of female doctors. Second on the top 10 list is a beach vacation for 48% of male docs and 54% of female docs. 

For men, road trips (23%), visiting a vacation home (20%), cruises (19%), camping/hiking (18%), cultural trips (museums, theatre, etc., 17%), luxury spas/hotels (16%), winter sports trips (15%), and adventure outings (15%) round out the list. 

For female physicians it's luxury spas/hotels (23%), road trips (22%), cultural trips (22%), vacation home (21%), camping/hiking (20%), cruises (17.5%), adventure (14%), and winter sports trips (13%). 

What Doctors Do for Fun 

It's not just golf. Doctors list a wide range of things they do when the sign on the office door says "closed." 

Top five pastimes:

1. Exercise/physical activity (69% of men, 63% of women)

2. Reading (59% of men, 71% of women)

3. Travel (55.6% of men, 63% of women)

4. Cultural events (41% of men, 53% of women)

5. Food and wine (41% of men, 49% of women) 

But it's easy on the wine for most doctors. In fact, it's no wine at all -- or any other alcoholic beverage -- for 27% of male doctors and for 35% of female doctors. Just over half of doctors limit their alcohol intake to less than one drink a day. Only 3% of male doctors and 1% of female doctors say they drink two or more drinks a day. 

Volunteer Work 

Time off work doesn't always mean fun. Two-thirds of doctors do volunteer work. 

Much of this volunteering means putting the white coat back on and offering free medical services in local areas. Working with religious organizations and tutoring/counseling are also popular volunteer work for doctors. 

Not All Doctors Born in the U.S. 

Just over two-thirds of doctors were born in the U.S. Nearly 20% came to the U.S. as an adult, while about 8% were born abroad but came to the U.S. as children. 

Doctors' Favorite Cars 

When the white coat is on the peg and doctors are heading home, what kind of car will they drive? 

Here are the top 10 doctor-mobiles (and the percentage of doctors who drive them):

1. Toyota (17%)

2. Honda (15%)

3. Lexus (8%)

4. BMW (7%)

5. Mercedes (5%)

6. Ford (5%)

7. Nissan (4%)

8. Chevrolet (4%)

9. Subaru (3.5%)

10. Audi (3%) 

Two percent of doctors say they don't own a car. 

20. Golfers Can Improve Their Putt with a Different Look: Visualize a Great Big Hole 

Witt JK, et al. Get Me Out of This Slump! Visual Illusions Improve Sports Performance.

Psychol Sci. 2012 Mar 5. [Epub ahead of print] 

ScienceDaily (Apr. 3, 2012) — Golfers looking to improve their putting may find an advantage in visualizing the hole as bigger, according to a new study from Purdue University. 

"People in our study made more successful putts in a smaller hole when a visual illusion helped them perceive it as larger," said Jessica K. Witt, an assistant professor of psychological science who studies perception in sports. "We know that how people perceive the environment affects their ability to act in it, such as scoring as basket or hitting a baseball, and now we know that seeing a target as larger leads to improved performance. 

"More work is needed to better understand this effect, but we think the perceived increase in target size will boost confidence in one's abilities." 

For the first time, Witt looked at how manipulating what athletes see could influence their immediate performance. Her findings are published in the April issue of Psychological Science. 

Witt's previous work has shown how perception and performance work together in softball, tennis and football. For example, softball players who hit the ball better saw it as bigger, and people successfully kicking a football through the goal posts saw the target as larger. 

In this golf study, 36 participants putted to two different-sized holes while a projector displayed a ring of smaller and larger circles around each hole to create an optical illusion. The smaller circles around the hole made it look bigger. Before putting, the person's perception of each hole was measured by having them draw the estimated size of the hole. Their perception was correlated with their scores, and those who saw the smaller hole, which was 5.08 centimeters in diameter, as bigger putted about 10 percent more successfully. 

"A future goal is to develop techniques to help athletes see their target differently," Witt said. "Effects of these visual illusions will then lead to improvements in performance."

This work was supported by funds from the National Science Foundation and the National Institutes of Health. Witt collaborated on the study with Sally A. Linkenauger, a postdoctoral fellow at the Max Planck Institute in Germany, and Dennis R. Proffitt, professor of psychology at the University of Virginia.

21. A History of Mass Hysteria

Periodically throughout recorded history, puzzling instances of psychiatric and neurologic symptoms have presented en masse: outbursts of thrashing and screaming, or jerky spasms and abrupt vocal tics affecting a group of individuals at once and often attributed to causes like possession, witchcraft, and malingering. Such occurrences of so-called "mass hysteria" continue to confound the medical community, but growing experience has improved the understanding and approach to these seemingly contagious psychogenic events. Episodes of mass hysteria cross many scientific disciplines and are of interest to emergency physicians, epidemiologists, psychiatrists, psychologists, and those who study behavioral, environmental, and occupational health.[1] The following slideshow explores some of the more prominent and interesting instances of this phenomenon, from the infamous Massachusetts witch hunt of the 1600s through the recent episode affecting teenage girls in upstate New York.

by Andrew N. Wilner, MD, Neurohospitalist, Lawrence and Memorial Hospital, New London, Connecticut