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: http://pediatrics.aappublications.org/content/early/2012/04/11/peds.2011-3375.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
Summary
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.
Full-text
(free): http://www.amjmed.com/article/S0002-9343(11)00998-3/fulltext
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…
The remainder
of the essay: http://www.nytimes.com/2012/04/10/nyregion/geriatric-emergency-units-opening-at-us-hospitals.html
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: http://www.nejm.org/doi/full/10.1056/NEJMp1201598
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 http://www.YouTube.com 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.
Full-text
(free at this reading): http://jama.ama-assn.org/content/early/2012/03/30/jama.2012.476.full
See also: http://www.choosingwisely.org
New York
Times article: http://www.nytimes.com/2012/04/09/opinion/do-you-really-need-that-medical-test.html
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).
Full-text
(free): http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-201206190-00429.full
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
Achalasia
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.
Full-text
(free): http://emj.bmj.com/content/29/4/306.full
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.
Full-text
(free): http://www.annals.org/content/156/7/500.full.pdf+html
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.
Full-text
(free): http://www.annals.org/content/156/7/512.full.pdf+html
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
